Table 1

Direct links of prison health to SDGs

SDGsPotential contributions of prison healthCross-over with existing international prison health policies
Goal 1—End poverty in all its forms everywhereConsidering that there is a bidirectional relationship between health and poverty, robust health services in prisons that are part of the general health services of the country similar to the UK, France and Norway12 will ensure the achievement of Targets 1.1 and 1.2 to eradicate extreme poverty and halve the no of those who currently live in poverty, respectively.
It has been estimated that only 5% of people in prisons would be qualified to undertake higher education, partly because of a high prevalence of early school leavers among this cohort.20 As most people in prison will eventually be released into the community, prison education policies should prioritise a combination of basic skills (eg, upskilling IT skills of prisoners in Grundtvig, Denmark), vocational skills (eg, skilled worker intensive training, Facharbeiterintensivausbildung in Vienna, Austria) and higher education learning (eg, prison-university partnerships across the UK) to accrue a community dividend via improved future employability, reduced social costs of crime and successful reintegration into the community.20
The Mandela Rules 2015
The Bangkok Rules 2010
Goal 2—End hunger, achieve food security and improved nutrition and promote sustainable agricultureA poor and insufficient diet can accelerate the probability of contracting a disease and hasten its progression. In order to provide access to safe, sufficient and nutritious food (Target 2.1), the issues of malnourishment (of both macronutrients and micronutrients) among prison populations, as well as the specific nutritional needs of female prisoners (including during pregnancy), children and young people in prisons must be addressed. Ensuring adequate nutrition to people in prisons, enabling healthy food choices and providing them with a basic understanding of the skills involved in day-to-day living, such as food preparation on a budget and healthier meal choices (which have been implemented in the USA, Western Europe and Canada) can contribute to the attainment of this goal.21 22The Mandela Rules 2015
The Havana Rules 1990
Goal 3—Ensure healthy lives and promote well-being of all individuals irrespective of ageThe following changes in areas of prison health can contribute to the achievement of Goal 3:
  • Antenatal and postnatal care: Women in prisons often experience inadequate access to prenatal and postnatal care, alongside the prevalence of issues concerning maternal mortality and health complications from pregnancy and its termination.23 Enhanced perinatal care during detention, such as pregnancy-related services (eg, providing appropriate calories for meals and prenatal care) and accommodation (eg, special housing or a bottom bunk),23 can improve both short and long-term outcomes, help to reduce the global maternal mortality rate (Target 3.1) and eliminate the preventable deaths of newborns (Target 3.2).

  • Communicable diseases: A combination of high-risk behaviours and inadequate access to preventive measures in prisons ensures the spread of communicable diseases.24 Prisons are a key setting in which to support the call to end the epidemics of AIDS, tuberculosis, malaria and hepatitis (Target 3.3). Access to voluntary and confidential testing, improved primary and specialist care services for diagnosis and treatment, prevention programmes (eg, needle and syringe programmes) and immunisation and vaccination will realise this aspiration.24

  • Non-communicable diseases: Alongside poor dietary intake and physical inactivity, cardiovascular issues have been reported to be the biggest killer in developed countries’ prisons.4 Prison health policies that combine prevention and treatment measures via physical activities, healthier diet, smoke-free prisons and both harm reduction and abstinence-based services on substance misuse12 25 can support the goal of reducing one-third of the incidents of premature mortality from non-communicable diseases (Target 3.4).

  • Substance misuse: 90% of people in prison have substance misuse needs.25 Establishing a substance misuse strategy for prisons that includes both pharmacological and psychosocial interventions, such as opioid substitution therapy, harm reduction and drug-free unit strategies,12 can contribute to realising Target 3.5 and improve the prevention and treatment of substance misuse.

  • Sexual and reproductive healthcare services: Women in prisons have a higher prevalence of sexually transmitted infections, such as chlamydia, gonorrhoea and HIV compared with men.26 Integrating sexual and reproductive health strategies and programmes within prisons, such as information and education, ensuring the availability of safer sex materials, contraception and sexual health clinics12 26 can help meet the aspirations of Target 3.7.

