Health and healthcare access among Zambia's female prisoners: a health systems analysis.

Stephanie M Topp,Chisela Chileshe,Clement N Moonga,George Magwende,Nkandu Luo,Jody S Heymann,Constance Mudenda,German Henostroza,Michael Kaingu

doi:10.1186/s12939-016-0449-y

Abstract

BackgroundResearch exploring the drivers of health outcomes of women who are in prison in low- and middle-income settings is largely absent. This study aimed to identify and examine the interaction between structural, organisational and relational factors influencing Zambian women prisoners’ health and healthcare access.MethodsWe conducted in-depth interviews of 23 female prisoners across four prisons, as well as 21 prison officers and health care workers. The prisoners were selected in a multi-stage sampling design with a purposive selection of prisons followed by a random sampling of cells and of female inmates within cells. Largely inductive thematic analysis was guided by the concepts of dynamic interaction and emergent behaviour, drawn from the theory of complex adaptive systems.ResultsWe identified compounding and generally negative effects on health and access to healthcare from three factors: i) systemic health resource shortfalls, ii) an implicit prioritization of male prisoners’ health needs, and iii) chronic and unchecked patterns of both officer- and inmate-led victimisation. Specifically, women’s access to health services was shaped by the interactions between lack of in-house clinics, privileged male prisoner access to limited transport options, and weak responsiveness by female officers to prisoner requests for healthcare. Further intensifying these interactions were prisoners’ differential wealth and access to family support, and appointments of senior ‘special stage’ prisoners which enabled chronic victimisation of less wealthy or less powerful individuals.ConclusionsThis systems-oriented analysis revealed how Zambian women’s prisoners’ health and access to healthcare is influenced by weak resourcing for prisoner health, administrative biases, and a prevailing organisational and inmate culture. Findings highlight the urgent need for investment in structural improvements in health service availability but also interventions to reform the organisational culture which shapes officers’ understanding and responsiveness to women prisoners’ health needs.

Highlights

Research exploring the drivers of health outcomes of women who are in prison in low- and middle-income settings is largely absent
Evidence remains thin in low-income settings, peer reviewed literature from high-income settings demonstrates that women prisoners experience higher rates of emotional, physical and sexual abuse compared with non-incarcerated women [2]
In sub-Saharan Africa, prisons research as a whole is lacking, and empirical research focussing on the experiences and issues of women prisoners is almost nonexistent [7]

Summary

Introduction

Research exploring the drivers of health outcomes of women who are in prison in low- and middle-income settings is largely absent. Marginalisation is due to a range of structural, relational and demographic factors compounded by weak advocacy for, or inclusion of women prisoners’ needs in domestic public policy debates [7, 8]. Despite their small absolute numbers, women prisoners represent the fastest growing incarcerated population globally and have seen a 22 % increase in sub-Saharan African prisons since 2000 [9, 10]. Growing concerns about HIV and TB epidemics in prison populations have resulted in several recent studies demonstrating high rates of infectious diseases in sub-Saharan African prisons [14,15,16,17], none of these report fully gender-disaggregated data making them less useful for understanding women prisoners’ disease burden or healthcare needs [18]

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