Table 2

Contextual factors contributing to ZaPHSS success

Contextual factor	Explanation	Significance to this evaluation	Illustrative quotes
Existing structures promoting prison healthcare	ZaPHSS interacted—and dovetailed—with government-created mechanisms for improving prison health (eg, the ZCSHealth Directorate and existing legislation and regional standards promoting better inmate health).	Existence of the ZCS HD reflected stated governmental commitment to prison healthcare. ZCS HD provided scaffolding for the conduct and realisation of ZaPHSS activities and goals. ZaPHSS enhanced the visibility and efficacy of ZCS HD by reducing social risks for staff who were afraid to raise the profile of prison health outside normal reporting lines.	“The [existence] of the Prisons Directorate of Health Services was one important factor [helping the project] cause then you had an entry point. Prior to that, you were talking to the HIV coordinator the other time you were talking with the Deputy Commissioner. The other time the Commissioner. So you did not really know what your entry point was and everyone wanted to be involved but without any direct focus. So the Directorate of Health Services in the Zambia prison service was an important thing that it happened and it helped.” (Official, Ministry of Health)
Favourable political backdrop	The Vice-President visited prison and made prisons a national story in 2014 with widely reported quote that Zambian prisons were ‘hell on earth’. This galvanised political support for action.	ZCS and public service are generally happy to participate in meetings recognising it as a priority of the Vice-President.	“The Ministry of Home Affairs, they were very supportive. They created the platform for us to engage the prison service […]” (NGO Official) “I think it is the buy-in from Prisons, there was a felt need within the Prisons. Also within the government, there was a felt need that the health systems in Prisons needed to be improved. With these two facts […] you had an entry point.” (Official, Ministry of Health)
Favourable operational backdrop	Shift from punitive to ‘corrections-based’ approach within the Zambian prison service	Strengthened emphasis on rights-based approach and recognition of international standards Space for discussions around inmates’ right to health and the benefits of this for officers and the service Personal support from powerful officials within Zambian Corrections	“It is only now that the issue of prison health is taken seriously because of the paradigm shift that has taken place, the whole world which has been transformed from punitive to correctional approach and which involves quality health care.” (Official 1, Zambian Prisons Service) “You know how we operate. Once there is acceptance from the top, there is acceptance through to the bottom.” (Official 3, Zambian Prison Service)
Existing civil society buy-in	Other NGO partners (UNODC*/SHARE II†) acted as important intermediaries using their institutional legitimacy to facilitate ‘relationships, conditions and spaces’ for debates and activities.	Boosted attendance of key government stakeholders at ZaPHSS workshops and meetings Promoted accountability, insofar as ZCS and other government stakeholder members were more likely to follow through on commitments to the health system made in the presence of valued partners	“ZaPHSS continued strengthening its relationship with other key prison stakeholders, particularly UNODC which co-funded PHAC Retreat of June 2015 along with other NGO parnters SHARe II project.” (Annual Report, Yr 2) “Apart from the MCDMCH and MOH being instrumental members of the technical working group that developed the ZaPHSS Framework, both attended the Prisons High Level Advocacy Meeting convened by UNODC and the ZaPHSS project.” (Annual Report, Yr 3)
CIDRZ reputation and access to resources	Long-term presence in prisons with established relationships between ZCS Health Directorate and CIDRZ TB unit	Viewed as a neutral party vis-à-vis the health system and thus capable of acting as a trusted partner Assisted ZCS to navigate access to MOH including relationship building, and to think through action plan priorities and follow-up Well-positioned to assist with resources (cash or in kind) for action plan implementation	“The trust between Zambia Prison Service and CIDRZ is there when you look at how CIDRZ has been supportive. When we started the TB program CIDRZ [in 2009/10 it] really worked well, the description of ZaPHSS and how it was going to work really gave hope to the Prisons Service. So there was trust already built so there was no doubting each other.” (Official, Ministry Home Affairs) “I think the issue of creating trust with the prison command and the officers was critical; this includes the officers in charge and the entire command and also the way CIDRZ followed the guidelines of operating in prison. [And] the other thing is financial commitment, CIDRZ really committed their finances towards this project.” (Official, Zambian Prison Service)

*UNODC, United Nations Office on Drugs and Crime (https://www.unodc.org/).
†SHARE II, Support to the HIV/AIDS Response in Zambia (http://jsi.com/JSIInternet/IntlHealth/project/display.cfm?ctid=na&cid=na&tid=40&id=7481).
CIDRZ, Centre for Infectious Disease Research in Zambia; HD, Health Directorate; MCDMCH, Ministry of Community Development Mother and Child Health; MOH, Ministry of Health; NGO, non-governmental organisation; PHAC, Prisons Health Advisory Committee; TB, tuberculosis; ZaPHSS, Zambian Prisons Health System Strengthening; ZCS, Zambian Correctional Service.