Five steps for strategy development
Step One – Identify your stakeholders
Section titled “Step One – Identify your stakeholders”Stakeholder engagement is arguably the most important component of any planning process. Engagement with healthcare professionals, prison administrators, people in prison, local health agencies, and local community representatives is pivotal.
This collaborative effort ensures that the planning process considers the specific challenges and nuances of how healthcare is managed within European prison settings.
For many European countries the agency responsible for the delivery of healthcare inside prison is the Ministry of Justice, for some the Ministry of Health and for others a mix between the Ministry of Justice (or Interior) and the Ministry of Health (Figure 3).
Source: WHO Health in Prisons European Database: https://www.who.int/data/region/europe/health-in-prisons-european-database-%28hiped%29
By actively seeking insights from key stakeholders, it is possible to gain a deeper understanding of the unique regulatory and cultural aspects that shape healthcare in your specific context.
Support from the prison administration responsible for each prison is essential. Gaining the support from key decision-makers within the prison administration is important for the long-term success of the programme, gaining the inclusion of top-level administrators, medical directors, heads of security and other relevant personnel.
Extending the identification of stakeholders into the community is important in order to integrate with the wider health community. This includes forging partnerships with external entities such as hospitals, specialist medical practitioners engaged with prison healthcare, local public health professionals, diagnostic laboratories, pharmacies, and relevant non-governmental organisations (NGOs).
Such collaborations are particularly vital for creating a seamless workflow to ensure continuity of care for individuals transitioning between the prison and external healthcare settings.
Stakeholders to engage with
Section titled “Stakeholders to engage with ”There are several different internal and external stakeholders who should be engaged in the process of developing the strategy (Figure 4).
Iconography by the International Network on Health and Hepatitis in Substance Users, 2024.
Before developing strategy, it is essential that leadership is committed to the process and that sufficient resources (human and financial) are put in place. Ownership of the process by senior officials and politicians is key to obtaining sufficient resources; without it, it will be difficult to ensure that the findings of the evaluation are acted upon.
In addition, a comprehensive and thorough evaluation of drug policy requires considerable skills and time, and so is costly. When designing the strategy, it is important to be realistic about how much can be achieved with the available resources (EMCDDA, 2017).
- Prison administration: Staff working in the governance of prison healthcare, including those working at the Ministry of Justice or Health.
- Prison Officers: Guards or wardens play a key role in facilitating access to healthcare services for people in prison and ensuring safety during service delivery.
- Prison health services: Staff including healthcare administrators, doctors, nurses, and other healthcare providers responsible for delivering medical care to people in prison.
- People living in prison: People living in prison who are directly affected by hepatitis should be involved in program planning, education, and advocacy efforts within the prison community.
- Public health officials: Professionals from this group can provide valuable guidance and support for implementing hepatitis prevention and treatment programs in prisons and can advise regarding monitoring and surveillance.
- Civil Society Organisations (CSOs): Organisations that specialise in prison healthcare or viral hepatitis advocacy can provide resources, expertise, and support.
- Community Health Organisations: Organisations that work on hepatitis prevention and education and could collaborate on programs in prisons.
- Research Institutions: Especially academic institutions engaged in work on hepatitis prevention and treatment and/or prison settings, which could provide evidence-based guidance for program implementation.
- Others:
- Ministry of Health/Justice/Interior and/or regional/local health authorities (if not covered in ‘internal’).
- NGOs: Organisations that work with people who use drugs and other drug services. In some cases, CSOs and NGOs may overlap.
Other external entities as considered relevant including local hospitals and specialist medical practitioners that provide in-reach care, diagnostic laboratories and pharmacies could also be involved in supporting access to treatment in prisons.
Co-designing programs with the input of both healthcare professionals, civil society, community organisations and people living in prison, ensures that interventions are not only clinically effective but also culturally and socially relevant and acceptable.
This collaborative process not only enhances the overall quality of care but also empowers the individuals within the prison system to actively participate in and take ownership of their health in the context of viral hepatitis.
Establishing a multi-disciplinary team
Section titled “Establishing a multi-disciplinary team”Establishing a multi-disciplinary team (a prison hepatitis elimination steering group) that includes healthcare staff, prison management, local public health staff and people with lived experience of viral hepatitis and/or time spent in prison, is a key task before starting the health needs assessment process and should flow from step one in identifying key stakeholders.
The team needs to meet early to familiarise, to define their roles and tasks and to determine the overarching aims and objectives of the whole process.
