The complex health needs of people in prison globally generally remain unmet, particularly in overcrowded prison systems with low levels of funding.
Environmental factors that negatively impact health in prisons include poor ventilation, lack of personal space, water, sanitation, hygiene, and nutrition. Recent reports have documented how people are held in cells without lights, ventilation or fans in conditions of tropical heat in the Maldives, with some only allowed out of cells once a month for about an hour; inadequate water supply, sanitation and hygiene in some prisons in El Salvador; and widespread presence of bed bugs in mattresses in Bulgaria. In Thailand, unannounced inspections found unhygienic practices in prison kitchens, including the use of expired ingredients, and drinking water contaminated with bacteria in two prisons.
Access to adequate healthcare remains among the biggest challenges for people in prison worldwide. For example, in Peru, the highest percentage of the 1,142 cases processed in 2021 by the Ombudsman’s Office, responsible for monitoring prison settings, involved violations of the right to health. Also in Türkiye, according to the Human Rights Association (İnsan Hakları Derneği), obstacles to the right to health are at the forefront of the rights violations experienced by people in prison, with increasingly severe isolation conditions causing damage to both their physical and mental health.
Inadequate healthcare staffing is another common challenge shared by most prison systems
People in prison face multiple barriers accessing health services, including long wait times to be seen by a medical professional. Even in high-income countries there are reports of lengthy waiting times such as in Australia where, in one prison, detainees claim it is not unusual to wait up to eight weeks to see a doctor and that many people experience unnecessary delays in accessing their prescribed medications.
Inadequate healthcare staffing is another common challenge shared by most prison systems, albeit with significant variation across countries and regions. In the most extreme situations, some prisons lack any medical personnel, as is the case in at least two prisons in the Central African Republic. Most prisons in Uganda do not have doctors or nurses, but clinicians, and the first point of contact for someone that is unwell is a fellow detainee known as a ward doctor. In Iran, prison regulations only require one general practitioner to be on site 24 hours a day for facilities holding over 3,000 people. In May 2023, the Committee against Torture asked Kazakhstan to recruit more medical personnel in prisons, including psychiatrists and for those in need of specialised treatment, such as HIV patients and people with disabilities. Elsewhere, however, the World Health Organization (WHO) has reported that in 2020, across 36 European countries surveyed, there were 36.4 healthcare staff per 1,000 people in prison. While there were more nurses and physicians compared to the community, there were far fewer dentists, with only 1.4 per 1,000 compared to 6.2 in the general population.
According to the latest UNAIDS figures from 2022, people in prison are five times more likely to be living with HIV than adults in the general population; in recent years, on average, more than 3% of the global prison population is living with HIV. The highest regional average of HIV prevalence in prisons is 12% in Eastern and Southern Africa, with rates as high as 21% in Zambia and 35% in Zimbabwe in 2022. Yet, treatment coverage continues to be poor. Among the 41 countries that reported on antiretroviral therapy (ART) coverage in prisons in recent years, 7 countries reported less than 35% coverage; only 14 reported more than 95%. Among 36 European countries surveyed by WHO, post-exposure prophylaxis (PEP) against HIV was available in all prisons in 75% of countries in 2020, but less than 60% had pre-exposure prophylaxis (PrEP) in all prisons.
A lack of political will remains the biggest underlying barrier to provision of preventive health services and treatment in prisons of communicable diseases like HIV/ AIDS and tuberculosis (TB). Other challenges discussed at the first world conference on prison health in 2022 included lack of screening on admission to prison and failure to identify active cases, poor adherence to treatment, inadequate staffing, training and motivation, poor supervision of medical staff in prisons, and challenges related to continuity of care.
There have been some positive moves to prevent and treat infectious diseases recently. In England, where the prevalence of hepatitis C in prisons is about 6%, compared to 0.7% in the community, a health service, private sector and charity partnership is running large-scale hepatitis C screening programmes in prisons. Also in Georgia, a free hepatitis C treatment that was extended to the penitentiary system from 2011–2014 led to a 98.7% cure rate between 2014 and 2021, including for people in pre-trial detention. Success of the initiative has been found to highlight the importance of partnerships, political commitment, government investment and community network empowerment.
Access to harm reduction measures in prisons globally remains piecemeal and inadequate.
Even in countries where some measures are available, they often do not extend to all prisons. The number of countries providing at least some services has been increasing, albeit very slowly. Between 2017 and 2022, 52 countries reported providing condoms and lubricants, 27 provided opioid agonist therapy (OAT) and 7 had needle and syringe programmes in prisons. UNAIDS have reported that many of these services rely heavily on donor funding and support, are unevenly distributed across prisons, and poorly linked to national HIV or public health programmes. In 2020 across 36 countries in Europe, the most common measure provided was condoms, which were only available in all prisons in less than half of countries in the region; only 3 countries (8.3%) offered needles and syringes free of charge in all prisons.
Security considerations continue to be frequently cited as the reason for not implementing harm reduction measures in prisons with claims, for example, that syringes may be used as weapons. However, positive health outcomes are continuously proven with research suggesting no evidence of misuse. In Moldova, where a prison needle exchange programme has been in place for over 20 years, the prevalence of hepatitis B and C in prisons has reduced between 2012 and 2021 from 13.1% to 1.6% and from 8.6% to 3.6%, respectively, and no aggression with needles has been recorded.
A study by The Economist that modelled the costs of reducing imprisonment while scaling up harm reduction assessed the impact on financials and HIV transmission in Belarus, Kazakhstan, Kyrgyzstan and Russia. It found that by shifting resources and investing the money saved from decriminalising drug use and possession for personal use (estimated €11.1bn in Russia over 20 years) to scaling up ART and OAT, the current HIV epidemics among people who inject drugs in the four study countries could be effectively controlled for no added cost.
There is increasing awareness of the benefits of transferring responsibility for prison health to the health ministry and clearly dividing roles between the ministry in charge of prisons and the health ministry, as recommended by WHO. While Kuwait placed prison health under the Ministry of Health since the creation of prison services in 1954, Norway was reportedly the first country to separate prison health from its justice ministry in the 1960s, and other countries including England and Wales, Finland and Portugal have since followed suit. Most recently, from January 2023, the healthcare of all people in detention in Kazakhstan falls entirely under the responsibility of the Ministry of Health, following the transfer of medical services in pre-trial detention centres in July 2022. WHO has found that, despite the same accreditation procedures for health services and ethical and professional standards for health staff in prisons in most countries in Europe, in at least 8 countries, clinical decisions can be overruled or ignored by non-healthcare prison staff, but this was less likely to occur among countries where the Ministry of Health was involved.