Health care facilities
Every prison must have a health care service, at least equivalent to that available in the community, that is accessible free of cost to all detainees, without discrimination. The role of the health care service must not be simply curative, but the prevention, treatment and care of physical and mental illness, as well as health promotion amongst the prison population. The facilities, equipment and medical supplies must be adequate to provide these health services to the size of prison population. Due to the closed setting of prisons, emergency facilities must be available on site and staff trained and regularly updated in their use.
Health care staff
The number and speciality of the health care staff available will be dependent on the size of the prison, but as a minimum there should be a general physician and sufficient nursing staff to meet the daily needs. A psychiatrist, as well as a psychologist and nurses with training in psychiatric care should also be available at a frequency related to the size of the prison population. Again, their role must not be confined simply to the treatment of mental illness but must include the promotion of the mental well-being of the prison population and staff, and the prevention of self-harm and suicide, as well as all forms of physical or psychological violence, such as bullying. Basic dental services should also be available within the prison at a frequency dependent on the prison population.
Health care policies
Historically most prison health care services have operated in isolation from the health services available to the surrounding community. While in many countries there have been increased efforts to run the prison health care service in close co-ordination with the national public health system, there are now moves to push for the full integration of the prison health service into the public health service. The aim is to ensure that national health policies and programs and standards are applied equally in prisons, and that the prison health staff have the same level of training and support and access to facilities as their colleagues working in public health structures in the community. In particular national policies and programs for specific diseases that are more prevalent in prisons must be applied within the prisons, in particular those for HIV-AIDS, Tuberculosis, blood borne diseases such as Hepatitis and mental illness.
Health care principles
Equivalence and Equity in Prison health care
The prison health service should at a minimum be run in close co-ordination with the national health care service. As a part of protecting and promoting the health of the detainees, the prison health care service should facilitate continuity of care and the psychological adjustment between the community and the prison and then back to the community. Ideally the prison health service should be integrated into the national health care service so as to ensure that health care in the prisons is at least equivalent to that in the community. Equivalence means that detainees receive at least the same level of health care as those in the community. In this way national health policies, programs and protocols will be applied equally in prisons as in the community.
But since the prison population is usually composed of marginalised and vulnerable individuals who are at higher risk of mental and physical illness, physical and sexual violence and substance dependency amongst other things, the prison population often has greater health needs. It is therefore usually the case that prisons require greater attention to health care, and more resources need to be directed to where the problems are greatest. This is termed equity of healthcare. Addressing these health needs not only protects the detainees and staff, but also protects the community. Ignoring them will hinder the fight to prevent the spread of HIV, Hepatitis and other blood borne infections as well as Tuberculosis and mental health problems in the community, as well as contributing to reducing recidivism.
Non-discrimination in prison health care
Health care in prisons should be provided free of charge and without discrimination. All detainees, whether under-trial (on remand) or sentenced, have the right to free health care. The specific health care needs of some groups, such as women, minors, victims of violence, people with disabilities and LGBTI detainees must be taken into account.
Consent, confidentiality and patient autonomy
Detainees retain the right to autonomy in matters relating to their own health. That is, they have the right to make informed choices on their healthcare, to provide their informed consent and not to be treated against their will, including forcibly. Detainees retain the right to confidentiality of their health care. Access to the health service, consultations and treatments must remain confidential. Thus the detainee must be able to contact the health service directly to request to be seen, and consultations and treatment should take place without the presence of prison guards. As in the community, a confidential individual medical file should be started for each detainee, and held in the health clinic, only accessible to the health staff.
Access to healthcare
Since prisons are closed settings, access to the healthcare services must be readily available within the prison. The physician and other health staff should be available on a daily basis to see both acutely ill detainees, and chronic or follow up cases. A member of the health staff should also be on duty in the night to respond urgently to medical emergencies and accidents. Visits by a psychiatrist/psychologist and by a dentist should be in accordance with the size and needs of the prison population. Detainees must have direct access to a member of the health staff to inform of their wish to be seen in the clinic. This may either be through a nurse who tours the sections daily, or through the detainee giving their name directly to the clinic. Access to the health service should not be filtered by prison staff or other detainees since this creates barriers to access and also interferes with medical confidentiality.
Medical consultations must be held confidentially between the patient and the health staff. Other prison staff should not be present, unless exceptionally when there is an acknowledged security risk. and even then the staff should be out of range of hearing of the consultation. Even if restraints are used for the movement of detainees to the clinic, they should not be used during the consultation as they interfere with the physician-patient trust and with any proper medical examination.
