On 21 November 2019, the World Health Organization published a status report on prison heath in the WHO European Region. This 97 page report presents an analysis of data collected on the health status of people in prison and prison health systems for 39 countries in the Region. The WHO survey collected data from Member States between 2016 and 2017.
From Prison Release To Community.
An estimated 6 million people are incarcerated each year in the Region. On any given day, more than 1.5 million people in the WHO European Region are incarcerated. After release, rates of reoffending and returning to prison are high. The report points out that this cycle between prison and community often leads to disjointed and ineffective health care outside of prison.
During the early days of a person’s release, the risk of suicide, self-harm and drug overdose is increased. This means that continuity of care during this transition is critical. Gaps in care during this period have significant negative public health implications and can constrain a country’s ability to address inequalities.
Here are some of the key facts from the WHO European Region.
Suicide and mental health
- 13.5% of deaths in prison are from suicide.
- 14% of Member States report that they do not screen for severe mental health disorders on or close to arrival in prison.
- WHO guidance recommends that on arrival in prison, all individuals should be screened as soon as practicable for signs of poor mental health, self-harm and suicidal behaviour.
- Only 51% of countries have national guidelines on prevention of post-release drug-related deaths.
- WHO guidance recommends that Member States implement medicines reconciliation and screening for substance use disorders for all individuals on arrival in prison.
HIV and Tuberculosis (TB)
- Prevalence rates for HIV vary from country to country, but the highest reported rate is 5.4% of the male prison population and 4.7% of female prison population.
- Prevalence rates for TB vary from country to country, but the highest reported rate is 25% of the prison population.
- WHO guidance recommends that Member States ensure that testing is available, but not mandatory, for HIV, hepatitis B, hepatitis C and sexually transmitted infections on arrival in prison; that pre- and post-test counselling is available in prisons; and that appropriate treatment or vaccination is available in prisons.
- WHO guidance also recommends that Member States implement testing for TB on arrival in prison.
An Opportunity For Better Health?
Prisons and other places of detention have an opportunity to deliver preventive and risk-reduction interventions and treatments to a population that previously may have lacked or had limited access to health care and a healthy lifestyle.
According to the report, prisons must be seen as settings in which health interventions can address existing health conditions and contribute to positive lifestyles and behaviour changes. Time in prison can also be used to improve people’s skills to help them find a job after release and reintegrate into society.
Member States should ensure that data are collected on the number of people entering and leaving prison, and demographics of people in prison. Health services in prisons must reflect the specific health needs of the population, based on formal health needs assessments.
Prison Health Systems
Regardless of which ministry has the authority for prison health care, the responsibility for quality assessment of hygiene, health care and organization of health services in custody should sit with the ministry responsible for health. Health services must adhere to international human right laws, ensure the clinical independence of health-care staff and provide services that are of an equivalent standard to those in the community.
Member States that do not completely cover all necessary health-care-related expenses in prison should extend health-care coverage to all people for all necessary health services to ensure that universal health coverage includes people in prison.
All Member States should ensure that formal arrangements are in place to enable integration of prison health services with the wider public health system to achieve continuity of care for individuals released from custody and continuity of universal health coverage for this key population.
Member States should follow the WHO Framework Convention on Tobacco Control by giving consideration to the establishment of a smoke-free prison estate and ensure that appropriate support is provided to individuals to quit tobacco-smoking, including nicotine replacement therapy and counselling.
Fresh and nutritious food options should be provided in place of nutrient-poor meals in prisons to prevent noncommunicable diseases (NCDs) and contribute to promoting healthy lifestyles and establishing a health- promoting environment.
The implementation or expansion of drug-free units in prisons is one mechanism by which prisons can become health-promoting environments.
Screening For NCDs
On arrival at prison, all individuals should be screened as soon as practicable (using validated screening tools) for immediate risks, including signs of poor mental health, self-harm and suicide, substance use disorder and medicines reconciliation.
