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Short Communication

Prison health as public health in Afghanistan? A policy analysis of the on-going reform process M. Michael* Alameda Santos 2491/72, 01419-002 Sa˜o Paulo, Brazil

article info Article history: Received 13 February 2013 Received in revised form 3 January 2014

and decision-makers of all relevant institutions. The author then participated in three meetings among key stakeholders focussing on the prison health service (PHS) reform during a follow-up visit to Kabul between 12 and 20 December 2012.

Accepted 14 January 2014 Available online xxx

Prison health service reforms

Introduction Our knowledge about prisoners’ health in developing countries is patchy. Even in affluent societies the state of prisoners’ health leaves a lot to be desired.1,2 Significant progress in health care provision has been made in a small number of states or regions that entrust, instead of the detaining authority, the health authority with providing health care for prisoners. The Swiss canton of Geneva was a pioneer in making prison health completely independent from the prison administration in a process that started in the mid1980s.3 Norway, France, England, Wales and parts of Australia are recent examples that are best documented.4e7 Overlooked so far is the recent very similar experience in one of the world’s poorest and most war-affected countries: Afghanistan. This article describes the progress reform has made and the challenges it is facing in that particular context. The article is the result of two visits to Afghanistan: an external evaluation commissioned by the European Union (EU) was conducted between 13 and 25 October 2012; the methodology consisted of a literature and document study, three prison visits and interviews (n ¼ 49) with representatives

Health problems in prison reflect, but magnify, problems present in communities; prisoners tend to have poorer health as a result of personal circumstances, lifestyle or environment.1,8 Prisons present also an unhealthy environment;9 poor conditions of detention may exacerbate health decline, disease transmission (tuberculosis10 and HIV/AIDS,11 among others), mental illness12 and substance abuse.13 Owing to the constant and intimate links with the community, prison health is public health.9 General concerns about the lack of quality of health care for prisoners (largely related to problems with recruitment of quality health staff and threats to their professional role14) have induced the above-mentioned countries into transferring PHS from the detaining authority to the Ministry of Health. Through the integration of prison and public health, prisoners have been recognized as temporarily incarcerated citizens. Other results of such reforms have been encouraging:1 resources for prison health have substantially increased15 and quality of staffing has improved; PHS has also gained through linking up with public health policies. Acceptable ethical standards and quality of care are easier to achieve if PHS are entirely independent of prison administrations;14 most importantly, opening PHS to public scrutiny is the most effective way of ensuring accountability and maintenance of standards.16

* Tel.: þ55 11 30 64 35 20, þ963 937 804 029. E-mail address: [email protected]. 0033-3506/$ e see front matter ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2014.01.007

Please cite this article in press as: Michael M, Prison health as public health in Afghanistan? A policy analysis of the on-going reform process, Public Health (2014), http://dx.doi.org/10.1016/j.puhe.2014.01.007

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The reform in Afghanistan Afghanistan has been a country at war for more than three decades; efforts made at state building have not matched expectations so far.17 Public health service provision has made significant progress in the past decade, in the form of donor-funded contracting-out of health services to NonGovernmental Organizations (NGOs). Uptake of public health services, however, has been slower than expected;18 the people’s preference still lies with the unregulated private sector. Tertiary care in Afghanistan is rudimentary; patients who can afford it seek even simple hospital care abroad. The Ministry of Public Health (MoPH), considered one of the best functioning public institutions, is fragmented however, and largely donor-dependent. Prison health in Afghanistan has to be understood and tackled as part of a very imperfect judiciary and penitential system.19 Afghanistan’s prisoner population of currently about 25,000 is also increasing rapidly, at an annual rate of roughly 20%. Around 750 among them are women, many raising their children in prison. Close to 1000 juveniles are detained in the Juvenile Rehabilitation Centres of the Ministry of Justice (MoJ). The General Directorate for Prisons and Detention Centers (GDPDC) was recently transferred from the MoJ to the Ministry of Interior (MoI), which has its own security apparatus. Prisoners’ living conditions can be unhealthy, which is often linked to overcrowding in Afghan prisons. Mental health problems and drug addiction were identified as widespread,20 as well as communicable diseases ranging from scabies to tuberculosis. PHS have been officially integrated in the 2010 version of the Basic Package of Health Services (BPHS) of the MoPH. Spread over a span of three-and-a-half years since 2009, PHS were and are still being added by NGOs as part of their provincial public health service provision in the majority of provincial prisons (well over 20 so far and eventually 30), with astonishingly few hitches despite the ‘clash of cultures’ between two very different institutions (NGOs/MoPH vs GDPDC/ MoI). Experience shows that the PHS reform in Afghanistan is able to make similar gains as observed in the other countries that have adopted it regarding quality of care, access to resources and professional independence, for instance. Most importantly, prison health, hitherto ignored and neglected, has come into the open in Afghanistan, which has been cited as one of the major accomplishments of such reforms.4,15 The reform still has to be considered as a work in progress, though: whilst the National Tuberculosis Programme is sufficiently integrated in PHS, not all essential elements of Harm Reduction and HIV/AIDS prevention are accepted in prisons yet and neither of these two programmes is integrated in PHS. Also, mental health services so vital for PHS are still deficient in Afghanistan in general. Contrasting with this relative success story in all medium and small prisons are PHS gaps for the Afghanistan’s biggest prison in the provinces of Herat, Kandahar and Kabul.a Owing to internal institutional constraints, USAID e which is the a

