Improving the health of people living in prisons in the WHO European Region The work of the Health in Prisons Programme of the WHO Regional Office for Europe, 2022–2023 A B S T R A C T This document presents the Action Plan of the WHO Regional Office for Europe Health In Prisons Programme (HIPP), adopted in 2022 for the period of 2022–2025, with the ultimate aim to improve the health of people deprived of liberty in the WHO European Region, contributing to a healthier and more humane environment within correctional facilities and impacting society at large. The Action Plan is organized according to five strategic goals, and a review of progress made until June 2023 is summarized, whilst also identifying priorities for action in the future. K E Y W O R D S Healthcare Prisons Policy Human rights Document number: WHO/EURO:2023-7708-47475-69784 © World Health Organization 2023 Some rights reserved. 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Foreword iv Acknowledgements v The Health in Prisons Programme (HIPP) of the WHO Regional Office for Europe in a nutshell 1 The HIPP Action Plan 2022–2025 3 Objective 1: Promoting intersectoral and sectoral advocacy, policy developments and legislation to improve the health of people in prisons 4 Objective 2: Strengthening the interface between prisons health systems and the wider national health systems to promote continuity of care for people in prisons. 5 Objective 3: Supporting evidence-based knowledge management on prisons health to increase the efficacy of services and to achieve better health outcomes 5 Objective 4: Fostering capacity building processes in Member States in prisons health 6 Objective 5: Building alliances among key stakeholders, coordinate, create synergies and mobilize resources to secure sustainability 7 Key outputs from 2022 to mid-2023 9 Ongoing and future work until 2025 15 Annex: Key Outputs from HIPP Action Plan 2019–2021 that have shaped Action Plan 2022–2025 17 i i i F O R E W O R D Prison health is a complex and multifaceted area of work that requires a comprehensive and strategic approach. Prisons serve as unique settings where individuals who have come into contact with the criminal justice system find themselves confined, often facing various health-related issues. It is our collective responsibility to ensure that the fundamental right to health is upheld for all individuals, regardless of their circumstances. This report presents progress made in meeting each of the five strategic goals set in the Action Plan 2022–2025 of the WHO Health in Prisons Programme (HIPP) aimed at supporting countries in moving towards healthier and more humane environment within correctional facilities. These goals are not only crucial for the well-being of incarcerated individuals, but also for society as a whole. The attainment of these strategic goals will undoubtedly require sustained commitment, collaboration, and innovation from all stakeholders involved. We are grateful to the financial contribution of our donors who have continuously trusted WHO-HIPP to deliver this demanding mandate. It is my hope that this document will serve as a driver for sustained and expanded support and as a catalyst for action, inspiring policymakers, practitioners, researchers, and advocates to come together and prioritize the health and well-being of incarcerated individuals. By doing so, we can work towards creating a more just and compassionate society that upholds the inherent dignity and right to health for all individuals, regardless of their circumstances. Dr. Carina Ferreira Borges WHO Regional Advisor, Alcohol, Illicit drugs and Prisons Health iv A C K N O W L E D G E M E N T S The development of this publication was coordinated by Filipa Alves da Costa, Public Health Specialist, WHO Regional Office for Europe, with the support of Sofia Crisóstomo, Health Policy Specialist, WHO Regional Office for Europe, under the guidance of Carina Ferreira-Borges, Regional Advisor Alcohol, Illicit Drugs and Prison Health, WHO Regional Office for Europe. The WHO Regional Office for Europe would like to acknowledge the contribution of Steering Group (SG) Members that throughout the years have continuously provided strategic guidance. We particularly acknowledge Stefan Enggist (Federal Office of Public Health, Switzerland) for his contribution to the development of the current work plan, as SG chair for the period. We also acknowledge the crucial contribution of Prof. Daniel Lopez-Acuna (Andalusian School of Public Health) in establishing the strategic direction of HIPP. In alphabetical order: Caterina Silvestri (Regional Health Agency of Tuscany), Chantal Edge (UK Health Security Agency), Daniel Rowan (Project ECHO), Dina Masalimova (AIDS Foundation East West), Elena Leclerc (International Committee of the Red Cross), Éamonn O’Moore (Health Protection Surveillance Centre, Ireland), Ehab Salah (United Nations Office on Drugs and Crime), Emily Wang (Yale University School of Medicine), Emma Plugge (Worldwide Prison Health Research & Engagement Network (WEPHREN)), Erika Duffell (European Centre for Disease Prevention and Control, Fadi Meroueh and Roberto Monarca (European Federation for Prison Health – Health without Barriers), Hanna Hemminki-Salin and Jussi Korkeamäki (National Institute for Health and Welfare of Finland), Heino Stöver (Frankfurt University of Applied Sciences), Henrique de Barros (Instituto de Saúde Pública da Universidade do Porto, WHO Collaborating Centre on Behavioral and Social Determinants of Noncommunicable Diseases), Irada Mammadova (WHO Collaborating Center on prevention and control of tuberculosis in prisons), Jörg Pont (Independent Consultant), Lara Tavoschi (University of Pisa), Linda Montanari (European Monitoring Centre for Drugs and Drug Addiction), Mafalda Vieira de Castro and Rui M Ramos Morgado (Directorate-General of Prison Services, DGSP, Ministry of Justice of Portugal), Marrit de Vries and Michel Westra (Ministry of Security and Justice of the Netherlands), Olivia Rope (Penal Reform International), Orsoyla Gáncsos (Council of Europe, Pompidou Group), Ruth Gray (Prison Health Care, SEHSCT), Silvija Geistarte and Ülla-Karin Nurm (Northern Dimension Prison Health Expert Group, NDPHS), Stuart Kinner (Centre for Adolescent Health, Murdoch Children’s Research Institute), Sunita Sturup-Toft (UK Health Security Agency), Teresa Galhardo (Directorate-General for Health, DGS, Ministry of Health of Portugal). The WHO Regional Office for Europe would also like to thank the Ministry of Social Affairs and Health of Finland, the Federal Office of Public Health of Switzerland and the United Kingdom Health Security Agency for their funding support to the Health in Prisons Programme (HIPP) of the WHO Regional Office for Europe, which has played a critical role in the implementation of the programme priorities throughout the previous Action Plan 2019–2021 and the current Action Plan 2022–2025. v
