Browsing by Author "Chileshe, Chisela"

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Exploring the drivers of health and healthcare access in Zambian prisons: a health systems approach.
(2016-Nov) Topp, Stephanie M.; Moonga, Clement N.; Luo, Nkandu; Kaingu, Michael; Chileshe, Chisela; Magwende, George; Heymann, Jody S.; Henostroza, German
BACKGROUND: Prison populations in sub-Saharan Africa (SSA) experience a high burden of disease and poor access to health care. Although it is generally understood that environmental conditions are dire and contribute to disease spread, evidence of how environmental conditions interact with facility-level social and institutional factors is lacking. This study aimed to unpack the nature of interactions and their influence on health and healthcare access in the Zambian prison setting. METHODS: We conducted in-depth interviews of a clustered random sample of 79 male prisoners across four prisons, as well as 32 prison officers, policy makers and health care workers. Largely inductive thematic analysis was guided by the concepts of dynamic interaction and emergent behaviour, drawn from the theory of complex adaptive systems. RESULTS: A majority of inmates, as well as facility-based officers reported anxiety linked to overcrowding, sanitation, infectious disease transmission, nutrition and coercion. Due in part to differential wealth of inmates and their support networks on entering prison, and in part to the accumulation of authority and material wealth within prison, we found enormous inequity in the standard of living among prisoners at each site. In the context of such inequities, failure of the Zambian prison system to provide basic necessities (including adequate and appropriate forms of nutrition, or access to quality health care) contributed to high rates of inmate-led and officer-led coercion with direct implications for health and access to healthcare. CONCLUSIONS: This systems-oriented analysis provides a more comprehensive picture of the way resource shortages and human interactions within Zambian prisons interact and affect inmate and officer health. While not a panacea, our findings highlight some strategic entry-points for important upstream and downstream reforms including urgent improvement in the availability of human resources for health; strengthening of facility-based health services systems and more comprehensive pre-service health education for prison officers.
Health and healthcare access among Zambia's female prisoners: a health systems analysis.
(2016-Sep-26) Topp, Stephanie M.; Moonga, Clement N.; Mudenda, Constance; Luo, Nkandu; Kaingu, Michael; Chileshe, Chisela; Magwende, George; Heymann, Jody S.; Henostroza, German
BACKGROUND: Research exploring the drivers of health outcomes of women who are in prison in low- and middle-income settings is largely absent. This study aimed to identify and examine the interaction between structural, organisational and relational factors influencing Zambian women prisoners' health and healthcare access. METHODS: We conducted in-depth interviews of 23 female prisoners across four prisons, as well as 21 prison officers and health care workers. The prisoners were selected in a multi-stage sampling design with a purposive selection of prisons followed by a random sampling of cells and of female inmates within cells. Largely inductive thematic analysis was guided by the concepts of dynamic interaction and emergent behaviour, drawn from the theory of complex adaptive systems. RESULTS: We identified compounding and generally negative effects on health and access to healthcare from three factors: i) systemic health resource shortfalls, ii) an implicit prioritization of male prisoners' health needs, and iii) chronic and unchecked patterns of both officer- and inmate-led victimisation. Specifically, women's access to health services was shaped by the interactions between lack of in-house clinics, privileged male prisoner access to limited transport options, and weak responsiveness by female officers to prisoner requests for healthcare. Further intensifying these interactions were prisoners' differential wealth and access to family support, and appointments of senior 'special stage' prisoners which enabled chronic victimisation of less wealthy or less powerful individuals. CONCLUSIONS: This systems-oriented analysis revealed how Zambian women's prisoners' health and access to healthcare is influenced by weak resourcing for prisoner health, administrative biases, and a prevailing organisational and inmate culture. Findings highlight the urgent need for investment in structural improvements in health service availability but also interventions to reform the organisational culture which shapes officers' understanding and responsiveness to women prisoners' health needs.
Mapping the Zambian prison health system: An analysis of key structural determinants.