The prison should have an adequate stock of medicines to provide treatment free of charge for the most common illnesses. A standard list of medicines should be in place, as in primary health care centres in the community. Detainees should receive the equivalent treatment to those in the community and should not have to pay for this treatment. Standard procedures for ordering and receiving supplies of medicines from a central pharmacy store should be in place so that there is never a rupture in the stock.
Referral to community health facilities
When specialist consultations, medical investigations, or treatments are not available in the prison, there must be arrangements for the referral of the patients from the prison to local hospitals or clinics. The clinical independence of the health staff means that security considerations must not interfere with the decisions to make such referrals. For those detainees who are admitted to outside hospitals, they should not be restrained to their beds, but instead measures should be taken to secure the room itself. In certain contexts, arrangements may be made for hospital specialists to conduct satellite clinics, and even some medical investigations, inside the prison. Standing arrangements and protocols must also be in place for the urgent evacuation of medical emergencies to the nearest hospital whenever necessary.
Medical screening on arrival
All detainees entering the prison, including those transferred from other places of detention, must receive an initial medical screening within a short time of admission, usually within a maximum of 48 hours. The purpose of the medical is to ensure continuity of care for any illness for which the person is already under treatment, to screen for any undiagnosed physical or mental illness, including any risk of self-harm or suicide, and to inform the detainee of about the health services available and how to access it. It is also the duty of the health staff to look for any signs or symptoms of torture and other ill-treatment, including sexual violence, even if the detainee does not complain of them, and to properly document and report such cases through independent and confidential channels.
The initial screening may be undertaken by a nurse, as long as the detainee is then later checked by the physician. A confidential individual medical file should be started for each new arrival and kept securely in the health clinic. Some more in depth screening, such as sexually transmitted infections, hepatitis and other blood borne infections can take place at a later date when there is more time to explain health issues to the detainee. Those detainees with drug or alcohol dependencies should receive treatment according to the national policies and programs available in the community. According to the latest guidance by the United Nations and World Health Organisation, a comprehensive package of interventions for HIV prevention, treatment and care should be introduced into prisons, including offering all detainees voluntary HIV counselling and testing at any time they have contact with the health services. Those detainees known to have HIV should be regularly screened for Tuberculosis as this is one of the major diseases affecting those with HIV.
Health promotion and prevention of disease
The prison health staff have the further responsibility to ensure that the prison environment in respect to hygiene, sanitation, water supply, lighting and ventilation, as well as the food, are not detrimental to the health of the detainees. As such they must routinely inspect the premises, in particular the sanitary facilities, and the food, including the kitchens, and make any necessary recommendations for improvement to the prison administration.
Numerous factors in prisons contribute to a higher prevalence and a greater incidence (new cases) of certain diseases and health problems. The prison population includes many vulnerable groups including victims of physical and sexual abuse, injecting drug users, alcohol dependency, and the mentally ill. Coupled with conditions of detention which can include overcrowding, poor hygiene, sanitation and ventilation, poor nutrition, inter-detainee violence and at risk behaviour such as injecting drugs, tattooing and also sexual contacts, diseases such as HIV, Hepatitis B and C, Sexually transmitted infections and Tuberculosis are more common in prisons. Many of these factors can also contribute to an increase number of cases of mental illness, and to acts of self-harm and suicide, particularly in new admissions who are particularly vulnerable.
The healthcare services, together with the prison administration and the Ministry of Health, have a responsibility to ensure that in particular national programs against tuberculosis and HIV-AIDS are included in prison health. In situations where Tuberculosis is recognised as a problem, the health staff may need to conduct active case finding, in which they directly screen the prison population and staff so as to identify, medically isolate and treat cases of TB. Education and information campaigns will also need to be conducted to increase the detainees, as well as prison staff awareness of the risks and of the availability of treatment.
The spread of HIV within the prison population requires specific action, and yet in many countries there is little attention paid to the issue. Countries must implement the comprehensive package of interventions for prison recommended by the UN and WHO, including access to voluntary testing, needle and syringe exchange, provision of condoms, drug dependency treatments etc.
In line with a public health approach to prisons, the health staff must also ensure that policies and programs for the protection and promotion of mental and physical health are included in the prisons. For example programs to improve attitudes to nutrition and exercise, for stopping smoking, anti-bullying, identifying and treating victims of physical and psychological violence, including sexual and domestic violence.
If it does not exist, the prison service should establish a health information system for the collection of epidemiological data on health in prisons. The basis for the system is the maintenance of individual medical files together with the routine collection of health data such as the types and the number of cases of specific diseases, any deaths in custody, and a record of the types and quantities of medicines prescribed. The data should be compiled in the same format as national epidemiological data collection and can be used to assist in health budget calculation and the maintenance of a central and prison level pharmacy stock.
