LEAVING NO ONE BEHIND IN PRISON HEALTH The Helsinki Conclusions Leaving no one behind in prison health The Helsinki Conclusions 24 © World Health Organization 2020 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted 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 the World Health Organization 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 the World Health Organization 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 the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). Document number: WHO/EURO:2020-742-40477-54346 L E A V I N G NO ONE BEHIND IN PRISON HEALTH The Helsinki Conclusions Leaving no one behind in prison health The Helsinki Conclusions 243Leaving no one behind in prison health The Helsinki Conclusions CONTENTS PREAMBLE Contribution of prison health to the overarching goal of “leaving no one behind” A public health approach to prison health Governance of prison health Equal standards for prison and community health care Importance of continuity of care between prison and community health Centrality of evidence for improving policy and practice Conclusions I. II. III. IV. V. VI. VII. 5 6 8 10 12 14 16 19 Leaving no one behind in prison health The Helsinki Conclusions 244 PREAMBLE The 6th Prison Health Conference was held on 26–27 March 2019 in Helsinki, Finland;1 it was co-hosted by the World Health Organization (WHO) Regional Office for Europe, Public Health England and the Government of Finland. The focus of debate at the conference was the concept of the interface between the health and justice systems, which must be seen through the prism of human rights and the principles established under the Mandela Rules and the Bangkok Rules. The conference also underscored the principle that efforts to improve public health and reduce health inequalities should be inclusive of prisons. It focused on the importance of prisons as a setting where there may be a negative impact on health resulting from incarceration and where the prevalence of some risk factors and health conditions is higher than in the community. It addressed the issue that the health care delivered to people in detention must be recognized as part of a pathway to and from community health services. It concluded that prison health is an important dimension in countries’ efforts to meet the aim of “leaving no one behind”, as part of their goals to realize universal health coverage and to achieve the United Nations Sustainable Development Goals. The relevance of cross-sector working between the Ministries of Justice and/or the Interior and the Ministry of Health, to promote good practice in prison health, was highlighted throughout the conference. The following are the salient conclusions reached during the 6th Prison Health Conference in Helsinki. 1 6th Prison Health Conference. Prison health systems: the interface with wider national health systems. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/__data/assets/pdf_file/0006/405870/Report-HIPP-6th-Conference-March-2019-Final- to-publish.pdf ). Leaving no one behind in prison health The Helsinki Conclusions 245Leaving no one behind in prison health The Helsinki Conclusions I. CONTRIBUTION OF PRISON HEALTH TO THE OVERARCHING GOAL OF “LEAVING NO ONE BEHIND” Leaving no one behind in prison health The Helsinki Conclusions 246 I. Contribution of prison health to the overarching goal of “Leaving no one behind” The fundamental health needs of people in detention, including juveniles and migrants, as well as people subject to pre-trial detention, are not always adequately met. There is a higher level of health and social care needs among people in detention, which arise from multiple complex needs prior to incarceration, as well as from issues related to equity, social cohesion and inclusiveness. The values underpinning a human rights-based approach to ensuring healthy lives underscore the right to the highest attainable standard of health as enshrined in the Constitution of the World Health Organization. The aim of Sustainable Development Goal 3, “Ensure healthy lives and promote well- being for all at all ages”, is to improve health among vulnerable populations and reduce inequities. This drive towards “leaving no one behind” focuses on equitable access and reaching those experiencing serious inequities in access to health and related social services compared with the rest of the population. This encompasses people in prisons. To achieve Sustainable Development Goal Target 3.8 – universal health coverage for all by 2030 – at least 1 billion more people will need to have access to essential health services in each five-year period between 2015 and 2030. In order to ensure that universal health coverage reaches the poorest, the most marginalized, women, children, and people with disabilities, as well as people in prison, efforts will have to be made to drive equitable access in these groups and to ensure that coverage of services reaches those most in need. European societies must still overcome important inequities in health and in access to health care to ensure that no one is left behind. This is critical for complying with the Global Sustainable Development Agenda and Goals approved by the United Nations General Assembly. It is therefore imperative to address the health needs of vulnerable