T H E H E A L T H I N P R I S O N S P R O G R A M M E ( H I P P ) O F T H E W H O R E G I O N A L O F F I C E F O R E U R O P E I N A N U T S H E L L This year, over 1.5 million Europeans will have their health needs neglected due to their legal status. The vision The WHO Health in Prisons Programme (HIPP) works to integrate prison health into the overall public health agenda and to reduce health inequalities. HIPP’s vision is to have a world where all people deprived of liberty have equivalent health care to those in the community and that a prison stay becomes an opportunity to reduce inequalities by providing means to rehabilitate through health. Our vision is based on the values enshrined in the WHO Constitution whereby the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being, including of those who have been deprived of their liberty. In order to ensure that universal health coverage reaches the poorest, the most marginalized and deprived of their liberty, efforts will have to be made to drive equitable access to healthcare and to ensure that coverage of services and continuity of care reaches those most in need. As such, we work with Member States to ensure that people in prison have access to the full scope of health services they need and that these are at least of equivalent professional, ethical and technical standards to those applying to public health services in the community. In addition, for health improvements achieved in prison to be sustained over the life course, continuity of care between prison and community health systems is vital. For this reason, the principle of continuity of care is an integral part of the equation of adequate health care for people in detention. The work Our main public health goal is to reduce, and eventually end, disparities in health status and in the availability of and access to health services for people in prisons with respect to people in the community. To be able to achieve this, the work is structured across five key pillars (see Fig. 1). Improving the health of people living in prisons in the WHO European Region | 1 Several principles drive our public health approach for prison health. Ensuring the health and human rights of people in prisons entails limiting discrimination and stigmatization in prison and removing impediments to their access to health promotion and preventive and curative interventions, as well as promoting professional autonomy and clinical independence of health care services in prisons in line with fundamental provisions of medical ethics. Another key principle is the need to minimize the negative impact of incarceration on health outcomes. Imprisonment generally renders people more vulnerable to health risks and exposes them to potential hazards and greater stress arising from seclusion, which can be compounded by poorly planned release from custody back to high-risk reinsertion into former environments. Fig. 1. Five pillars for improving prison health F I V E P I L L A R S F O R I M P R O V I N G P R I S O N H E A LT H D ev el op m en t o f p ol ic y an d le gi sl at iv e fra m ew or ks fo r h ea lth in p ris on s M on ito rin g he al th in p ris on s B ui ld in g na tio na l c ap ac ity fo r p ris on h ea lth c ar e O rie nt at in g an d su pp or tin g ca pa ci ty in re se ar ch o n pr is on h ea lth Su pp or tin g th e in te gr at io n of p ris on he al th a nd w id er c om m un ity h ea lth 2 | Improving the health of people living in prisons in the WHO European Region T H E H I P P A C T I O N P L A N 2 0 2 2 – 2 0 2 5 During HIPP Steering Group meeting held in 2021, the strategic directions for increasing comprehensiveness, visibility and expansion of HIPP were reconsidered (see Fig. 2). The Action Plan 2022–2025 takes stock of the progress made under Action Plan 2019–2021 (annex), seeking to realign and reorganize technical activities, and identify opportunities for increasing visibility, establishing partnerships and alliances, building synergies and mobilizing resources. It addresses the key issues associated to the dovetailing of prison’s health systems and the national health systems to ensure adequate access to quality health care for people in prisons, and for promoting continuity and quality of care. The transition from these two Action Plans (2019–2021 and 2022–2025) was marked by periods of enhanced health threats, including of pandemic nature, natural hazards and human conflicts, all of which affect the society at large and those living in detention. Lessons learnt from these periods shifted the focus of work into building resilient prison health systems. Therefore, the current Action Plan, structured around the same five key objectives, also focuses on supporting Member States to prepare, prevent, detect and respond to health hazards and health security, in particular infectious diseases, including of epidemic and pandemic nature, and to build connectedness with the wider health systems (see Fig. 3). Fig. 2. Strategic directions for increasing comprehensiveness, visibility and expansion of the HIPP Fig. 3. Five key objectives of the HIPP Action Plan 2022–2025 Specific health needs requiring ad-hoc public health interventions in prison and after incarceration General health needs requiring care in regular health system during and after incarceration Need for a coordinated effort of the Criminal Justice System and the Health System →+ Pre pare Bu ild Respond Detect Prevent Improving the health of people living in prisons in the WHO European Region | 3 The five key objectives of the Action Plan have been established in 2019 and maintained in the current action plan, as illustrated below. Five objectives of the Action Plan 1. Promoting intersectoral and sectoral advocacy, policy developments and legislation to improve the health of people in prisons. 