# INTRODUCTION

# Background
There are more than 10.2 million people 1 in prisons or detention facilities throughout the world, and their numbers are growing. Overcrowding has been a major issue for years, affecting detainees and prison management. This has serious repercussions for the resources -human and financial -that are needed to ensure proper health care in prisons.
Prisons also contain people who are often vulnerable to ill health because of their background, their environment and their behaviour in prison. As a result, the demand for prison health services is greater than that for community health services. Despite this, prisons usually receive far less support in the form of resources and funding for health care. 2 There is generally agreement throughout the world on the need to strengthen prison health systems, and policymakers must take this into account in their strategic planning.
Strategic and policy-related decisions must be based on detailed and upto-date information on the performance of prison health systems and the health-related needs of detainees. Assessments of prison health systems are undertaken to gather precisely such information.

# Introducing the guide
This document is based on the findings of assessments -of health systems and needs -conducted jointly by the ICRC and the Swiss Tropical and Public Health Institute over several years in prisons throughout the world (Cambodia, Iraq, Jordan, the area under Palestinian authority, Lebanon, Sri Lanka, Thailand, Tunisia, etc.).

# Target audience
This document is intended for people and organizations who want to carry out a comprehensive assessment of the health system and health-related needs throughout a penitentiary system. It may be especially useful for health specialists, such as doctors and nurses working in prisons, researchers or managers of health programmes. Imprisonment must never pose a threat to the health of the people incarcerated. Detainees have as much right to health care as members of the general population. It is the responsibility of national governments to ensure that this right is protected.

# Where to use the guide
Although the document is concerned mainly with prisons, the approach set out in it, and the tool kit, may be used in other places of detention as well, such as police stations or immigration detention centres.

# Guiding principles
The document is guided by the following principles:
- Prisoners must have equal access to health care, regardless of their legal situation. 3
- Good prison health is good public health. 4 
- The health and well-being of detainees is a "whole-of-government responsibility". 5 
- Strong health systems are essential for improving health outcomes. 6 

# Contents
This document consists of a practical guide divided into eight chapters and a set of tools (interview guides, checklists and questionnaire) laid out over six annexes. AIM AND SPECIFIC OBJECTIVES

# AIM AND SPECIFIC OBJECTIVES
The aim of a comprehensive assessment is to provide the pertinent national authorities with an overview of the prison health system and of the healthrelated needs of detainees.
Qualitative and quantitative data collected through an assessment help the authorities to set evidence-based priorities, allocate resources and draw up plans of action, with a view to improving access to health care and health outcomes for detainees.
The specific objectives of the assessment are to:
- provide a description of the detainee population of the country and of detainees' health problems 
- analyse the physical and social determinants of health in prisons 
- evaluate the performance of the prison health system, and its linkage to the national health system - - assess the extent to which existing health services meet the needs of detainees 
- identify the strengths and shortcomings of the prison health system, and means to address the latter
- provide a baseline for developing projects and programmes to strengthen the prison health system and meet detainees' needs.

# ORGANIZING AN ASSESSMENT
National governments assess health systems in prisons and detainees' health needs in order to improve the performance of the system. Such assessments are of great significance and should be conducted at the request of the ministry concerned: for instance, the ministry of health (or its equivalent), the ministry of the interior (or its equivalent), the ministry of justice, or the ministry of defence.
The ministry should identify the necessary resources (an implementing partnerorganization and budget) and provide its full support for the execution of the assessment.
Detailed planning, meticulous preparation and effective organization: all these are essential for carrying out a successful assessment.

# 1) Establishing a working body at the ministerial level
A working body, permanent or temporary -such as a steering committee for prison health -must be set up before the assessment. Ideally, this should be done by the ministry responsible for prison health and must consist of officials from the other ministries involved -preferably from their central level -and from the implementing organization. The working body will be responsible for the following:
- developing the ToR for the assessment
- approving the composition of the assessment teams (see below)
- approving the country-specific assessment methodology and data collection tool
- approving the assessment implementation plan 
- liaising with the national ethics committee and obtaining its approval (if required)
- coordinating and facilitating the fieldwork of the assessment teams, which includes visiting selected detention facilities and meeting with senior members of the prisons' management teams, public health authorities and the various stakeholders working in prisons.