groups, including people in prison, for whom access to health and related social services is often inadequate. Leaving no one behind in prison health The Helsinki Conclusions 247Leaving no one behind in prison health The Helsinki Conclusions II. A PUBLIC HEALTH APPROACH TO PRISON HEALTH Leaving no one behind in prison health The Helsinki Conclusions 248 A public health approach is necessary to align strategies, policy options and interventions for improving health outcomes among people in prison. The Moscow Declaration 2003 (“Prison health as part of public health”) and the Lisbon Conclusions 2018 (“Prison health in all policies”) point in this direction. Prison health programmes should therefore: (a) address specific health needs that require public health interventions; (b) address general health needs that require care in regular health systems; and (c) provide support and preparation for release after a period of imprisonment, including continuity of care. The following principles may be taken as the basis for a policy framework to define public health strategies for prison health: ■ reduce, and eventually end, disparities in health status and in the availability of and access to health services for people in prison compared to people in the community; ■ ensure the health and human rights of people in prison, limiting discrimination and stigmatization and removing impediments in access to health promotion and preventive and curative interventions; ■ promote the professional autonomy and independence of health care services in prisons and health professionals in line with the fundamental provisions of medical ethics; and ■ minimize the negative impact of incarceration on health outcomes by considering health risks specific to the prison setting. A public health approach to prison health therefore implies: ■ focusing on the health risks and needs of a defined population; ■ not being constrained by organizational or professional boundaries; ■ generating long-term as well as short-term solutions; ■ basing decision-making on data and intelligence; ■ rooting responses to tackle problems in evidence of effectiveness; and ■ orienting action with and for the communities. II. A public health approach to prison health Leaving no one behind in prison health The Helsinki Conclusions 249Leaving no one behind in prison health The Helsinki Conclusions III. GOVERNANCE OF PRISON HEALTH Leaving no one behind in prison health The Helsinki Conclusions 2410 All of the above requires a coordinated effort on the part of the criminal justice sector and of the health sector at national and/or subnational level. A paradigm shift is also required, from punishment and exclusion to a modern, multidimensional approach of inclusion that promotes rights-based health and social well-being, along the lines of the recommendations contained in the WHO Regional Office for Europe’s 2013 policy brief Good governance for prison health in the 21st century. The Ministry of Health and/or the national health system are the most appropriate entities to organize and deliver prison health as recommended by the revised Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules) and the United Nations Bangkok Rules. Nevertheless, priority attention should be given to encouraging and enabling effective intersectoral cooperation across health and justice to promote, ensure and improve adequate health care for people who experience incarceration and to promote access, continuity and quality of care within prisons and in the community. In this regard, the 6th Prison Health Conference in Helsinki highlighted the relevance of the following aspects: ■ there should be universal principles of governance, such as access to high- quality essential health care services and continuity of care, human rights, and the need for clinical independence of health care staff; ■ it should be understood that there are no “universal blueprints”, or unique structural mechanisms, to determine how to manage and deliver prison health care; ■ transfer of responsibilities between the justice and health sectors should encompass detailed preparation and planning, a high degree of multi- stakeholder collaboration, and good governance to ensure good prison health; and ■ prison health services must be person-centred and person-informed to meet the needs of justice-involved individuals. Countries should embrace a health systems approach, where prisons are not separated from the continuity-of-care pathway but integrated with community health services. Moreover, it is essential that the independence of health professionals from punitive functions is upheld. III. Governance of prison health Leaving no one behind in prison health The Helsinki Conclusions 2411Leaving no one behind in prison health The Helsinki Conclusions IV. EQUAL STANDARDS FOR PRISON AND COMMUNITY HEALTH CARE Leaving no one behind in prison health The Helsinki Conclusions 2412 It is important to highlight that additional efforts will be required in health care for people in detention in order to achieve the same outcomes as those enjoyed by people in the outside community. In addition, there is a human rights dimension in boosting national efforts in prison health. This is closely linked to the issue of equity both in terms of the health status of a