Within the first week of custody, all individuals should undergo a thorough health assessment to screen for all physical and mental health needs. Individuals requiring treatment should be referred to appropriate health-care services.
Member States should implement validated screening tools that capture information on NCDs, including cardiovascular disease, respiratory disease, diabetes and cancer, and their associated risk factors – tobacco-smoking, harmful alcohol use, nutrition and physical activity.
Data from health screening in prison should be captured and reported at national level to monitor: prevalence rates of diseases and risk factors; changes in health status; improvements in health outcomes in the prison population; and prison health systems’ progress in addressing the health needs of the population.
Member States that currently do not screen for oral health issues on reception to prison should ensure that dental health-care services are available for assessment and treatment of oral health issues both on entry to prison and throughout imprisonment.
Member States should ensure that: testing is available, but not mandatory, for HIV, hepatitis B, hepatitis C and sexually transmitted infection (STIs) on entry to prison; pre- and post-test counselling is available; and appropriate treatment or vaccination is available in prison.
Testing for TB on reception to prison should be implemented in all Member States and treatment commenced for individuals testing positive to minimize the risk of transmission of TB within prisons.
Prevention Of Infection
All countries should ensure that evidence-based infection control measures, such as condoms, lubricants and disinfectants, are easily and discreetly available in prisons to help prevent the transmission of infections.
The implementation of needle and syringe exchange programmes in prisons should be considered by all Member States as an example of a harm-reduction intervention to minimize the risk of transmission of infections, in line with community practice to ensure equivalence of care.
Member States should ensure that the full vaccination course for hepatitis B is offered to all individuals entering prison not know to be immune to hepatitis B due to a full vaccination course or previous infection.
Treatment For Mental Health And Substance Use Disorders
Member States that currently do not offer opioid substitution therapy (OST) for both sentenced and pre-trial individuals should implement programmes in line with WHO guidance.
National guidelines for the treatment of severe mental health disorders in prisons should be developed, implemented and monitored by all Member States to ensure equivalence of care for those with mental health disorders in prison. This should include access to specialized mental health treatment for people with a mental health disorder and mental health promotion for all within prison.
All Member States should develop and implement national guidelines for the prevention of post-release drug-related deaths, including the provision of appropriate medication on release from prison and arrangements for continuity of care with community health services.
This report highlights a number of areas in which Member States, on the whole, are not complying with WHO guidance on health in prisons.
The report also yields some key messages about the state of prison health in Europe and provides general recommendations that will help to ensure Member States can continue to monitor and improve prison health systems.
The first key message is that collection of national health data on individuals and prison populations is lacking. This is evident in the incomplete data for many of the Health in Prisons European Database (HIPED) indicators and represents a failure to understand the basic health needs of the prison population. It therefore is vital that Member States are able to monitor the health status of those in prison through comprehensive data-collection systems. Only then will the WHO HIPED be able effectively to compare health in prisons across Europe and contribute to policy decisions for prison health in the Region.
The second key message is to emphasize the importance of creating a health-promoting environment in prisons in which individuals receive high-quality health care that is of an equivalent standard to that in the community, regardless of which ministry has the authority for health care in prisons.
Prison is a setting in which health promotion can take place, so prisons need to be health-enabling environments that can contribute to an improvement in health and well-being. Prisons provide an opportunity to change lifestyles, and time spent in custody can be used to improve existing health conditions through appropriate treatments and modify health-risk behaviour for NCDs through, for example, cessation of tobacco-smoking and improved nutrition and physical activity.
There are many different models of prison health-system governance in the European Region, and most survey respondents reported that the responsibility for prison health services lies with the Ministry of Justice, rather than the Ministry of Health. It is essential that prison health is viewed as part of the broader public health agenda and that prison health policy is recognized and incorporated into general public health policy. Intersectoral working is essential to ensure close collaboration among ministries to promote improvements in prison health systems, and that all those member states contribute to “leaving no one behind.”
Full Report Here: Status report on prison health in the WHO European Region (2019)