Background
Zambian prisons
Zambian prisons health system strengthening project
Every prison shall have a PrHC whose membership will comprise ZCS officers and inmates. The committee will be overseen by one prisons staff preferably the HIV coordinator. For purposes of adequately receiving and addressing inmates’ health concerns, the PrHC shall have a subcommittee comprising inmates and overseen by a ZCS officer preferably the HIV Coordinator. The Prison facility management (e.g. Officer In-Charge with authority from the ZCS-HD) shall have the authority to appoint those serving on the prisons health committees, including inmates who shall be selected from those with health backgrounds and/or those considered reformed/well behaved. However, inmates to serve on this subcommittee should be those that have received some training on health issues e.g. Peer Educators, HIV Counsellors. It is important for PrHC members to know that PrHC work is voluntary. Involvement in the PrHC will be unpaid, but will involve capacity building and participation in decision making related to facility-level health issues and services. Specific Duties: • Act as a link between inmates and the health centre/prison administration on health matters • Work together with other inmates to identify health problems in prisons • Work together with Prison Administration to address identified health concerns in prisons • Jointly coordinate health activities in prisons according to ZCS-HD directives • Provide a platform for discussion of health issues between inmates representatives and Prison Administration • Ensure that all inmates participate in prisons health activities • Collate and routinely report on health service information to ZCS-HD and ZCS HQ. |
Methods
Study Design & Procedures
Study population | Activity | Inclusion criteriaa | Number of respondents |
---|---|---|---|
ZCS Headquarters | IDI | Employed by/seconded to ZCS | 7 |
MOH / MCDMCH / MHA Officials | IDI | Currently employed by MOH, MCDMCH or MHA Involved with Zambian prison health services | 3 |
NGO other community stakeholders | IDI | Current NGO or community member involved with prison health services | 2 |
Facility Officers in Charge | IDI | Current appointment as the officer in charge (or acting) in a Correctional facilityb | 3 female 4 male |
Appointed PrHC members | FGD | Appointed members of PrHC Able to provide informed consent | 8 FGDs (Totalling 21 Females 51 Males) |
Non-PrHC inmates | FGD | Inmate non-member of PrHC Able to provide informed consent | 8 FGDs (Totalling 23 Female 46 Males) |
Data management
Analysis
Challenges and limitations
Ethical considerations
Results
Contextual factors
The Officer-in-Charge is the owner of everything here. So if he does not want something to happen, then for sure it cannot happen. But he is supportive of this committee. That is why we have seen them do well. (F4, Female, Non Member).
It’s such a nice composition of men and women that are in this committee, in the sense that not only do we have officers, three quarters of the members, if not all, are what we might call ‘Cell Captains.’ In short, they are leaders and being leaders, it’s very easy to sensitize or disseminate to fellow in-mates where issues to do with health are concerned (F7, Male Member, 9).
PrHC outcomes
State domain – Impact on government actors
The officers here are involved [more] than [my last prison]. They really go out of their way to help us; I have used the clinic like four times. They are so involved. In [the other place] they would even push you away. (F5, Male, Non-Member 11).And the officers also are really leading by example. When the vaccines for elephantitis came they also [received it] in our presence, even the medicines for bilharzia they also drank. (F7, Male, Non-Member 12).
The formation of the PrHC has really brought change, even in our working culture, because [previously] we were just waiting for patients to come; we were not involving people on the ground […] but [because of] the PrHC our coordination has really improved. (F6, Female Officer-Health Worker).
Personally I have matured since this committee came in. All those things that I used to see as challenges I now see hope in them. This committee has helped me grow such that all the things I used to see as problems I now see hope in them. (F3, Male Officer, Member).
Over the past 4 months we made a decision that we improve drainage [in the bathroom]. Because we have had issues and this place used to flood. We requested through the PrHC and the Officer-in-Charge instructed the Department of Works and Supply here in prison that it should be done. (F3, Male Member).
We have done a bit good in garbage disposal. Serious measures were taken to be disposing our garbage [frequently] through the council. (F6, Male Officer, Member).