vulnerable group and in terms of its access to health and related social services. Equity is a human rights issue. The progressive realization of the right to health involves efforts to improve health across all populations and to reduce inequities in the enjoyment of health. As the Nelson Mandela Rules state, international law recognizes the right of everyone, including people deprived of their liberty, to the enjoyment of the highest attainable standard of physical and mental health. However, in practice, many people in detention receive health care of a far inferior standard to that available in the outside community, if they receive treatment at all. People in detention with existing health care conditions may have their health needs ignored or neglected, and others may develop health problems while in prison because of the poor living conditions prevalent in many prison settings. The time has come to address the key issues associated with dovetailing prison health systems and national health systems to ensure adequate access to high-quality health care for people who experience incarceration and to promote continuity and quality of care. The conclusions of the 5th Prison Health Conference, held in Lisbon, Portugal, in 2017, highlighted that treatment and prevention programmes restricted to prison settings are unlikely to bring sustained benefits to people experiencing imprisonment. This underscores the need to improve the links between public health interventions in prison and in the community in order to improve continuity of care and achieve better health outcomes. The importance of the principle of equivalence – that people in detention are entitled to the same standard of health care as members of the public, without discrimination – is widely recognized, in the Nelson Mandela Rules and elsewhere. Furthermore, in increasingly complex health care settings, the principle of equivalence cannot be achieved so long as isolated or fragmentary prison health systems exist in parallel with wider national health systems, inadequately connected to and coordinated with them. IV. Equal standards for prison and community health care Leaving no one behind in prison health The Helsinki Conclusions 2413Leaving no one behind in prison health The Helsinki Conclusions V. IMPORTANCE OF CONTINUITY OF CARE BETWEEN PRISON AND COMMUNITY HEALTH Leaving no one behind in prison health The Helsinki Conclusions 2414 V. Importance of continuity of care between prison and community health Imprisonment generally renders individuals more vulnerable to health risks and exposes them to potential hazards and greater stresses arising from seclusion; such dangers can be compounded by poorly planned release from custody and reinsertion into former high-risk environments. For this reason, the principle of continuity of care should be keyed into the equation of adequate health care for people in detention. Continuity of care between prisons and the community requires that close structural relations are established between health and social services in prison and in the community. This is especially so because people in prison form a dynamic population that continually moves back and forth between states of freedom and incarceration. The continuum of care in the definition of successful universal health coverage – from promotion to palliation – places emphasis on the need for health services to prevent and relieve suffering across all disease groups and all age groups in an equitable manner. This should be applicable to people in detention. Prison can be a critical setting in a person’s life course in which unmet health needs can be identified and addressed. However, for health improvements achieved in prison to be maintained over the life course, continuity of care between prison and community health systems is vital. Leaving no one behind in prison health The Helsinki Conclusions 2415Leaving no one behind in prison health The Helsinki Conclusions VI. CENTRALITY OF EVIDENCE FOR IMPROVING POLICY AND PRACTICE Leaving no one behind in prison health The Helsinki Conclusions 2416 VI. Centrality of evidence for improving policy and practice Advocacy efforts, policy formulation and continuous improvement of practice in prison health require sound evidence on the effectiveness of interventions, governance arrangements and health systems performance. It is also of paramount importance to keep boosting efforts to improve monitoring and evaluation of the health status of people in detention and the health care provided to them. In this regard, it is critical to sustain efforts to improve surveillance, to create prison health data sets at national or subnational level, to provide research that can inform decision- making, to conduct systematic evaluations, and to document best practices. Leaving no one behind in prison health The Helsinki Conclusions 2417Leaving no one behind in prison health The Helsinki Conclusions Leaving no one behind in prison health The Helsinki Conclusions 2418 Based on the above considerations, the 6th Prison Health Conference in Helsinki reached the following 10 conclusions. 1. The organization and practice of countries’ prison health programmes and services should adhere to international standards of human rights and follow the principles established under the Mandela Rules and the Bangkok Rules. 