2. Strengthening the interface between prisons health systems and the wider national heath systems to promote continuity of care for people in prisons. 3. Supporting evidence-based knowledge management on prisons health to increase the efficacy of services and to achieve better health outcomes. 4. Fostering capacity-building processes in prisons healh in Member States. 5. Building alliances among key stakeholders, coordinate, create synergies and mobilize resources to secure sustainability. Objective 1: Promoting intersectoral and sectoral advocacy, policy developments and legislation to improve the health of people in prisons Promoting intersectoral and sectoral advocacy, policy developments, and legislation is crucial for improving the health of people in prisons, with a particular emphasis on achieving equity for vulnerable populations such as women, children, and adolescents, by addressing their specific needs. Moreover, a robust communication strategy is essential to raise awareness about the unique challenges faced by incarcerated individuals and advocate for their rights and well-being. By fostering collaboration between different stakeholders, developing targeted policies, and enacting inclusive legislation, significant strides can be taken towards achieving health equity and improving the overall health outcomes of those deprived of liberty. Legislation • Foster legal capacity building for Member States to get national legislation and policy addressing the health of people in prisons in line with international law and standards. – Provide legal research and analysis services/tools to Member States to assess their prison health law and policy against international law and standards. • Assess the need and feasibility to provide “Model Legislation” on prisons and health for Member States; and, if appropriate, develop it. – Provide support for implementing models considering alternatives to incarceration and diversion to treatment by sharing best practices Equity • Develop a rights-based framework for assessing the health status of woman in prisons and for responding to women’s specific health needs in the context of incarceration. • Build on the work developed with the UN Task Force on Children Deprived of Liberty, including UNICEF, University of Melbourne and other partners, to produce legislative work focusing on children/ adolescents. Communication • Develop a professional HIPP communication strategy tailored and addressed to different stakeholders. A C T IO N S 4 | Improving the health of people living in prisons in the WHO European Region Objective 2: Strengthening the interface between prisons health systems and the wider national health systems to promote continuity of care for people in prisons. Strengthening the interface between prisons’ health systems and the wider national health systems is imperative to ensure the equivalence of health-care services and promote continuity of care for people in prisons. By fostering integration between these systems, people in prisons can receive consistent and comprehensive healthcare that mirrors the standards set in the general community. This integration becomes even more crucial in the ongoing response and recovery from the COVID-19 pandemic, where maintaining a seamless flow of health-care services can help mitigate the disproportionate impact of the virus on incarcerated populations. By enhancing collaboration, sharing information, and coordinating efforts, a well-integrated system can effectively address the unique health-care needs of people in prisons, while also facilitating their successful reintegration into the community upon release. Equivalence, continuity of care • Review inequalities in service provision for people in prisons and the general community. • Generate evidence to support quality of services and clinical management in prison. – Third edition of the Book “Prisons and Health”. – Consider using the Book to identify areas where it would be relevant to explore clinical management specific for prisons and practical implementation. Integration • Advocate for policy development that fosters prison health integration into public health, using COVID-19 experience and lessons learned as evidence of the need for MS to adapt their policies. – Focus on the integration of prison health information systems in public health systems. Consider developing pilots at country level to test possible solutions of integration. – Develop policy briefs highlighting successful transitions of governance for health in prisons to the Ministry of Health. Ongoing response and recovering from COVID-19 • Identify developments in collaboration between prison health systems and the wider national health systems which occurred during the pandemic and use these to build back better. • Identify developments in good practice to be expanded beyond COVID-19. Objective 3: Supporting evidence-based knowledge management on prisons health to increase the efficacy of services and to achieve better health outcomes Supporting evidence-based knowledge management in prison health is crucial for improving the efficacy of services and achieving better health outcomes. Translating research into practice allows the effective application of evidence- based interventions and strategies within prisons. Furthermore, by upscaling evidence gathering, prisons can ensure that decisions