ABSTRACT
Background & Objectives
Sierra Leone suffers from a high TB burden and is among the poorest countries worldwide. Anticipating the fulfillment of the 2030’s TB control target, the Sierra Leonean government decided to active case-finding promotion in their correctional system (SLCS), together with providing quality TB care and prevention services provision. However, funding for such activities is insufficient. We aimed to perform a SWOC analysis of early active TB case detection in Sierra Leone’s correctional facilities.
Methods
A WHO Prison Health Framework-based healthcare performance assessment and system analysis were piloted in three SLCS facilities in Freetown in June 2022 to inform SWOC analysis. The evaluation applied a self-developed questionnaire based on the Sierra Leone Correctional Service Act 2014, the United Nations Office on Drugs and Crime (UNODC) checklist of the Mandela Rules, the minimum standards relating to HIV, HCV, TB, and harm reduction in prisons, and the validated WHO Harmonized Health Facility Assessment (HHFA) Combined questionnaire (April 2021). Data gathered by staff interviews during facility inspections were analyzed to develop improvement strategies.
Results
The SLCS assessment found that framework-based criteria were not met in 32, fully achieved in 22, and partly achieved in 67 of 121 pre-defined categories. The SWOC analysis identified more weaknesses and challenges than strengths and opportunities, resulting in overlapping improvement strategies. Areas significantly underserved were prison hygiene, nutrition, living conditions combined with overcrowding, and several health services, such as immunization, oral, ophthalmic, mental care, health protection, and promotion.
Interpretation & Conclusions
The SWOC findings are crucial for the government’s TB goals. However, proper financing is essential to all strategies, as the interventions request appropriate budgeting to function sustainably. The SLCS needs reliable funding mechanisms to transfer strategies into practice. Generally, Sierra Leone’s health system requires strengthening concerning universal health coverage and primary healthcare access to improve TB services and outcomes.
1. Introduction
Proper planning of TB screening programs is particularly essential in countries WHO has declared TB high-burden countries (HBCs).[1] Generally, the TB HBCs are low- and middle-income countries (LMIC), which regularly face the great challenge of distributing scarce financial resources so that the health sector and other population health-relevant sectors, such as economy, education, and security, receive sufficient financing for a minimum of positive development. Especially in low-income countries, e.g., in sub-Saharan Africa, TB, malaria, HIV/AIDS, and other infectious diseases are leading death causes like poverty, hunger, a fragile economy, and an overall poor infrastructure threat people’s health and lives every day.[2]
Sierra Leone is among the lowest in GDP, access to electricity, and clean water. Compared to the global average, Sierra Leone’s population has a lower life expectancy of 74.48% (54.07 years vs. 72.6 years) while the infant mortality rate is 2.77-fold, the maternal mortality rate even 5.3-fold higher than the world average. .[3] Overall, the population’s low health status adversely impacts Sierra Leone’s economic potential and the state system’s financing, including the health care system.[4]
Concerning the current TB situation in Sierra Leone, 24,000 incident TB cases were estimated for 2020, including 2,800 children. That estimate reflects a 5% increase compared to 2019 and continues the upwards trend observable since 2010. With 2,400 deaths registered in 2020, TB ranked the fifth cause of death concerning communicable, maternal, neonatal, and nutritional diseases.[5]
Although the Sierra Leonean government extended the 1973’s National Leprosy Control Program with a TB control component in 1990 and enforced program development through strategic plans, with the National TB and Leprosy Strategic Plan 2016-2020 (CORE PLAN) as the most recent, the local authorities failed to reach the global plan’s 90-(90)-90 targets to combat TB. In 2020, 66% of all infected with TB were reached, and 88% of those diagnosed with TB were successfully treated.[5–7]
Early identification of inmates with potentially infectious pulmonary TB (PTB) and targeted care of sick inmates is essential to effectively control TB within the prison system.[8] Concerning the increased infection risk for contact persons, the WHO recommends combining active and passive TB case-finding in prisons.[9]
Among different case-finding strategies, systematic screening of high-risk groups is essential to the WHO’s “End TB Strategy.” [10] That is also true in the correctional system, so initial screening of prisoners for active pulmonary TB is an established part of the medical admission examination in some countries, such as Berlin prisons in Germany.[11,12]
Anticipating the fulfillment of 2030’s TB control target, the Sierra Leonean government decided, among other measures, to “Promote active case finding in prisons and provide quality TB care and prevention services.” [13] One planned activity to achieve that goal is to “Carry systematic TB screening among prison workers, remands and inmates” and increase TB care and prevention awareness and service provider capacity building in the prison setting.[13,14]
However, Sierra Leone is among the poorest countries worldwide, and funding such activities is insufficient.[3] Thus, the government needs a “simple, fast and more sensitive point of care TB diagnostic test that can be readily implemented in resource-limited settings.” [15] We aimed to perform a SWOC analysis to assist in early active TB case detection in Sierra Leone’s correctional facilities.
2. Methods
2.1. Research Tools
TB screening services are commonly not provided solely or exclusively in health care practice, no matter the underlying setting’s characteristics. Usually, TB screening may be defined as a health care service component in a particular setting, such as the prison system, corresponding to the systems thinking approach, which combines different interventions to use them.[16] Concerning TB screening services, the U.S. Preventive Services Task Force provided a well-suited generic analytic framework that we adapted to Sierra Leone’s correctional system (Figure 1).[17]
Figure 1: : Generic Analytic Framework for Prison Entry TB Screening (modified)[17]
A six-step system analysis of health interventions assisted us with identifying feedback loops, bottlenecks, leverage points, and the proceeding SWOC analysis (Figure 2). Steps 1 to 3 are meant to promote system structure understanding, whereas steps 4 to 6 focus on investigating system effectiveness.[16] DAGitty version 3.0, released on 2019-01-09, helped visualize the factors’ interactions concerning TB entry screening in the SLCS system.[18]
Figure 2: The WHO Prison Health Framework[23]
2.2. Data Collection and Analysis
Three questionnaires were applied to conduct the investigations: the self-developed questionnaire based on the Sierra Leone Correctional Service Act and the United Nations Office on Drugs and Crime (UNODC) checklist of the Mandela Rules to derive information about prison and SLCS-specific health and human rights regulations, another self-developed questionnaire concerning the minimum standards relating to HIV, HCV, TB and harm reduction in prisons, and the validated WHO Harmonized Health Facility Assessment (HHFA) Combined questionnaire (April 2021).[19–22] Due to time constraints, the self-developed questionnaires were not validated.
