The health of female prisoners in Indonesia Amala Rahmah, James Blogg, Nurlan Silitonga, Muqowimul Aman and Robert Michael Power
Amala Rahmah is based at HIV Cooperation Program for Indonesia, Jakarta, Indonesia. James Blogg is an Injecting Drug Use Advisor, based at HIV Cooperation Program for Indonesia, Jakarta, Indonesia. Dr Nurlan Silitonga is based at HIV Cooperation Program for Indonesia, Jakarta, Indonesia. Muqowimul Aman is based at Department of Correction, Ministry of Justice and Human Rights, Jakarta, Indonesia. Professor Robert Michael Power is the Head, based at Centre for International Health, Burnet Institute, Melbourne, Australia.
Abstract Purpose – Indonesian law provides prisoners with basic rights, including access to education, health care and nutrition. Yet, structural and institutional limitations, notably overcrowding and under-resourcing, prohibits penal institutions from fulfilling these commitments for female prisoners. The purpose of this paper is to explore their health concerns. Design/methodology/approach – Six prisons and one detention centre were researched, comprising: female prisoners (n ¼ 69); clinical officers (six); clinic heads (seven); wardens (seven); heads of prisons (seven); and a Directorate representative. Data were collected through observation, focus group discussions, in-depth interviews and a semi-structured questionnaire. Raw data were transcribed and analysed thematically, adopting the General Principles of Grounded Theory. Findings – Both “formal” and “informal” health-coping strategies were dependent upon a range of factors which determined access to treatment, medicines and other items procured both inside and outside of the prison, as well as referral services. Informal systems of support existed for women, especially in regard to pregnancy and raising of babies born in detention. Systems that maintain harmony within cell blocks were identified as an important informal coping strategy. Originality/value – This research is important in informing policy and practice. There is a clear need for gender-sensitive legislative frameworks, penal policies and prison rules to ensure women’s needs are addressed. The identified coping strategies were considered viable, but do not replace the need for a health system providing women prisoners with levels of care as available in the community, including commensurate budgeting, personnel, access and referral to more specialised external health services. Keywords Health in prison, Health policy, Human rights, Prisoners, Offender health, Overcrowding Paper type Research paper
Introduction and background
The research was funded by the Australian Government through Department of Foreign Affairs and Trade under HIV Cooperation Program for Indonesia. There were no conflicts of interest for any of the staff. Dr James Blogg had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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Imprisoned women experience a wide range of problems, including physical and mental health complaints, environmental stressors, overcrowding, poor access to gender-specific health services, sexual abuse and poor nutrition (Prison Reform Trust, 2006). Female prisoners with drug problems also have higher rates of tuberculosis, hepatitis, anaemia, hypertension, diabetes and obesity than male prisoners (Penal Reform International, 2007). Female prisoners have often worked as sex workers or been victims of sexual violence before their incarceration and are therefore at greater risk of sexually transmitted infections such as chlamydia, syphilis, gonorrhoea and HIV than women in the community (Covington, 2006). Currently, Indonesian law protects prisoners with basic rights, including access to spiritual and physical care, education, health care and decent food (Government Regulation Republic of Indonesia, 1999). However, overcrowding in Indonesian prisons currently ranges from 19 to 55 per cent, which makes it difficult for institutions to fulfil their obligations (Ministry of Justice and Human Rights, 2009). There has been an abundance of research into the determinants, correlates and outcomes of prisoner health in recent years. Topic areas focusing on prisoner health have covered issues such as substance use (Vagenas et al., 2013), mental health (Schwalbe et al., 2013), oral health (Reddy et al., 2012), HIV infection (Dolan and Larney, 2010), treatment of sex offenders (Birger et al., 2011), cancer (Dahiya and Croucher, 2010) and mortality (Brown, 2010). The research
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DOI 10.1108/IJPH-08-2013-0038
has been conducted in a wide range of countries including India (Reddy et al., 2012), China (Lai et al., 2008), Jordan (Schwalbe et al., 2013), Azerbaijan (Cozac and Elliott, 2011), Taiwan (Huang et al., 2011), Israel (Birger et al., 2011), Indonesia (Nelwan et al., 2010), Thailand (Sherman et al., 2010), Myanmar (Brown, 2010), Malaysia (Choi et al., 2010), Pakistan (Altaf et al., 2009), and Kyrgyzstan (Moller et al., 2008). In Indonesia, only nine out of 421 prisons and detention centres have been specially designed to accommodate women and children. A 2010 study found that even though only 6 per cent of female prisoners had a history of injecting drug use 92 per cent of these women had been arrested on a drug-related charge (Blogg et al., 2014). Although the number of female prisoners is only about 5 per cent of the total number of prisoners in Indonesia, the increased rate of incarceration of women is much higher than for men, whilst the rate of release of female prisoners (i.e. those qualifying for parole) is lower than that of men (Ministry of Justice and Human Rights, 2009). A recent study in Indonesian prisons showed links between higher levels of HIV sero-positivity and concomitant health problems in females compared to males. HIV prevalence was 1.1 per cent in males and 6 per cent in females. Among females the key factors associated with HIV were testing positive for syphilis and a history of drug use. Of those with history of drug use, 12 per cent female and 6.7 per cent male tested positive for HIV (Blogg et al., 2014). The qualitative research reported in this paper complements the HIV and Syphilis Prevalence and Risk Behaviour Study Amongst Prisoners in Prisons and Detention Centres in Indonesia (Blogg et al., 2014) as it explores broader health concerns and responses, including sexual and reproductive health. All the prisons included in this study had a health clinic that could be accessed by female prisoners during set times. Free basic health care was found to be generally available, including the provision of medicines and medical services. For those who could afford to buy medicines outside of prison this could be obtained with help from their family. Only prisoners at Lapas Kerobokan, Bali and Rutan Pondok Bambu, Jakarta have access to a dedicated methadone programmes and access to staff trained in the treatment of drug dependency. However, female prisoners at Lapas Anak Wanita, Tangerang are able to access methadone through doses brought in from the methadone programme at the nearby Lapas Pemuda, although their staff are not trained to dispense methadone. All female prisoners are able to keep their babies/infants with them in prison until the child reaches two years of age, but there are no special facilities for child rearing. Many prisons adopt an informal system whereby each cell block has a leader or daily sentry to maintain order amongst the block’s inmates. The objective of this qualitative study was to explore the health needs and health-coping strategies of female prisoners in six prisons and one detention centre in Indonesia in order to make recommendations to improve the health status of female prisoners.
