Leave no one behind: including the health of prisoners in international development frameworks is essential for achieving sustainable development goals

Purpose – The pledge of the 2030 Agenda for Sustainable Development is “to leave no one behind.”However, there are significant groups of people who are at risk of being left behind. The health and social issues facing prisoners are well known, but past initiatives to address them through international development initiatives have failed to gain widespread support. Thepurpose of this paper is to advocate for inclusion of prison health care in current international development frameworks such as Universal Health Coverage and the 2030 Sustainable Development Goals. Design/methodology/approach – This is a commentary paper. Findings – The governments of most countries have accepted both the 2030 Agenda for Sustainable Development and Universal Health Coverage as frameworks for future national development planning. Including prison health care in these frameworks will provide a powerful platform for those advocating for better prison health services and will allow governments wary of offending public opinion to make significant changes to the way prisons are managed. Providing better prison health care services will not only lead to better long-term population health outcomes overall but will also contribute to achieving the 2030 Agenda aspiration to “leave no-one behind.” Originality/value – This paper provides a discussion of current international development guidance and identifies that prison health care is not sufficiently recognized as an essential contributor to achieving the sustainable development goals.

However, there remain significant populations not recognized as stakeholders in global development architecture and processes and who as yet have little or no voice in what happens to them or what is done in their name [3]. These are people under various forms of legal constraints such as refugees, displaced people, asylum seekers, migrants and prisoners. Of these, only prisoners do not appear in the international development community's standard lists of "vulnerable groups" [4], that is, people who need advocates to argue their case in high-level development fora. Therefore, we argue that prisoners face a high risk of being a group "left behind" by global development aspirations.
People passing through the criminal justice system are a subpopulation whose health status and social needs, both immediate and long-term, are too often not taken into account by planners at the national development level. The numbers involved are quite significant. Globally, upward of 11m people are in prison at any one time [5], all of whom need access to quality health services. In addition to meeting the needs of those in prison, health services are needed for a substantial number of other incarcerated groups, such as pretrial detainees, prisoners on parole, those given noncustodial sanctions and those held in police cells, military prisons and immigration detention.
Of particular concern for public health, over 30m people move in and out of prison over the course of a year, a large number of whom leave prison with HIV, hepatitis B/C and/or active TB [6]. In many countries, women who are pregnant at the time of conviction give birth in prison, and younger children accompany their mothers while they are in prison [5]. The global trend toward harsher sentencing guidelines has caused a steep rise in the number of elderly people in prisons, many of whom have disabling chronic diseases [5]. Between 2000 and 2015, the global prison population rose by almost 20%, and this trend is forecast to continue [5].
In many lower-and middle-income countries, the prison health care system is financed, administered and staffed separately from the national health system, and therefore, prison health services do not always meet norms and standards set out in national health policies and plans [7]. Many prison health services are constrained by a lack of resources, which is particularly evidenced by the scale of mental health problems seen in former prisoners, particularly children, and the quality of mental health services offered in prisons [7,8]. One part of the solution to these problems lies in adding prison health to the curricula of medical and nursing undergraduate and postgraduate education [9].
The specific health and social issues facing prisoners are well known [10]. The desirability of meeting those needs through integrated national public health and prison health services is well recognized [11] and promoted by various conventions, such as the 1995 Healthy Prisons Approach and the 2003 Moscow Declaration [7] and initiatives such as the Health-Promoting Prison concept [12]. Up to now, these largely European initiatives have failed to gain global traction [12], but Agenda 2030, in aspiration if not in actual goals and targets, now offers a framework in which to move forward.
The International Health Partnership for UHC 2030 (UHC2030) [13] is a multistakeholder global initiative established in 2017 to advocate for increased political commitment to Health Systems Strengthening (HSS) and Universal Health Coverage (UHC). In their paper on health systems and sustainable development, Kieny et al. [14] demonstrate how such strategic investments in the health sector are critical to achieving Agenda 2030: UHC allows countries to attain equitable and sustainable health outcomes, and HSS builds the institutions and provides the resources needed, to improve, maintain and restore the health of their populations.
However, we argue that national HSS and UHC programs cannot be fully effective unless people living in detention have access to integrated services, which provide continuity of care of the same quality and standards as the services for the broader population. Including prison health in national public health programs will contribute directly to achieving the relevant Agenda 2030 goals on nutrition (SDG2), health (SDG3) and reduced inequalities (SDG10), but will also contribute to achieving other important global development goals.
People leaving prison are very often rejected by their communities and have difficulty finding accommodation and employment. They may end up in hostels or on the streets, where their health problems may go unaddressed and their health condition deteriorates [8]. Poverty and homelessness are key risk factors for both poor mental health status and recidivism [4]. HSS and UHC programs, which consider the health and social needs of prisoners, both in detention and after they leave detention, will contribute to meeting both SDG1 (end poverty in all its forms everywhere) and SDG8 (promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all).
More importantly, we argue that the development of effective prison health care systems helps to build institutions that make value-added contributions to national development beyond their primary criminal justice or public health mandate and thus contributes to achieving SDG16 (promote inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions for all).
Including prison health in international development frameworks is a win-win proposition: (1) it contributes significantly to the international development community's ability to achieve its goal of leaving no one behind; (2) it encourages governments already committed to achieving the SDG and implementing UHC to lift planning and resourcing of prison services from departmental level to national development planning level, which in turn (3) provides opportunity and legitimacy for more research in prisons, particularly in countries where governments now restrict it; and (4) it gives advocates for prisoners and improved prison services a broader and more solid platform from which to argue their case. Arguing for the human rights of prisoners is a sensitive area, but addressing the issue through the UHC lens of health rights may be a more palatable approach to overcoming those sensitivities.

Conclusion
Numerous challenges face governments in the delivery of effective prison health care. The 2030 Agenda offers governments both an opportunity and a framework to address these challenges. Providing better prison health care services will not only lead to better long-term population health outcomes overall but will also contribute to achieving the 2030 Agenda aspiration to "leave no-one behind."