Information about SLCS healthcare performance was gathered by personal interviews among various stakeholders involved in healthcare service delivery and healthcare-related activities within the correctional facilities and the National Leprosy and Tuberculosis Control Program (NLTCP). The pilot evaluation of the three SLCS facilities in Freetown took place from June 7 to 14, 2022.
After the interviews and internet search, all information from the three questionnaires was merged into one overall assessment matrix. The WHO Prison Health Framework considering the particularities of prisons and other confinement settings, served as a matrix foundation to analyze prison health system performance (Figure 2).[23] We extended the matrix by key performance indicators (KPIs), which were the key points stated at the beginning of each chapter of the WHO Prisons and Health Guide (2014) (KPI data shown in the results section).[24] The KPIs reflect the vision of inmates’ health improvement, health risk reduction, and risk mitigation within society related to imprisonment. [24]
The available data and information were sorted to the different WHO Prison Health Framework criteria. Consequently, 121 categories were assessed based on the KPIs. The findings were descriptively summarized and assessed by the level of achievement.
The achievement graduation scheme for KPIs with sub-items was as follows:
“No (N)” if more than 50% of the sub-item achievements were assessed with “No,”
“Partly (P)” if less than 50% of the sub-item achievements were assessed with “No,” or less than 90% of the sub-item achievements were assessed with “Yes,”
“Yes(Y)” if more than 90% of the sub-item achievements were assessed with “Yes.”
In the next step, the performance assessment results were transferred to a SWOC analysis to identify strengths, weaknesses, opportunities, and challenges regarding TB screening on admission to an SLCS facility.[25] Its findings were translated into a TOWS matrix to provide improvement strategies for the anticipated optimization of TB screening on admission to an SLCS facility.[26]
3. Results
3.1. Healthcare Performance Assessment
Table 1 (see supplement) summarizes the healthcare performance assessment results by achievement levels, based on the WHO Prison Health Framework and WHO Prisons and Health Guide criteria for the pilot evaluation. The WHO Prison Health Framework-based criteria were not met in 32 of 121 assessment categories, fully achieved in 22, and partly achieved in 67 categories.
Areas significantly underserved or in poor conditions (marked as “N” in Table 1) were prison hygiene, nutrition, and living conditions combined with overcrowding, immunization, mental, oral health, and ophthalmology services, and the availability of sexual/reproductive health products, needles, syringes, information on safe tattooing practices, inmates’ acceptability of prison healthcare delivery, and therapeutic spaces for people with drug use problems. Concerning continuity of infection control, testing for COVID-19 before release was missing. Besides that, the health system performance was not determinable regarding care quality due to lacking standardized procedures for reporting medication errors, notifying adverse drug reactions, and identifying people at risk of suicide/self-harm. Regarding health outcomes, no information was collected on self-reported health status and well-being, morbidity data about mental disorders, non-communicable diseases (NCD), dental disorder cases, mortality numbers regarding suicides, drug-related overdose deaths in prison (and following release), and COVID-19-related deaths. Need-adjusted health services were lacking for older inmates with complex ill conditions and pretrial detainees. All findings were transferred to the system analysis to set the grounds for SWOC analysis.
3.2. System Analysis
Figure 3 visualizes the interactions of the key influences and interventions with active TB as an outcome and the outcome of active TB identified through system analysis.
Figure 3: Interaction of Key Influences and Interventions on Active TB as Outcome and the Outcome of Active TB
The exposure was tuberculosis in the SLCS with the resulting outcomes of Active TB, Treatment completion, Cure, Death, Failure, and Interruption. The pathways with essential impact on the total effect of M. tuberculosis on Active TB, Treatment completion, Cure, Death, Failure, and Interruption in the SLCS were:
Housing/Living Conditions SLCS, Hygiene/Sanitation, Inmate Acceptability, Inmate Adherence, Inmate Characteristics, Inmate Consent, Med Staff Availability, Nutrition, Separation/Isolation
Housing/Living Conditions SLCS, Hygiene/Sanitation, Inmate Characteristics, Inmate Health Literacy, Nutrition, Separation/Isolation
Housing/Living Conditions SLCS, Hygiene/Sanitation, Inmate Characteristics, Prevalence of DR-TB, Prevalence of LTBI, Prevalence of active TB, Separation/Isolation.
That means the factors encompassed by the pathways have a significant positive or negative influence on TB exposure and TB-related outcomes depending on the factors’ effect direction.
3.3. SWOC Analysis
The SWOC analysis aimed to identify significant strengths, weaknesses, opportunities, and challenges concerning SLCS’s prison healthcare performance and TB screening procedures on admission to an SLCS facility (Table 2, see supplement).
Strengths
The prison and healthcare personnel are the big and ultimate plus of the SLCS. Their motivation and willingness to ensure conditions in compliance with the human rights of the detainees despite omnipresent structural violence is the main and vital driver for procedural improvements. That also applies to any inmate outcomes, including active TB. Additionally, the medical staff already performed physical examinations on admission and followed the national TB guidelines concerning case notification and treatment. Screening and treatment were also available for other communicable and non-communicable diseases, as were some health protection measures, all-cause mortality reporting, and published inspection reports of prison hygiene, nutrition, and living conditions. The Ministry of Internal Affairs is the authority responsible for SLCS healthcare financing.