related to health services are grounded in the most current and relevant data. Therefore, it is essential to strengthen good monitoring and surveillance mechanisms capable of providing comparable data, as well as research capacity in the field of prison health, enabling the development of robust studies and generation of A C T IO N S Improving the health of people living in prisons in the WHO European Region | 5 A C T IO N S evidence specific to this unique population. Promoting knowledge around the needs of understudied and growing population subgroups, such as the elderly, is vital. By integrating evidence-based knowledge management practices, prison health systems can provide high-quality care, improve health outcomes, and contribute to the overall well- being of people in prison. The United Nations System Common Position on Incarceration recognizes WHO leadership in the area of prison health, notably as an information hub in what concerns health data. Translating research into policy and practice • Use findings from HIPED survey to orient capacity building initiatives for Member States. • Use findings from HIPED survey to promote policy dialogues that are meaningful and tailored for each Member State. Upscaling evidence gathering • Intensify the frequency of data collection. • Expand the focus of HIPEDS to include detention in the context of migration. • Expand beyond the European region. Strengthening research capacity in the field of correctional health • Develop a research agenda with priority research topics. • Orient and promote research, in accordance with ethical standards, disseminating evidence on interventions, building capacity and promoting engagement in prisons health through various partners, namely WEPHREN, or consortia created for specific projects or actions/topics, such as RISE-Vac. Promoting knowledge and development for best health outcomes of elderly people in prisons • Describe the health status of elderly people in prisons. • Identify promising human rights-based interventions for elderly people in prisons. • Develop evidence-based elderly-focused interventions. Objective 4: Fostering capacity building processes in Member States in prisons health Fostering capacity building processes in Member States in prisons health involves a comprehensive approach to addressing the challenges and opportunities within prisons. This includes identifying gaps in health-care delivery, infrastructure, and staff training, and proposing innovative solutions to bridge these disparities. By investing in training programs, implementing evidence-based practices, enhancing collaboration among health-care professionals and expanding to the prison workforce needed to support development and implementation, HIPP will contribute to improve the overall performance of prison health systems. These capacity building efforts prioritize the development of sustainable and efficient health-care models that prioritize the well-being and rehabilitation of people in prison, ensuring their access to quality care while also promoting public health and health security. 6 | Improving the health of people living in prisons in the WHO European Region A C T IO N S Identifying gaps and proposing solutions • Develop an integrated strategic capacity building package approach. – Identify gaps in capacity building offer. – Explore collaborations needed to use and disseminate already existing resources. – Identify target groups; format of delivery; regional outreach or other strategies. – Integrate new communication technologies, leveraging COVID-19 gained experiences, in the capacity building approach. • Pursue the work initiated under the previous work plan on Workforce development and Competency Frameworks. Improving performance • Provide technical assistance, based on the WHO Prison Health Framework, to build capacity in Member States to assess their prison health system performance. • Develop a Train the trainers’ course for health workers in prisons, using the Burden of NCDs report as template, by collaborating with Yale School of Medicine. Consider adapting the course to e-learning format. • Launch and test a course through which capacity building may be created in different areas through partnerships (e.g., infectious diseases with the United Kingdom Health Security Agency; drug use disorders with the European Monitoring Centre for Drugs and Drug Addiction). • Consider creating an expert group of trainers that may be used for a prison specialized school. • Strengthen existing collaborations and resources that may support capacity building initiatives, namely through WHO Collaborating Centres (e.g., WHO Collaborating Centre on prevention and control of tuberculosis in prisons; WHO Collaborating Centre on Behavioral and Social Determinants of Noncommunicable Diseases). Objective 5: Building alliances among key stakeholders, coordinate, create synergies and mobilize resources to secure sustainability Building alliances among key stakeholders is crucial for the successful implementation and sustainability of Health In Prisons Programme (HIPP). By coordinating efforts and fostering collaboration, stakeholders can pool their expertise, resources, and funding to address complex challenges. This collective approach not only ensures a broader impact but also enhances the visibility and attractiveness of the initiative, attracting more support from diverse sources. Moreover, co-creation with people in prisons is a transformative approach that enables their active participation and involvement, ensuring that their voices are heard, and their perspectives are integrated into the overall strategy. Improving the health of people living in prisons in the WHO European Region | 7 A C T IO N S Funding • Develop a fundraising strategy for the HIPP focusing on key elements: 1) the establishment of a multi-year funding framework and baseline for the HIPP action plans; 2) a guidance on possible funding mechanisms to sustain the core infrastructure and delivery capacity of the HIPP; 3) the organizational