  • Universal health coverage: People in prison should have access to universal healthcare that is safe, effective and affordable (Target 3.8). To achieve this target, prison healthcare provisions should be organised by the Ministry of Health, rather than by the Ministry of Justice or Interior.12 The notion of equivalent healthcare in prisons and the community has driven systemic improvement in the structure, organisation and regulation of healthcare in the UK, France and Norway that have adopted this arrangement.12

  • Tobacco control: The implementation of the WHO Framework Convention on Tobacco Control (Target 3·A) can be promoted by establishing smoke-free prisons, similar to England and Scotland.27 28 Considering that 80% of individuals in prison are smokers, compared with 24% of the general population, smoking bans and support for nicotine dependence will decrease tobacco use among individuals in prison and staff and improve air quality within prisons.27 28

  • Research and development of vaccines and medicines primarily for developing countries: To attain Target 3.B, prisons can accelerate vaccination opportunities to people who are often underserved by community vaccination programmes. For instance, experts have called for people in prisons to be prioritised for the national COVID-19 vaccination strategy, given their risk profile of underlying chronic conditions, age and living environment.29

  • Increase in health financing to improve the recruitment, retention and training of the health workforce, especially in developing countries: This goal can be promoted by the recruitment of an appropriate number of healthcare staff to work in prisons, as well as by ensuring that they undergo a process of professionalisation demonstrated to increase the quality of care in prisons, similar to the experiences of healthcare services in prisons in England.30

  • To support Target 3.D, health contingency plans should encompass prison establishments. For instance, to flatten the COVID-19 pandemic curve in prisons, plans should include risk communication, testing, social distancing, medical isolation or quarantine, operations guidance and the use of personal protective equipment.7 An examination of the dynamics of transmissions of COVID-19 in prisons, alongside infection control strategies and non-pharmacological interventions (eg, social distancing, population cohorting and isolation plans)7 could provide valuable insights into the risks and protective factors and help devise targeted interventions for COVID-19.