Weaknesses
The identified weaknesses were related to a poorly maintained and outdated infrastructure that does not meet the current needs of inmates and staff regarding welfare, safety, and security. Lacking human and material capacities caused several underserved SLCS services concerning food, water, electricity, housing, and specific healthcare services, e.g., dental, mental, and eye care. Most identified weaknesses were caused by systemic failures, which were mostly related to financial and infrastructural deficiencies. They are internal factors but rely on external circumstances such as sufficient funding and budgeting of infrastructural conditions, human and material resources, and the reliable availability of daily necessities like drinking water, electricity, or food.
Opportunities
Opportunities for development and improvements within the SLCS refer to governmental policies and laws to fulfill international human rights regulations and the UN Sustainable Development Goals. In addition, established national development and control programs, such as the National Leprosy and TB Control Program, are a valuable cooperation source. Other options could arise from collaborative national and international networks comprising civil society movements, governmental and non-governmental organizations engaged in (health) system strengthening, confined populations, or disease management. Discovering new human resources, extending IT support, and applying a quality management system may open further doors for beneficial development strategies.
Challenges
The challenges the SLCS faces are based on Sierra Leone’s fragile economic situation. Insufficient financial capacities were responsible for the infrastructural, personnel, material, and procedural deficits observable within the SLCS facilities. Thus, building reliable SLCS funding and financing mechanisms is the most challenging issue when the entire national system calls for monetary support and economic development.
Summary
The SWOC analysis found more weaknesses and challenges than strengths and opportunities (Table 2, see supplement). Thus, the strategies focusing on weaknesses to take advantage of opportunities or to overcome challenges comprise more activities for improvement than those involving SLCS’s strengths. Nevertheless, the strategies include some identical leverage points and thus overlap. Conclusively, all findings are crucial for the government’s mission to fulfill the globally established long-term goal of ending TB by 2035. However, the utmost essential to all strategies is proper SLCS financing, as all interventions request appropriate funding and budgeting to function reliably.
Further considerations about mitigating the bottlenecks and fostering the leverage points identified are presented in detail in the discussion section.
4. Discussion
Concerning the SLCS health performance assessment, about 16.5% (22) of the 121 categories assessed reached the full criteria achievement, while 26.4% (32) of the analyzed categories did not meet the requirements defined. The 67 remaining categories (57.1%) partly fulfilled the key performance indicators (Table 1, see supplement).
These findings, combined with those of the system analysis, resulted in four different TWOS strategies to improve the early detection of active TB embedded in the overall SLCS system and healthcare delivery services (Table 2, see supplement).
Nevertheless, from a public health perspective, the prison environment also offers opportunities to control the spread of TB:
Because they are highly controlled environments, however, prisons can achieve infection prevention and control through systematic screening on arrival at prison, regular health monitoring of all people in prison and targeted controls on movement in and out of facilities. The prison environment can also allow for identification of vulnerable individuals, early detection, rapid testing and contact tracing, as well as awareness raising and support initiatives, and vaccination and treatment programmes which can reach entire prison populations.[27]
None of the four strategies provided can be judged as preferable, as all areas need promotion and support. Ultimately, all strategies must be applied to achieve any development and improvement. However, serving one strategy will surely leverage positive proceedings within the other strategies’ tasks as all strategies share joint realms. Nonetheless, the utmost vital duty is establishing a sustainable and sufficient funding mechanism for the SLCS. Otherwise, although the SLCS may set procedural improvements into force, it is questionable whether the SLCS staff will have the resilience to run the processes continuously and properly when daily facing enormous structural violence concerning infrastructure, consumables, salaries, human and material resources, working and living conditions, and security.
The most important issue is establishing a sufficient and reliable financing and budgeting mechanism to develop the underserved SLCS areas with unmet KPIs.
In the last decade, other institutions put efforts into SLCS assessments, also focusing on the essentials of the SLCS system. In December 2015, the International Criminal Justice and Prisons Consultant Glenn Ross published a Capacity Assessment Report about the Sierra Leone Correctional Services.[28]
Ross concluded that the Correctional Service:
Does not have the current capacity to ensure the safety and security of inmates, staff, and society.
Does not have the current capacity to provide for inmate welfare, although it does have some plans deserving of being supported.
Has a developing capacity to provide for the reformation, rehabilitation, and reintegration of inmates but requires assistance.
Has a partial capacity to provide for human resources and logistical capabilities, but that assistance is still required.
Does have the current and future capacity to provide for the welfare of staff.
That there are opportunities available to the Correctional Service that would enable or support prison reform.
That the community is supportive of prison reform, or at the least not opposed to it.
That the management team of the Correctional Service has the desire and the capability to embrace the opportunities for change and to maximise them.[28]
- In the overall assessment, Ross pointed out SLCS’s need for assistance concerning financial, human, and technological resources in addition to technical support in various areas.[28]
- ‘The proceeding UNDP – SLCS project “Promoting Institutional Reform of the Sierra Leone Correctional Services” from October 1, 2016, to March 31, 2019, funded by the US Department of State, Bureau of International Narcotics and Law Enforcement Affairs (INL), achieved some improvements concerning international human rights standards for inmates and staff by decongestion and additional staff recruitment.[29]
- nonetheless, the issues of overcrowding, staff shortage, and other essential services such as hygiene, sanitation, nutrition, and adequate housing and living conditions are still present seven years later. Additionally, the loss of the hospital infrastructure by the fire in the Pademba Road facility in April 2020 significantly weakened the SLCS health service capacities in the three Freetown-based facilities. The negative effects are observable until today as the government has been unable to reconstruct the hospital and reinstall the equipment.