(2017-Jul) Topp, Stephanie M.; Moonga, Clement N.; Luo, Nkandu; Kaingu, Michael; Chileshe, Chisela; Magwende, George; Henostroza, German
Health and health service access in Zambian prisons are in a state of 'chronic emergency'. This study aimed to identify major structural barriers to strengthening the prison health systems. A case-based analysis drew on key informant interviews (n = 7), memos generated during workshops (n = 4) document review and investigator experience. Structural determinants were defined as national or macro-level contextual and material factors directly or indirectly influencing prison health services. The analysis revealed that despite an favourable legal framework, four major and intersecting structural factors undermined the Zambian prison health system. Lack of health financing was a central and underlying challenge. Weak health governance due to an undermanned prisons health directorate impeded planning, inter-sectoral coordination, and recruitment and retention of human resources for health. Outdated prison infrastructure simultaneously contributed to high rates of preventable disease related to overcrowding and lack of basic hygiene. These findings flag the need for policy and administrative reform to establish strong mechanisms for domestic prison health financing and enable proactive prison health governance, planning and coordination.
Screening for tuberculosis and testing for human immunodeficiency virus in Zambian prisons.
(2015-Feb-01) Maggard, Katie R.; Hatwiinda, Sisa; Harris, Jennifer B.; Phiri, Winifreda; Krüüner, Annika; Kaunda, Kaunda; Topp, Stephanie M.; Kapata, Nathan; Ayles, Helen; Chileshe, Chisela; Henostroza, German; Reid, Stewart E.
OBJECTIVE: To improve the Zambia Prisons Service's implementation of tuberculosis screening and human immunodeficiency virus (HIV) testing. METHODS: For both tuberculosis and HIV, we implemented mass screening of inmates and community-based screening of those residing in encampments adjacent to prisons. We also established routine systems – with inmates as peer educators – for the screening of newly entered or symptomatic inmates. We improved infection control measures, increased diagnostic capacity and promoted awareness of tuberculosis in Zambia's prisons. FINDINGS: In a period of 9 months, we screened 7638 individuals and diagnosed 409 new patients with tuberculosis. We tested 4879 individuals for HIV and diagnosed 564 cases of infection. An additional 625 individuals had previously been found to be HIV-positive. Including those already on tuberculosis treatment at the time of screening, the prevalence of tuberculosis recorded in the prisons and adjacent encampments – 6.4% (6428/100,000) – is 18 times the national prevalence estimate of 0.35%. Overall, 22.9% of the inmates and 13.8% of the encampment residents were HIV-positive. CONCLUSION: Both tuberculosis and HIV infection are common within Zambian prisons. We enhanced tuberculosis screening and improved the detection of tuberculosis and HIV in this setting. Our observations should be useful in the development of prison-based programmes for tuberculosis and HIV elsewhere.
The health system accountability impact of prison health committees in Zambia.
(2018-Sep-24) Topp, Stephanie M.; Sharma, Anjali; Chileshe, Chisela; Magwende, George; Henostroza, German; Moonga, Clement N.
BACKGROUND: From 2013, the Zambian Corrections Service (ZCS) worked with partners to strengthen prison health systems and services. One component of that work led to the establishment of facility-based Prison Health Committees (PrHCs) comprising of both inmates and officers. We present findings from a nested evaluation of the impact of eight PrHCs 18 months after programme initiation. METHODS: In-depth-interviews were conducted with 11 government ministry and Zambia Corrections Service officials and 6 facility managers. Sixteen focus group discussions were convened separately with PrHC members (21 females and 51 males) and non-members (23 females and 46 males) in 8 facilities. Memos were generated from participant observation in workshops and meetings preceding and after implementation. We sought evidence of PrHC impact, refined with reference to Joshi's three domains of impact for social accountability interventions - state (represented by facility-based prison officials), society (represented here by inmates), and state-society relations (represented by inmate-prison official relations). Further analysis considered how project outcomes influenced structural dimensions of power, ability and justice relating to accountability. RESULTS: Data pointed to a compelling series of short- and mid-term outcomes, with positive impact on access to, and provision of, health services across most facilities. Inmates (members and non-members) reported being empowered via a combination of improved health literacy and committee members' newly-given authority to seek official redress for complaints and concerns. Inmates and officers described committees as improving inmate-officer relations by providing a forum for information exchange and shared decision making. Contributing factors included more consistent inmate-officer communications through committee meetings, which in turn enhanced trust and co-production of solutions to health problems. Nonetheless, long-term sustainability of accountability impacts may be undermined by permanently skewed power relations, high rates of inmate (and thus committee member) turnover, variable commitment from some officers in-charge, and the anticipated need for more oversight and resources to maintain members' skills and morale. CONCLUSION: Our study shows that PrHCs do have potential to facilitate improved social accountability in both state and societal domains and at their intersection, for an extremely vulnerable population. However, sustained and meaningful change will depend on a longer-term strategy that integrates structural reform and is delivered through meaningful cross-sectoral partnership.