Among which the notorious Pul-i-Charkhi prison in Kabul, which alone houses close to 7000 male prisoners.

official donor to the MoPH for public health service provision in these provincesb e is unable to fund the PHS component of the BPHS (which also represents in these provinces a disproportionate part of the budget). Whilst for the prison in Kandahar the gap has always been filled through one or the other donor and implementer,c the responsibility for PHS in the prisons in Herat and Kabul is neither here nor there. This has been highly unfair to all parties concerned: to the prisoners deprived of adequate services and to the variety of actors (MoPH, MoI and NGOs) trying to fill gaps without proper means and structure. The remaining yearly budget shortfall of roughly USD$1 million for the three ‘gap provinces’ not only robs almost half of Afghanistan’s prisoners of their entitlement, but ended up threatening the PHS reform as a whole.

The policy process and its outlook At policy level, the decision for and design of the PHS reform in 2008 proceeded remarkably swiftly, probably owing to the fact that initial key decisions were taken by individuals rather than by institutions (although the process of policy formulation and PHS package design included all major stakeholders). The reform process as a whole is currently jeopardized owing to the significant funding gap for the three provinces mentioned and to the lack of a Memorandum of Understanding between the MoPH and the MoId regarding the respective rights and responsibilities of PHS provision. A rough stakeholder analysis according to their respective interest and power shows, for instance, that among the most powerful stakeholders the donors show possibly more interest than the GDPDC itself.e Similarly in England, where the Home Office (the government department that oversees the criminal justice system) was reluctant to give up control, the prison service consistently resisted incorporation into the NHS.2 Even among Afghanistan’s three major health donors (among which the EU had always been particularly supportive), PHS had not been discussed at high level in recent years, before the present evaluation. The MoPH is a fragmented institution, which reflects on its attitude towards the PHS reform: although the Minister herself has professed her support, other key decision makers would rather aim at devolution of PHS to the MoI. Other interested parties e mainly international organizations e have relatively little power. A new element since 2008 is considerable support e b

The other two main donors are the World Bank and the European Union. c At present, the International Committee of the Red Cross (ICRC). d The Memorandum signed by the MoJ and the MoH has become obsolete with the recent shift of the GDPDC to the MoI (apart from the MoJ’s Juvenile Rehabilitation Centres for which it is still valid). e Care for prison authority staff has always been high on the agenda of the GDPDC. The GDPDC since the shift to the MoI has become one of its seven forces (such as border police and others). It has still not all the privileges the others have, though (such as automatic access to the police hospital in Kabul). Whereas no specific provisions are taken, guards and other prison staff and even their family members are in practice always included in PHS provision at provincial level.