Consider who on the team is going to lead the work and who is to undertake each of the specific tasks (i.e. chairing the steering group etc). In considering the composition of your team it is important to take the time to consider whether you have the right people involved, in terms of the skills or experience that are required on the team and that team members are engaged from the outset.
The considerations below should be taken into account:
- Identify which stakeholders you need to engage. What are their roles? Are you including community-led and civil society organisations as stakeholders? Download a stakeholder mapping template.
- Convene a multi-disciplinary team of key stakeholders early in the process to help guide the work of developing and implementing a strategy.
- Gaining support from prison administration/governance at the earliest stages is critical to ensuring the success of any effort to scale up services.
- A key starting point is to engage with all those involved in commissioning and administering prison healthcare to discuss and agree upon the objectives of the elimination approach.
- How might key champions be enlisted?
Step Two – Conduct a healthcare needs assessment
Section titled “Step Two – Conduct a healthcare needs assessment”The aims of a healthcare needs assessment are to gather information to plan, assess and change services for the better and to improve health in other ways (Marshall T, 2001).
Conducting a systematic healthcare needs assessment can help formulate a clear picture of current services and identify areas for change or improvement to ensure that services provided are appropriate and reflective of the needs of your target population. The process of completing a needs assessment also provides an opportunity to involve stakeholders in the planning of services to gain their engagement and ensure they feel ownership (Marshall T, 2001).
In the prison context, conducting a healthcare needs assessment as the first stage of the planning process is crucial to identify and quantify health issues and needs, and review existing service provision. Having a comprehensive overview of the situation will ultimately ensure that the needs of the population in relation to viral hepatitis, are fully considered and addressed.
There are four key possible stages of the needs assessment phase that are outlined in detail below, but it should be noted that the needs assessment should be part of a continuous process aimed at providing continuous quality improvement of the services (Figure 5). Download a needs assessment template.
What hepatitis and prevention and control services are cost effective and should be provided in prison settings?
Stage 3: Outline what services are currently available
Stage 4: Define what services are needed for your prison
Source: Adapted from Marshall T, 2001
Stage 1: Understand your prison environment
Section titled “Stage 1: Understand your prison environment ”The strategy is developed at prison level and it is important to understand the prison environment and the constraints and enabling factors for the scale-up of viral hepatitis services.
Factors for consideration include the healthcare workforce capacity, the structure of the prison (e.g. logistics, spaces, time schedules etc), access restrictions and movements of the prison population through the prison estate and between the prison and the community, which can all influence potential for implementation of prevention, testing and treatment services.
Stage 2: Describe your prison population
Section titled “Stage 2: Describe your prison population ”A clear understanding of the demographic profile of the prison population and the legal status of the population is important for the development of any services in the prison setting (see Section 1: eliminating viral hepatitis in prisons).
Short prison stays may result in exacerbated transmission risks for blood-borne viruses including viral hepatitis in prisons and in the wider community, given that rapid turnover may influence the dynamics of the prison population and access/completion of care services. People in prison are particularly at increased risk of HCV infection given the high prevalence of injecting drug use in many prisons and the often suboptimal access to harm reduction measures (Hajarizadeh B, 2023).
Studies conducted among eight countries across Europe in 2022, the lifetime prevalence for injecting any illicit drug whilst inside prison ranged from 2.9% (Spain) to 14.3% (Latvia), whereas the lifetime prevalence for injecting any illicit drug before imprisonment ranged from 7.8% (Cyprus) to 37.6% (Czechia) (EUDA, 2024).
Further demographic information on people in prison in Europe can be found in Section 1 and at the latest WHO Status Report on Prison Health and SPACE report of the European Council.
Key considerations:
- What type of prison do you work in? (i.e. remand/sentenced, high/low/medium security, open/close regime, female/male, youth etc)
- What is its maximum prison capacity?
- Who is responsible for healthcare services in your prison? Is it the Ministry of Justice, the Ministry of Health, the Ministry of Interior or a collaboration between Ministries?
- What is the size of the current prison population and the throughput (i.e. number of new receptions)? What is the set-up (i.e. how many wings?)?
- What data related to health services, and specifically related to hepatitis services, are currently collected and what are these data used for?
- What health information systems are in place? Are data sets computerised or manual? (See Section 4: Monitoring and Evaluation).
- Is information available to other prisons in case of transfer? Is this available to the community when a prisoner is released?
