Prisoner Health in Zambia: what does a systems-thinking approach reveal?

By Stephanie Topp (James Cook University)

In Zambia, as in sub-Saharan Africa, the prison population is predominantly male and experiences high rates of disease including HIV and tuberculosis.  Notwithstanding growing recognition of this problem, the issue of prison health has historically been given low priority by both Zambian and international policy makers. Prisoners are often stigmatized and the public is largely ambivalent about prisoner wellbeing. Yet the high degree of mobility between prison and the community, via released prisoners and oscillating prison officers and visitors, means that diseases transmitted and acquired in prison are both a human rights concern and public health issue.

As with public health anywhere, effective management of health in prison requires an understanding of clinical, behavioural, social and structural determinants (see for example another recently published study on structural determinants of prison health system performance in Zambia found here).  While the total number of prisoners in Zambia remain modest, Zambian prisoners experience some of the worst rates of overcrowding in the world.  Structural factors such as these are increasingly recognized as drivers of poor prisoner health outcomes.  At the same time, though, almost no research has been conducted to understand the way the (poor) environmental conditions intersect with prison-specific social and cultural dynamics to affect health outcomes.

In this recently published study in Health Policy and Planning, which formed part of the Zambian Prisons Health System Strengthening (ZaPHSS) project, a partnership between the Centre for Infectious Disease Research in Zambia (CIDRZ) and the Zambian Prisons Service (ZPS), we aimed to better understand these dynamics.

What did we find?

Due in part to differential wealth of inmates and their support networks on entering prison, and in part to the accumulation of authority and material wealth within prison, we found enormous inequity in the standard of living among prisoners at each site – including substantial variations in sleeping conditions, access to vegetables, access to soap, and ability to reach onsite or offsite health services.

Importantly, these inequities grew and were strengthened by the failure of the Zambian prison system to provide basic necessities (including food rations, soap and appropriate infrastructure).  The resulting inequities placed some individuals (notably those who were poorer and younger) at great risk of coercion (including for sex) by ‘wealthier’ and more powerful prisoners and officers.  These same individuals were generally less capable of taking measures to protect their health or access health services in a timely manner.

Approaching the issue of prisons health using this “systems-oriented” approach provides a more comprehensive picture of the way resource shortages and human relationships within Zambian prisons interact and affect prison health. While not a panacea, the study highlights some strategic entry-points for important upstream and downstream reforms including urgent improvement in the availability of sufficient and good quality rations; human resources for health and more comprehensive pre-service health education for prison officers.

Stephanie is a Senior Lecturer in Global and Development at James Cook University, QLD, Australia and a Health Systems Advisor for the ZaPHSS Project run by the Centre for Infectious Disease Research in Zambia. She is a member of the Power in Health Systems & Emerging Voices for Global Health Thematic Working Groups. You can follow her on Twitter: @globalstopp

Image credit: Jobs For Felons Hub


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