Methodology This study was conducted in six prisons and one detention centre, which included those designated specifically for the imprisonment of women (Lapas Wanita) and those that housed both men and women: Lapas Wanita Bulu, Semarang; Lapas Anak Wanita, Tangerang; Lapas Wanita Malang, East Java; Rutan Medaeng, East Java; Rutan Pondok Bambu, Jakarta; Lapas Wanita, Bandung; and Lapas/Rutan Kerobokan, Bali. These six prisons and one detention centre were chosen based on the criterion that they accommodated the highest populations of female prisoners in Indonesia. Participants in this study comprised female prisoners (n ¼ 69) who were chosen randomly based on each prison’s list of registered prisoners. A convenience sample of clinical officers (six); clinic heads (seven); wardens (seven), heads of prisons (seven); and a representative from the Director General of Correctional Services were also selected to represent the range of views of prison staff across the sector. The 69 female prisoners were interviewed in groups of eight to ten
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women. Each group had to include at least one participant who was pregnant or breastfeeding. Of these 69 participants, 61 per cent were imprisoned for drug-related offences. Data were collected from September to December 2009. Qualitative data were collected through observation, focus group discussions (FGDs) and indepth interviews. A semi-structured questionnaire covering illness and health service access was conducted during the FGD to complement other qualitative data. Furthermore, a literature review was conducted on correctional law and justice related to the themes of the study. The raw data were transcribed and analysed thematically, adopting the General Principles of Grounded Theory (Neuman and Lawrence, 2003; Cresswell, 2003). Ethics approval was received from Ministry of Justice and Human Rights Ethics Committee (reference no. PAS.3HM.04.03.118). Independent oral voluntary informed consent was obtained from all respondents.
Results Prisoner characteristics Of the 69 female prisoners who participated in this study from seven prisons, the majority were serving sentences for drug offences (61 per cent). Other offenses included: fraud (7.2 per cent), homicide (7.2 per cent) and robbery (7.2 per cent). Participants’ ages ranged from 31 to 40 years old (53.7 per cent), followed by 21 to 30 years (26.9 per cent) and 41 to 50 years (16.4 per cent). The majority of participants graduated from high school (44 per cent). Fewer participants had only graduated from junior high school (17.6 per cent), elementary school (14.7 per cent) or had not graduated from elementary school (11.8 per cent). A minority had graduated from college (11.8 per cent). The majority of participants were married (53.7 per cent). Other participants were divorced (22.4 per cent), single (9 per cent), widowed (7.5 per cent) and those in a casual relationship (7.5 per cent). The majority of participants were housewives (39 per cent). About a third worked in the private sector (30 per cent), with 10 per cent having worked as private merchants. The remaining stated occupations that included writing, lecturing, farming or singing at a karaoke centre. The largest group of participants had one child (30.4 per cent) with 20.1 per cent having two children, 14.5 per cent not having any children, 11.6 per cent had three and 8 per cent had four children. Whilst in prison, most participants with children entrusted them to the care of their parents (37.7 per cent), or husbands (15.3 per cent), siblings (8.7 per cent), friends (2.9 per cent) or parents-in-law (2.9 per cent). The highest reported expenditure while in prison was for toiletries (93 per cent); washing equipment (74 per cent); sanitary napkins (68 per cent); medicine, including vitamins (51 per cent) and cosmetics (48 per cent); and clothes (46 per cent). Knowledge of HIV/AIDS and health problems. The majority of participants had heard about HIV and AIDS (87 per cent). Most of these participants (78 per cent) knew that HIV is preventable and knew specifically how to prevent HIV by: not having sexual intercourse with a person living with HIV (PLWH) (55 per cent); avoiding sharing needle syringes (78.2 per cent); having sexual intercourse only with one faithful spouse (76.8 per cent) and using condoms for sexual intercourse with PLWH (74 per cent). The majority of participants knew that mosquito bites are not a risk for transmitting HIV (55 per cent) and 43 per cent knew that using common cutlery, bathing and using washing accessories do not present a risk for transmitting HIV. The majority (58 per cent) had talked about HIV and AIDS, either with their friends during their sentence (41 per cent) or with a prison health officer (23 per cent), NGO officer (18.8 per cent), friends outside the prison (15.9 per cent), parents (13 per cent), prison officer (5.8 per cent) or with a sibling (11.6 per cent). All participants reported having a medical complaint whilst in prison. These included: headaches (69.5 per cent), a sore back (40.6 per cent), cough or flu (34.7 per cent), problems with their digestive tract (23 per cent) and pruritus or scabies (23 per cent). For illnesses of the reproductive system, most said that they had excessive menstrual pain (33.3 per cent) or irregular menstruation (27.5 per cent). Other issues were vaginal bleeding (4 per cent), itchiness