Relevant factors of your prison population to be considered when developing services (i.e. you should try to quantify these factors in terms of numbers/proportions):
- Socio-demographic information:
- Age (range)
- Sex
- Gender
- Country of birth/nationality
- Level of education
- Legal status
- Judicial status (on remand, sentenced)
- Average length of prison sentences
- Numbers with past imprisonments
- Substance use
- Prevalence of drug use before prison/lifetime/last year/last month
- Drug use in prison
- Type of substances used, frequency of use and route of administration
- Injecting behaviour
- Sharing drug injecting equipment
- Heavy alcohol consumption
- Other risk behaviours
- Tattooing
- Piercing
- Others (e.g. unsafe sex)
- Burden of infectious diseases
- Hepatitis B prevalence
- Hepatitis C prevalence
- Hepatitis B and A vaccine coverage
- Hepatitis B and C treatment needs
- Other infectious diseases e.g. HIV, tuberculosis
- Complications of disease associated with hepatitis B and C infection i.e. cirrhosis or liver cancer
Stage 3: Outline what services are currently available
Section titled “Stage 3: Outline what services are currently available ”When planning a suitable implementation or scale-up approach to viral hepatitis services in prison settings, it is important to have a good understanding of the existing hepatitis prevention and care services available, as well as their corresponding strengths and weaknesses.
This assessment serves as the foundational step in crafting an effective and targeted strategy. In some prisons in Europe, there are existing hepatitis services available, and an implementation plan will not be needed that starts from scratch, but the plan can build upon these services to help strengthen them.
Through a thorough understanding of the current landscape, healthcare providers inside prison can identify the gaps, challenges, and successes of the current system. It allows for an informed approach, tailoring interventions to specific needs and addressing potential barriers.
Additionally, an understanding of the current services enables the development of a seamless integration plan, ensuring that the scaling-up process aligns with existing frameworks and optimises available resources.
Stage 4: Define what services are needed for your prison
Section titled “Stage 4: Define what services are needed for your prison”Defining the services that are needed should take into consideration information gathered from the previous three stages on the prison environment, the prison population and the existing services available. Services should be developed in accordance with local needs and with the latest evidence for effective prevention, testing and treatment services.
Assessing which services are needed to be taken into consideration:
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Prevention servicesincluding harm reduction, infection prevention and control and vaccination.
- A model questionnaire to collect information on drug-related services available in prison is available from EUDA.
- Availability of HBV and HAV vaccination options.
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Testing for HBV and HCV (including who is tested and what types of testing are available e.g. antibody/RNA, point-of-care, phlebotomy etc)
- The diagnostic pathway (when is testing undertaken, how are results recorded and reported and what happens to individuals diagnosed with HBV or HCV)
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Availability of treatment for HBV and HCV, including whether there are any restrictions for treatment and what treatments are available.
- The logistics of treatment (including whether treatment can be delivered within single period of incarceration in a specific institute or if it could involve movement between prisons and/or between prison and the community).
- How treatments are administered in the prison, i.e. who administers the treatment and whether people in prison can be ‘in possession’ of their medications for self-administration or whether they must always have supervised consumption by healthcare staff?
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What resources are currently available to help deliver healthcare services? i.e. human resources (not only those funded services provided by the prison and/or health system but also advocacy and volunteer groups working with prisoners as well as peers), financial resources and direct goods.
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What are the professional backgrounds amongst the prison health workforce? What training is needed and available to upskill healthcare providers? What other resources may be available e.g. voluntary/NGOs who work with prisoners?
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What are the current challenges in accessing healthcare? i.e. stigma and discrimination, difficulties in easily engaging with the medical sector, language barrier, rigid prison schedules, lack of knowledge of interventions, lack of human or financial resources to support care provision, etc.
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What are the social needs of the population? Consider the social determinants of health affecting people in prison, such as non-discrimination and access to health services of the same quality as those available in the community.
Social determinants of health comprise economic and social conditions, which are shaped and influenced by socioeconomic and political factors, including education, occupation and income (WHO, 2024).
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How is continuity of care ensured once the person leaves prison to return to the community or to another establishment?
Step Three – Developing your strategy and identify priorities and actions
Section titled “Step Three – Developing your strategy and identify priorities and actions”Developing a comprehensive strategy for the establishment or scale-up of viral hepatitis services in a European prison necessitates a strategic approach taken by the multi-disciplinary prison hepatitis elimination steering group that is rooted in the findings of the needs assessment.
The assessment helps to identify the health priorities and the services required along the care cascade (ranging from prevention, testing, treatment and aftercare) that are most appropriate to address these needs. You can learn more about the care cascade in Section 3.
A key component in developing this strategy is a methodological assessment of the workforce and resources required for successful implementation, including considerations such as staff time, laboratory costs, and medication procurement. It is important to consider including in the strategy discrete and measurable components such as actions to be undertaken by specific timepoints as well as key objectives.