- The missing essential healthcare infrastructure is a critical step back from the improvements the before-mentioned UNDP-SLCS and other development projects achieved, as it worsens the prison environment for inmates and SLCS staff. Despite all obstacles and difficult working conditions, the SLCS management and staff remain highly supportive and appreciative of international researchers, combined with huge empathy for their work. The burden and challenges they accept while attempting to fulfill their duties following national law and international human rights regulations were impressive to experience.
- In the end, the current overall situation for the SLCS is still like Aruna Kallon from the Centre for Accountability and the Rule of Law in Sierra Leone stated in an online press release on June 12, 2014:
Arguably, the underfunding of the prisons and the short supply of logistics, coupled with overcrowding, are responsible for the poor services rendered by prison officers to the detriment of detainees. There is, therefore, an overarching need for government to consider increasing funding to the prisons department, which is often the least funded, unlike the Judiciary and Police, which receive the lion’s share of funds allocated to the justice sector.
In conclusion, a combination of effective implementation and an increased funding by the government to the prisons would be a good shoulder for the prisons department to climb. For our justice system to match international standards, vigorous and genuine efforts should be made to improve the efficiency and effectiveness of the system so that justice and the enjoyment of basic freedoms do not become the luxury of only the privileged in society. [30]
- Kallon’s demands and conclusion have remained justified until today. Although the hurdles within the SLCS system are not easy to overcome and may persist in the future, a way out of this dilemma is using the strategies identified by the SWOC analysis for positive SLCS development by improving the critical areas that are underserved now.
- Without a doubt, constructing a new modern correctional center at Songo village or another appropriate site is the most vital measure to enforce as this approach has the potential to solve several serious issues at the same time, namely overcrowding, poor prison environment in terms of hygiene, sanitation, housing, living, and staff working conditions. The international donor community may offer financial aid to ensure inmates’ human rights are recognized and safeguarded by an SLCS environment beneficial for both persons in detention and employed.
- A disaster risk management plan, including public health aspects, should accompany the realization of a new modern prison facility. Such a plan aims to achieve a disaster-resilient correctional system over the entire spectrum of possible threats.
4.1. Limitations and Strengths
- Our work was the first to operate with the WHO Prison Health Framework in West Africa. Research activities mainly relied on data and information collected by methods derived from qualitative research. However, the research efforts focused more on data and information of a quantitative than qualitative nature. Therefore, the data collection methods did not strictly follow qualitative approaches such as guided interviews or focus groups. The reasons for applying multiple questionnaires for the correctional facility and health service assessment lay in their individual service area coverage and limitations, which impacted the range and depth of information and data collection.
- The findings generated by the WHO Prison Health Framework application can deliver valuable information for target decision-making within the SLCS and at the governmental level to foster prison health services, healthcare equivalence, and comprehensive human rights fulfillment for persons in detention in Sierra Leone.
- A more comprehensive, in-depth system analysis than that performed was behind the scope of this investigation. However, considering the areas and key performance indicators investigated, all information needed for a broad but detailed exploration of the SLCS health and overall system are available and can be updated annually by applying the methods used for this pilot assessment. The recommendations from the KPI achievement level findings apply within the system analysis context. They may significantly improve the criteria covered by the SLCS healthcare performance assessment and strengthen the health and SLCS overall system if implemented and developed further as a routine.
5. Conclusions
- The observed prison health service situation in the three SLCS facilities calls for system strengthening, focusing on living condition improvement and essential health service delivery concerning high-burden diseases such as TB. However, Sierra Leone is prone to financial resources and skilled personnel. These restrictions significantly impact daily life and health services in any resource-limited setting, including TB case-finding strategies like TB entry screening in prisons.
- As Aruna Kallon wrote, “a combination of effective implementation and an increased funding by government to the prisons” are the leverages to sustainable improvements of the inmates’ living conditions, working conditions, and service provision within the SLCS concerning the international human rights standards. [30]
- The construction of a new SLCS facility at Songo village or another appropriate location can properly support the Sierra Leonean government to guarantee international human rights standards and fulfill the 2030’s TB control target in the SLCS. [13]
The SLCS needs a reliable national funding mechanism fostered by international donor organizations to convert system-strengthening recommendations into practice and, foremost, to plan and execute the construction of a modern, resilient, and sustainable correctional center with sufficient inmate capacities.