The Mandela Rules 2015
The Bangkok Rules 2010
Goal 4—Ensure inclusive and equitable quality education and promote lifelong learning opportunities for allA large no of people who come in contact with prisons have been excluded from equitable, quality education and lifelong opportunities, which is a risk factor of offending.31 Encouraging and tailoring their participation in educational and vocational courses will enable them to participate more fully in educational opportunities,31 in line with Targets 4.1, 4.2 and 4.3. Meeting these targets will also eliminate gender disparities in education (Target 4.5), help achieve a high level of literacy and numeracy (Target 4.6), promote lifelong learning and contribute towards the nation’s economy. In emphasising Target 4.C, the quality of educational staff in prisons should be commensurable with that of educational staff in the community. Initiatives such as transnational learning from Portugal and the UK to support prison education staff in Romania, as well as training for new prison teachers in France conducted by both the Ministries of Education and Justice,20 can be considered.The Mandela Rules 2015
The Bangkok Rules 2010
The Havana Rules 1990
The Beijing Rules 1985
Goal 6—Ensure availability and sustainable management of water and sanitation for allEnsuring access to safe water (Target 6.1) and proper sanitation in prisons (Target 6.2) is key to meeting Goal 6. This need has been highlighted by the COVID-19 pandemic, where providing soap and tissue, using hand sanitiser, increasing laundry services and ensuring adequate personal protective equipment for staff are necessary infection control measures.14 Additionally, ending the use of unscreened toilets, providing regular access to showers and clean bedding, and measures to address water scarcity issues12 should be embedded as part of the resourcing policy of prisons (Target 6.4).The Mandela Rules 2015
The Bangkok Rules 2010
The Havana Rules 1990
Goal 8—Promote sustained, inclusive and sustainable economic growth, full and productive employment, and decent work for allEnsuring effective rehabilitation programmes in prisons will promote a healthier population that can better contribute to sustaining per capita economic growth (Target 8.1). Measures to be considered here include appropriate educational and vocational training programmes delivered in prisons20; encouraging enterprises to hire people with a history of imprisonment, particularly in those industries where workforce shortages are an issue32; and removing barriers to re-employment of people in prison, where appropriate (Target 8.3). Furthermore, considering that gaining employment after imprisonment can be challenging, productive employment post-incarceration can also be promoted via the provision of support to entrepreneurship33 (Target 8.5). Supporting the ability of people leaving prison to gain access to a bank account and financial advice (as part of their resettlement) can also facilitate their access to welfare programmes and their return to the workforce32 (Target 8.10).The Mandela Rules 2015
The Bangkok Rules 2010
The Tokyo Rules 1990
The Havana Rules 1990
The Beijing Rules 1985
Goal 10—Reduce inequality within and among countriesAs people in prison often come from the most deprived communities, incorporating them into the purview of Targets 10.1 and 10.2 can help sustain the income growth of the bottom 40% of the population, which can, in turn, reduce social inequalities and yield dividends in the form of safer, healthier and more resilient communities. Removing arbitrary and discriminatory practices that otherwise inhibit the rehabilitation of those who are imprisoned, such as stop and search,34 and reforming laws on drug use35 and sex work,36 is an important element in achieving this goal (Target 10.3). Given that economic conditions directly influence the availability of adequate healthcare for people in prison, another essential step is improving the regulation and monitoring of global financial markets17 (Target 10.5).The Havana Rules 1990
The Beijing Rules 1985
Goal 11—Make cities and human settlements inclusive, safe, resilient and sustainableIn 115 countries, the data demonstrate that the number of people in prisons exceeds official prison capacities.37 Investments into the modernisation of prisons without necessarily increasing prison capacity (Target 11.1 on adequate housing), as well as into housing pathways for imprisoned people on release,12 will be vital to ensure that prisons are safe, resilient and sustainable by 2030. Although prisons are congregate settings by their very nature, clear policies for reducing communicable disease transmission, such as being able to physically distance people in prison to manage COVID-19, are critical.7 Other key measures include the restriction of prison transfers, enhanced medical appointments, regular and improved ventilation and disinfection and the establishment of protocols for isolation and quarantine that do not amount to solitary confinement conditions.14
Improving public transport for prisoners’ family members, especially those with children, and their friendship network,38 in line with Target 11.2 of providing affordable and sustainable transport by 2030, can also promote the rehabilitation of this population. Efforts to reduce the number of deaths of people affected by environmental disasters (Target 11.5) should take prisons into account at the contingency planning stage.39 40 Creating green spaces in prisons (Target 11.7) can positively impact the mental well-being of people in prison and on the rehabilitative role of prison environments.40
The Mandela Rules 2015
Goal 16—Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable and inclusive institutions at all levelsTargets 16.1 and 16.2 aspire to reduce all forms of violence and related death rates. Addressing the health-related drivers of violent behaviours and incidents (eg, substance misuse, mental illness and adverse childhood experiences)12 can reduce reoffending rates and create a safer community. Safety in prisons, which would benefit not only people in prison but also the prison staff, can be enhanced by adopting preventive mechanisms and improving reporting and response mechanisms for various forms of violence (eg, self-harm, arsons, riots, hostage-taking, bullying and victimisation).12 17
Prisons should aim to become more open, accountable and transparent about their investments, spending and service delivery17 (Target 16.6). Guaranteeing public access to information (Target 16.10) can propel prison institutions towards meeting this development goal. In compliance with Target 16.7 regarding ensuring participatory decision-making, as part of the inclusivity and empowerment drive, people in prison should be considered part of the process of developing and (where appropriate) delivering services in prisons. Several prisons in England have prison councils that allow prison representatives to consult on policy, practices and peer-support schemes.41 This strategy can be replicated elsewhere to improve inclusivity and empowerment.41
The Mandela Rules 2015
The Bangkok Rules 2010
The Tokyo Rules 1990
The Havana Rules 1990
The Beijing Rules 1985
  • SDGs, Sustainable Development Goals.