Reform of Penitentiary Healthcare

An analysis of the state policy concept regarding the reform of the State Penitentiary Service of Ukraine (SPSU), as well as the reforms initiated in Ukraine in the field of public health, shows that there is no clear understanding at the political level that healthcare in correctional facilities is an integral part of public health and is one of the key issues affecting public health, especially when it concerns socially dangerous diseases.
The absence of a deep analysis of the problems existing in Ukraine’s penitentiary healthcare sector over a significant period (about 20 years) has not allowed for the initiation of any concrete measures to rectify the situation in the field of prisoner healthcare.
The structure and levels of morbidity and mortality have changed. Tuberculosis and HIV epidemics have led to a situation where the forces and resources of the healthcare service within the SPSU system are no longer capable of maintaining the effectiveness of their operations (prisons have become reservoirs of tuberculosis, including drug-resistant forms, HIV, hepatitis, and other socially dangerous diseases, as well as sources of their spread). The growth of preventable mortality demonstrates the structural inefficiency of the system.
The provision of medical assistance in the penitentiary system has largely become focused on treating already advanced forms of diseases instead of implementing large-scale health-promotion and preventive measures.
What is to be done? How can the system be led out of its deep crisis? Surely, it is necessary to simply keep pace with the times and carry out reforms.
The goal of reforming the healthcare service in Ukraine’s penal system is to ensure equal and fair access for all members of society to medical services, along with a high level of quality and timeliness. Every patient coming to any medical facility must understand what assistance they can receive, just as a doctor, in turn, must know exactly what assistance they are obliged to provide to the patient.