# 2) Forming assessment teams
Organizing and conducting an assessment of a prison's health system and detainees' health needs is a multidisciplinary exercise.
To ensure the objectivity of an assessment, and to make sure that it has an added value, the assessment teams must be independent of the ministry responsible for prison health.
The assessment should be led by a core team made up of health professionals and containing at least two representatives of the independent implementing organization:
- - A principal assessor, who will serve as the team leader and will be responsible for designing and carrying out the assessment. This person should have a degree in public health or work experience in a related field, particularly health systems strengthening and epidemiology (mainly qualitative study designs and sampling methods), as well as the skills necessary to conduct assessments of this kind.
- A medical doctor or nurse who has worked in prison settings, preferably in the country concerned.
The core team should be assisted by other people from the implementing organization: an assessment support team. This team will conduct individual interviews with detainees and collect information on the determinants of health. It may include non-specialist personnel visiting prisons in the country concerned (ICRC detention delegates, for example), interpreters, and/or experts in water and hygiene, food and nutrition, and penitentiary systems.
The assessment teams must be debriefed every day while the assessment is in progress.
Tasks of the core assessment team Administrative and logistical support for the assessment teams -including arrangements for travel and transportation -should be ensured.

# A step-by-step plan for organizing an assessment

# Training the assessment teams
Giving the teams the necessary training is crucial for the success of the assessment. It is very important to ensure that all team members understand the objectives of the assessment and the approach being employed, and that they have the requisite interviewing skills. Enough time should be set aside for training.

# Ethical considerations
The ethical aspects of the assessment must be given serious consideration.
Participants, both authorities and detainees, should be given all information pertinent to the assessment, to ensure that they understand and accept its principles and aim. Step 1: Establishing a working body at the ministerial level
Step 6: Obtaining the approval of the ethics committee, if required
Step 2: Developing the ToR for the assessment
Step 5: Choosing the methodology and adapting the tools
Step 3: Forming the assessment teams Approving the composition of the assessment teams
Step 4: Reviewing national policies and frameworks
Step 8: Fieldwork Data collection
Step 9: Entering and analysing data
Step 10: Preparing and submitting report Formal presentation

# Priority Setting and Action Plan
Participation in the assessment must be voluntary. Before interviewing detainees, secure their informed consent, orally or in writing.
Participants have the right to withdraw from an interview at any time. It should be made clear to them that refusing to participate in the assessment, or withdrawing from it at some stage, will not jeopardize the quality of the care to which they are entitled.
The anonymity of the participants must be safeguarded.
The approval of the national ethics committee should be obtained if required.

# ASSESSMENT DESIGN AND SAMPLING METHODOLOGY 7
There are two main kinds of assessment or study design: qualitative and quantitative. They differ in the methodologies they use and in the information they target and collect. The core assessment team must therefore define the design according to the objectives of the assessment.
For assessing a prison health system, it might be best to carry out a qualitative assessment first. If a quantitative assessment is found to be necessary after the initial assessment, a quantitative study design must be developed and implemented, bearing in mind the particular context and target groups. In this case, a biostatistician should be involved in the study design and analysis of the data collected.
Qualitative study designs -these usually take the form of qualitative interviews, focus-group discussions or direct observation -do not search for statistical significance; they seek to explore, in depth, certain concepts and patterns and the perceptions of participants. Quantitative study designs -usually 'surveys' -seek to obtain generalizable information (from a representative sample) that can be expressed numerically: as percentages, means/medians or ratio measures. A design of this kind also requires statistical analysis.
Combining both has numerous important advantages: for instance, a qualitative study can be carried out before a survey to ascertain the types of question that should be put to participants; or afterwards, to explore in a more detailed way the patterns revealed by the survey.
The sampling methodology will be determined by the study design: quantitative studies require sampling methodologies to obtain a representative sample in statistical terms, so that the percentages, means/medians or ratio measures calculated from it can be used to make inferences about the whole; qualitative studies, on the other hand, require samples that are representative of patterns and perceptions and do not have to yield statistics.

# Qualitative assessment
The sample must reflect the characteristics of the detention facilities and the various concepts and perceptions that need to be explored in depth.