elements for the fundraising functions. • Map current and potential European and global donors in the area of prison health. • Consider actions that attract new funding bodies (e.g., expand HIPP to become global). • Consider actions on specific domains that would attract additional funding. • Develop a communication marketing package that describes HIPP mandates, achievements and future action plan. • Initiate individual meetings with Member States and consider adapting plan to obtain their support. • Attract new Member States to the Steering Group and initiate communication with potential donors (including their inclusion in a donor round table). Visibility, attraction, and creation of a platform for advancing various objectives within the action plan • Organization and running of a World Conference on Prisons and Health on an annual basis and starting in 2023. Co-creation with people in prisons • Advocate for the inclusion of people with lived prison experience, relevant regional and/or national civil society organizations and community-based organizations, in the development of programmes, interventions and policies that address people in prisons. • Identify one individual or organization to join the Steering Group 8 | Improving the health of people living in prisons in the WHO European Region K E Y O U T P U T S F R O M 2 0 2 2 T O M I D - 2 0 2 3 Publications Health in prisons – COVID-19. Minimum dataset: summary of data reported from May 2020 to October 2021. Copenhagen: WHO Regional Office for Europe; 2022 (https://apps.who.int/iris/handle/10665/351496). This report presents epidemiological information on COVID-19 in prisons, obtained from voluntary submissions of Member States to the WHO Minimum Dataset Reporting System for places of detention. It contains longitudinal data on occupancy rate, standardized cumulative cases in prison, vaccination coverage, testing and isolation practices. Disaggregation of data by sex and age group is also presented whenever available. Leaving no one behind in prison health: the Helsinki conclusions. Copenhagen: WHO Regional Office for Europe; 2020 (https://apps. who.int/iris/handle/10665/352128). Co-hosted by the WHO Regional Office for Europe, Public Health England and the Government of Finland, the 6th Prison Health Conference took place in Helsinki in March 2019, under the theme “Leaving no one behind in prison health”. Discussions highlighted that efforts to improve public health and reduce health inequalities should be inclusive of prisons and confirm that prison health is an important dimension of countries’ efforts to leave no one behind, to realize universal health coverage and to achieve the United Nations Sustainable Development Goals (SDGs), particularly SDG 3 and SDG 10. Addressing the noncommunicable disease (NCD) burden in prisons in the WHO European Region: interventions and policy options. Copenhagen: WHO Regional Office for Europe; 2022 (https://apps. who.int/iris/handle/10665/352257). The aim of this brief is to shed light on the scale of the NCD burden in prisons and the unique challenges they present for individuals and society both during and following incarceration. The brief also highlights best practices, interventions and policies to address NCDs and their risk factors in the prison context, while also noting special considerations for their implementation in specific contexts and settings. Improving the health of people living in prisons in the WHO European Region | 9 Good practices in managing infectious diseases in prison settings: a snapshot of responses to COVID-19 implemented around the globe between May and September 2020. Copenhagen: WHO Regional Office for Europe; 2022 (https://apps.who.int/iris/handle/10665/352611). This report captures various health-related policies and practices that were implemented inside prisons and other places of detention during the COVID-19 pandemic. It is intended as a resource for policy-makers, prison managers and health-in-prisons practitioners, highlighting the preparedness, responsiveness, risk assessment, risk mitigation and case management of COVID-19 inside prisons. The report presents good practices from countries and regions, selected according to specific criteria, in enhancement of health-care practices in prisons. Cancer and cardiovascular health inequities in prison settings: a rapid literature review. Copenhagen: WHO Regional Office for Europe; 2022 (https://apps.who.int/iris/handle/10665/360079). This report describes a rapid review to assess inequities in cancer and cardiovascular disease care in prisons. The evidence showed lower cancer screening rates in prison populations than in non-prison populations. People spending any time in prison present at a later stage for all cancer types and for preventable diseases. The main findings suggest that prison health screening programmes can improve health and reduce costs for health systems. Health education programmes in prison can improve screening rates and health literacy among those on low incomes and the fewest years of education. Investments made in health education have the potential to improve cardiovascular health. Gaps in the evidence, notably related to cardiovascular disease, suggest that additional research is needed on health inequities in prisons. Mpox prevention and control factsheets. WHO Regional Office for Europe and the United Nations Office for Drugs and Crime (UNODC) have developed these factsheets intended for people living in prisons and for visitors, that summarize signs and symptoms, transmission routes and the risks associated with mpox in simple language. Key recommendations intended for health and security workers in detention facilities are conveyed to ensure the health and well-being of staff and people living in these facilities. Mpox prevention and control among people living in prison. Copenhagen: WHO Regional Office for Europe; 2023 (https://www.who.int/europe/publications/m/ item/mpox-prevention-and-control-among-people-living-in-prison). 