Legal standards (6) Print
United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules)
1. The provision of health care for prisoners is a State responsibility. Prisoners should enjoy the same standards of health care that are available in the community, and should have access to necessary health-care services free of charge without discrimination on the grounds of their legal status.
2. Health-care services should be organized in close relationship to the general public health administration and in a way that ensures continuity of treatment and care, including for HIV, tuberculosis and other infectious diseases, as well as for drug dependence.
1. Every prison shall have in place a health-care service tasked with evaluating, promoting, protecting and improving the physical and mental health of prisoners, paying particular attention to prisoners with special health-care needs or with health issues that hamper their rehabilitation.
2. The health-care service shall consist of an interdisciplinary team with sufficient qualified personnel acting in full clinical independence and shall encompass sufficient expertise in psychology and psychiatry. The services of a qualified dentist shall be available to every prisoner.
1. The health-care service shall prepare and maintain accurate, up-to-date and confidential individual medical files on all prisoners, and all prisoners should be granted access to their files upon request. A prisoner may appoint a third party to access his or her medical file.
2. Medical files shall be transferred to the health-care service of the receiving institution upon transfer of a prisoner and shall be subject to medical confidentiality.
1. All prisons shall ensure prompt access to medical attention in urgent cases. Prisoners who require specialized treatment or surgery shall be transferred to specialized institutions or to civil hospitals. Where a prison service has its own hospital facilities, they shall be adequately staffed and equipped to provide prisoners referred to them with appropriate treatment and care.
2. Clinical decisions may only be taken by the responsible health-care professionals and may not be overruled or ignored by non-medical prison staff.
A physician or other qualified health-care professionals, whether or not they are required to report to the physician, shall see, talk with and examine every prisoner as soon as possible following his or her admission and thereafter as necessary. Particular attention shall be paid to:
(a) Identifying health-care needs and taking all necessary measures for treatment;
(b) Identifying any ill-treatment that arriving prisoners may have been subjected to prior to admission;
(c) Identifying any signs of psychological or other stress brought on by the fact of imprisonment, including, but not limited to, the risk of suicide or self-harm and withdrawal symptoms resulting from the use of drugs, medication or alcohol; and undertaking all appropriate individualized measures or treatment;
(d) In cases where prisoners are suspected of having contagious diseases, providing for the clinical isolation and adequate treatment of those prisoners during the infectious period;
(e) Determining the fitness of prisoners to work, to exercise and to participate in other activities, as appropriate.
The physician or, where applicable, other qualified health-care professionals shall have daily access to all sick prisoners, all prisoners who complain of physical or mental health issues or injury and any prisoner to whom their attention is specially directed. All medical examinations shall be undertaken in full confidentiality.
United Nations Rules for the Protection of Juveniles Deprived of their Liberty
Every juvenile shall receive adequate medical care, both preventive and remedial, including dental, ophthalmological and mental health care, as well as pharmaceutical products and special diets as medically indicated. All such medical care should, where possible, be provided to detained juveniles through the appropriate health facilities and services of the community in which the detention facility is located, in order to prevent stigmatization of the juvenile and promote self-respect and integration into the community.
Every juvenile has a right to be examined by a physician immediately upon admission to a détention facility, for the purpose of recording any évidence of prior ill-treatment and identifying any physical or mental condition requiring medical attention.
The medical services provided to juveniles should seek to detect and should treat any physical or mental illness, substance abuse or other condition that may hinder the integration of the juvenile into society. Every detention facility for juveniles should have immediate access to adequate medical facilities and equipment appropriate to the number and requirements of its residents and staff trained in preventive health care and the handling of medical emergencies. Every juvenile who is ill, who complains of illness or who demonstrates symptoms of physical or mental difficulties, should be examined promptly by a medical officer.
Any medical officer who has reason to believe that the physical or mental health of a juvenile has been or will be injuriously affected by continued detention, a hunger strike or any condition of detention should report this fact immediately to the director of the detention facility in question and to the independent authority responsible for safeguarding the well-being of the juvenile.
A juvenile who is suffering from mental illness should be treated in a specialized institution under independent medical management. Steps should be taken, by arrangement with appropriate agencies, to ensure any necessary continuation of mental health care after release.
Juvenile detention facilities should adopt specialized drug abuse prevention and rehabilitation programmes administered by qualified personnel. These programmes should be adapted to the age, sex and other requirements of the juveniles concerned, and detoxification facilities and services staffed by trained personnel should be available to drug- or alcohol-dependent juveniles.