# 1) Selection of detention facilities
A list of all detention facilities of interest in the country should be made available to the core assessment team. It should contain the following information:
- type, size and location of each facility
- data on the size of the detainee population and the turnover rate
- the main characteristics of the detainee population (gender, age groups, vulnerable groups, legal and health status)
- the existence or otherwise of a health facility and/or health services.
Ideally, an assessment should cover all the detention facilities in a country. If that is not feasible for logistical (e.g. too many facilities that are too far apart from one another) and/or security reasons, a sub-sample of detention facilities must be selected. The sample should include the largest facility and some smaller facilities, vulnerable groups, and places with and without health facilities and/or health services.
Experience shows that including about one-third of all detention facilities in a country assures representativeness.
At first, all detention facilities with similar characteristics are stratified into subsets. Then, they are randomly selected from the subsets to form a sample.
When there are sizeable differences in the number of detention facilities in each subset, the size of the detainee population associated with a particular subset will determine how many facilities should be selected from that subset: a greater detainee population means more facilities (see the example below). If the detention facilities are very similar, no stratification is needed and one may proceed directly to the random selection of detention facilities.
Subsets in stratified sampling: An example There are 30 detention facilities of various sizes in the country:
- - 10 remand facilities -small, medium and large (subset 1)
- 15 facilities for men -small, medium and large (subset 2)
- 2 facilities for women -small and medium (subset 3)
- 2 facilities housing drug users -medium (subset 4)
- - 1 prison hospital (subset 5).
The required sample size is 10, and each of the 5 subsets should be represented.
The sample may include 3 remand facilities, 4 facilities for men, 1 facility for women and 1 facility housing drug users-and the prison hospital. The geographical location of the facilities may be taken into account.

# 2) Selection of participant-detainees
A sample should be taken from the detainee population of the selected facilities.
It is important to have a sample for each category of detainee (see example below), in order to reflect the various differences and similarities in experience and perception. Usually, a sample size of 10 to 20 per subgroup is required.
Purposive sampling is used to determine the number of detainees in each subgroup. In purposive sampling, it is the focus or purpose of an assessment that determines which categories of detainee should be selected.
Purposive sampling can be advantageous because it entails interviewing specific types of detainee: those who used health-care services, those with chronic conditions, or those with diseases regarded as health priorities.
In large detention facilities (e.g. those with over 1,000 detainees), the assessment teams can stop interviewing detainees once they reach the 'saturation point' , usually after around 20 interviews, because beyond this point they are unlikely to collect more pertinent data or insights. When the detainee population is small (e.g. fewer than 100 detainees), the sample size of each subgroup should be adjusted accordingly (i.e. fewer than 10 to 20 per subgroup). Some detainees will refuse to participate in the assessment. Past experience shows that the rate of refusal is usually very low; therefore, there is no need to adjust the sample size. When one detainee declines to be interviewed, the assessment team can select another.
If it is difficult to obtain a representative sample, the core assessment team may decide to use a non-representative sample and afterwards mention or draw attention in the report to this limitation of the sampling methodology.

# Exclusion criteria:
- detainees who were in the selected facility for a very short period (e.g. less than two weeks), and who were therefore less likely to have used the health services Take the internal dynamics of the facility into account (access to health services for detainees, gatekeeping system, etc.), and include the most vulnerable detainees in the sample.
The layout of the detention facility should be taken into account while doing the sampling. In facilities where detainees sleep in dormitories, the sampling should include each dormitory. If the dormitories are indistinguishable from one another, the sampling may be limited to only a few of them, selected at random.

# Quantitative assessment
If a quantitative design to assess prison health systems is to be used, it must be decided first whether the assessment should be carried out at the country level or the prison level, or at the level of detainee subgroups within a prison. It is important that the sampling methodology be proportional to population size: this means that bigger groups are more likely to be represented than smaller ones, which will yield more representative statistics that enable inferences to be made for the whole.
If the assessment involves an entire country, more detainees from bigger prisons will be interviewed than detainees from smaller prisons; some prisons may not be included (owing to the randomness of the sampling). It is important to remember that the findings of a countrywide assessment are relevant only for the country as a whole, and that it will not be possible to make inferences about specific prisons. Therefore, if after a countrywide assessment, there is a need to assess one or more prisons closely, each prison of interest will have to be surveyed separately.
There are two main sampling techniques: simple random sampling and cluster random sampling. They are systematic (see below) in the selection of individual detainees (simple random sampling) or clusters of detainees (cluster random sampling) by using a sample interval. The size of the sample will depend on the degree of precision the assessors require and the expected prevalence(s) of what the assessors want to measure (if that is not known, to be conservative, proceed on the basis of an expected prevalence of 50%, as that will yield the largest possible sample).
If simple random sampling is applied, a standard size of 96 individuals is used; this accounts for an expected prevalence of 50% and a precision of +/-10% around the obtained percentage (). For simple random sampling, a full list of detainees at a given prison is required (or of detainees at all the prisons in a given country, depending on the level at which the assessment is pitched); the sample will be drawn randomly from this list.
If a full list of detainees is not available, then cluster random sampling has to be used. For this sampling method, 30 clusters, each containing 7 detainees (a total of 210 detainees), is used to obtain the same precision of +/-10%.