Please cite this article in press as: Michael M, Prison health as public health in Afghanistan? A policy analysis of the on-going reform process, Public Health (2014), http://dx.doi.org/10.1016/j.puhe.2014.01.007

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although not matched by power e of the PHS reform at provincial level. Where implemented, prison directors e although expectations still exceed PHS resources e are reportedly happy with the improvements PHS have brought, which is evidenced by a number of ‘certificates for good performance’ extended by prison directors to the respective health service NGO (this support of the provincial prison directors is all the more remarkable because in none of the other quoted countries the impetus for change came primarily from the prison administrations but from public health professionals who expressed concerns about the quality of prison health4). Also, at local level the perception prevails that prisoners should be treated humanelyf and both local authorities and civil society have been mobilized to support PHS (mechanism completely lacking in the metropolitan context in Kabul), of which a number of local Prison Health Committees are an expression. PHS tends not to be high on the agenda of State Institutions, and not only in Afghanistan. After the initial and successful policy formulation and roll-out, the further implementation process suffered from relative neglect at the level of policy-makers and from their rapid turnover, with the result that by mid-2012 the reform threatened to go the way of similar planned PHS reforms in Italy and Spain, for instance e that is, nowhere.21,22 Policy implementation, in Gill Walt’s analysis, cannot be seen as part of a linear or sequential policy process, in which political dialogue takes place at the policy formulation stage (as it did in Afghanistan in 2008), and implementation is undertaken by administrators or managers, Rather, she reminds us that policy implementation is a complex, interactive process demanding, among others, anticipation of objections by key stakeholders and sufficient attention to financial aspects of the policy.23 Following Walt’s conceptual framework of health policy making, the observation can be made that whilst much attention had been given to the content of the reform (PHS Strategy and Package), aspects of power (in this case, of a donor to withhold funds) were underestimated and in the process, the lack of progress in key provinces was tolerated for too long, to the point of jeopardizing the reform as a whole. In the last quarter of 2012, however, as a result of placing PHS once more on the agenda, a considerable shift in the attitude of key stakeholders has taken place, which raises hope that the reform can be fully implemented after all. The recent series of meetings concluded with a consensus among key decision-makers of the MoPH and the GDPDC/MoI that the PHS reform should be completed, with special focus on filling the gaps in the three provinces where Afghanistan’s biggest prisons are located. Owing to the lack of alternative funding and implementing mechanisms (e.g. PHS implementation by the MoPH with funds allocated from the Ministry of Finance, which was tried and rejected), the only viable alternative therefore to fund PHS provision in these three provinces other than through the standard BPHS funding by the respective donor in charge of the province (USAID in this case), is that the MoPH taps into the pool fund provided by the other two donors, the European Union and the World Bank. The so-called f

As opposed to another attitude also observed in Afghanistan: that prisoners should be punished and rather deprived of rights.

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System Enhancement for Health Action Transition (SEHAT) fund will be made available to the MoPH for five years: 2013e2018.g Within the agreed policy framework, the MoPH can allocate SEHAT funds at its discretion. The allocation is currently under way; the PHS Department, like many others, has already submitted its budget for this specific sub-sector. The decision for allocation lies therefore now entirely with the MoPH (considering that PHS is officially a part of the BPHS), which of course faces the huge dilemma of too many and conflicting priorities. It can be argued that PHS deserves to be treated with particular attention as it targets one of the most vulnerable populations in the country whose health has repercussions on the population as a whole; and also because it constitutes an inter-sectoral service affecting the functioning of another Ministry (the general expectation is that the GDPDC should return within about five years to its rightful place, the MoJ, which is notoriously less well funded than the MoI). The implementation gaps described, however, should not distract totally from the achievements made so far in the majority of provincial prisons. In spite of limited expectations some months ago to complete the PHS reform, there is at present hope that all prisoners in Afghanistan as a very vulnerable group e and with no other choice than to rely on PHS e can benefit from lasting health services at least equivalent to the public health services offered to the rest of the Afghan population.

Author statements Ethical approval Not required.

Funding European Union (Grant EuropeAid/131612/C/SER/AF to EPOS, the EU’s implementing consulting firm).

Competing interests None declared.

references

1. Fazel S, Baillargeon J. The health of prisoners. Lancet 2011;377:956e65. 2. Smith R. Prisoners: an end to second class health care? Br Med J 1999;318:9543. 3. Elger BS. Prison medicine, public health policy and ethics: the Geneva experience. Swiss Med Wkly 2011;141:w13273. 4. Hayton P, Boyington J. Prisons and health reforms in England and Wales. Am J Public Health 2006;96(10):1730e3. g

The total for this period amounts to roughly USD$350 million (including a contribution of USD$30 million by the Afghan government), of which USD$300 million are destined for health service delivery.

