ORGANIZATIONAL MODELS OF PRISON HEALTH CONSIDERATIONS FOR BETTER GOVERNANCE Abstract There is currently a variety of models of prison health accountability across the WHO European Region. The WHO Regional Office for Europe recommends that leadership should come from health ministries if health equity between prisons and the outside community is to be achieved. Most importantly, a whole- of-government approach is required to improve the quality of health services in prisons. This policy brief describes the governance and organizational models for prison health adopted by three European countries – Finland, Portugal and England. Each of these has a different arrangement in place, either under the Ministry of Health or under the Ministry of Justice working in partnership with the Ministry of Health. Those that have undergone a change in governance model have done so at different moments and adopted a different approach to implementing the change. Each of the three countries is considered separately, then similarities and differences between them are highlighted. Finally, recommendations are given for countries considering making a transition in the governance model that will improve the health services provided and the health status of people in prison. Keywords PRISONS PRISONERS GLOBAL HEALTH PUBLIC HEALTH HEALTH SERVICES HEALTH POLICY HEALTH SERVICES ACCESSIBILITY RIGHT TO HEALTH HEALTH SERVICES ADMINISTRATION CLINICAL GOVERNANCE MODELS, ORGANIZATIONAL Document number: WHO/EURO:2020-1268-41018-55685 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Photos: ©WHO/Enf. Jorge Tavares. Contents Acknowledgements iv Abbreviations v 1. Background 1 2. Finland 2 2.1 General presentation of prison and health-care system 2 2.1.1 Main actors 2 2.1.2 Coordination between the main actors 2 2.1.3 Historical perspectives 4 2.2 Characteristics of prisons and people in prison 4 2.3 Delivery of care 5 2.3.1 Introduction 5 2.3.2 Availability 6 2.3.3 Range of services provided, including for specific health issues and specific groups 6 2.3.4 Continuity of care 6 2.3.5 Quality of care 7 2.3.6 Patients’ rights 7 2.3.7 Financial aspects 7 2.3.8 Health coverage in prison – costs 7 2.3.9 Health information 7 2.4. Evidence on the impact of changing the governance model 8 3. Portugal 9 3.1 General presentation of prison and health-care system 9 3.1.1 Main actors 9 3.1.2 Coordination between the main actors 9 3.1.3 Historical perspectives 9 3.2 Characteristics of prisons and people in prison 11 3.3 Delivery of care 12 3.3.1 Introduction 12 3.3.2 Availability 12 3.3.3 Range of services provided, including for specific health issues and specific groups 13 3.3.4 Continuity of care 14 3.3.5 Quality of care 15 3.3.6 Patients’ rights 15 3.3.7 Financial aspects 15 3.3.8 Health coverage in prison – costs 15 3.3.9 Health information 15 3.4 Evidence on the impact of changing the governance model 16 4. England 17 4.1 General presentation of prison and health-care system 17 4.1.1 Main actors 17 4.1.2 Coordination between the main actors 17 4.1.3 Historical perspectives 20 4.2 Characteristics of prisons and people in prison 22 4.3 Delivery of care 23 4.3.1 Introduction 23 4.3.2 Availability 23 4.3.3 Range of services provided, including for specific health issues and specific groups 24 4.3.4 Continuity of care 25 4.3.5 Quality of care 25 4.3.6 Patients’ rights 25 4.3.7 Financial aspects 26 4.3.8 Health coverage in prison – costs 26 4.3.9 Health information 26 4.4. Evidence of impact 26 5. Discussion 29 6. Recommendations 31 7. Conclusion 33 References 35 III Acknowledgements The development of this publication was coordinated by Filipa Alves da Costa, Consultant, WHO European Office for the Prevention and Control of Noncommunicable Diseases, under the guidance of Carina Ferreira-Borges, Programme Manager, Alcohol, Illicit Drugs and Prison Health, WHO Regional Office for Europe. The WHO Regional Office for Europe is very grateful for the important contributions received from Hanna Hemminki-Salin, Chief Physician of Outpatient Services, Health Care Services for Prisoners, Finland; Mafalda Vieira de Castro, Public Health Physician, Directorate-General of Prison and Reintegration Services, Portugal; Merja Mikkola, Development Manager, Finnish Institute for Health and Welfare, Finland; Rui Manuel Ramos Morgado, Coordinating Physician for the Directorate- General of Prison and Reintegration Services, Consultant Physician in Family and General Medicine, Portugal; and Sunita Stürup-Toft, Public Health England and United Kingdom Collaborating Centre for WHO Health In Prisons Programme, United Kingdom. We are also very thankful for the comments received from Ihor Perehinets, Technical Adviser, Division of Health Systems and Public Health, and Ogtay Gozalov, Tuberculosis Programme in the Division of Communicable Diseases, Health Security & Environment at WHO Europe. The document received important contributions in terms of structure, content and format from Sunita Stürup-Toft, Public Health England and UK Collaborating Centre for WHO Health In Prisons Programme, United Kingdom. We would also like to thank Nino Berdzuli, Director, Division of Country Health Programmes, and João Breda, Head, WHO European Office for the Prevention and Control of Noncommunicable Diseases, for their overall leadership and support for the development of this report. The publication was made possible by funding from the Government of Finland. IV Abbreviations ART antiretroviral therapy AVI Regional State Administrative Agency (Finland) CCGCS Centre of Competencies for the Management of Health Care(Portugal) DGRSP Directorate-General of Prison and Reintegration Services (Direção Geral de Reinserção e Serviços Prisionais) (Portugal) DHSC Department of Health and Social Care (United Kingdom) DSS Direction of Health Services (Portugal) GP general practitioner HBV hepatitis B virus HCV hepatitis C virus HMPPS Her Majesty’s Prison and Probation Service (United Kingdom) INSA National Health Institute Dr Ricardo Jorge (Instituto Nacional de Saúde Doutor Ricardo Jorge) (Portugal) LGBTQ lesbian, gay, bisexual, transgender and queer NCD noncommunicable disease NICE National Institute for Health and Care Excellence (United Kingdom) NHS National Health Service (United Kingdom) OST opioid substitution therapy P-NHS Portuguese National Health System PHE Public Health England SPMS Shared Services of the Ministry of Health (Serviços Partilhados do Ministério da Saúde) (Portugal) TB tuberculosis THL Finnish Institute for Health and Welfare (Terveyden ja hyvinvoinnin laitos) VTH Unit for Prisoners’ Health Services (Vankiterveydenhuollon yksikkö) (Finland) V 1. Background Since 2013, as set out in the policy brief Good governance for prison health in the 21st century, WHO and partners have recognized that states have a special, sovereign duty of care for people in prison (1).