10 | Improving the health of people living in prisons in the WHO European Region Mpox prevention and control in people visiting prison. Copenhagen: WHO Regional Office for Europe; 2023 (https://www.who.int/europe/publications/m/ item/mpox-prevention-and-control-in-people-visiting-prison). Mpox prevention and control - Key recommendations for protecting people living and working in prison (directed at prison officers and healthcare staff). Copenhagen: WHO Regional Office for Europe; 2023 (https://www. who.int/europe/publications/m/item/mpox-prevention-and-control-key- recommendations-for-protecting-people-living-and-working-in-prison). Status report on prison health in the WHO European Region 2022. Copenhagen: WHO Regional Office for Europe; 2023 (https://apps. who.int/iris/handle/10665/365977). This report provides an overview of the performance of prison health systems in the WHO European Region. It contains 2020 data obtained through a survey collected from 36 countries, where a total of 613 497 people were deprived of their liberty. In most of these countries, responsibility for delivering prison health care was shared between the Ministry of Health and the Ministry of Justice/the Interior. Preventive services, such as vaccines, were universally offered for COVID-19 in all Member States, even though deficiencies still persisted in access to vaccination for other diseases such as hepatitis B. The response implemented for COVID-19 was good, except when people were transitioning into the community. Continuity of care was an area needing investment, with only around half of Member States ensuring access to community health services. The most prevalent condition was mental health disorders, but the ratio of psychiatrists to people in prison did not ensure equity of care and access to treatment was suboptimal. Harm minimization focused mostly on access to drug use treatment and less on safe injecting or tattooing practices. Access to hepatitis C (HCV) treatment was not on track to achieve HCV elimination and needs urgent attention. The most common cause of death in prisons was suicide, followed by COVID-19 and drug overdose. Overcrowding was reported in 20% of Member States. Even though Member States are improving their capacity to provide disaggregated data, further investment is needed to increase capacity to provide morbidity and health behaviour data. Data stored and publicly available in the Global Health Observatory Health in prisons European database (HIPED) [on-line database]. In: WHO/ Europe. Copenhagen: WHO Regional Office for Europe; 2023 (https://www. who.int/data/region/europe/health-in-prisons-european-database-(hiped)). Improving the health of people living in prisons in the WHO European Region | 11 Training Innovation in NCD policy and action: a course for Prison Health Care Workers. May–November 2022 The WHO European Regional Office for Europe, in collaboration with the Yale School of Medicine, has developed an online training course to empower and enhance professional development of national counterparts and clinicians working with prisons and other detention facilities. The course gave its participants the knowledge and innovative tools to: review the latest evidence on the burden of noncommunicable diseases (NCD) such as cardiovascular diseases, obesity and overweight, cancer, respiratory diseases, and mental health disorders; and their risk factors; implement successful NCD practices in a prison context; develop further advocacy strategies; and train their peers to deliver the WHO-recommended interventions. The course counted with 36 representative nominated by Ministries of Health from 24 Member States in the WHO European Region (Andorra, Armenia, Austria, Belarus, Bulgaria, Croatia, Estonia, Finland, France, Hungary, Italy, Ireland, Kyrgyzstan, Lithuania, Luxembourg, Malta, Montenegro, Portugal, Republic of Moldova , Romania, San Marino, Serbia, Slovak Republic and Türkiye), in addition to 11 individual participants from Bermuda, Cyprus, Montserrat, St Helena Island, Turks and Caicos and the United Kingdom. Events Launch of the Status Report on prison health in the WHO European Region 2022. 15 February 2022 HIPP launched the Status report on prison health in the WHO European Region 2022. This was a hybrid event in Lisbon, Portugal, co-hosted by Portugal’s Ministry of Health and Ministry of Justice with special participation by the Ministry of Science, Technology and Higher Education. ©WHO/Filipa Alves da Costa 12 | Improving the health of people living in prisons in the WHO European Region Portuguese National policy dialogue on the implications of the findings of the Status Report on prison health in the WHO European Region 2022. 15–16 Feb 2023 Following the international launch of the Status Report, a national dialogue took place, in a decentralized manner (Lisbon and Porto), where an ample debate involving all key stakeholders were invited to participate, namely deputy ministers of Ministry of Health, Ministry of Justice, Ministry of Science, Technology and Higher Education, health practitioners working in prison, prison officers, prison administrators, civil society organisations, academia and representatives of disease registries. The event was co-organized with the Institute of Public Heath of University of Porto (ISPUP), following its designation as WHO Collaborating Centre on Behavioral and Social Determinants of Noncommunicable Diseases. Health in Prisons and Places of Detention International Conference. Making prisons and places of detention resilient to infectious diseases, including epidemic and pandemic threats. 