1. Governance and Leadership for prison health

Also known as stewardship, it is one of two cross-cutting building blocks of all health systems: it provides the oversight and guidance for developing an efficient and effective prison health system.

To ensure that detainees have access to healthcare of an appropriate standard, good leadership and governance require both political and technical action to provide prison health policies and strategies, legal regulatory frameworks, organizational and administrative structures. It also requires partnership-building - developing formalized and effective links with public health services and non-governmental agencies - and inter-ministerial coordination.

This building block ensures that appropriate regulations and standard operating procedures are properly enforced. It focusses on system-design and health outcomes and allows accountability, with close monitoring of the health system performance and service delivery.

2. International standards for prison health: translating international Minimum Standards on the Treatment of Prisoners into Healthcare Practice SYSTEM

In 2015 the United Nations Standard Minimum Rules for the Treatment of Prisoners (the “Nelson Mandela Rules”), were updated for the first time since 1957. Substantive revisions were made to include up-to-date guidance to meet current international standards in detention, notably in healthcare. The Nelson Mandela Rules, along with other relevant international “soft law” instruments such as The United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders (“Bangkok Rules”) and The United Nations Rules for the Protection of Juveniles Deprived of their Liberty (“Havana Rules”), provide an effective framework that all nations should strive to apply in the delivery healthcare in places of detention.

Unfortunately, at times the operational reality in places of detention does not meet these standards: the observed gaps in healthcare service delivery can potentially compromise the health of detainees, of staff and of the public, and create barriers to rehabilitation and reintegration. It is therefore critical for both detention administrators and healthcare professionals to reflect on the various aspects of these key instruments to identify both opportunities and challenges in translating internationally accepted minimum standards into current operational and clinical practice in places of detention, as part of the recommended “whole-of-government approach” to prison healthcare.

3. Prison Health Management Information System

Health Management Information System (HMIS) is the second cross-cutting building block of a health system. It provides the basis for understanding needs and serves as a starting point for planning, management and decision-making in health facilities and organizations.

HMIS should produce regular reports on health statistics and can support the development of health surveillance systems and response capacity.

Drug dependence is a public health concern as it affects not only individuals, but also their families, friends, co-workers and communities. It generates crime, violence, social, cultural and economic problems and health consequences, especially mental health, and the rapid spread of infectious diseases like HIV/AIDS and hepatitis, most common cause of mortality among drug users. Various studies have indicated that globally, the percentage of people in prison with drug problems, ranges from 40 to 80 percent amongst offenders entering prison and is on the increase.

Prison health authorities, public health officials, policy-makers in governments need a functioning health management information system and accurate data that can ensure the collection, compilation, analysis, dissemination and use of reliable and timely health information.

Prison health data – ideally integrated into the national reporting system - is necessary to establish priorities, draft budgets, and design cost-effective health interventions, both on a regular basis and during public health emergencies.

HMIS involves three domains of health information: on health determinants, on health systems performance and on health status (morbidity, mortality) and inequalities within the prison population.

4. Health needs of women and other vulnerable groups of detainees

More than 714 000 women and girls are held in penal institutions throughout the world, representing an estimated 2% to 9% of the global prison population. In Asian and Pacific countries, women and girls constitute an average of 7% of the total population, having increased at four times the rate of the general population since 2000 [3] . These women - often imprisoned with their children - have specific needs that should be met during their detention, as described in the United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders (“Bangkok rules”) released in 2010 [4] . They aim to highlight the specific needs of this group, to underline their rights and to set the minimum standards that States should meet in their respective detention systems.

Other vulnerable group of prisoners who, for whatever reason, face an increased risk to their safety, security, dignity or well-being as a result of imprisonment, also require attention, specific consideration and protection. Such groups include juveniles, the mentally ill or developmentally disabled, LGBTI people, members of ethnic, political or religious communities, persons with specific legal, administrative or political status, foreigners, the elderly, the physically disabled or chronically ill, etc.

These vulnerable prisoners deserve specific programs which consider special health care needs, corresponding to their individual health assessment and background, in order to ensure their wellbeing during their incarceration.

3.World Female Imprisonment List 2017 – World Prison Brief.

4.The Bangkok Rules 2011 – United Nations Office on Drug and Crime.