# Quantitative design: Sampling procedures
If a countrywide assessment is to be done, proceed in the following way:
If a list of detainees at all the prisons in the country is available, proceed with simple systematic random sampling:
- - List all the detainees at each prison and number them in sequence; beside each prison, give the figures for the population of that prison and the cumulative population at that point in the table.
- Divide the total detainee population of the country (the sum of all the detainees at all the prisons) by 96 (3000/96=31, which will be our sampling interval).
- Select a random number between 1 and 31 (using a random number table or random number generation software, or from the serial number of a banknote); that random number will tell the assessors which detainee to interview first (match the random number to the detainee number in a table like the one above) and, since the numbering is consecutive by prison, also the prison where that person may be found.
- Add 31 (the sampling interval) to that random number, and you will get the second detainee to interview; repeat this until you reach the total sample size of 96 (systematic random sampling).
- - You will find that you will have to interview more detainees in the bigger prisons than in the smaller ones ("sample selection proportional to population size").
If a list of detainees at all the prisons in the country is not available, proceed with systematic cluster random sampling:
- List all the prisons in the country with their population and the cumulative population.
- Divide the total detainee population of the country (the sum of all the detainees at all the prisons) by 30, the number of clusters needed (3000/30=100, which will be our sampling interval). 3,000
- Select a random number between 1 and 100 (either from a random number table or random number generation software, or from the serial number of a banknote); the random number will give you the first cluster. For example, if our random number is 56, the first cluster will be in prison A (see table above), since the number 56 is within the cumulative population of prison A.
- Add 100 (the sampling interval) to the random number, and you will get the second cluster (56+100=156), which will also be in prison A. Repeat this until you reach the total sample size of 30 clusters. Every time you add the sampling interval (100) to a random number, check the figures for cumulative population to see in which prison the cluster falls (in the table above, clusters 1-12 will be in prison A, 13-17 in Prison B, and 17-30 in prison C).
- - For each cluster select seven detainees as randomly as possible. For example, go to the centre of the prison, spin a bottle or a pen, and then go in the direction that the bottle or pen points to; then, select seven detainees there to interview. If there is more than one cluster in the same prison, follow the bottle/pen method described above at various places in the prison. Prisons with more than one cluster are likely to be relatively big, so picking more than one starting point should be relatively easy.
If a prison-level assessment has to be done, proceed in the following way:
If a list of all detainees at a prison, by block, is available, proceed with simple systematic random sampling: follow the same steps as those for country-level assessments, but replace the prisons with the blocks.
When a list of all the detainees at a prison is not available, it is more difficult to carry out cluster sampling in a single prison because it may not be possible to identify 30 starting points for the 30 clusters without the risk of overlap (in other words, there is a risk of surveying the same detainee more than once).