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in the genital area (5.8 per cent), leucorrhoea (5.8 per cent) or complications of pregnancy (2 per cent). Women prisoners and health-seeking behaviour A thematic analysis of the data highlighted both “formal” and “informal” coping strategies around health. The access to the various aspects of these coping strategies depended on a number of factors both internal and external to the prison or detention centre. “Formal”: access to health services. As the clinic is the only health service available in prison, a common theme according to the clinical officers interviewed was the inadequate number of doctors and nurses allocated to service prisons. Each prison visited usually had only one medical officer, one doctor and one nurse although many prisons have no doctor or no health staff at all and must rely upon monthly visits from their supervising prison’s doctor (Ministry of Justice and Human Rights, 2014). Most prisoners with health complaints reported they had attended the prison clinic (84 per cent). Even though, on average, 60-80 patients attended each clinic per day, study participants indicated they were not confident that the service provided was of high quality. During FGDs female prisoners expressed a low opinion of the service provided by prison clinics. They reported that clinics often prescribed the same medicine for different symptoms: [y] whether it is diarrhoea or a sore back, the medicine [given] is the same. Same colour, same shape, same brand [y] (Female prisoner, Surabaya). [y] to go to the clinic is not about getting well, it is just so that the illness will not become more severe. Even though we go there repeatedly, we do not get well. But we don’t have any other choice [y] (Female prisoner, Jakarta). [y] where else can we go, there is no choice. I only go to the clinic if the illness is severe. If not, I still prefer a traditional coin massage [y] (Female prisoner, Semarang). [y] at the clinic everything is limited. I understand that they are busy and also that we are a burden to the state but it is their responsibility. If they put us in here and then they neglect us, I think it’s better if we are outside [y] (Female prisoner, Surabaya).
FGDs and interviews explored the referral and health support system. A system for referral to health services outside of prison exists with prisons usually having established their own network with a local hospital. For cancer, asthma or other common problems, referral is relatively easy and well established. However, referral for illnesses related to HIV and AIDS is more complex. Even though almost all prisons have a referral hospital designated to provide treatment with antiretroviral therapy, this did not mean that referral to these services could be easily arranged. For example, the women at Tangerang women’s prison reported difficulty in being referred to Tangerang General Hospital. This was related to the need for prisons to give a guarantee regarding payment for external health services. Consequently, the hospital was unwilling to treat PLWH. Clinic staff commented on the need for a better system for dealing with each hospital administration to facilitate this process, especially regarding the payment guarantee, the supply of medicines and guarding of female prisoners while they were in the hospital. According to the heads of prisons, the problem with hospital referral was not limited to the higher cost of the treatment in hospital. Problems also arose due to additional costs for the meals, transport and scheduling of guards, when a police officer had to be hired to guard a patient. The problems associated with referral were exacerbated when the prisoner had no relatives to contribute to treatment costs. Prison heads stated that there was no specific budget for health treatment. Rather, there was a general budget to cover all prisoner-related expenses. As such, allocation of funds to support referral depended upon each situation and the policy adopted at each prison. “Formal”: access to drug substitution therapy. A methadone service for drug-dependent opioid users was established in some hospitals in 2004. At Kerobokan Prison, Bali, a referral system operated if a prisoner had previously been a methadone patient outside of prison. These
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prisoners would automatically obtain routine treatment inside prison by producing a referral letter from their regular clinic (i.e. community health centre or hospital). When a prisoner nears the end of his or her sentence, the methadone officer prepares a referral for treatment to be continued outside the prison. This model of providing prisoners with the same treatment they were accessing in the community, does not apply in all cases. Prison officials reported endeavouring to obtain additional resources, such as additional staff, medicines, reagents or laboratory equipment from the local community health centre or hospital. Problems and obstacles can arise because community health centres and prisons fall under different government departments and are often located in different geographical areas. Even though insufficient coordination between departments constrains the effort to obtain additional resources, prisoners qualify for support under the national scheme which guarantees health services for the poor: [y] we already tried to cooperate with the local health service to get additional medicines, but they have difficulty accounting for medicine they give to prisons [y] (Doctor, Jakarta). [y] it’s difficult to ask for additional resources (like doctors and nurses) from a community health centre. They also have their own patients to look after every day, it could be hundreds, so I have to treat them all by myself [y] (Doctor, Bandung).