2. Prison health is an important dimension in countries’ efforts to “leave no one behind”, as part of the attainment of the goals to realize universal health coverage and to achieve the United Nations Sustainable Development Goals. For this reason, efforts to improve public health and reduce health inequalities should be inclusive of prisons. 3. A public health approach is necessary to align strategies, policy options and interventions intended to improve the health outcomes of people in detention and to ensure that they have equitable access to health services. 4. It is critical, in advancing the prison health agenda, to continue working to improve the living conditions of people in detention, as well as the working conditions of prison health workers. 5. A fundamental tool for improving policies and practices in prison health is the generation of evidence on the effectiveness of interventions, governance arrangements and health systems performance; also vital is continuous improvement of monitoring and evaluation of the health status of people in detention and of the health care provided to them. 6. Prison health programmes should address specific health needs that require public health interventions and general health needs that require care in regular health systems, and provide support and preparation for release after a period of imprisonment, including continuity of care. 7. The principle of continuity of care should be central to planning appropriate health care for people in prison, requiring close structural relations between health and social services in prison and in the community. 8. It is essential to ensure the independence of health professionals from punitive functions and to facilitate continuity of health care between prison and community. 9. Regardless of which sector has primary responsibility for running prison health services, close collaboration and synergy between the Ministries of Justice and/ or the Interior and the Ministry of Health are fundamental and must focus on the importance of universal principles such as access to high-quality essential health care services and continuity of care, human rights, and the need for clinical independence of health care staff. 10. Alliances should be fostered at national level in order to create a movement in favour of prison health and to improve policies, practices and legislation; these alliances should include all relevant stakeholders. VII. CONCLUSIONS Leaving no one behind in prison health The Helsinki Conclusions 24 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int
LEAVING NO ONE BEHIND IN PRISON HEALTH The Helsinki Conclusions Leaving no one behind in prison health The Helsinki Conclusions 24 Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). Document number: WHO/EURO:2020-742-40477-54342 © World Health Organization 2020 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted 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 the World Health Organization 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 the World Health Organization 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 the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. L E A V I N G NO ONE BEHIND IN PRISON HEALTH The Helsinki Conclusions Leaving no one behind in prison health The Helsinki Conclusions 243Leaving no one behind in prison health The Helsinki Conclusions CONTENTS PREAMBLE Contribution of prison health to the overarching goal of “leaving no one behind” A public health approach to prison health Governance of prison health Equal standards for prison and community health care Importance of continuity of care between prison and community health Centrality of evidence for improving policy and practice Conclusions I. II. III. IV. V. VI. VII. 5 6 8 10 12 14 16 19 Leaving no one behind in prison health The Helsinki Conclusions 244 PREAMBLE The 6th Prison Health Conference was held on 26–27 March 2019 in Helsinki, Finland;1 it was co-hosted by the World Health Organization (WHO) Regional Office for Europe, Public Health England and the Government of Finland. The focus of debate at the conference was the concept of the interface between the health and justice systems, which must be seen through the prism of human rights and the principles established under the Mandela Rules and the Bangkok Rules. The conference also underscored the principle that efforts to improve public health and reduce health inequalities should be inclusive of prisons. It focused on the importance of prisons as a setting where there may be a negative impact on health resulting from incarceration and where the prevalence of some risk factors and health conditions is higher than in the community. It addressed the issue that the health care delivered to people in detention must be recognized as part of a pathway to and from community health services. It concluded that prison health is an important dimension in countries’ efforts to meet the aim of “leaving no one behind”, as part of their goals to realize universal health coverage and to achieve the United Nations Sustainable Development Goals. The relevance of cross-sector working between the Ministries of Justice and/or the Interior and the Ministry of Health, to promote good practice in prison health, was highlighted throughout the conference. The following are the salient conclusions reached during the 6th Prison Health Conference in Helsinki. 