# DATA-COLLECTION METHODOLOGY
Based on assessments conducted by the ICRC in various countries -of prison health systems and health needs -eight areas or blocks of crucial information have been identified.
This document takes the WHO Health System Framework, 8 which describes health systems in terms of six core components or building blocks, as a source of reference. Two other building blocks or core components -"Physical and social determinants of health" and "Detainees' perceptions" -are added to the WHO framework, to enable objective or impartial assessment of the general conditions of detention and to capture detainees' views on the provision of health services. Furthermore, detainees are regarded not only as beneficiaries or service users, but as actors capable of influencing the system.
The data that are collected should be pertinent to the aim and the specific objectives of the assessment.
1) Review of national policies and frameworks, and other countryspecific information related to health in prisons (secondary data source)
It is important to understand the context within which a prison health system operates. Therefore, when setting out to collect data, begin by: - collecting information about the types of prison and their capacity, and the legal and demographic profiles of the detainee population.
The assessment will also rely on in-country sources of data on health. These sources include:
- national health policies and strategic plans, the country's epidemiological profile and health reports from the ministry of health, WHO reports, acts or laws on patients' rights, SOP at prisons, including protocols for managing specific diseases (for example, TB and HIV/AIDS)
- all essential information available about the prevalence of various diseases and illnesses in prisons.
2) Interviews with prison and health authorities, health-care providers, prison staff, detainees, and stakeholders outside prisons (primary data source)
When setting out to collect data from the various stakeholders, begin by interviewing the prison and health authorities at the local level; you must first explain the objectives and the methodology of the assessment to them.
Interviews with prison staff, health-care providers at prisons and referral health facilities, detainees (service users) and relevant stakeholders outside prisons -such as organizations, national and international, involved in the provision of health care in prisons -are crucial for evaluating the performance of prison health systems and for assessing detainees' needs.
The interviews should be conducted in every detention facility selected for the assessment and in the surrounding area (district, province, county, etc.).
It is also very important to interview the prison and health authorities at the central, decision-making level, in order to have their views on the strengths and weaknesses of the prison health system, and on ways to address the latter.

# 3) Conducting the interviews
Sufficient time should be set aside for each interview: an interview with a detainee usually takes about 45 minutes.
Interviews should be conducted, whenever possible, in a comfortable location, one that is also free from the risk of interruption. In order to ensure confidentiality, those locations should be chosen that afford the greatest amount of privacy.
Interviews with detainees should be conducted out of earshot of custodial staff; this particular condition should be agreed upon in advance.
Prison authorities must guarantee the security of assessment teams conducting interviews in their prisons.
Observations made during prison visits are of utmost importance, as they provide vital information about a particular setting and the general environment, and about the prison health facility and the referral health facility. Such direct observation must concern itself mainly with the physical and social determinants of health (also known as the 'general conditions of detention'): living conditions, clothes, bedding, general and personal hygiene, water, food, occupational and educational activities, etc.

# ASSESSMENT TOOL
The assessment should allow for collection of the minimum amount of data required for evaluating the health system's performance and ascertaining detainees' needs.
The tool (Annexes 1-6) is designed to give the assessment teams a framework, and guidelines, for conducting interviews at various levels; and to enable uniform and comprehensive data collection. It consists of two interview guides, three checklists and one questionnaire (see below).
All the subjects covered by the assessment should be reflected in the pertinent interview guides, the checklists, and in the questionnaire. The assessment is likely to benefit when all participants are asked the same questions.
The interview guides aim to be as flexible as possible, so that the core assessment team can adapt them to any given context. Experience shows that it is best not to rely on a set list of questions while interviewing prison and health authorities at central and local levels. Interviewers should be ready to discuss any issue raised by stakeholders, who should feel free to express their views. The interview guide is most useful as an aide-memoire.
The questionnaire for detainees and the checklists consist mainly of closed questions, which makes it possible to gather qualitative and quantitative data that are reliable and can be compared.
The checklists can be used with various groups of people (not only those mentioned here), as required by the assessment.
There is no specific guide for interviewing representatives of organizations involved in the provision of health care in prisons. These interviews should be open, but relevant questions from the interview guides and the checklists may be asked.

# Composition of the assessment tool
Two interview guides: Three checklists for in-depth interviews with key stakeholders:
- one for health-care providers at prisons - - another for the head of the central pharmacy
- the third for health-care providers at referral health facilities.
One questionnaire:
- designed for individual interviews with detainees.

# DATA ANALYSIS
The final steps of the assessment are designed to gather the findings and analyse them. The results of the analysis should be interpreted carefully, so that conclusions can be formed and recommendations formulated as precisely as possible.
The first step in data analysis is to arrange or file all the data that have been collected under categories corresponding to the contents of the report. The following approaches may be helpful:
- Interviews with prison and health authorities, health-service providers, prison staff and stakeholders outside prisons:
Focus on one area at a time and group the answers of each respondent accordingly.
For interviews conducted with the help of the interview guides and the checklists, a SWOT matrix might be helpful in structuring information.
- Interviews with detainees:
Detainees' answers to open and closed questions from the questionnaire for detainees should be coded and analysed, using the Epi Info and/or SPSS software. It is also possible, but much less practical, to enter data into Excel spreadsheets.
Focus on one area at a time and group the statistics and information gathered from detainees' responses accordingly.
- Epidemiological data:
Focus on the health conditions that are most prevalent and most serious among detainees, and on the corresponding indicators selected for measurement (see below). If possible, comparison should be made with similar health indicators for the general population of the country.