REFERENCES
[1] World Health Organization. Use of High Burden Country Lists for TB by WHO in the Post-2015 Era. Geneva: World Health… Geneva: 2015. [2] Skolnik R. Global Health 101. 4th edition. Burlington, Massachusetts: Jones & Bartlett Learning; 2019. [3] World Bank. World Development Indicators. DataBank n.d. https://databank.worldbank.org/source/world-development-indicators (accessed November 29, 2020). [4] Bloom D, Canning D. Health as Human Capital and its Impact on Economic Performance. Geneva Pap Risk Insur Issues Pract 2003;28:304–15. [5] Stop TB Partnership. SIERRA LEONE TB Dashboard n.d. https://www.stoptb.org/static_pages/SLE_Dashboard.html (accessed December 28, 2021). [6] Siroka A. Costing of the Sierra Leone National Strategic Plan for TB 2016-2020. Geneva: WHO Global TB Programme; 2015. [7] Stop TB Partnership. Global Plan to End TB 2018-2022. Geneva: 2019. [8] Robert Koch-Institut. Tuberkulose – Thorax-Röntgenuntersuchungen bei Asylsuchenden gemäß § 36 Absatz 4 IfSG 2015. https://www.rki.de/DE/Content/InfAZ/T/Tuberkulose/Tuberkulose_Roentgen-Untersuchungen_Asylsuchende.html (accessed April 13, 2020). [9] World Health Organization. Tuberculosis in prisons. WHO 2020. http://www.who.int/tb/areas-of-work/population-groups/prisons-facts/en/ (accessed April 13, 2020). [10] World Health Organization. Systematic screening for active tuberculosis: an operational guide. Geneva: World Health Organization; 2015. [11] Boes L. Die Tuberkulosesituation im Berliner Justizvollzug. Epidemiol Bull Nr 11-122014 2014:12. [12] Pape S, Groß F, Ulrichs T. [The Tuberculosis Situation in the Berlin Prison System from 2011-2016-a Follow-up Study]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019;62:893–903. https://doi.org/10.1007/s00103-019-02977-z. [13] Ministry of Health and Sanitation. National Leprosy and Tuberculosis Strategic Plan (2016-2020) CORE PLAN. Freetown: Government of Sierra Leone; 2016. [14] Telisinghe L, Charalambous S, Topp SM, Herce ME, Hoffmann CJ, Barron P, et al. HIV and tuberculosis in prisons in sub-Saharan Africa. Lancet Lond Engl 2016;388:1215–27. https://doi.org/10.1016/S0140-6736(16)30578-5. [15] Tadesse M. Improving the diagnosis of tuberculosis in hard to diagnose populations: Clinical evaluation of GeneXpert MTB/RIF and alternative approaches in Ethiopia. PhD Thesis. University of Antwerp, 2018. [16] Riegelman R, Kirkwood B. Public Health 101: Improving Community Health. 3rd edition. Burlington, MA: Jones & Bartlett Learning; 2018. [17] Mabry-Hernandez I, Curry S, Phillips W, García F, Davidson K, Epling J, et al. U.S. Preventive Services Task Force Priorities for Prevention Research. Am J Prev Med 2018;54:S95–103. https://doi.org/10.1016/j.amepre.2017.08.014. [18] Textor J, van der Zander B, Gilthorpe MS, Liskiewicz M, Ellison GT. Robust causal inference using directed acyclic graphs: the R package “dagitty.” Int J Epidemiol 2016;45:1887–94. https://doi.org/10.1093/ije/dyw341. [19] World Health Organization. Harmonized Health Facility Assessment Questionnaires 2023. https://www.who.int/data/data-collection-tools/harmonized-health-facility-assessment/questionnaires (accessed February 22, 2023). [20] The Sierra Leone Correctional Service Act 2014. vol. Vol. CXLV, No. 49. 2014. [21] United Nations Office on Drugs and Crime. Assessing Compliance with the Nelson Mandela Rules: A Checklist for Internal Inspection Mechanisms. Vienna, Austria: 2018. [22] Sander G, Shirley-Beavan S, Stone K. The Global State of Harm Reduction in Prisons. J Correct Health Care Off J Natl Comm Correct Health Care 2019;25:105–20. https://doi.org/10.1177/1078345819837909. [23] Alves da Costa F, Verschuuren M, Andersen Y, Stürup-Toft S, Lopez-Acuña D, Ferreira-Borges C. The WHO Prison Health Framework: a framework for assessment of prison health system performance. Eur J Public Health 2022;32:565–70. https://doi.org/10.1093/eurpub/ckac020. [24] World Health Organization. Prisons and Health. Copenhagen: World Health Organization, Regional Office for Europe; 2014. [25] Davalagi SB, Palicheralu BS, Murthy SSN, Hurlihal S. Acceptance of artificial intelligence (AI)-based screening for breast health in urban slums of central Karnataka, India – SWOC analysis. J Fam Med Prim Care 2022;11:6023–8. https://doi.org/10.4103/jfmpc.jfmpc_143_22. [26] Senthilkumar S, Durai MM, Sharmila A, Poornima J. Business Policy and Strategic Management. New Delhi, India: S. Chand Publishing; 2014. [27] Penal Reform International. Prisons in Crises: Health crises n.d. https://www.penalreform.org/global-prison-trends-2021/special-focus-2021-prisons-in-crises/health-crises/ (accessed January 2, 2022). [28] Ross G. Capacity Assessment Report – Sierra Leone Correctional Services. Freetown: United Nations Development Programme; 2015. [29] United Nations Development Programme. From Prisons to Corrections: Promoting Institutional Reform of the Sierra Leone Correctional Services 2016. [30] Kallon A. Sierra Leone Prisons Service Behind Bars: Is Additional Funding a Remedy? Press 2014. https://www.carl-sl.org/pres/sierra-leone-prisons-service-behind-bars-is-additional-funding-a-remedy/ (accessed August 22, 2022). [31] Forget EJ, Menzies D. Adverse reactions to first-line antituberculosis drugs. Expert Opin Drug Saf 2006;5:231–49. https://doi.org/10.1517/14740338.5.2.231. [32] Ramachandran G, Swaminathan S. Safety and tolerability profile of second-line anti-tuberculosis medications. Drug Saf 2015;38:253–69. https://doi.org/10.1007/s40264-015-0267-y.
ARTICLE INFORMATION
1. Acknowledgments
This research would not have been realized without the permission of the Minister of Internal Affairs, Mr. David Maurice Panda-Noah, and the SLCS Director General, Mr. Joseph Lamboi. Particular appreciation is given to the outstanding support from SLCS Deputy Director-General Colonel Sahr David Thomas Ngaujah.
Appreciation is also extended to Reverend Remie Tonkie, Regional Health Officer Ibrahim Lamin, and other SLCS staff members for their patience in answering numerous interview questions, their valuable responses, providing access to sites and documents, making appointments, and accompanying the travels to extramural institutions, and last but not least their heart-warming empathy.
So are members of the National Leprosy and Tuberculosis Control Program, Dr. Kassa Hailu Ketema, National Professional Officer – TB, WHO Sierra Leone, Walter-Neba Chenwi, Esq., UNDP Rule of Law Programme Specialist, Reverend Paul Brima Bangura, National Executive Director of the Civil Society Movement against TB, Sierra Leone (CISMATSL), and Mr. Andrew M. Jefferson, a senior researcher at the Danish DIGNITY Institute. Appreciation also goes to Mr. Ahmed Jalloh and his colleagues from Prison Watch Sierra Leone (PWSL), who introduced me to the SCLS management and provided crucial assistance with other information.
