Barriers to healthcare delivery in Iranian prisons: a qualitative study

• Date: 17 August 2020
• Pages: 373-388
• DOI: https://doi.org/10.1108/IJPH-01-2020-0008
• Published date: 17 August 2020
• Subject Matter: Health & social care,Criminology & forensic psychology,Prisoner health,Sociology,Sociology of crime & law,Public policy & environmental management,Policing,Criminal justice
• Author: Ahmad Hajebrahimi,Khalil Alimohammadzadeh,Seyed Mojtaba Hosseini,Ali Maher,Mohammadkarim Bahadori

Barriers to healthcare delivery in Iranian

prisons: a qualitative study

Ahmad Hajebrahimi, Khalil Alimohammadzadeh, Seyed Mojtaba Hosseini,

Ali Maher and Mohammadkarim Bahadori

Abstract

Purpose –High quality health-care delivery is not only the governments’ responsibility but also every

prisoner’s right. Health care in prison and, particularly, of Iranian prisoners is increasingly important

topic because of the rising number of the prison population. This paper aims to explore health-care

managers’ perspectives and experiences of prisons and the barriers to health-care delivery in Iranian

prisons.

Design/methodology/approach –A qualitative research design was conducted in Iran from October

2018 to August 2019. The participantsconsisted of 51 health-care managers (50 men and one woman)

from Iranian prisons. A combination of face-to-face (N= 42) and telephonic (N = 9) semi-structured

interviews were used because of the geographical distribution of the respondents. Thefirst part of the

interview guide consistedof demographic characteristics, and the second part consisted of threemain

open ended-questions. Interviews were recorded and transcribed, and thematic descriptive analysis

was used to interpretthe data.

Findings –The barriers to health-caredelivery in Iranian prisons were categorizedinto four main topics:

human resources, financing, facilities and barriers related to the health-care delivery process. Data

synthesis identified the followingthemes for barriers to human resources: barriers to human resources

planning(with eight sub-themes); barriers to education(with three sub-themes); andmotivational barriers

(with seven sub-themes). Moreover, barriers to financing consisted of five sub-themes. The barriers to

facilities consisted of barriers related to physical infrastructures (with two sub-themes) and barriers

related to equipment (withsix sub-themes). Finally, barriers to the health-care deliveryprocess included

the followingthemes: communication barriers (withsix sub-themes); legal barriers (with five sub-themes);

and environmental-demographic factors(with seven sub-themes).

Originality/value –Identifyingthe barriers to health-care deliveryin Iranian prisons plays a critical role in

the improvementof planning, decision-makingand the health-care delivery process.

Keywords Health-care delivery, Prison, Prisoner, Health-care management

Paper type Research paper

Introduction

The prison setting is one of the most challenging for health care, health protection and

disease prevention (Moller et al.,2009). In 2015, more than 10 million people were

incarcerated worldwide. Approximately 30 million people are imprisoned each year

(Butler and Murphy, 2014;Pont et al., 2018). India, Thailand, Iran, Indonesia, Turkey,

Brazil, Mexico, South Africa and the Ukraine all have prison populations exceeding

100,000 individuals (Fazel and Baillargeon, 2011;Walmsley, 2009). There is increasing

evidence that medical care provision is effective at reducing the number of offenders

whoreturntoprisonafterrelease(

Harman and Paylor, 2004;MacDonald et al., 2012;

Sto

¨ver et al., 2008).

Prisoners have the same right as other people to be healthy and well. The United Nations

Basic Principles for the Treatment of Prisoners indicate how the entitlement of prisoners to

Ahmad Hajebrahimi is based at

Department of Healthcare

Management, School of

Management and Social

Sciences, North Tehran Branch,

Islamic Azad University, Tehran,

Iran.

Khalil Alimohammadzadeh is

basecd at Department of

Healthcare Management, School

of Management and Social

Sciences, North Tehran Branch,

Islamic Azad University, Tehran,

Iran and Health Economics policy

Research Center, Tehran Medical

Sciences Islamic Azad University,

Tehran, Iran.

Seyed Mojtaba Hosseini is based

at Department of Health Services

Management, School of

Management and Social

Sciences, North Tehran Branch,

Islamic Azad University, Tehran,

Iran.

Ali Maher is based at Department

of Economics and Health Policy,

School of Management and

Medical Education, Shahid

Beheshti University of Medical

Sciences, Tehran, Iran.