1 6th Prison Health Conference. Prison health systems: the interface with wider national health systems. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/__data/assets/pdf_file/0006/405870/Report-HIPP-6th-Conference-March-2019-Final- to-publish.pdf ). Leaving no one behind in prison health The Helsinki Conclusions 245Leaving no one behind in prison health The Helsinki Conclusions I. CONTRIBUTION OF PRISON HEALTH TO THE OVERARCHING GOAL OF “LEAVING NO ONE BEHIND” Leaving no one behind in prison health The Helsinki Conclusions 246 I. Contribution of prison health to the overarching goal of “Leaving no one behind” The fundamental health needs of people in detention, including juveniles and migrants, as well as people subject to pre-trial detention, are not always adequately met. There is a higher level of health and social care needs among people in detention, which arise from multiple complex needs prior to incarceration, as well as from issues related to equity, social cohesion and inclusiveness. The values underpinning a human rights-based approach to ensuring healthy lives underscore the right to the highest attainable standard of health as enshrined in the Constitution of the World Health Organization. The aim of Sustainable Development Goal 3, “Ensure healthy lives and promote well- being for all at all ages”, is to improve health among vulnerable populations and reduce inequities. This drive towards “leaving no one behind” focuses on equitable access and reaching those experiencing serious inequities in access to health and related social services compared with the rest of the population. This encompasses people in prisons. To achieve Sustainable Development Goal Target 3.8 – universal health coverage for all by 2030 – at least 1 billion more people will need to have access to essential health services in each five-year period between 2015 and 2030. In order to ensure that universal health coverage reaches the poorest, the most marginalized, women, children, and people with disabilities, as well as people in prison, efforts will have to be made to drive equitable access in these groups and to ensure that coverage of services reaches those most in need. European societies must still overcome important inequities in health and in access to health care to ensure that no one is left behind. This is critical for complying with the Global Sustainable Development Agenda and Goals approved by the United Nations General Assembly. It is therefore imperative to address the health needs of vulnerable groups, including people in prison, for whom access to health and related social services is often inadequate. Leaving no one behind in prison health The Helsinki Conclusions 247Leaving no one behind in prison health The Helsinki Conclusions II. A PUBLIC HEALTH APPROACH TO PRISON HEALTH Leaving no one behind in prison health The Helsinki Conclusions 248 A public health approach is necessary to align strategies, policy options and interventions for improving health outcomes among people in prison. The Moscow Declaration 2003 (“Prison health as part of public health”) and the Lisbon Conclusions 2018 (“Prison health in all policies”) point in this direction. Prison health programmes should therefore: (a) address specific health needs that require public health interventions; (b) address general health needs that require care in regular health systems; and (c) provide support and preparation for release after a period of imprisonment, including continuity of care. The following principles may be taken as the basis for a policy framework to define public health strategies for prison health: ■ reduce, and eventually end, disparities in health status and in the availability of and access to health services for people in prison compared to people in the community; ■ ensure the health and human rights of people in prison, limiting discrimination and stigmatization and removing impediments in access to health promotion and preventive and curative interventions; ■ promote the professional autonomy and independence of health care services in prisons and health professionals in line with the fundamental provisions of medical ethics; and ■ minimize the negative impact of incarceration on health outcomes by considering health risks specific to the prison setting. A public health approach to prison health therefore implies: ■ focusing on the health risks and needs of a defined population; ■ not being constrained by organizational or professional boundaries; ■ generating long-term as well as short-term solutions; ■ basing decision-making on data and intelligence; ■ rooting responses to tackle problems in evidence of effectiveness; and ■ orienting action with and for the communities. II. A public health approach to prison health Leaving no one behind in prison health The Helsinki Conclusions 249Leaving no one behind in prison health The Helsinki Conclusions III. GOVERNANCE OF PRISON HEALTH Leaving no one behind in prison health The Helsinki Conclusions 2410 All of the above requires a coordinated effort on the part of the criminal justice sector and of the health sector at national and/or subnational level. A