Additionally, I want to thank all members of the Bah family for their cordial hospitality and tremendous support during my stay in Freetown. The same applies to several other Sierra Leoneans who facilitated my daily life in Freetown in so many ways.
2. Conflicts of interest
The authors declare no conflict of interest.
3. Ethics approval
The research was performed with the permission of the Minister of Internal Affairs, Mr. David Maurice Panda-Noah. No individual data were collected, stored, or reported, allowing conclusions to anyone living in confinement.
4. Consent to participate
Not applicable.
5. Financial Support & Sponsorship
6. Authorship
Stephanie Pape designed the research methodology and conducted the assessment and analysis. Shiddharudha Shivalli, Kabiru Gulma, and Laurent Cleenewerck contributed to the research methodology. Sahr David Thomas Ngaujah assisted with gathering data and information. Stephanie Pape is responsible for the descriptive data analysis, interpretation, and manuscript draft. Shiddharudha Shivalli and Laurent Cleenewerck supervised the research. Sahr David Thomas Ngaujah, Kabiru Gulma, Shiddharudha Shivalli, and Laurent Cleenewerck contributed to reviewing and editing the manuscript.
SUPPLEMENT
Table 1: SLCS Healthcare Performance Assessment – Overall Achievements
| WHO Prison Health Framework – Criteria | Overall Achievement
Y = Yes P = Partly N = No |
| BUILDING BLOCK 1. HEALTH SYSTEM | |
| 1) Organization | |
| Prison healthcare governance: agency/ministry responsible; level of governance (national, subnational, or regional) | P |
| Community healthcare governance | P |
| Inspection of prison hygiene, nutrition, and living conditions | N |
| 2) Financing | |
| Healthcare finance: agency/ministry responsible | Y |
| Coverage of prison health care by a national health insurance program (including national health service, if applicable) | P |
| Coverage of community health care by national health insurance program (including national health service, if applicable) | P |
| 3) Vision and strategy | |
| 1. The essentials about prisons and health | P |
| Existence of a prison health strategy | P |
| Implementation of prison health strategy | P |
| Evidence of use of prison health data for planning purposes | P |
| 4) Health information | |
| Existence of a system for recording deaths in custody and parameters included (e.g., cause of death) | P |
| Existence of systems for the notification of infectious diseases | Y |
| Completeness of reporting systems | P |
| Education and training for healthcare providers responsible for coding (e.g., diagnosis or causes of death) | P |
| Existence of health records in prisons | P |
| Exhaustiveness of data captured in health information records in prisons | P |
| Capacity of systems for timely reporting of surveillance data (e.g., COVID-19) | P |
| Integration of prison information in the national health information system and systems in place for transferring information to the national system | P |
| BUILDING BLOCK 2. HEALTH SERVICE DELIVERY | |
| 1) Preventive services: disease prevention | |
| Existence of urgent health needs assessments at prison admission | Y |
| Existence of a detailed review of health needs subsequently conducted | P |
| Health problems evaluated in such assessments: | P |
| Behavior issues (alcohol use, drug use, injection drug use, smoking status) | P |
| Screening for mental health disorders | P |
| Evaluation of NCDs and their control (assessment of blood pressure, calculation of body mass index (BMI), assessment of respiratory problems) | Y |
| Assessment of oral health problems | N |
| Assessment of signs and symptoms of infectious diseases, including availability of screening (TB, MDR-TB, HIV, HCV, HBV, STIs) | Y |
| Availability of screening for selected cancers (cervical cancer, colon cancer, breast cancer), including evaluation of methods and inclusion criteria in comparison to the community | P |
| Access to HBV vaccination | N |
| Provision of other immunization services against vaccine-preventable diseases in line with national vaccination plan | N |
| 2) Preventive services: health protection | |
| Cleaning products availability (e.g., bleach) | Y |
| Sexual/reproductive health products availability (e.g., condoms, tampons) | N |
| Needle/syringe availability | P |
| COVID-19 protective material (e.g., hand sanitizer, face masks) | N |
| 3) Preventive services: health promotion | |
| 21. Promoting health in prisons: a settings approach | P |
| Availability of information on safe tattooing practices | N |
| Availability of therapeutic spaces for people with drug use problems | N |
| Smoke-free policies implemented | Y |
| Policies in place for promotion of physical activity | P |
| 4) Rehabilitation | |
| Availability of user-driven treatment and recovery plans | P |
| Availability of educational and employment training programs | P |
| 5) Medical care: provision of primary care | |
| 20. Primary health care in prisons | P |
| Infectious disease outbreak preparedness | P |
| Access to diagnostic tests | P |
| Provision of primary care for infectious diseases, including access to and completion of treatment | P |
| 8. TB prevention and control care in prisons | P |
| TB: access to and completion of treatment | Y |
| MDR-TB: access to and completion of treatment | Y |
| 7. HIV and other blood-borne viruses in prisons | P |
| HIV: access to and continuity of treatment | P |
| STI: access to and completion of treatment | Y |
| HBV: access to treatment | Y |
| Provision of primary care for mental health disorders: | |
| Mental health assessment and access to treatment | N |
| Substance use disorders and access to pharmacological treatment | N |
| Provision of primary care for oral health disorders: | N |
| Oral health visits | N |
| Provision of primary care for NCDs: | P |
| Diabetes routine visits and access to pharmacological treatment | P |
| Ophthalmology routine visits | N |
| CVD routine visits and access to pharmacological treatment | P |
| Access to hypertension pharmacological treatment | Y |
| Access to cancer treatment | Y |
| 6) Medical care: arrangements for secondary and tertiary care: | |
| Diversion to specialized treatment for mental health disorders | N |
| Diversion to specialized cancer treatment | Y |
| 7) Medical care: continuity of care | |
| Registration with a general practitioner | P |
| Protocols for continuity of care, including establishment of shared care plans | P |
| Medication reconciliation at admission | P |
| Supply of medication upon release | P |
| Availability of testing for COVID-19 ahead of release | N |
| 8) Health system performance: availability | |
| Workforce:
→ Number of healthcare staff → Number of physicians → Number of psychiatrists → Number of dentists |