“Informal”: health-seeking behaviour. Individual relationships in a block or cell had different dynamics, but were important in accessing resources. Members who had served the longest sentences were reported as having the best chance of managing resources and were often the ones more dominant in enforcing rules in the block. Appointment of people of responsibility within the block was usually carried out by discussion although they were sometimes self-appointed. FGD results showed that block leaders were usually appointed as a result of: block members feeling able to share their problems with them; seniority (due to age or how long they have been in prison); their ability to manage conflict. However, it was noted that appointment of block leaders was not related to economic status, physical power or access to special facilities in prisons and was an informal arrangement. As well as relying on the support of the block leader and attending the prison clinic for health services, 46 per cent women reported asking their friends in their block for help. Others bought off-the-shelf medicines (16 per cent) or consulted a hospital or doctor outside prison (7 per cent). Almost all participants thought that the clinic was the easiest way to access help with health issues whilst inside prison (64 per cent), and the next easiest option was to consult a friend (13 per cent). Female prisoners reported being able to afford to get pregnancy check-ups with a specialist outside of the prison. This option was easier for women in detention centres to arrange, as most detainees are only on remand, which makes it easier for them to access services outside the prison. “Informal”: pregnant prisoners and babies. Interviews and other data revealed that it is not uncommon for women to give birth while in prison. New mothers tend to receive advice from other prisoners about getting enough rest and eating healthier food. It is common for all of the cell block to participate in the raising of a baby, including bathing, changing nappies or washing the clothes of baby and mother. New mothers reported that: [y] here, I didn’t really feel tired after delivering a baby. My friends helped me. Some help me to carry the baby while I wash my clothes, change diapers, prepare milk [y] (Female prisoner, Surabaya). [y] when I had a baby, everyone helped me, the prison officers, my friend in the block. I just sleep in the room. If my baby cries because it’s hungry, then they give the baby to me [y] (Female prisoner, Malang). [y] ten days after the delivery, my friend helped me wash my clothes and the baby’s. Free. I just sleep in my room [y] (Female prisoner, Malang).
“Informal”: health-seeking support networks. If a block member needed treatment, the health official usually receives this request via another member of the cell block. This route of communication was common across the prisons that were assessed. Block members often facilitated the process of getting the patient to the clinic officer. In an emergency situation, usually
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one block member will tell the block guard who will get the clinical officer. If the clinic is open, the clinical officer will come to the block, but if the clinic is closed, extra effort is needed to contact the health officer if they live at the prison. This system of support is most evident when the prisoner is pregnant or has recently delivered a baby, or if a baby or infant needs help: [y] usually if someone has a serious illness we are the first to know, usually we call for the guards and they make the arrangements with the clinic [y] (Female prisoner, Surabaya).
Prisoners willing and able to treat their sick friends constitute a strong form of social capital. To support this, routine, agreed-upon contributions are collected by and from prisoners in most cell blocks and used for the common benefit of the block including: paying for health services; treating babies; or paying for child-birth delivery. These fees are also used to buy necessities such as sanitary napkins, soap, sugar, tea and other common goods: [y] this fee is used for people who get sick. Sometimes if there is a need to refer to hospital, we use this money [y] (Female prisoner, Tangerang).
“Informal”: maintaining harmony and conflict management between prisoners. Disputes between prisoners are common, usually over simple matters related to the tidiness of the block, such as disposal of used sanitary napkins, untidy beds, glasses or plates left unwashed after use, or the daily sentry (block member responsible for maintaining order) not doing her job. However, physical violence is rare, which is probably related to the strong emotional bonds that were reported between prisoners: [y] I often say, “you live together here. Get on together, face your difficulties together, don’t fight. Usually they follow this advice” [y] (Warden, Tangerang). [y] often they fight but usually it’s just a quarrel, there are no fist fights [y] (Female prisoner, Surabaya). [y] we never fight here, it’s a quiet life [y] (Female prisoner, Malang).
A baby or a child in the prison can be a catalyst for creating harmony between female prisoners. A baby is the responsibility of all members of the cell block which includes ensuring that the baby has a decent living environment while in prison e.g. providing comfortable bedding, ensuring there’s no smoking nearby, keeping those with transmissible diseases at a safe distance. Prisoners reported taking turns to look after a baby while the mother washes clothes, prepares milk or rests: [y] if there is a baby or a child, we will be more tidy. If someone has a cough, we separate them from the baby, our room is also cleaner [y] (Female prisoner, Tangerang).