paradigm shift is also required, from punishment and exclusion to a modern, multidimensional approach of inclusion that promotes rights-based health and social well-being, along the lines of the recommendations contained in the WHO Regional Office for Europe’s 2013 policy brief Good governance for prison health in the 21st century. The Ministry of Health and/or the national health system are the most appropriate entities to organize and deliver prison health as recommended by the revised Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules) and the United Nations Bangkok Rules. Nevertheless, priority attention should be given to encouraging and enabling effective intersectoral cooperation across health and justice to promote, ensure and improve adequate health care for people who experience incarceration and to promote access, continuity and quality of care within prisons and in the community. In this regard, the 6th Prison Health Conference in Helsinki highlighted the relevance of the following aspects: ■ there should be universal principles of governance, such as access to high- quality essential health care services and continuity of care, human rights, and the need for clinical independence of health care staff; ■ it should be understood that there are no “universal blueprints”, or unique structural mechanisms, to determine how to manage and deliver prison health care; ■ transfer of responsibilities between the justice and health sectors should encompass detailed preparation and planning, a high degree of multi- stakeholder collaboration, and good governance to ensure good prison health; and ■ prison health services must be person-centred and person-informed to meet the needs of justice-involved individuals. Countries should embrace a health systems approach, where prisons are not separated from the continuity-of-care pathway but integrated with community health services. Moreover, it is essential that the independence of health professionals from punitive functions is upheld. III. Governance of prison health Leaving no one behind in prison health The Helsinki Conclusions 2411Leaving no one behind in prison health The Helsinki Conclusions IV. EQUAL STANDARDS FOR PRISON AND COMMUNITY HEALTH CARE Leaving no one behind in prison health The Helsinki Conclusions 2412 It is important to highlight that additional efforts will be required in health care for people in detention in order to achieve the same outcomes as those enjoyed by people in the outside community. In addition, there is a human rights dimension in boosting national efforts in prison health. This is closely linked to the issue of equity both in terms of the health status of a vulnerable group and in terms of its access to health and related social services. Equity is a human rights issue. The progressive realization of the right to health involves efforts to improve health across all populations and to reduce inequities in the enjoyment of health. As the Nelson Mandela Rules state, international law recognizes the right of everyone, including people deprived of their liberty, to the enjoyment of the highest attainable standard of physical and mental health. However, in practice, many people in detention receive health care of a far inferior standard to that available in the outside community, if they receive treatment at all. People in detention with existing health care conditions may have their health needs ignored or neglected, and others may develop health problems while in prison because of the poor living conditions prevalent in many prison settings. The time has come to address the key issues associated with dovetailing prison health systems and national health systems to ensure adequate access to high-quality health care for people who experience incarceration and to promote continuity and quality of care. The conclusions of the 5th Prison Health Conference, held in Lisbon, Portugal, in 2017, highlighted that treatment and prevention programmes restricted to prison settings are unlikely to bring sustained benefits to people experiencing imprisonment. This underscores the need to improve the links between public health interventions in prison and in the community in order to improve continuity of care and achieve better health outcomes. The importance of the principle of equivalence – that people in detention are entitled to the same standard of health care as members of the public, without discrimination – is widely recognized, in the Nelson Mandela Rules and elsewhere. Furthermore, in increasingly complex health care settings, the principle of equivalence cannot be achieved so long as isolated or fragmentary prison health systems exist in parallel with wider national health systems, inadequately connected to and coordinated with them. IV. Equal standards for prison and community health care Leaving no one behind in prison health The Helsinki Conclusions 2413Leaving no one behind in prison health The Helsinki Conclusions V. IMPORTANCE OF CONTINUITY OF CARE BETWEEN PRISON AND COMMUNITY HEALTH Leaving no one behind in prison health The Helsinki Conclusions 2414 V. Importance of continuity of care between prison and community health Imprisonment generally renders individuals more vulnerable to health risks and exposes them to potential hazards and greater