Developing countries face numerous challenges, with health care and services key among them, and it is often the most vulnerable – such as prison inmates – among an already disadvantaged population who suffer most and have the least access to preventive and curative care. As evidence of this, the landlocked south-central African nation of Zambia, which has the sixth-highest HIV prevalence in the world at 14.3 per cent, has rates of HIV in prisons as high as 33 per cent. Tuberculosis is also endemic, with Lusaka Central Prison having a rate of tuberculosis infection four-and-a-half times that of the surrounding district.
University of Melbourne PhD candidate Stephanie Topp has been working in Lusaka with the Centre for Infectious Disease Research in Zambia (CIDRZ) as a technical adviser and research associate, and has on-the-ground experience of supporting the Zambian Prisons Service to deliver services to this complex population.
“Contrary to popular perception, prison populations are not isolated from the general community, but are in fact highly mobile,” she says, “with people entering, transferring within, and exiting facilities constantly.” Of the nation’s 53 prisons, she says only 17 have access to basic health services. Overcrowding is a huge issue too. “Prisons are at 208 per cent capacity on average, and as bad as 700 per cent in some facilities. The Zambian Prison Service (ZPS) has only 35 health professionals for a system with 17,000 inmates.
“Worryingly, a 2010-11 study of Lusaka Central Prison by CIDRZ showed the rate of HIV infection increased between entry into the prison and exit”. She says factors affecting rate of TB and HIV infection include poor nutrition, stress and limited access to testing and treatment, which speed the progress of the disease, and thus further increase the risk of transmission. “The normalisation of risky behaviours such as interpersonal violence or unprotected sex is also a likely factor in relation to HIV infection.”
Ms Topp says that when prisoners – who have potentially contracted diseases during their incarceration – are released after serving their sentence, this risk of disease spread is transferred from the inmate population to the public at large. “Addressing health and health systems in the prison ‘petrie dish’ is thus critical to any broader attempt to address population health, in Zambia as in any other country,” she says.
Ms Topp has worked to improve health systems in Zambia since 2007 after researching the influences shaping HIV policy in Papua New Guinea as a Rhodes Scholar at the University of Oxford. She is completing her PhD at the University of Melbourne’s Nossal Institute for Global Health, and her thesis is a health systems analysis of primary care centres in Zambia. Her current work is as part of a CIDRZ team that is looking to strengthen the underlying health system in Zambian prisons.
“Currently, the Zambian Prisons Health Directorate lacks a dedicated budget and relies mostly on funds donated for HIV and AIDS interventions, which don’t have a strong focus on health planning and co-ordination. “Dependence on these types of funding makes it almost impossible to improve preventive or curative care in the long term. We needed to address root causes of weak health services in the prisons,” she says.
At the same time, funding for disease-specific activities like tuberculosis screening or safe sex campaigns are more likely to gain the attention of donors and media. Yet, with the extreme political sensitivities, for instance men having sex with men, which remains illegal in Zambia, such activities may be difficult, if not impossible to carry out. “In Zambia there are still many groups – both within government and non-government – unwilling to endorse simple interventions likes condom distribution in prisons. Although there are also many progressive individuals who continue to push the envelope. “Ultimately, our choice to focus our work on basic health infrastructure was driven by our recognition that in order to deliver these disease-specific interventions routinely – not as a one-off campaign – it was absolutely essential to have a functioning, evidence-based system in place. We recognised that without a strong health system in place, improved service delivery and better health outcomes in any area would be difficult to sustain. Through its European Union–funded Zambia Prisons Health Systems Strengthening Project (ZaPHSS), CIDRZ has been working to increase engagement between government ministries and develop systems for coordinated planning and decision-making. “Because the health systems in place to service prison inmates are so weak – we had to start from the top,” she says. “So far, the project has helped the ZPS and health ministries to publish a joint prisons health framework, to address the fact that Zambia’s prison health system has historically worked in isolation from the wider health service and struggled to meet the needs of inmates.”
In the prisons themselves, she says CIDRZ has introduced tuberculosis screening and trained inmates as peer educators who assisted with HIV and tuberculosis screening of 6,436 inmates in 2010-11. In January 2014, the ZPS agreed to the formation of facility-level health committees formed from prison officers and health professionals and with inmate sub-committees who will be trained to deliver preventative information and basic disease surveillance. Prisons Deputy Commissioner Lloyd Chilunkika has described ZaPHSS as helping the prisons service jump start long-needed improvements in prisons health, saying the health directorate had, up to now, been present but not highly functional due to structural and operational challenges.
And in an encouraging development the Ministries of Home Affairs, Health and Community Development will this year commit to collaboration on improved inmate health services. Though such achievements may not have the glamour of traditional health campaigns, Ms Topp says systems-based approaches to health are essential for making health campaigns sustainable. “In the end, the success of vaccine campaigns and treatments activities are rarely sustainable and only partially successful without strong health systems, and our driving rationale is to have a long term-impact on the health services available to this incredibly vulnerable population.”
By Stuart Winthrop