“Informal”: social relationships between female prisoners and prison officials. Despite the reluctance to be open with prison guards, prisoners had a different attitude towards health officers. This relative openness was reportedly because prisoners considered health officers to be more concerned with prisoners’ well-being: [y] if we tell something to the guard, sometimes it can come back to us if something happens [y] (Female prisoner, Surabaya). [y] I feel closer to the women from the clinic, they care about our health and are more relaxed and not so strict [y] (Female prisoner, Malang). [y] they could talk to me more easily compared to the security staff, maybe because they feel it’s safer here in the clinic and we do not deal with discipline [y] (Doctor, Jakarta). [y] they are more relaxed with health officers, they can share their story with me even though I’m a man [y] (Doctor, Bandung).
Relationships between prisoners and health officers can act as a bridge for creating personal and social relationships between prisoners in a block. Depression, stress and other psychological symptoms were reportedly reduced after consulting with health officers: [y] it’s better to share with people from the clinic, they will not tell each other [y] (Female prisoner, Surabaya).
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I give advice even though I don’t have a psychology background, but giving advice to others is a basic skill. Usually they change and begin to accept their condition, but my time is usually limited because I have other patients [y] (Doctor, Jakarta).
Even though prisoners reported good relations with health officers, most reported that they kept certain confidences from them, did not communicate regularly with health officers, and that their closest friend and confidante was another prisoner.
Conclusion and discussion This study has identified a number of issues that exacerbate health problems for women in prison and correctional facilities in Indonesia. These include: ’
Overcrowding. As of March 2014 only 27 per cent of provinces had prisons which were collectively not overcrowded. The total prison system currently contains 164,000 inmates, but was designed for o111,000, representing 148 per cent overcapacity (Ministry of Justice and Human Rights, 2014).
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Lack of female-focused health facilities. Prisoners interviewed reported low quality services which were usually unable to respond adequately to their basic health needs.
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Staff and resources. The responses reported by clinical officers are backed up by current data: as of February 2014 only 679 doctors and paramedics were allocated to care for the 164,000 inmates. The budget to cover non-food services (which must include health services) is o6 per cent of the total budget to run the prison system. However, even this small budget is currently under pressure (Ministry of Justice and Human Rights, 2014).
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A male-dominated prison system. As of March 2014, 8,382 women represented only 5 per cent of prisoners. Consequently, female prisoners were forced to rely upon approaches developed for a service developed to incarcerate men (Ministry of Justice and Human Rights, 2014).
A range of formal and informal coping strategies are adopted by women in an attempt to address health issues experienced in prison including: accessing services internal and external to the prison; peer support within each block; developing relationships with prison staff; pooling of funds by prisoners; and communal childcare and shared responsibility. As noted in the introduction the Government of Indonesia has a policy whereby all female prisoners (regardless of their conviction) are able to keep their babies/infants with them in prison. However, once the child reaches two years of age it must be given to a family member for care in the community. There are no special facilities provided to support the rearing of children in prison although the policy does provide for supplementary food for infants (President of Indonesia, 1999). Many prisons adopt an informal system whereby each cell block has a leader or daily sentry to maintain order amongst the block’s inmates. There is no regulation that supports such a system. Indonesian cell blocks are usually designed for five to 40 inmates. However, the number of block residents may be far higher due to overcrowding of the prison system. Women in Indonesia’s prisons and detention centres adopt a range of health-seeking behaviours to meet their needs. Access to basic medication is often dependent on women’s ability to pay. If the formal clinic or health system is unable to provide appropriate health services, women must resort to a range of coping strategies, including informal networks of support within the prison or cell block. While this is beneficial in terms of prisoner morale and solidarity, it does not resolve the need for a health system that can provide women prisoners with the level of care that they can receive in the community, with commensurate budgeting, personnel and funding with access to referral to more specialised external services. Women prisoners have less access to health care and other services than men. Women have limited access to reproductive and post-natal health care and have a range of special needs that should be met while in prison.
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Health service access is limited by prison budgets and dependent upon the goodwill of external health providers. Addressing immediate health care and access to health services is urgent and achievable. However, this is reliant upon the authorities desire to fulfil the obligations under the health care system and also allocating appropriate funds. As an interim step to improving access to services ongoing capacity building is needed for prison staff to develop their knowledge on women prisoner’s health needs, including reproductive health and HIV prevention, treatment, care and support. This focus on improving the education and knowledge of those responsible for the care of women prisoners will improve the likelihood that those prisons that develop their own health plans will meet the needs of the inmates. Indonesian prisons reflect global trends as more women are being incarcerated. As the UNODC (2008) report notes, globally female prisoners represent about 5 per cent of the total prison population and this proportion is increasing, especially in countries with high levels of illicit drug use. UNAIDS (2008) has concluded that, ultimately, alternatives to imprisonment should be developed for women. This study supplements recent work conducted by Hinduan et al. (2013) on the HIV-related knowledge and attitudes of Indonesian prison officers and the Nelwan et al. (2010) study on the implications of HIV screening in Indonesian prisons, highlighting the importance of multi-method research in this field. Given the high proportion of women sentenced for drug possession, diversionary sentencing of drug offenders can have the dual benefits of responding to the overcrowding of prisons with people with drug problems and providing more access to effective treatment in the community. The potential for drug diversion programmes is currently under consideration in Indonesia, and, given the recent plans to release 27,000 inmates to reduce overcrowding (Perdani, 2013), such a strategy in dealing with drug using offenders could be of wide ranging benefit.