Without doubt the Officer-in-Charge of this prison has been important. We all know that if he wanted he could have been blocking all our decisions. The committee has scored a lot [and] the Officer-in-Charge has really contributed. (F3, Male Member).
I would say the officer-in-charge [has been] supportive; and without his support, there was not going to be any successes. (F8, Officer Member).
The formation of this health committee really started bringing change, [but] ever since Officer Faith (*name changed) left, not [so much]. Things started changing but now they have come to a standstill. (F2, Female Inmate Member 5).
Society domain - impact on inmates’ knowledge
I am proud of the knowledge that I got in this committee. I used to think that you cannot stay in the same place with the people who are sick with HIV/AIDS but now I have changed […] I have learnt a lot. (F4, Female Member 7).
The coming of this committee has taught us a lot such that we now know the symptoms of these illnesses. (F7, Male Non-Member).
Prior to being a PrHC member, if I saw, for instance, stagnant water, I always said: “Whoever is responsible for this job will do it.” But after becoming a PrHC member it actually made me realize that … If there is an outbreak it will affect me too. So in a nutshell, it has really brought a sense of responsibility [F5, Male Inmate Member 9).
I would say it’s unique in the sense that inmates have representation [on the PrHC] in each and every cell in the prison; so they have information on what is going on [and] who is sick and that actually is unique in its own way. (F1, Officer-in-Charge).
What I know is that, the way the committee works, the communication and making of the decisions, it is collective […] [Inmates] are heavily involved in the making of the decisions. (F7, Officer-in-Charge).
The PrHC has helped us positively, because prisoners make their own decisions. They talk to their own friends and try to counsel each other. (F2, Deputy Officer-in- Charge).
I have seen a dramatic change because [of] the cooperation that I am receiving from the inmates [...] We have seen a lot of illnesses reducing in this facility because of the inmates we are working with and the way they are relating with their friends. I never knew that an inmate would take care of their fellow inmates, people abandoned [even] by their relatives. (Facility 3, Male Officer, Member).
Society domain - impact on inmates’ service access and living conditions
One of the biggest successes has been the introduction of a TB register in the cells. In the past during TB screening in the morning, one of our fellow inmates would just walk in a cell and ask “How many have not gone for screening?,” and based on how many will raise their hands, you would leave out some. So the chances of having one person with TB hiding would be very high. But the introduction of the registers in these cells has made us as committee members register every person […] We don’t even need to stand and ask “How many have not gone for TB screening?,” because all you have to do is go to your register. (F6, Male Inmate Member).
The dissemination of information, we never used to work like this. But now we have a lot of peer educators and they are working hard in terms of sensitizing the inmates and even the work the inmates and the officers are doing is good. (F3, Male Inmate Member).
Improved Service / Environmental Conditions | F1-M | F2-F | F3-M | F4-F | F5-M | F7-M | F8-M | Total | |
---|---|---|---|---|---|---|---|---|---|
1 | PrHC support to prison clinic: counselling, health education, TB symptom screening | 1 | 1 | 1 | 1 | 4 | |||
2 | HIV counselling and accompanied referrals | 1 | 1 | 2 | |||||
3 | Adherence support for inmates with chronic conditions | 1 | 1 | 2 | |||||
4 | Prompted Officer in Charge to commit engaging Works Department to unblock drains in inmate bathrooms | 1 | 1 | ||||||
5 | Improved notification / upward reporting of health issues to Office in Charge | 1 | 1 | 1 | 1 | 4 | |||
6 | PrHC led ban on indoor smoking enforced by senior (Special Stage) inmates | 1 | 1 | ||||||
7 | Advocacy to ensure inmates’ receive timely follow-up visits to clinic | 1 | 1 | ||||||
8 | Prompted local council to restart rubbish collection improving general hygiene Improved notification / upward reporting of health issues to Officer in Charge | 1 | 1 | ||||||
9 | New health and safety measures for food storage and rubbish removal | 1 | 1 | ||||||
Total | 1 | 2 | 4 | 3 | 2 | 2 | 3 | 17 |
There are a lot of things. I will tell you that before this committee came, inmates used to suffer a lot because the people at the clinic used to take forever to see them. But when this committee came, it made things easier for the inmates as they received a lot of information on prevention issues. So they now know how to prevent themselves from these illnesses. (F4, Female Inmate Member 8).