# - - Observations:
Identify and analyse patterns revealed by direct observation at the selected detention and referral health facilities, and by information gathered from the prison staff and from pertinent documents, reports and reviews.
- Documents:
Ensure that the documents are readily accessible by organizing them by category: policies (legal and health), laws, SOP, reports, etc.
The analysis should take into account all eight components or blocks of the prison health system. The qualitative information drawn from primary and secondary sources should be supplemented with the relevant quantitative indicators for monitoring health systems. Because of the dynamic links between the building blocks, the indicators may also have relevance of more than one kind. 9 Furthermore, understanding the prison health system through the building blocks requires that each block be compared with the national health system.

# Leadership and governance
This is one of two cross-cutting building blocks, and the one that can ensure effective national guidance for developing an efficient prison health system. 'Leadership and governance' plays a role in the areas covered by each of the building blocks and can have a positive or an adverse effect on the entire system. Weak governance may mean an inability to address gaps in the system and promote the necessary changes.
To ensure that detainees have access to health care of an appropriate standard, the following core elements should be present at the national level: Analysing the functioning of these various elements is an essential part of any assessment of prison health systems.

# Health information system
This is the second cross-cutting building block. It provides a basis for understanding needs and serves as a starting point for planning. Prison heath authorities, public health officials, policymakers in government, decisionmakers of every kind: all of them need accurate data to establish priorities, draft budgets, and design cost-effective activities. Every building block of the prison health system will be influenced by the performance of the HIS.
It will always be necessary to use a variety of sources to gather data on the health status of detainees. At the prison level, these sources can take various forms: medical registers, records of medical examinations carried out on detainees' arrival, statistical reports on prison health, or prison health staff and the detainees themselves. The central level can be a useful source when consolidated data are available. Information can also be obtained from other stakeholders involved in prison health, such as community health services and volunteer organizations. 

# Health-care financing
Health-care financing is a key building block and the backbone of the health system. It is essential for ensuring the equitability, effectiveness and sustainability of prison health services.
Systems for financing health care in prisons usually have two functions: pooling funds and supervising or regulating their expenditure. Pooled funds may come from various sources: taxes, insurance, donations, bonds, work programmes, etc.
Expenditure for health care in prisons should cover all the activities of a prison health system. Analysis of such expenditure, together with a detailed knowledge of the health needs of detainees, enables resources to be allocated more effectively.
Any policy for financing health care in prisons should seek to ensure that detainees can obtain the services they need free of charge. 10 10  

# Human resources for health care
Human resources for health care constitute another key component of the prison health system.
The right of everyone to enjoy "the highest attainable standard of physical and mental health" 11 imposes on prison authorities an obligation to guarantee the availability of sufficient numbers of trained health staff capable of providing services of the expected range. An effective human resources policy for prisons and provision of opportunities for professional development for prison health staff, such as continuing education programmes, are crucial for ensuring that this right of detainees is respected.
As in the national health system, human resources for a prison health system should include clinical staff (doctors, nurses, pharmacists, laboratory technicians, etc.), and managerial and support staff (managers, health data managers, financial officers, etc.).
In general, the ratio of physicians and nurses to detainees should be the same as or higher than that at the community level. Staffing requirements for health care in prisons will depend on various factors; they have not been formally defined at the international level. The general assumption is that the services offered should cover the health needs of detainees and that health staff should be accessible day and night, including on weekends; the presence of an on-site inpatient unit will create specific needs for human resources, the exact nature of which will depend on the level of care provided by the unit.
Qualified personnel are a necessary but not sufficient condition for providing detainees with an acceptable level of health care. To be effective, a prison health system must also provide personnel with adequate working conditions in terms of health facilities, medical supplies, salaries and training opportunities. In all these areas, the prison health system must operate, at the very least, at the same level as the public health system.