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Huang, Y., Kuo, H., Lew-Ting, C., Tian, F., Yang, C., Tsai, T., Gange, S. and Nelson, K. (2011), “Mortality among a cohort of drug users after their release from prison: an evaluation of the effectiveness of a harm reduction program in Taiwan”, Addiction, Vol. 106 No. 8, pp. 1437-45. Lai, S., Chang, W. and Liao, K. (2008), “Assessment of health status among incarcerated men”, American Journal of Medical Science, Vol. 335 No. 6, pp. 465-8. Ministry of Justice and Human Rights (2009), “Prison database system, total prisoners”, available at: www. depkumham.go.id (accessed 9 December 2009). Ministry of Justice and Human Rights (2014), “Prison database system, medical care”, available at: www. ditjenpas.go.id/?option¼com_statistik&task¼ndw (accessed 24 October 2010). Moller, L., van den Bergh, B., Karymbaeva, S., Esenamanova, A. and Muratalieva, R. (2008), “Drug use in prisons in Kyrgyzstan: a study about the effect of health promotion among prisoners”, International Journal of Prison Health, Vol. 4 No. 3, pp. 124-33. Nelwan, E., Van Crevel, R., Alisjahbana, B., Indrati, A., Dwiyana, R., Nuralam, N., Pohan, H., Jaya, I., Meheus, A. and Van Der Ven, A. (2010), “Human immunodeficiency virus, hepatitis B and hepatitis C in an Indonesian prison: prevalence, risk factors and implications of HIV screening”, Tropical Medicine and International Health, Vol. 15 No. 12, pp. 1491-8. Neuman, P. and Lawrence, W. (2003), Social Research Methods, Qualitative and Quantitative Methods, 5th ed., Allyn and Bacon, Boston, MA. Penal Reform International (2007), Women in Prison: Incarcerated in a Man’s World: Study Findings, Department of Public Health, University of Oxford, Oxford. Perdani, Y. (2013), “More rehab centers needed to curb drug abuse”, Jakarta Post, 30 August, available at: www.thejakartapost.com/news/2013/08/30/more-rehab-centers-needed-curb-drug-abuse.html (accessed 6 November 2014). President of Indonesia (1999), “Government regulation no. 32 regarding the requirements and rights of citizens detained in prison”, Dirjenpas website, available at: www.ditjenpas.go.id/pas2/ph/pp/PP% 20NO%2032%20TAHUN%201999%20SYARAT%20DAN%20TATA%20CARA%20HAK%20WBP.pdf (accessed November 2013). Prison Reform Trust (2006), Bromley Briefings Prison Fact File, Prison Reform Trust, London. Reddy, V., Kondareddy, C., Siddanna, S. and Manjunath, M. (2012), “A survey on oral health status and treatment needs of life-imprisoned inmates in central jails of Karnataka, India”, International Dentistry Journal, Vol. 62 No. 1, pp. 27-32. Schwalbe, C., Gearing, R., Mackenzie, M., Brewer, K. and Ibrahim, R. (2013), “The impact of length of placement on self-reported mental health problems in detained Jordanian youth”, International Journal of Law Psychiatry, Vol. 36 No. 2, pp. 107-12. Sherman, S., Sutcliffe, C., Srirojn, B., German, D., Thomson, N., Aramrattana, A. and Celentano, D. (2010), “Predictors and consequences of incarceration among a sample of young Thai methamphetamine users”, Drug and Alcohol Review, Vol. 29 No. 4, pp. 399-405. UNAIDS (2008), Women’s Health in Prison; Correcting Gender Inequality in Prison Health, UNAIDS. UNODC (2008), Handbook for Prison Managers and Policymakers on Women and Imprisonment, UNODC, Vienna. Vagenas, P., Azbel, L., Polonsky, M., Kerimi, N., Mamyrov, M., Dvoryak, S. and Altice, F.L. (2013), “A review of medical and substance use co-morbidities in Central Asian prisons: implications for HIV prevention and treatment”, Drug and Alcohol Dependence, Vol. 132 No. S1, pp. S25-S31.
Further reading available at: http://smslap.ditjenpas.go.id/public/sdm/current/monthly/kanwil/db59bd20-6bd1-1bd1badstudy’s9-313134333039/year/2014/month/1 (accessed 20 March 2014). available at: http://smslap.ditjenpas.go.id/public/grl/current/monthly/year/2014/month/3 (accessed 20 March 2014). available at: http://smslap.ditjenpas.go.id/public/sdm/current/monthly/year/2014/month/1 (accessed 20 March 2014).
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Copyright of International Journal of Prisoner Health is the property of Emerald Group Publishing Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Amala Rahmah is based at HIV Cooperation Program for Indonesia, Jakarta, Indonesia. James Blogg is an Injecting Drug Use Advisor, based at HIV Cooperation Program for Indonesia, Jakarta, Indonesia. Dr Nurlan Silitonga is based at HIV Cooperation Program for Indonesia, Jakarta, Indonesia. Muqowimul Aman is based at Department of Correction, Ministry of Justice and Human Rights, Jakarta, Indonesia. Professor Robert Michael Power is the Head, based at Centre for International Health, Burnet Institute, Melbourne, Australia.
