“We called them for a long time. But by the time they came, she had already died” – The role of health systems and policy research in supporting reform for Women prisoners
By Stephanie Topp
In sub-Saharan Africa women prisoners constitute between 1% and 4% of the total prison population. Despite these low rates – a situation mirrored around the world where the median rate of female prisoners is around 4.4% – women prisoners in sub-Saharan Africa and elsewhere are particularly vulnerable. Evidence (predominantly from high-income countries) highlights the fact that women prisoners often experience higher rates of physical and mental disease compared to their male counterparts, and higher rates of emotional, physical and sexual abuse compared with non-incarcerated women. This vulnerability is due to a range of structural, relational and demographic factors, compounded by weak advocacy for and inclusion of women prisoners’ needs in domestic public policy debates.
Women prisoners represent the fastest growing incarcerated population globally and in sub-Saharan African prisons alone, there has been a 22% increase since 2000. Despite this, sub-Saharan African evidence on which to base advocacy or reform is lacking. Empirical research focussing on the experiences and issues of women prisoners is almost non-existent, (with a few notable exceptions here and here). Although growing concerns about HIV and TB epidemics in sub-Saharan prison populations has resulted in more recent studies (e.g. here and here) demonstrating high rates of infectious diseases, few of these report fully gender-disaggregated data making them less useful for understanding women prisoners’ disease burden or healthcare needs.
The Centre for Infectious Disease Research in Zambia has worked with the Zambian Corrections Service to map the interactions between some already-documented problems with the physical infrastructure, living conditions and nutritional status of Zambian women prisoners and other gender-driven social and cultural trends that place women prisoners at particular risk. This is part of the Zambian Prisons Health System Strengthening (ZaPHSS) project. In Zambia, with the exception of provision for female prison officers, structural conditions, security procedures, healthcare services, visitation guidelines and daily activities remain based on a predominantly male model of imprisonment. Yet paradoxically, women prisoners are actually afforded fewer services and less educational programming than their male counterparts. The relatively small overall number of women prisoners, moreover, means that gender specific concerns and gender mainstreaming in Zambian prison policy or officer training is not a political priority.
The health-systems informed work conducted under ZaPHSS has helped to reveal the dynamic relationship between prison resourcing, administrative biases, and inmate-officer relationships in creating and exacerbating health-related vulnerabilities. It has demonstrated, for example, how Zambian female prisoners’ access to health services is not only limited by the absence of internal clinics in any of the women’s facilities, but also by the priority given to male prisoners in accessing transport to reach external health centres, and by the ad hoc responsiveness of female officers to requests for healthcare – responsiveness influenced by factors including each individuals inmates’ status and wealth. The potential impact of these intersecting structural, organisational and relational factors is captured in one respondent’s account of the outcome for a critically ill cell-mate:
Women prisoners and their incidental children (those born in prison or accompanying them whilst they are incarcerated) are some of the least visible and most marginalised members of society. And the above mentioned work provides just a small insight into the way vulnerabilities and inequities experienced by women in society at large are being exacerbated and deepened by the prison experience. In the context of achieving Universal Health Coverage, such inequities should be viewed as unacceptable. In the equity-oriented field of health policy and systems research, moreover, we need to do more to bolster the evidence-base in what remains a chronically under-researched and poorly advocated-for population.