This health committee, they should include more people to work. When they add more people, it may be easier […] There are a lot of us, [we need more than] two or three. (F6, Female Non-Member, 4).
State-society domain - impact on inmate-officer relationships
Yes, decision-making is really unique in the sense that when we are meeting, we don’t count to say: "this is an officer, this is a [such and such]," we all treat each other as members. Each suggestion or every observation that has been brought forth is discussed accordingly. And if there is a decision, it is supported by each and every member, thank you very much. (F7, Male Inmate Member 2).
Things have changed. At the time [the PrHC] just started, we were not writing reports like we are doing now. We never used to go deeper in the way we were doing things. Even the communication we had with the officers was not good as it is now. You know, […] we check on each other and if we see that the officers are relaxing we tell them, and also if they see that we are relaxing they tell us. Together we make sure that work is done in prison. So things have changed from when it started. There are a lot of follow ups. (F4, Female Inmate Member).
Here I can say I see that convicts and officers are working together. It is something good. Because it’s easy for convicts to relate to their [inmate] friends. They can know my [health] weaknesses. Now the problem is: How they can help me quickly [if I am sick]? So on my side, I think [the PrHC] has become a good thing for the prisoners to work together with officers [to be able to help quickly]. The work has become easy to finish our illnesses. (F7, Male Non-Member).
Let’s say the toilets are supposed to be cleaned. Now as an in-mate, where am I going to get the [cleaner] to put in the toilet? So I will tell the health committee inmate who is more superior than me and who is closer to the officer: “We need this [toilet cleaner] and maybe we also need gloves. Can you tell this officer?” So they will go and see the people, and if they have some, they will give us. (F5, Male Non-Member).
Mechanisms Catalysing PrHC outcomes
Productive state-society communication
The inmates and the officers, especially us the officers, sometimes we used to be shy to come out in the open because we are officers. But thank God, there are inmates who are helping officers to come out in the open freely so that they can know and help each other. (F4, Female Officer Member 4).
It is actually a good thing that [the PrHC] consists of inmates and officers because if it was only for inmates, it could have been difficult for us to meet just as inmates. We would be cited as people who would incite illegal activities. (F8, Male Inmate Member 4).
[The PrHC] is effective. It is highly responsive to any matter arising that is related to health. What I mean by being responsive is that, as we sit in the offices here, … We are now not worried that there will be a health issue that will arise that we won’t know about. We will now hear through the committee. (F8, Officer in Charge).
If I can call it as a bottom up approach to decision making because they are the ones on the ground to bring out issues and recommend courses of action which [I am] able to consider and approve. (F7, Officer in Charge)
Trust
Concerning decision making it’s not just an officer who influences [it], no. It’s actually the whole group [who] decides. It’s not something that comes from one person. It’s about group work and the majority always wins. We sit down and talk […] and the unique part is the way we’ve been working with us inmates and officers, that’s one unique part. (F1, Male Member 3).
With the formation and the existence of the prisons health committee we have also seen the relationship between the officers and the inmates being not as enemies, but as colleagues who can work together when it comes to health matters. We have also seen prison officers, even the Commissioner, address the inmates despite their rank. All this is because of the prisons health committee. [F8, Female Officer Member].
Before […] there was a phrase they used and it goes: “An inmate is a snake.” But now we are considered to be human beings and when you are sick, they will consider you to be a patient. You will receive all the patient’s human rights, thank you so much. (F8, Male Inmate Member 4).
Co-production
These successes have been possible because the committee members are able to work together and through the regular meetings. They are able to see their successes and failures together so they improve. (F4, Female Officer 2).