Abstract Purpose – Indonesian law provides prisoners with basic rights, including access to education, health care and nutrition. Yet, structural and institutional limitations, notably overcrowding and under-resourcing, prohibits penal institutions from fulfilling these commitments for female prisoners. The purpose of this paper is to explore their health concerns. Design/methodology/approach – Six prisons and one detention centre were researched, comprising: female prisoners (n ¼ 69); clinical officers (six); clinic heads (seven); wardens (seven); heads of prisons (seven); and a Directorate representative. Data were collected through observation, focus group discussions, in-depth interviews and a semi-structured questionnaire. Raw data were transcribed and analysed thematically, adopting the General Principles of Grounded Theory. Findings – Both “formal” and “informal” health-coping strategies were dependent upon a range of factors which determined access to treatment, medicines and other items procured both inside and outside of the prison, as well as referral services. Informal systems of support existed for women, especially in regard to pregnancy and raising of babies born in detention. Systems that maintain harmony within cell blocks were identified as an important informal coping strategy. Originality/value – This research is important in informing policy and practice. There is a clear need for gender-sensitive legislative frameworks, penal policies and prison rules to ensure women’s needs are addressed. The identified coping strategies were considered viable, but do not replace the need for a health system providing women prisoners with levels of care as available in the community, including commensurate budgeting, personnel, access and referral to more specialised external health services. Keywords Health in prison, Health policy, Human rights, Prisoners, Offender health, Overcrowding Paper type Research paper
Introduction and background
The research was funded by the Australian Government through Department of Foreign Affairs and Trade under HIV Cooperation Program for Indonesia. There were no conflicts of interest for any of the staff. Dr James Blogg had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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Imprisoned women experience a wide range of problems, including physical and mental health complaints, environmental stressors, overcrowding, poor access to gender-specific health services, sexual abuse and poor nutrition (Prison Reform Trust, 2006). Female prisoners with drug problems also have higher rates of tuberculosis, hepatitis, anaemia, hypertension, diabetes and obesity than male prisoners (Penal Reform International, 2007). Female prisoners have often worked as sex workers or been victims of sexual violence before their incarceration and are therefore at greater risk of sexually transmitted infections such as chlamydia, syphilis, gonorrhoea and HIV than women in the community (Covington, 2006). Currently, Indonesian law protects prisoners with basic rights, including access to spiritual and physical care, education, health care and decent food (Government Regulation Republic of Indonesia, 1999). However, overcrowding in Indonesian prisons currently ranges from 19 to 55 per cent, which makes it difficult for institutions to fulfil their obligations (Ministry of Justice and Human Rights, 2009). There has been an abundance of research into the determinants, correlates and outcomes of prisoner health in recent years. Topic areas focusing on prisoner health have covered issues such as substance use (Vagenas et al., 2013), mental health (Schwalbe et al., 2013), oral health (Reddy et al., 2012), HIV infection (Dolan and Larney, 2010), treatment of sex offenders (Birger et al., 2011), cancer (Dahiya and Croucher, 2010) and mortality (Brown, 2010). The research
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DOI 10.1108/IJPH-08-2013-0038
has been conducted in a wide range of countries including India (Reddy et al., 2012), China (Lai et al., 2008), Jordan (Schwalbe et al., 2013), Azerbaijan (Cozac and Elliott, 2011), Taiwan (Huang et al., 2011), Israel (Birger et al., 2011), Indonesia (Nelwan et al., 2010), Thailand (Sherman et al., 2010), Myanmar (Brown, 2010), Malaysia (Choi et al., 2010), Pakistan (Altaf et al., 2009), and Kyrgyzstan (Moller et al., 2008). In Indonesia, only nine out of 421 prisons and detention centres have been specially designed to accommodate women and children. A 2010 study found that even though only 6 per cent of female prisoners had a history of injecting drug use 92 per cent of these women had been arrested on a drug-related charge (Blogg et al., 2014). Although the number of female prisoners is only about 5 per cent of the total number of prisoners in Indonesia, the increased rate of incarceration of women is much higher than for men, whilst the rate of release of female prisoners (i.e. those qualifying for parole) is lower than that of men (Ministry of Justice and Human Rights, 2009). A recent study in Indonesian prisons showed links between higher levels of HIV sero-positivity and concomitant health problems in females compared to males. HIV prevalence was 1.1 per cent in males and 6 per cent in females. Among females the key factors associated with HIV were testing positive for syphilis and a history of drug use. Of those with history of drug use, 12 per cent female and 6.7 per cent male tested positive for HIV (Blogg et al., 2014). The qualitative research reported in this paper complements the HIV and Syphilis Prevalence and Risk Behaviour Study Amongst Prisoners in Prisons and Detention Centres in Indonesia (Blogg et al., 2014) as it explores broader health concerns and responses, including sexual and reproductive health. All the prisons included in this study had a health clinic that could be accessed by female prisoners during set times. Free basic health care was found to be generally available, including the provision of medicines and medical services. For those who could afford to buy medicines outside of prison this could be obtained with help from their family. Only prisoners at Lapas Kerobokan, Bali and Rutan Pondok Bambu, Jakarta have access to a dedicated methadone programmes and access to staff trained in the treatment of drug dependency. However, female prisoners at Lapas Anak Wanita, Tangerang are able to access methadone through doses brought in from the methadone programme at the nearby Lapas Pemuda, although their staff are not trained to dispense methadone. All female prisoners are able to keep their babies/infants with them in prison until the child reaches two years of age, but there are no special facilities for child rearing. Many prisons adopt an informal system whereby each cell block has a leader or daily sentry to maintain order amongst the block’s inmates. The objective of this qualitative study was to explore the health needs and health-coping strategies of female prisoners in six prisons and one detention centre in Indonesia in order to make recommendations to improve the health status of female prisoners.
