A/HRC/43/45 B. Health-related debt 37. Health-related debt – a growing cause of financial insecurity and impoverishment in many households around the world, be it due to maternity services, unexpected hospitalization, a chronic disease or the need for costly or rare medication or frequent services and facilities – often arises from high out-of-pocket medical expenses that people cannot afford. Such expenses increasingly expose people to risks of financial hardships; global estimates suggest that some 33 million people experience financial hardship due to essential surgery that requires out-of-pocket payments, and are pushed into poverty as a result. 44 38. The primary factor underlying high out-of-pocket expenses is lack of access to adequate essential health care, services or facilities: more than 50 per cent of the global population has no access to adequate essential health care and, in most countries, the accessibility and affordability of essential health care are limited or not guaranteed. In many countries, health packages may cover too few interventions, may not cover medicines, or provide insufficient financial protection;45 health insurance does not necessarily protect the insured from medical debt. 39. In the United States of America, for instance, an estimated one in three individuals reported having difficulty paying their medical bills, despite the fact that many people with medical debt are insured. 46 The insured are often required to incur very high costs for deductibles, co-payments and other fees, which they may not be able to afford.47 40. Catastrophic health expenditure is also attributed to the prevalence of unregulated and unorganized private medical practices in some countries. 48 Putting in place an adequate, universal health-care system and allocating sufficient public funding and resources can be one crucial way to reduce high out-of-pocket medical costs, and therefore health-related poverty and indebtedness. 41. Health-related debt can have long-lasting, devastating consequences for individual debtors, whether the debt arose from a one-off intervention or has become a recurrent lifesaving expense. Persons with medical debt are in a particularly vulnerable situation, as often they have lost their sources of income owing to illness or injuries. Indebted households may sell their assets or turn to more borrowing to pay off the debt, thereby falling into debt trap and, consequently, the poverty trap. 42. Lack of food, inadequate access to nutritious food, malnutrition and hunger seriously affect the physical health of people, especially children, pregnant women, the chronically ill and older persons. For people who are late in their payments or in default, bills and hunger are too often connected, sometimes forcing them to resort to “pay day loans” and food aid. The Special Rapporteur on extreme poverty and human rights found that food bank use increased almost fourfold between 2012–2013 and 2017–2018, and that there were now more than 2,000 food banks in the United Kingdom, up from just 29 at the height of the financial crisis.49 43. In some parts of the world, persons who are unable to pay their medical debt can lead to their detention in medical facilities (either public or private). While the extent of this practice remains unknown, the limited academic research conducted suggests that hundreds 44 45 46 47 48 49 10 ILO, Universal social protection for human dignity, social justice and sustainable development, International Labour Conference, 108th session, Geneva, 2019, p. 103. Ibid. Karen Pollitz et al., “Medical Debt among People with Health Insurance”, Henry J. Kaiser Family Foundation, 2014. David Bank and Jenny Griffin, “Financing Out-of-Pocket Medical Debt and Keeping Bill Collectors at Bay”, Aspen Institute, 2015. Wim Van Damme et al., “Out-of-pocket health expenditure and debt in poor households: evidence from Cambodia”, Tropical Medicine and International Health, vol. 9, No. 2, p. 278; World Health Organization (WHO), “India tries to break cycle of health-care debt”, WHO Bulletin, vol. 88, No. 7, 2010. A/HRC/41/39/Add.1, para. 22.