In recent years, several member states of the WHO European Region have transferred responsibility for healthcare in places of deprivation of liberty to their ministries of health. These include Norway, France, and the United Kingdom. Italy, some Swiss cantons, and two autonomous regions of Spain have carried out similar reforms. Currently, several other countries are considering such a reform or have already begun it: these are Kazakhstan, Kosovo, the Republic of Moldova, and Finland.
In all likelihood, this process will continue. Representatives of several states that have implemented or planned to implement this transfer of responsibility reported on the positive results of the reform at an international conference in London in 2004. Their unanimous conclusion was that the benefits [of the transfer] could be great. Assessments conducted indicate that the quality of care provided to prisoners has improved in all four countries. There is greater understanding and reflection in national health policies regarding the specific healthcare needs of prisoners. Staffing and the quality of personnel have improved, and ties with the community have been strengthened.
Individual member states of the European Region have additionally reported such benefits as improved resource and financial provision for addressing key issues of penitentiary healthcare, and the inclusion of prisoners in mainstream public health initiatives. The most recent factual data for the Region confirm that the performance indicators of penitentiary healthcare services can improve significantly after the transfer of responsibility to ministries of health. It is clear that transferring penitentiary healthcare under the jurisdiction of the Ministry of Health and, accordingly, integrating it into the national healthcare system will be a lengthy process, but there are every reason to believe that such a nationwide approach to healthcare in places of deprivation of liberty will have positive effects in the long term.
Our state is at a stage of profound socio-economic transformations. The period of reforming public healthcare in Ukraine is the best time for changes in state policy regarding the reform of the State Penitentiary Service of Ukraine.
It is urgently necessary to review the concept of state policy in the sphere of reforming the State Penitentiary Service of Ukraine, approved by the Decree of the President of Ukraine on 8 October 2012, taking into account the transfer of responsibility for healthcare in places of deprivation of liberty to the Ministry of Health.
At the level of the Ministry of Justice of Ukraine, a working group of experts should be created, which, taking into account global experience, can prepare a step-by-step reform plan. Considering global experience, the reform will be a lengthy process and may take no less than 10 years. (According to the Minister of Health on 24 July 2014, a Strategic Advisory Group on Health was created at the Ministry of Health, which will work on preparing a national strategy for building a new healthcare system in Ukraine for the period 2015–2025. It will include the best domestic and international specialists (over 100 applications were received for the competition). The final result of the group’s work should be a detailed step-by-step action plan for the implementation of the Concept and Strategy for building a new healthcare system.)
Thus, the Strategic Advisory Group on Health must necessarily include specialists in the field of penitentiary healthcare.
Problems and causes of the inefficiency of penitentiary healthcare operations:
1. Low quality of medical assistance
2. Problems with medication supply
3. Staffing crisis
4. High depreciation of capital assets
5. Low access to medical assistance in secondary and tertiary level hospitals
6. Medical personnel, dependent on the administration of the penal institution, find themselves involved in conflicts between the need to provide quality medical assistance and the administration’s efforts to maintain compliance with the regime of detention and punishment of prisoners.
An assessment of the human resource potential of medical units reveals a critical situation that has developed:
- There is no policy or strategy for the development of human resources, including issues of their financing;
- Deficit of qualified medical personnel (a number of institutions operate without doctors) and technical staff;
- Ageing of medical personnel (young people do not enter the system due to low wages and lack of professional growth, difficult working conditions, the mentality of the contingent served, regime requirements in institutions, etc.);
- Low level of knowledge of the regulatory legal acts of the Ministry of Health of Ukraine;
- Accreditation of facilities is carried out formally and does not stimulate the improvement of work quality;
- Allowances for work in risk zones are not paid in full;
- Necessary funding for the training of medical personnel is not allocated.
Some features of healthcare in prisons by levels of medical assistance and the possibility of transferring it under public healthcare:
If one compares the system of working with a patient at the primary level of medical assistance in rural areas (a rural outpatient clinic or a paramedic-midwife station) and the work in the medical unit of a penitentiary institution, we practically see the same patient pathway. And the problems in the organisation of medical assistance are practically the same, in particular the volume of clinical-biochemical and radiological examinations, consultations by narrow specialists, the number of the population served, etc. It should be noted that doctors in prison medical units (regardless of specialisation) have long been working on the principle of a ‘family doctor’. Thus, primary healthcare in the prison system is already formed and fully fits into the concept of reforming public healthcare.
The main role of medical assistance at the secondary and tertiary levels should be assigned to multi-profile hospitals for the provision of intensive care, primarily emergency care, as it is precisely their activity that the life and health of patients depend on. It is these hospitals that constitute about 90% of all inpatient facilities in developed countries of the world. But not every region in Ukraine has multi-profile and specialised penitentiary medical institutions to which a patient can be promptly referred. Therefore, emergency assistance in most regions is provided in the nearest public healthcare institutions (it is at this stage that conflicts most often arise between the need to provide quality medical assistance and the administration’s efforts to maintain compliance with the regime of detention and punishment of prisoners). Thus, this stage of providing medical assistance to patients from places of deprivation of liberty can be resolved without significant financial investments.
The hospitalisation of patients with chronic somatic and acute infectious diseases, or hospitalisation for the restoration of functions impaired as a result of disease or injury with the aim of preventing disability and conducting rehabilitation, is currently carried out only in penitentiary medical institutions. It is at this level that the low quality of medical assistance leads to numerous problems; in particular, untimely hospitalisation and the initiation of adequate treatment are quite often the cause of deaths and disability. Patients have to wait a long time for permission for planned hospitalisation in these institutions, and then a lot of time is spent on transporting (transferring) patients, during which they, as a rule, do not receive adequate treatment. A large percentage (up to 20%, depending on the hospital’s profile) of unjustified hospitalisations is also registered for reasons of both a medical and non-medical nature; that is, if one objectively examines the use of beds in these institutions, it should be determined that they are used extremely inefficiently. This stage of providing medical assistance is the most complex and economically costly.
Considering the above, a condition for carrying out the reform will be the separation of primary and secondary levels of care and the transfer of facilities that are under departmental subordination to the territorial level.
Thus, the structural reorganisation of Ukraine’s healthcare system through the creation of hospital districts that unite institutions of several rural districts or cities, depending on the density and nature of population settlement, taking into account transport communications, material-technical and human resource potential of inpatient facilities, their profile of activity, and the structure of medical services, must necessarily take into account the presence of criminal-executive system institutions in these districts.

This article was prepared within the framework of the project ‘Promoting the Improvement of Conditions of Detention and the Level of Protection of Human Rights for Special Groups of Prisoners’, which is implemented with the support of the Embassy of the Kingdom of the Netherlands in Ukraine.