# Medical supplies
This building block of the prison health system focuses on policies, laws and regulations related to medical supplies and expenditure on pharmaceuticals and equipment, and to the procurement, storage, use and accessibility of these items. Like the building block on service delivery, its concerns are the availability and the provision of health care for detainees.  Governments establish their national essential drug lists according to the pattern of disease in their countries. To create such lists for prison health facilities, SOP for data collection must be established and data analysed. Data analysis is also necessary for making decisions about the financing of health care.
The equipment should fit the services offered at the prison's health facility. Standard lists are useful because they can define how various facilities should be equipped, based on their size and capacity in terms of human resources, the availability of specialized services, the distance to the nearest hospital, etc.

# Health-service delivery 12
The WHO's World Health Report 2000 says that "the people and organizations which deliver medical care are not the whole system; rather, they exercise one of the principal functions of the system". The objective of the prison health system is to improve detainees' health, which it does by delivering appropriate health services.
The following are the key areas to evaluate while assessing the delivery of health services in prisons:
- availability and effectiveness of prison health services  Provision of primary health care is the basis of a prison health system, as it is for the public health system that serves the community outside prison. Primary health care in prison includes: i) medical examinations on entry; ii) management of communicable diseases; iii) management of non-communicable and chronic diseases; iv) antenatal and postnatal care; v) dental and eye care; vi) mentalhealth care, including treatment for substance use disorders; and vii) health promotion and prevention of disease.
The effectiveness of the prison health system also depends on a system that ensures continuity of care for detainees (the 'through-care' system). This system provides integrated health services for detainees for the duration of their incarceration, and sometimes beyond that. However, it has certain periods of vulnerability: when detainees enter prison, when they leave and re-enter prison before and after court visits, when they are transferred to another prison and when they are discharged from custody.

# Physical and social determinants of health 14
Detainees' health is inextricably linked to detention conditions, which is why the latter must comply with specific standards.
The following areas are examined and analysed under this building block:  

# Detainees' perceptions
The perceptions of the people it serves can be of great help in understanding how a health system works or in evaluating its effectiveness.
Detainees' perceptions should be included in any assessment of a prison health system and its components, as they will provide indispensable information on the gap between policy goals and achievements and on detainees' needs and priorities.

# REPORT
The format of the report will vary from one country to the next. However, all reports, regardless of format, should provide a comprehensive overview of the assessment's findings.
Structure of the report: An example Executive summary The performance of a health system is not linear. Pay attention to the links between the blocks. Other key areas of concern - - Physical and social determinants of health (accommodation, food, water, hygiene, outdoor access, occupational and educational activities, etc.)

# Respect for medical ethics
- Collect other information if relevant (surveys, audits, statistics, etc.)
Annex 2. Interview guide for use with health authorities at local and central levels (ministry of health, senior members of the management team at prison health services and at referral facilities)
To obtain detailed information on prison health systems you may use selected questions from the checklist for health-care providers at prisons and/or the checklist for health-care providers at referral facilities.
Leadership and governance
1. Can you describe the organization of health care in prisons? Does it differ from the way the national health system provides health care?
2. What are the policies, strategies and SOP related to the prison health system and how are they implemented? Are they connected to the national health system?
3. Do you have any agreements or MoUs with partners (the ministry of health, the ministry in charge of prisons, NGOs, etc.)?
Health-service delivery 4. What aspect of health-care provision works well in the prison?
5. What are the shortcomings, gaps or challenges in the current system (prison and national)?
6. What can be done to improve the system?

# Remember to cover the following areas in the interview:
- access to health care (including referrals) and health staff - - access to drugs and equipment - - burden of disease (i.e. the HIS)
- health-care financing (how the budget is prepared, by whom, and what it includes: salaries, medicines, equipment, etc.).
The performance of a health system is not linear. Pay attention to the links between the blocks.

# Respect for medical ethics
- To what extent are medical ethics respected?
Other key areas of concern 

# Confidentiality
The confidentiality of the report should be protected, and it should be shared only with the authorities concerned.
It is important to keep in mind that completing and submitting an assessment report is not the end of the process. Ideally, the report should serve the authorities as a tool for setting priorities and drafting an action plan for improving access to health care and health outcomes for detainees.

# ANNEXES

# MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of armed conflict and other situations of violence and to provide them with assistance. The ICRC also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the Geneva Conventions and the International Red Cross and Red Crescent Movement. It directs and coordinates the international activities conducted by the Movement in armed conflicts and other situations of violence.