5. Drug treatment and harm reduction in prisons

About 275 million people worldwide - roughly 5,6 percent of the global adult population - used an illicit drug in 2016 (UNODC World Drug Report, 2018). Approximatively 11 percent of people who use illicit drugs suffer from a drug use disorder including drug dependence. Only one out of 6 people in need of drug dependence treatment has access to treatment programs. Drug dependence is a public health problem which affects not only individuals but also their families, friends, co-workers and communities. It generates crime, violence, social, cultural and economic problems and health consequences, especially mental health, and the rapid spread of infectious diseases like HIV / AIDS and hepatitis, which are the most common cause of mortality in drug users.

Various studies have indicated that globally, the percentage of people in prison who have a drug problem ranges from 40 to 80 percent amongst offenders entering prison, and that this proportion is increasing. Because it is a chronic disease, essential treatment services need to be accessible at different levels of health systems including in prisons, with linkages to community services. Without continuity of care, risks of relapse into drug use are very high after release, which increases their risk of returning to prison. Treatment as an alternative to imprisonment must be voluntary and human-rights compliant.

Finally, the imprisonment of drug users without other alternative measures contributes to prison overcrowding, which creates challenges to the authorities in terms of security, space, water, sanitation, food, healthcare but also the spread of drug use.

6. Mental health in prisons

High numbers of people with severe mental health disorders enter detention facilities all over the world. In many cases, adults with mental illness enter detention with a history of chronic health problems, unemployment, homelessness, financial instability, drug use and other high–risk behaviors.

Mental health care within places of detention including referral to external mental health services, is usually inadequate, and where it exists, it is often solely focused on psychiatric care. The mental health needs of different groups of detainees such as women, children and young people, older prisoners, prisoners from minority ethnic or cultural groups and foreign detainees, may not be properly addressed or may even be undetected. Furthermore, as conditions in detention facilities are not conducive to good mental health, all detainees are at risk of experiencing a decline in their mental state. Also, detention may result in treatment interruption for mentally ill people requiring regular medication, resulting in a rapid deterioration of their psychological state. Finally, detention systems may fail to ensure the continuity of medical care for detainees transferred from one place to another or released into the community.

Health services working with the criminal justice system should endeavour to prevent people with mental health problems from receiving prison sentences, and to divert them instead for treatment in either community– or hospital-based services. Once in prison, access to comprehensive psychosocial services is required to address all the detainees’ needs.

7. Communicable diseases in prisons

Prisons and places of detention pose particular threats for transmission of contagious diseases. Potential factors that could amplify contagious diseases in prisons and places of detention include: overcrowding, poor personal hygiene; poor food handling and hygiene; inadequate nutrition; inadequate ventilation; inadequate daylight in the cells; limited facilities for diagnosis, treatment and medical isolation; and lack of qualified health personnel in prisons. Additionally, people in prisons and places of detention often come from groups at higher risk for certain infectious diseases (e.g. Tuberculosis, HIV / AIDS, hepatitis) than the general population; their prevalence is therefore generally higher in prisons than in the surrounding community.

Prisons are confined environments for prisoners but not for contagious diseases, that can spill-over into the community through contact with prison staff and visiting community members, and after release.

Effective prevention and control of communicable diseases in prisons not only improve the health and quality of life of detainees, but is also an essential public health measure to protect the general population.

8. Protecting dignity and health: role of health professionals in prisons

As stated in The Universal Declaration of Human Rights - a milestone document in the history of human rights - “The recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world”.

Although there is no universal definition of what dignity is, it is understood to include the right to health and to autonomy, and to living conditions in which every person can develop a sense of being respected and safe. However, lack of respect for human dignity, discrimination against vulnerable groups including detainees, and inequalities that put people at increased risk of disease are critical challenges faced by today’s society.

Prisoners are vulnerable to ill health because of their background, their environment, and their behaviour both outside and inside prisons. Another factor that contributes to prisoners’ vulnerability is that they are entirely dependent on the prison staff of for all aspects of their daily lives as well as for their health, protection and safety.

Regardless of circumstances, the goal of healthcare professionals working in the places of detention must remain to ensure the welfare and dignity of the patient. They can and should protect prisoners at risk of violations, and take action in the face of breaches of their rights by using professional ethics and standards to support their action. There is a considerable body of international “soft law” that has implications for prison health care, such as the United Nations General Assembly resolutions and the World Medical Association declarations.