Medicines should be administered only for necessary treatment on medical grounds and, when possible, after having obtained the informed consent of the juvénile concerned. In particular, they must not be administered with a view to eliciting information or a confession, as a punishment or as a means of restraint. Juveniles shall never be testees in the experimental use of drugs and treatment. The administration of any drug should always be authorized and carried out by qualified medical personnel.
European prison rules
Prison authorities shall safeguard the health of all prisoners in their care.
Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation.
Principles and Best Practices of the Protection of Persons Deprived of Liberty in the Americas
Principle IX – Admission, registration, medical examinations and transferts
3. All persons deprived of liberty shall be entitled to an impartial and confidential medical or psychological examination, carried out by idoneous medical personnel immediately following their admission to the place of imprisonment or commitment, in order to verify their state of physical or mental health and the existence of any mental or physical injury or damage; to ensure the diagnosis and treatment of any relevant health problem; or to investigate complaints of possible ill-treatment or torture.
Extract from the 3rd General Report on the CPT's activities [CPT/Inf (93) 12]
While in custody, prisoners should be able to have access to a doctor at any time, irrespective of their detention régime […]. The health care service should be so organised as to enable requests to consult a doctor to be met without undue delay.
A prison's health care service should at least be able to provide regular out-patient consultations and emergency treatment (of course, in addition there may often be a hospital-type unit with beds). The services of a qualified dentist should be available to every prisoner. Further, prison doctors should be able to call upon the services of specialists.
As regards emergency treatment, a doctor should always be on call. Further, someone competent to provide first aid should always be present on prison premises, preferably someone with a recognised nursing qualification.
Out-patient treatment should be supervised, as appropriate, by health care staff; in many cases it is not sufficient for the provision of follow-up care to depend upon the initiative being taken by the prisoner.
Guidelines on the Conditions of Arrest, Police Custody and Pre-Trial Detention in Africa
25. Procedural and other safeguards
States should have in place, and make known, laws, policies and standard operating procedures, which accord with Member States’ obligations under the African Charter on Human and Peoples’ Rights and other international law and standards, to:
h. Have in place measures, including health assessment screenings, to reduce suicide and self-harm, such as alternatives to custody, diversion to mental healthcare, promotion of family support, drug treatment and detoxification, and training for officials to identify and address persons who are at risk of suicide and self-harm.
Questions for monitors (27) Print
What are the location, size and facilities of the prison health clinic?
Is there a pharmacy stock and how are medicines ordered and delivered?
Are emergency equipment (e.g. defibrillators) and drugs available?
How many staff are based at the prison (e.g. physician, nurses, psychiatrist, psychologist, dentist)? What are their qualifications and competencies ? Which days are they present?
Do hospital specialists visit the prison?
Do gynaecologists visit women in prison?
Do paediatrician visit detained minors?
What are the links between the Prison health service and the national health service?
Are health staff under the responsibility of the Ministry responsible for prisons (such as Ministry of Justice or Ministry of Interior) or under the Ministry of Health?
Are Ministry of Health policies, programs and treatment protocols applied within the prisons or are there separate Prison health policies?
How do detainees gain access to the prison health clinic? Are there any barriers to this access such as having to pass the request through a guard or another detainee?
What is the waiting time between a request and being seen in the clinic?
Is anyone other than the health staff present during the consultation?
Are detainees restrained during the consultation?
Following the consultation is an explanation of the diagnosis and treatment given, and is the treatment available free of charge?
Can detainees be referred to local Ministry of Health facilities?
What is the waiting time for a routine referral or for an emergency referral?
Are restraints used inside the community health facility (during transport only or during consultations or during in-patient stays?)
How are the results of outside consultations transmitted back to the prison and what is the system in place for subsequent follow-up?
Is there a medical screening on arrival at the prison? Within what time frame is it performed, and by whom? What does the medical screening involve?
Is an individual medical file started for each detainee? is the file kept confidentially from the prison administration?
Do detainees with existing illnesses continue their treatment on admission to the prison?
Were any allegations or signs of ill-treatment prior to arrival in the prison examined and documented by the prison health staff? What happened to this information?
Do health staff routinely tour the prison premises to check the hygiene, sanitation, nutrition etc.? What action can they take in the event that problems are noted?
Are national public health programs such as the prevention, treatment and care of HIV-AIDS, Tuberculosis and mental health applied in the prison?
Are there programs in place to address drug and alcohol dependency?
What health promotion activities are carried out in the prison?