Mohammadkarim Bahadori is

based at Health Management

Research Center, Baqiyatallah

University of Medical Sciences,

Tehran, Iran.

Received 26 January 2020

Revised 22 April 2020

28 April 2020

13 May 2020

17 May 2020

30 May 2020

Accepted 1 June 2020

The authors would like to thank

the State Prisons and Security

and Corrective Measures

Organization; Urmia University

of Medical Sciences and

Islamic Azad University, North

Tehran Branch, for their

supports and assistance

throughout all aspects of their

study.

DOI 10.1108/IJPH-01-2020-0008 VOL. 16 NO. 4 2020, pp. 373-388, ©Emerald Publishing Limited, ISSN 1744-9200 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jPAGE 373

the highest attainable standard of health care should be delivered: “Prisoners shall have

access to the health services available in the country without discrimination on the grounds

of their legal situation” (Coyle, 2014;Fazeland Baillargeon, 2011). The health of prisoners is

threatened by a health-care system withpoor quality, which has suffered from severe, long-

term underfunding. Financial constraints, exacerbated by inappropriate legislation, have

prevented the authorities from taking account of the specific needs of the most vulnerable

and disadvantaged prisoners (Bobrik et al., 2005;Fazel and Baillargeon, 2011;Sung,

2010).

In addition, there are many people with serious and often life-threatening conditions in

prisons. Sooner or later most prisoners will return to the community, taking with them new

diseases and untreated conditions that may pose a threat and add to the disease burden in

the community. Thus,it is important that this vulnerable groupreceives health protection and

treatment for anyillness (Coyle and Stern, 2004;Enggistet al.,2014;Wolff and Shi,2011).

Jails and prisons face unique challenges. Prisoners returning to the community experience

profoundly negative health consequences, including recidivism, high rates of overdose and

death, relapse to drug and alcohol use, discontinuation of medication, uncontrolled chronic

medical and psychiatric conditions and engagement in high risk behaviors that facilitate

transmission of Human Immunodeficiency Virus (HIV), blood-borne infections and sexually

transmitted infections (STIs) (Bobrik et al.,2005;Butler and Murphy, 2014;Kruglov et al.,

2008;Lawrinson et al.,2008;Roman, 2004). These behaviors in turn raise the risk of

cardiovascular disease and some cancers. Mental illness, which increases the risk of crime

and repeat offending, is common in prisoners. The extent to which the prison itself raises

the risk of illness has only been investigated in relation to infectious diseases and is

unknown in relation to most other disorders (En ligneWallace, 1998;Watson et al.,2004;

Wilper et al.,2009).

On the other hand, many studies have shown barriers to providing mental health services

including legal, process and physical infrastructures (Fazel and Baillargeon, 2011;Jacobi,

2005;Oxelson, 2009;Samele et al.,2016). Ba

cak and Ridgeway believed that the

availability of health-related programsin prisons has numerous benefits for prisoners, given

that most prisoners suffer from mental and physical health problems. Therefore, identifying

the barriers to health-care deliverysystems in prisons can be useful in improving the current

condition (Ba

cak and Ridgeway, 2018). In addition, Gonzalezand Connell found that lack of

treatment continuity is one of themost significant challenges of health-care delivery systems

in US prisons (Reingle Gonzalez and Connell,2014).

It is therefore vital for public health-care systems to create the necessary conditions for the

timely diagnosis and adequate medical treatment of prisoners, as well as to understand the

key challenges faced by prisoners upon release and the factors contributing to increased

frequency of these challenges (Butler and Murphy, 2014;Morozova et al.,2013).

International and national policies emphasize the importance of imprisonment as an

opportunity to address thehealth needs of a “hard to reach” sector of society and the prison

as a place where prisoners’ health can be assessed, maintained and improved (Condon

et al., 2007a,2007b;Wolff and Shi, 2011).

On the other hand, the management of prisons and places of detention has become a

difficult and challenging task. This is often not recognized by government and society.

The complex and wide range of prisoner needs, combined with their increasing

awareness of their rights, greater expectations (in some countries), access to an

effective complaint system and legal assistance, are factors that play a considerable

role in understanding how to better provide health services for them (Enggist et al.,

2014;WHO, 2013). Governments are responsible for protecting public health, meaning

that they must ensure that prisoners in their care are not exposed to serious health-

related threats (Pont et al.,2018;WHO, 2013).

PAGE 374 jINTERNATIONAL JOURNAL OF PRISONER HEALTH jVOL. 16 NO. 4 2020