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5. Iversen JH. Norwegian Directorate of Health Prison. Health reforms in Norway e the “Import Model”. Available at: www.ndphs.org/? download,3613,11.35þJonþHilmarþIversen.ppt; November 24, 2009 (accessed 31 January 2013). 6. Cour des Comptes, Paris. Le service public pe´nitentiaire: “pre´venir la re´cidive, ge´rer la vie carce´rale”. Available at: http://www. ccomptes.fr/Publications/Publications/Le-service-publicpenitentiaire; July 20, 2010 (accessed 31 January 2013). 7. Levy M. Prisoner health care provision: reflections from Australia. Int J Prison Health 2005;1(1):65e73. 8. Watson R, Stimpson A, Hostick T. Prison health care: a review of the literature. Int J Nurs Stud 2004;41:119e28. 9. World Health Organisation. In: Møller Lars, Sto¨ver Heino, Ju¨rgens Ralf, Gatherer Alex, Nikogosian Haik, editors. Health in prisons. A WHO guide to the essentials in prison health. Copenhagen, Denmark: WHO Regional Office for Europe; 2007. 10. Coninx R, Maher D, Reyes H, Grzemska M. Tuberculosis in prisons in countries with high prevalence. Br Med J 2000;320:440e2. 11. Weinbaum CM, Sabin KM, Santibanez SS. Hepatitis B, hepatitis C, and HIV in correctional populations: a review of epidemiology and prevention. AIDS 2005;19(Suppl. 3):S41e6. 12. Kimmet E, Rickford D. Neglecting the mental health of prisoners. Int J Prison Health 2009;5(3):166e70. 13. Fazel S, Bains P, Doll H. Substance abuse and dependence in prisoners: a systematic review. Addiction 2006;101:181e91. 14. Pont J, Sto¨ver H, Wolff H. Dual loyalty in prison health care. Am J Public Health 2012;102(3):475e80. 15. Department of Health. Prison health and public health: the integration of prison health services. Report from a conference organised by the Department of Health and the International Centre

16. 17.

18.

19.

20.

21.

22.

23.

for Prison Studies London. International Centre for Prison Studies. King’s College London e School of Law; 2 April 2004. Anon. Health care for prisoners: implications of “Kalk’s refusal”. Lancet 1991;337:647e8. Giustozzi A. Development Studies Institute, Crisis States Research Centre, LSE London. Afghanistan: transition without end e an analytical narrative on state-making. Working paper 40. Available at: http://eprints.lse.ac.uk/22938/1/wp40.2.pdf; November 2008 (accessed 31 January 2013). Michael M, Pavignani E, Hill PS. Too good to be true? An assessment of health system progress in Afghanistan, 2002e2012. Med Confl Surviv 2013;29(4):322e45. Washington Post. Are Afghan prisons locked in failure? Article by Marisa L. Porges. Available at: www.afghanistannewscenter. com/news/2011/october/oct12011.html#7; October 1, 2011 (accessed 31 January 2013). UNODC. Drug use survey 2010 Sarpoza prison, Kandahar, Afghanistan. Assessment of drug use levels and associated high risk behaviours amongst the prison population of Sarpoza Prison, Kandahar. Available at: http://www.unodc.org/documents/ afghanistan/Prison_Reform/SPDUS_Full_Report_130710_new_ cover.pdf; June 2010 (accessed 31 January 2013). Perrone M. Il Sole 24 Ore-Sanita`. Salute in carcere, riforma in “alto mare”. Available at: www.ristretti.it/commenti/2009/giugno/ pdf10/medicina_penitenziaria.pdf; 16e22 giugno 2009. Published July 16e22 (accessed 31 January 2013). Sociedad Espan˜ola de Sanidad Penitenciaria. Integracio´n de la sanidad penitenciaria: un reto que todos debemos asumir. Rev Esp Sanid Penit 2011;13(2):67e8. Walt G. Health policy. An in introduction to process and power. London: Zed Books Ltd; 1994: p. 177.

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Prison health as public health in Afghanistan? A policy analysis of the on-going reform process.

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