Accès aux soins de santé

Analysis

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.