stresses arising from seclusion; such dangers can be compounded by poorly planned release from custody and reinsertion into former high-risk environments. For this reason, the principle of continuity of care should be keyed into the equation of adequate health care for people in detention. Continuity of care between prisons and the community requires that close structural relations are established between health and social services in prison and in the community. This is especially so because people in prison form a dynamic population that continually moves back and forth between states of freedom and incarceration. The continuum of care in the definition of successful universal health coverage – from promotion to palliation – places emphasis on the need for health services to prevent and relieve suffering across all disease groups and all age groups in an equitable manner. This should be applicable to people in detention. Prison can be a critical setting in a person’s life course in which unmet health needs can be identified and addressed. However, for health improvements achieved in prison to be maintained over the life course, continuity of care between prison and community health systems is vital. Leaving no one behind in prison health The Helsinki Conclusions 2415Leaving no one behind in prison health The Helsinki Conclusions VI. CENTRALITY OF EVIDENCE FOR IMPROVING POLICY AND PRACTICE Leaving no one behind in prison health The Helsinki Conclusions 2416 VI. Centrality of evidence for improving policy and practice Advocacy efforts, policy formulation and continuous improvement of practice in prison health require sound evidence on the effectiveness of interventions, governance arrangements and health systems performance. It is also of paramount importance to keep boosting efforts to improve monitoring and evaluation of the health status of people in detention and the health care provided to them. In this regard, it is critical to sustain efforts to improve surveillance, to create prison health data sets at national or subnational level, to provide research that can inform decision- making, to conduct systematic evaluations, and to document best practices. Leaving no one behind in prison health The Helsinki Conclusions 2417Leaving no one behind in prison health The Helsinki Conclusions Leaving no one behind in prison health The Helsinki Conclusions 2418 Based on the above considerations, the 6th Prison Health Conference in Helsinki reached the following 10 conclusions. 1. The organization and practice of countries’ prison health programmes and services should adhere to international standards of human rights and follow the principles established under the Mandela Rules and the Bangkok Rules. 2. Prison health is an important dimension in countries’ efforts to “leave no one behind”, as part of the attainment of the goals to realize universal health coverage and to achieve the United Nations Sustainable Development Goals. For this reason, efforts to improve public health and reduce health inequalities should be inclusive of prisons. 3. A public health approach is necessary to align strategies, policy options and interventions intended to improve the health outcomes of people in detention and to ensure that they have equitable access to health services. 4. It is critical, in advancing the prison health agenda, to continue working to improve the living conditions of people in detention, as well as the working conditions of prison health workers. 5. A fundamental tool for improving policies and practices in prison health is the generation of evidence on the effectiveness of interventions, governance arrangements and health systems performance; also vital is continuous improvement of monitoring and evaluation of the health status of people in detention and of the health care provided to them. 6. Prison health programmes should address specific health needs that require public health interventions and general health needs that require care in regular health systems, and provide support and preparation for release after a period of imprisonment, including continuity of care. 7. The principle of continuity of care should be central to planning appropriate health care for people in prison, requiring close structural relations between health and social services in prison and in the community. 8. It is essential to ensure the independence of health professionals from punitive functions and to facilitate continuity of health care between prison and community. 9. Regardless of which sector has primary responsibility for running prison health services, close collaboration and synergy between the Ministries of Justice and/ or the Interior and the Ministry of Health are fundamental and must focus on the importance of universal principles such as access to high-quality essential health care services and continuity of care, human rights, and the need for clinical independence of health care staff. 10. Alliances should be fostered at national level in order to create a movement in favour of prison health and to improve policies, practices and legislation; these alliances should include all relevant stakeholders. VII. CONCLUSIONS Leaving no one behind in prison health The Helsinki Conclusions 24 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int