20–21 Jun 2023 Jointly organized by the WHO Regional Office for Europe and the United Kingdom Health Security Agency (UKHSA), the 2023 Health in Prisons and Places of Detention International Conference will focus on the vulnerabilities of prisons and places of detention to infectious diseases, with the aim of making them more resilient to endemic and epidemic threats. Speakers included WHO and UKHSA officials, academic experts, and other stakeholders. The conference explored: how the health of people in prisons and places of detention and the performance of prison health systems are affected by infectious diseases, including diseases of an epidemic and pandemic nature; successes and failures in the preparedness of prisons and places of detention for infectious diseases and the effectiveness of responses to these threats; and ways to build resilient prison health systems and how this aligns with efforts to strengthen the health system at large. It is expected that discussions held during the conference contribute to inform guidelines for Member States to strengthen their responses to infectious diseases in prisons and places of detention, and to reinforce the relationships between prison health systems and the wider health system. ©WHO/Filipa Alves da Costa Improving the health of people living in prisons in the WHO European Region | 13 HIPP Steering Group meetings The HIPP Steering Group kept providing strategic guidance to the programme and to the implementation of the HIPP action plan, including contributions to publications and other activities developed. It held its annual meetings on 5 May 2022 and 22 Jun 2023 and additional extraordinary meetings when matters arising justified additional discussion (e.g., HIPED preparation). Participation in prison health-related networks HIPP integrates various prison health-related networks, e.g., the UN Task Force on Children Deprived of Liberty, the Expert Group on Health in Prison of the Northern Dimension Partnership in Public Health and Social Well-Being, the Steering Committee of WEPHREN, and the Advisory-Board of the RISE-Vac Consortia 14 | Improving the health of people living in prisons in the WHO European Region O N G O I N G A N D F U T U R E W O R K U N T I L 2 0 2 5 2023: • The London Conclusions. This report will summarize the findings and main conclusions drawn from the Health in Prisons and Places of Detention International Conference. • “Principles for Making prisons and places of detention resilient to infectious diseases, including epidemic and pandemic threats”. These principles will be derived from a mixed methods methodology, including literature review and expert opinion collected during the 2023 Health in Prisons and Places of Detention International Conference. • Report “Three years of COVID-19 as an International Health Emergency of International Concern”. • Short Report: surveillance of mpox in places of detention. This report will summarize the notifications sent by voluntary contributions of Member States during 2022/2023. • The report from the first ever Country Dialogue held in Portugal to discuss national findings from HIPED survey: “Lançamento do Relatório sobre a situação da saúde prisional na Região Europeia da OMS: 2022 (Launch of the Status report on prison health in the WHO European Region: 2022)”. • Report on “Prison health in Azerbaijan: achievements, challenges and opportunities”. • “Including prisons in Influenza Surveillance Systems: considerations for implementation”. We are conducting an assessment of Member States’ capacity to include prisons as contributors to surveillance systems for Influenza. Surveillance is an essential component of the integration of prisons in wider public health systems. 2024: • Following the successful intersectoral policy dialogue conducted in Portugal, during 2024, two additional national policy dialogues will be conducted according to Member States’ requests. • In 2007 and in 2014, WHO-HIPP issued a report which has been considered a key resource for all working in prison health. The book entitled “Prisons and Health”. The 3rd edition of the book “Prisons and Health” is being developed during 2023 for launch in 2024. 2025: • A toolkit on access to quality care for people living in detention in the WHO European region will be developed during 2024/2025. This toolkit will be developed progressively, and the first two modules to be worked during 2024 are the “organizational capability framework” (developed to support organization of services in detention places), and a “competency framework” (developed to support Human Resources career development and continuous professional training). • Status Report on prison health in the WHO European Region 2025. Requests for nomination of focal points is ongoing and data collected will reflect the year of 2023. Improving the health of people living in prisons in the WHO European Region | 15 Training 2023: • E-learning course entitled “Making prisons and places of detention resilient to infectious diseases, including epidemic and pandemic threats” directed at prison officers and at prison health workers through Future Learn. • E-learning course on “Innovation in NCD policy and action: a course for Prison Health Care Workers” Events 2024: • Health in Prisons and Places of Detention International Conference hosted by the Ministry of Justice of the Netherlands. 2025: • Health in Prisons and Places of Detention International Conference, venue and host to be decided. 16 | Improving the health of people living in prisons in the WHO European Region A N N E X : K E Y O U T P U T S F R O M H I P P A C T I O N P L A N 2 0 1 9 – 2 0 2 1 T H A T H A V E S H A P E D A C T I O N P L A N 2 0 2 2 – 2 0 2 5 Some of the workstreams developed under the current Action Plan 2022–2025 result from previous work conducted under Action Plan 2019–2021 and its key outputs. K E Y O U T P U T S F R O M T H E P R E V I O U S A C T I O N P L A N Publications The first three publications collectively address the specific challenges posed by COVID-19 in prison settings. They have in common the aim to protect the health and well-being of all those who live and work in, and visit, these settings, and to support equivalence of care. The publication on the WHO prison health framework establishes the essential domains to monitor prison health system’s performance and suggests indicators for surveillance, in order to support informed decision-making. Preparedness, prevention and control of COVID-19 in prisons and other places of detention: interim guidance, 8 February 2021. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/ handle/10665/339830). This guidance was specifically developed for prisons and detention places to support staff working in prisons, as well as health and prison authorities, to prepare, prevent and address a potential outbreak of COVID-19. The guidance, it aims to protect the health and well-being of all those who live and work in, and visit, these settings and the population at large. The first interim guidance was published in April 2020. Improving the health of people living in prisons in the WHO European Region | 17 WHO COVID-19 prison surveillance protocol: monitoring and reporting COVID-19 in prisons and other places of detention. WHO Regional Office for Europe; 2021. (https://apps.who.int/iris/handle/10665/341499). This protocol sets the principles and definitions of a surveillance system devised by HIPP to monitor the evolution of COVID-19-related epidemiological data in prisons and other places of detention and to report the main measures adopted to prevent, control and manage the spread of the disease. Why people living and working in detention facilities should be included in national COVID-19 vaccination plans: advocacy brief. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/ handle/10665/341497). This advocacy brief was produced with the support of United Nations Office on Drugs and Crime and Penal Reform International, to support equivalence of care by calling for people living and working in prisons to be included in COVID-19 national vaccination plans. The brief highlights the evidence of enhanced risk of congregate living, aggravated by several environmental factors, including overcrowding, water sanitation, and limited access to fresh air. It also touches on inequalities in health status and unequal health-care provision, including access to personal protective equipment and to testing. The WHO prison health framework: a framework for assessment of prison health system performance. World Health Organization. Regional Office for Europe. Copenhagen: WHO Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/344561). This publication supports informed decision-making by providing a cohesive frame of reference for policy design and implementation. It describes the conceptualization, development and operationalization of the framework, which is intended to monitor and measure health-care delivery in a standardized way. The framework establishes the essential domains to monitor prison health system’s performance and suggests indicators for surveillance. The framework was used to establish Health In Prisons European Database (HIPED)survey, a periodic assessment of 53 Member States, whose results become available through the Global Health Observatory, aiming to inform progress in achieving equivalence of care for people living in prison. Training Capacity building in Member States is key to change and improve how prison health professionals develop and retain the competencies (knowledge, skills and attitudes) needed to foster prison health. During the COVID-19 pandemic, HIPP provided support to several Member States using varied formats, highlighting the need for tailored approaches. 18 | Improving the health of people living in prisons in the WHO European Region Training Prison Health workers in Armenia on Covid-19 prevention and control. 14–15 Oct 2021 Training for prison doctors in managing COVID-19 in prisons, as part of the “Solidarity for Health Initiative: addressing the COVID-19 pandemic in the Eastern partnership”. This tailor-made course was produced upon request of the Country Office in Armenia. Directed at prison physicians, it consisted of eight modules and counted with 78 participants. Multimedia Three videos and one podcast were produced to expand the traditional remit of HIPP by giving voice to people with lived experience, an area to be further pursued in future work. . “The most important thing inside prison is health”: Bruno shares his story. 17 Jul 2021 https://www.who.int/europe/multi-media/item/the-most-important-thing- inside-prison-is-health---bruno-shares-his-story “I walked through Recovery’s door”: Margaret’s story of fighting drug addiction after prison. 15 Nov 2021 https://www.who.int/europe/news/item/15-11-2021-i-walked-through- recovery-s-door-margaret-s-story-of-fighting-drug-addiction-after-prison Recovering from alcohol addiction in prison: Bruce shares his story. 16 Set 2021 https://www.who.int/europe/news/item/16-09-2021-recovering-from-alcohol- addiction-in-prison-bruce-shares-his-story Podcast in Russian “Depriving people of their freedom should not deprive them of their health. Oncological diseases within the framework of imprisonment.” Part one: Лишение людей свободы не должно лишать их здоровья. Онкологические заболевания в рамках тюремного заключения. Часть первая [Depriving people of their liberty should not deprive them of their health. Cancer as part of imprisonment. Part one]. (buzzsprout.com) Part two: Лишение людей свободы не должно лишать их здоровья. Онкологические заболевания в рамках тюремного заключения. Часть вторая [Depriving people of their liberty should not deprive them of their health. Cancer as part of imprisonment. Part two]. (buzzsprout.com) Part three: Лишение людей свободы не должно лишать их здоровья. Онкологические заболевания в рамках тюремного заключения. Часть третья [Depriving people of their liberty should not deprive them of their health. Cancer as part of imprisonment. Part three]. (buzzsprout.com) Improving the health of people living in prisons in the WHO European Region | 19 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.who.int/europe WHO/EURO:2023-7708-47475-69784 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 (Kingdom of the) North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Türkiye Turkmenistan Ukraine United Kingdom Uzbekistan 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. 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