P |
| Supply continuity for vaccines and other medicines | P |
| Availability of additional preventive services, such as post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), and needle and syringe exchange program (NSEP) | P |
| 9) Health system performance: accessibility | |
| Out-of-pocket payments for services or health-related products | P |
| 10) Health system performance: acceptability | |
| Prison healthcare delivery | N |
| Consent for health tests, assessments, and interventions | P |
| 11) Health system performance: quality of care | |
| Assessments of the availability of essential medicines | P |
| Standardized procedure for reporting medication errors | N |
| Standardized procedure for notifying adverse drug reactions | N |
| Standardized procedure for identifying people at risk of suicide/self-harm | N |
| Mechanism for ensuring patient involvement in healthcare planning and reform | P |
| BUILDING BLOCK 3. HEALTH OUTCOMES | |
| 1) Health and well-being | |
| Self-reported health status and well-being | N |
| Access to mental health counselors | N |
| Availability of contacts with family and social networks outside prison | P |
| 2) Morbidity | |
| Mental disorder cases, including psychotic disorder cases and suicide attempts | N |
| NCD cases, including hypertension, CVD, diabetes, and cancer | N |
| Infectious disease cases, including TB, MDR-TB, HIV, HCV, HBV, STIs, and COVID-19 | Y |
| People with oral health problems | N |
| 3) Mortality | |
| Number of deaths in prison by any cause (all-cause mortality) | Y |
| Number of suicides in prison | N |
| Number of drug-related overdose deaths in prison (and following release) | N |
| Number of COVID-19-related deaths (specific indicator developed for 2020/2021) | N |
| INFLUENCING FACTOR 1. PRISON ENVIRONMENT | |
| 4. Violence, sexual abuse, and torture in prisons | P |
| Overcrowding (official capacity and prison population) | N |
| Solitary confinement | P |
| Availability of basic and improved sanitation | N |
| Availability of facilities and procedures to allow physical activity | P |
| Access to outdoor green space | P |
| Nutritional options aligned with cultural and gender needs (food systems in place) | N |
| INFLUENCING FACTOR 2. HEALTH BEHAVIORS | |
| Overweight and obesity | P |
| Tobacco use | P |
| Alcohol use | P |
| Drug use | P |
| Injection drug use | P |
| Physical activity (exercise routines) | P |
| CROSS-CUTTING PRINCIPLE 1. ADHERENCE TO INTERNATIONAL STANDARDS FOR HUMAN RIGHTS AND GOOD PRISON HEALTH | |
| 2. Standards in prison health: the prisoner as a patient | P |
| 3. Prison-specific ethical and clinical problems | P |
| Scope and standard of health services in prison and their equivalence with the outside community | P |
| Workforce accreditation, professional and ethical standards, and their equivalence with the outside community | P |
| Incorporation of international prison law into national law | P |
| Clinical independence | Y |
| Publicly available inspection reports of prison hygiene, nutrition, and living conditions | Y |
| Existence of complaints system | P |
| Consideration of prisons in health prevention plans (including vaccination) | P |
| CROSS-CUTTING PRINCIPLE 2. REDUCING HEALTH INEQUALITIES AND ADDRESSING THE NEEDS OF SPECIAL POPULATIONS | |
| 17. Prisoners with special needs | P |
| National standards to meet the health needs of vulnerable people (women, children and youth, LGBTIQ, foreign nationals, ethnic minorities, people who use drugs, elderly, people with disabilities) | P |
| Meeting distinctive needs of foreign and migrant people in prison: availability of information in multiple languages | P |
| 18. Women’s health and the prison setting | P |
| Meeting the needs of women in prison: female healthcare staff | Y |
| Meeting the needs of women in prison: pregnancy tests offered | Y |
| Meeting the needs of women in prison: deliveries (births) in prison | P |
| 19. The older prisoner and complex chronic medical care | N |
| 6. Health in pretrial detention | N |
Table 2: SLCS SWOC Analysis Results
| Internal Factors
External Factors |
Strengths
(1) A definite authority responsible for healthcare financing, (2) Participation in infectious diseases notification systems, (3) Provision of health need assessments at prison admission, (4) Non-communicable disease (NCD) evaluation and control, (5) Screening of infectious diseases, (6) Cleaning products available for health protection, (7) Sustainable smoke-free policies, (8) Treatment access and continuity or completion for TB, HIV, STI, HBV, hypertension, and cancer, including referrals to secondary and tertiary care, (9) Morbidity data delivery for TB, (10) All-cause mortality data delivery, (11) Clinical independence, (12) Publicly available inspection reports of prison hygiene, nutrition, and living conditions, (13) Meeting the needs of female inmates in terms of female healthcare staff and pregnancy test availability, (14) Motivated and empathetic healthcare personnel applicable to positively impact inmates’ health-related behavior. |
Weaknesses
(1) Healthcare and prison staff shortage; (2) Loss of the hospital infrastructure, including medical and laboratory equipment; (3) Poor prison environment conditions (sanitation, hygiene, nutrition, housing, overcrowding); (4) Poor or missing IT infrastructure for medical control and patient documentation, (5) Weak supply chain of medical and non-medical equipment and consumables, (6) SLCS personnel pursuing their interests predominantly, (7) Poor oral health services in terms of prevention, diagnosis, and treatment, (8) No immunization services, (9) Lacking health protection services concerning sexual/ reproductive health products and needle/syringe availability, (10) Lacking health promotion services related to the availability of information on safe tattooing practices and therapeutic spaces for people with drug use problems, (11) Poor provision of primary care for mental health disorders, including referrals to secondary and tertiary care, (12) No ophthalmology routine visits, (13) No COVID-19 testing before release, (14) No information about inmates’ acceptability of prison healthcare delivery, (15) Lacking standardized procedures for reporting medication errors, notifying adverse drug reactions, and identifying people at risk of suicide/self-harm, (16) No information about health outcomes, e.g., self-reported health status and well-being, morbidity data about mental disorders, NCD, dental disorder cases, and mortality numbers regarding suicides, drug-related overdose deaths in prison (and following release), and COVID-19-related deaths, (17) No need-adjusted health services for older inmates with complex ill conditions and pretrial detainees. |
