Bridging the health gap in Portugal’s prisons

Portugal has embarked on an ambitious journey to integrate prison health services into its National Health Service. This initiative seeks to close the health equity gap between the general population and those incarcerated, ensuring that individuals in prisons receive the same quality of health care as those living in the community.

Addressing health inequities in prisons

Historically, prison health care in many countries, including Portugal, has been fragmented, with services managed separately from the national health infrastructure. This has led to huge disparities in care with those in prison often facing greater health challenges than the rest of the population, with higher rates of infectious diseases, mental health issues and substance use disorders. They are also less likely to receive timely and adequate treatment, a gap that Portugal aims to close through this integration.

"Someone in prison should only have their freedom affected - everything else that pertains to their human rights must be guaranteed, including the right to health," says Professor Henrique Barros, Director of the WHO Collaborating Centre on Behavioural and Social Determinants of Noncommunicable Disease at the University of Porto. "Our goal is to ensure that prison health is seen as public health, where everyone receives the same standard of care regardless of their circumstances."

The plan aims to provide equitable access to health care, including preventative services and chronic disease management, aligning prison health standards with those available to the general public.

A comprehensive health plan

Portugal's efforts to overhaul prison health services have been strongly supported by WHO/Europe, which has provided technical guidance and facilitated policy dialogues. A working group comprising representatives from the ministries of health, justice, and science, technology and higher education, alongside other stakeholders, including civil society, has been established to oversee the transition. This group developed a comprehensive prison health plan built on 6 key pillars: health protection and promotion, disease prevention, disease management (which covers access, retention and continuity of care), social reintegration, information systems and technology, and research.

Key elements of the plan include:

• Telehealth services: the roll-out of telehealth services in prisons improves access to health care, particularly for those in remote locations or with limited access to in-person medical consultations.
• Electronic medical records (EMRs): the transition to EMRs in prisons ensures better continuity of care, as medical records can follow individuals from incarceration through to their release, enabling seamless health-care management.

Political will and stakeholder engagement

One of the standout features of this initiative is the strong political commitment at the highest levels of government. The ministers of health, justice, and science, technology and higher education have publicly endorsed the integration, with all 3 ministries working in close collaboration. This political will has been crucial in advancing the plan, despite challenges related to budget allocations and the reorganization of responsibilities between ministries.

"Government commitment can enable the strategic plan and nourish it to its full potential," says Ana Paula Martins, Minister of Health, reinforcing the strong political will behind the initiative.

A major lesson learned from the integration process is the importance of bringing together a diverse group of stakeholders. Experts from various fields - mental health and drug use disorders, infectious diseases, noncommunicable diseases (NCDs), information technology, civil society, and the lived experiences of incarcerated people (represented through civil society) - have contributed to the plan. Their collective expertise ensures that it addresses the complex health needs of individuals in prison.

Challenges and future steps

Despite political will and a promise of action, challenges remain. For instance, ensuring the availability of a specialized health workforce trained to handle the unique needs of incarcerated people is a hurdle yet to be overcome. The working group has emphasized the need for continuous training programmes for health-care professionals working in prisons.

Addressing mental health issues within prisons remains a top priority. Those in prison experience higher rates of mental health conditions than the general population, and Portugal's prison health plan includes specific actions aimed at improving mental health services in these settings.

As Portugal moves forward with the roll-out of its prison health plan, there is a clear commitment to monitoring progress. The government has set a 2030 deadline for full implementation, with regular evaluations scheduled to ensure the health plan's recommendations are being met. In the future, efforts will seek to enhance services further, including expanding cancer screenings, improving access to substance use disorder treatments and strengthening overall health-care infrastructure.

Human rights and public health

At the heart of Portugal's prison health reform is a deep commitment to upholding human rights and public health principles. By ensuring that incarcerated people receive the same standard of care as the general population, Portugal is setting a powerful example for other countries facing similar challenges.

"We need to move towards a system where prison health care is fully integrated into the National Health Service so the standard of care remains the same inside and outside of prison," says Professor Barros.

This sentiment underscores Portugal's recognition that prison health is, fundamentally, public health.

The situation in Europe's prisons

People in prisons face higher health burdens, including:

• up to 10 times higher rates of tuberculosis, and increased risk of HIV and viral hepatitis
• lower cancer screening rates and delayed diagnoses
• high suicide rates and unmet mental health needs
• an ageing population with inadequate prison facilities.

What WHO/Europe is doing to address this:

• supporting integration of prison health into national health systems
• fostering the improvement of information systems and upskilling the health-care workforce
• making prison admission a key health-care access point
• promoting education and training for health workers.

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