Evaluation of a health system strengthening initiative in the Zambian prison system

Abstract

IntroductionIn 2013, the Zambian Correctional Service (ZCS) partnered with the Centre for Infectious Disease Research in Zambia on the Zambian Prisons Health System Strengthening project, seeking to tackle structural, organisational and cultural weaknesses within the prison health system. We present findings from a nested evaluation of the project impact on high, mid-level and facility-level health governance and health service arrangements in the Zambian Correctional Service.MethodsMixed methods were used, including document review, indepth interviews with ministry (11) and prison facility (6) officials, focus group discussions (12) with male and female inmates in six of the eleven intervention prisons, and participant observation during project workshops and meetings. Ethical clearance and verbal informed consent were obtained for all activities. Analysis incorporated deductive and iterative inductive coding.Results Outcomes: Improved knowledge of the prison health system strengthened political and bureaucratic will to materially address prison health needs. This found expression in a tripartite Memorandum of Understanding between the Ministry of Home Affairs, Ministry of Health (MOH) and Ministry of Community Development, and in the appointment of a permanent liaison between MOH and ZCS. Capacity-building workshops for ZCS Command resulted in strengthened health planning and management outcomes, including doubling ZCS health professional workforce (from 37 to78 between 2014 and 2016), new preservice basic health training for incoming ZCS officers and formation of facility-based prison health committees with a mandate for health promotion and protection. Mechanisms: continuous and facilitated communication among major stakeholders and the emergence of interorganisational trust were critical. Enabling contextual factors included a permissive political environment, a shift within ZCS from a ‘punitive’ to ‘correctional’ organisational culture, and prevailing political and public health concerns about the spread of HIV and tuberculosis.ConclusionWhile not a panacea, findings demonstrate that a ‘systems’ approach to seemingly intractable prison health system problems yielded a number of short-term tactical and long-term strategic improvements in the Zambian setting. Context-sensitive application of such an approach to other settings may yield positive outcomes.

“It's Not Like Taking Chocolates”: Factors Influencing the Feasibility and Sustainability of Universal Test and Treat in Correctional Health Systems in Zambia and South Africa

“…A key contribution of this study is its consideration of both the interventional and contextual factors likely to affect UTT, synthesized through comparison of the influence of the different political, correctional, and health service delivery systems in Zambia and South Africa, respectively. It is also one of still very few articles 29 – 31 from the region describing any form of health intervention in the correctional context. Given the dearth of literature, we focus the Discussion on 3 major, cross-cutting lessons synthesized from the findings presented above, which are relevant to the broader study questions but also important flags for policy makers and programmers who may be considering UTT roll-out in correctional systems elsewhere.…”

“…The influence that the capacity of the correctional health system had on the feasibility and sustainability of UTT in correctional facilities is an intuitive but central finding. In Zambia, some recent progress in establishing internal health systems was noted, 29 , 31 but it was insufficient to independently support and sustain UTT. Chronic shortages of health providers on site, a still minimally staffed ZCS Health Directorate, a nearly absent health information system, and a weak supply chain undermined independent (ZCS-led) health service planning and delivery.…”

“…Counterintuitively, interviews with incarcerated males in the Zambian facility in this study described a strong culture of peer support for HIV testing and treatment, describing it as an important factor in their willingness to seek care, even where physical access was limited. As recent work has suggested that key populations in Zambia continue to face barriers to service utilization in the mainstream health system, 29 , 31 , 45 more work is needed to explore and trace the factors that may have enabled and strengthened this unusual and encouraging situation in the correctional facility.…”

The health system accountability impact of prison health committees in Zambia

“…This study provides insight into the formation and impact of a uniquely representative body – PrHCs – in the Zambian prison system. The establishment of PrHCs occurred against the backdrop of a project which was seeking to strengthen national and sub-national prison health system governance [ 22 , 36 ] with the aim of improving health service access and health outcomes for Zambian inmates. PrHCs were seen as the frontline embodiment of a broader effort to strengthen the responsiveness of the prison health system to inmate health needs, and the accountability of a range of stakeholders for the actions and decisions therein.…”

Cross-sectional assessment of tuberculosis and HIV prevalence in 13 correctional facilities in Zambia

“…and its associated risk factors in Zambia correctional facilities. [7][8][9][10] This study aimed to determine the current prevalence of all forms of TB, bacteriologically confirmed TB and drug-resistant (DR) TB, and the prevalence of HIV in 13 Zambian correctional facilities.…”