| Opportunities
(1) Governmental efforts on prison health (MOHS CORE PLAN) – financing (2) Technological progress in the field of TB diagnostics (3) National Leprosy and TB Control Program (NLTCP) (4) Civil movement societies, governmental (GOs), and non-governmental organizations (NGOs) (5) Information Technology (6) (International) Correctional service associations (7) International correctional system commissioners (8) Human resources (9) Quality management system |
Opportunity-Strength (OS) Strategies
è Application for financial, personnel, and material support from the MOHS to enable a sufficient response to the CORE PLAN implications è Closer cooperation with the NLTCP staff concerning annual mass screenings and applying GeneXpert services to every newly admitted inmate (more accurate entry screening); applying a more accurate in-house screening algorithm than currently established; investigating the benefits of new innovative diagnostics in the SLCS setting. è Engaging more intensely with civil movement societies, GOs, and NGOs, e.g., Doctors without Borders (MSF), CISMAT-SL, Prison Watch SL, AdvocAid, Don Bosco Fambul, UNDP, and other organizations focusing on prison health, human rights, and (health) system strengthening. è Collaboration with other nations’ correctional systems to share information, policies, procedures, and experiences. è Collaboration with international correctional system commissioners to share information, policies, procedures, and experiences. è Fostering and promoting SLCS staff and ensuring their welfare to indicate the appreciation of their motivation and dedication to inmate care. |
Opportunity-Weakness (OW) Strategies
è Applying for funding to overcome contextual risk factors such as overcrowding and the loss of the hospital infrastructure to significantly improve prison hygiene, nutrition, living conditions, and the control of disease transmission by comprehensive infrastructural development of the SLCS facilities. That should also include designated wards to appropriately house inmates with mental disorders and isolate those with infectious diseases. Also, that involves regular payments of staff salaries and affordable housing close to the working places apart from the welfare, safety, and security of inmates and staff. è Implementing an electronic hospital management information system (HMIS) to monitor and report inmate health outcomes and control the medicines and medicinal products supply chains, storage, and consumption; generating these data support annual budget planning and SLCS financing. è Implementing an electronic quality management system and standard operating procedures for all relevant SLCS activities to monitor and control concerning safety and security of inmates, staff, and society, inmates and staff welfare, human resource, and logistics capability. è Strengthening healthcare/medical staff resources by integrating medical, pharmacy, biotechnological, and nursing students in prison health services as part of their educational training. |
| Challenges
(1) Funding sources (funding sources, donors, legislature) (2) Economic overall situation of Sierra Leone (3) Prison environment: (4) TB epidemiology and services: (5) Prison health services: (6) Inmates’ characteristics, i.e., comorbidities, risk factors, health literacy, acceptability, consent, and adherence to counseling and healthcare interventions |
Challenge-Strength (CS) Strategies
è Applying for funding with the Ministry of Internal Affairs as the responsible authority for SLCS financing to improve the overall prison environment conditions concerning housing, hygiene, sanitation, nutrition, and overcrowding in each facility. è Training, support, and promotion of the SLCS healthcare and general staff to foster their impact on inmate characteristics improvements, i.e., comorbidity management, risk factor mitigation, increasing health literacy, SLCS health service acceptability, consent, and adherence. è Intensifying TB screening, treatment, and monitoring efforts to decrease the transmission risk and control TB effectively in an under-financed prison setting. è Implementing a reliable system for reviewing or reporting inmates’ acceptability of prison healthcare delivery to identify hurdles and needs for improvement. è Establishing health protection and promotion initiatives to lower the prevalence of underweight, ill-condition, and infectious diseases among inmates and detainees. |
Challenge- Weakness (CW) Strategies
è Applying for funding with international door organizations coordinated by the Ministry of Internal Affairs to finance infrastructural development projects, including: è Improving the overall prison environment conditions concerning housing, hygiene, sanitation, nutrition, and overcrowding in each facility. è Reconstructing the hospital infrastructure with the formerly established SLCS health services and delivery quality levels. è Moving the main male correctional center from Pademba Road to a newly constructed SLCS facility at Songo Village (acc. published plannings). è Improving the working conditions for SLCS staff by considering appropriate salaries, occupational health services, and housing opportunities in the surroundings of SLCS facilities. è Assessing and discussing alternatives to pretrial detention considering overcrowding reduction with the Ministry of Internal Affairs as the responsible authority. è Ensuring financial, infrastructural, and personnel capacities to enable full-service capabilities of SLCS’s general and medical staff. è Employing additional general and medical personnel to provide extended services as needed acc. to strategic SLCS development policies è Regular staff training programs to maintain full-service capabilities of SLCS’s general and medical staff. è Implementing or extending prison health services regarding · Disease prevention, especially concerning · Health protection measures, particularly · Health promotion activities, such as · • Primary care for · Establishing SOPs to measure the quality of care acc. (inter)national guidelines concerning through è Implementing an electronic hospital management information system (HMIS) and promoting publicly available health surveys of inmate morbidity and mortality. è Reducing health inequalities and increasing awareness of populations with special needs, such as older, sick, and disabled inmates, or detainees, e.g., by enabling the SLCS staff, healthcare personnel, and social workers to provide housing, healthcare, and social services during confinement and prior to release adapted to the needs of older inmates and to implement separation of untried from convicted inmates. |
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