Considerations to ensure sufficient resources include human resources (i.e. project lead, healthcare and prison staff), finances for additional costs such as overtime and advertising, and technology and equipment (including medical resources, data recording systems and lab test capacity). An example of the necessary resources needed is outlined in the Hepatitis Intensive Test and Treat (HITT) Project Toolkit.
In developing the strategy, there should be a multi-disciplinary agreement covering all relevant local services, such as infectious disease and hepatology (liver disease) services, drug treatment services, and any harm reduction programs.
The role of the prison hepatitis elimination steering group is critical in securing this agreement across the different stakeholder groups. This agreement should be detailed in the strategy and should outline the roles and responsibilities of key partners in providing services as part of the plan.
The resources needed should be clearly outlined, and consideration given to setting performance targets with realistic timelines.
An effective communication plan lies at the core of the strategy and should include regular communications to key stakeholders regarding the development and implementation of the strategy.
A communication strategy should also outline key actions required to address knowledge gaps among staff and people living in prison, attitudinal barriers, and health literacy challenges. Tailoring communication approaches for both the prison staff and the prison population is crucial. This involves considering the unique dynamics within the prison environment and implementing targeted measures to bridge communication gaps.
The Hepatitis Intensive Test and Treat (HITT) project toolkit outlines information that needs to be communicated before the HITT project is implemented. This information includes general awareness raising regarding the toolkit, whether training for blood-borne virus (BBV) testing is required, and the development of standardised answers to questions which may be posed by people in prison during the event (i.e. when will I know my results and what will happen if I get a positive result?).
The communications plan developed should detail the type, frequency and format of communications, who is responsible for delivering the communications and a contingency plan.
A further consideration is that the plan should acknowledge the importance of sustainability, with a focus on activities that can endure beyond the initial implementation phase.
Step Four – Monitoring and evaluation
Section titled “Step Four – Monitoring and evaluation ”The fourth step is to define clear targets for the elimination of hepatitis and tools to measure their achievement. It is critical that the implementation of any plan or strategy is monitored. The first step is to define clear and measurable local targets that are aligned with the implementation plan.
Some activities may have a greater impact than others and targets related to these activities should be prioritised in the planning process. View the WHO indicators and targets for hepatitis elimination. You can learn more about the priorities for monitoring and evaluation in the prison setting in Section 4.
Monitoring project and evaluating project progress can lead to better practice, determining what worked well, where the challenges were and how these could be overcome in future projects. Debriefing meetings and collation of offline feedback are two methods of evaluating and obtaining feedback from all stakeholders including the project team, laboratories, pharmacies and peer support teams.
View the template mapping out your quality improvement process.
Detailed information on monitoring is included in Section 4: Monitoring and Evaluation.
Step Five - Ensuring the strategy is appropriately financed
Section titled “Step Five - Ensuring the strategy is appropriately financed”Ensuring the strategy that is developed is subsequently appropriately financed is crucial. It is important to identify and address any challenges associated with the initial resourcing needed to firstly build up the services and then to sustain the implementation of these services.
This requires a comprehensive examination of existing resources and the resources needed and an agreement on the associated costs to ensure both the initial implementation and long-term sustainability of the strategy. Consulting national hepatitis plans (where these exist) or national plans regarding prisons, as an appropriate starting point to determining where funds may be located and leveraged, will support your strategy.
Firstly, consider leveraging existing resources or services to support your strategy. For example, are there existing funded programs for HIV or other infectious diseases into which hepatitis B and C services might be integrated to keep costs down. Leveraging existing programs as a way to scale up hepatitis services is particularly advantageous in settings where securing additional funding is challenging or resources are more limited.
Another critical step is the mapping of any potential additional resources that may be required to cover the identified costs associated with implementation of the strategy. By anticipating additional expenses, the strategy becomes more resilient to unforeseen challenges. This includes considering the full spectrum of resources needed, from the cost of diagnostics and treatment, to personnel and resources required in relation to training.
Exploring potential sources of funding is essential. This involves consideration of the funding pathway for prison healthcare services and the long-term resources needed for implementation of the strategy.
Accessing funding sources requires an understanding how to navigate any funding application processes and local public health services play an important supportive role here. Embedding the strategy within broader health initiatives while gaining approval or support from the Ministry in charge of funding enhances the credibility and sustainability of the funding model.
Seeking external support for funding applications may be a key consideration in some circumstances. Identifying available support and resources to assist in the application process enhances the chances of securing funding. The INHSU Prisons Advocacy Toolkit can serve as a valuable resource in this regard, providing guidance and tools for successful advocacy efforts.