Methodology This study was conducted in six prisons and one detention centre, which included those designated specifically for the imprisonment of women (Lapas Wanita) and those that housed both men and women: Lapas Wanita Bulu, Semarang; Lapas Anak Wanita, Tangerang; Lapas Wanita Malang, East Java; Rutan Medaeng, East Java; Rutan Pondok Bambu, Jakarta; Lapas Wanita, Bandung; and Lapas/Rutan Kerobokan, Bali. These six prisons and one detention centre were chosen based on the criterion that they accommodated the highest populations of female prisoners in Indonesia. Participants in this study comprised female prisoners (n ¼ 69) who were chosen randomly based on each prison’s list of registered prisoners. A convenience sample of clinical officers (six); clinic heads (seven); wardens (seven), heads of prisons (seven); and a representative from the Director General of Correctional Services were also selected to represent the range of views of prison staff across the sector. The 69 female prisoners were interviewed in groups of eight to ten
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women. Each group had to include at least one participant who was pregnant or breastfeeding. Of these 69 participants, 61 per cent were imprisoned for drug-related offences. Data were collected from September to December 2009. Qualitative data were collected through observation, focus group discussions (FGDs) and indepth interviews. A semi-structured questionnaire covering illness and health service access was conducted during the FGD to complement other qualitative data. Furthermore, a literature review was conducted on correctional law and justice related to the themes of the study. The raw data were transcribed and analysed thematically, adopting the General Principles of Grounded Theory (Neuman and Lawrence, 2003; Cresswell, 2003). Ethics approval was received from Ministry of Justice and Human Rights Ethics Committee (reference no. PAS.3HM.04.03.118). Independent oral voluntary informed consent was obtained from all respondents.
Results Prisoner characteristics Of the 69 female prisoners who participated in this study from seven prisons, the majority were serving sentences for drug offences (61 per cent). Other offenses included: fraud (7.2 per cent), homicide (7.2 per cent) and robbery (7.2 per cent). Participants’ ages ranged from 31 to 40 years old (53.7 per cent), followed by 21 to 30 years (26.9 per cent) and 41 to 50 years (16.4 per cent). The majority of participants graduated from high school (44 per cent). Fewer participants had only graduated from junior high school (17.6 per cent), elementary school (14.7 per cent) or had not graduated from elementary school (11.8 per cent). A minority had graduated from college (11.8 per cent). The majority of participants were married (53.7 per cent). Other participants were divorced (22.4 per cent), single (9 per cent), widowed (7.5 per cent) and those in a casual relationship (7.5 per cent). The majority of participants were housewives (39 per cent). About a third worked in the private sector (30 per cent), with 10 per cent having worked as private merchants. The remaining stated occupations that included writing, lecturing, farming or singing at a karaoke centre. The largest group of participants had one child (30.4 per cent) with 20.1 per cent having two children, 14.5 per cent not having any children, 11.6 per cent had three and 8 per cent had four children. Whilst in prison, most participants with children entrusted them to the care of their parents (37.7 per cent), or husbands (15.3 per cent), siblings (8.7 per cent), friends (2.9 per cent) or parents-in-law (2.9 per cent). The highest reported expenditure while in prison was for toiletries (93 per cent); washing equipment (74 per cent); sanitary napkins (68 per cent); medicine, including vitamins (51 per cent) and cosmetics (48 per cent); and clothes (46 per cent). Knowledge of HIV/AIDS and health problems. The majority of participants had heard about HIV and AIDS (87 per cent). Most of these participants (78 per cent) knew that HIV is preventable and knew specifically how to prevent HIV by: not having sexual intercourse with a person living with HIV (PLWH) (55 per cent); avoiding sharing needle syringes (78.2 per cent); having sexual intercourse only with one faithful spouse (76.8 per cent) and using condoms for sexual intercourse with PLWH (74 per cent). The majority of participants knew that mosquito bites are not a risk for transmitting HIV (55 per cent) and 43 per cent knew that using common cutlery, bathing and using washing accessories do not present a risk for transmitting HIV. The majority (58 per cent) had talked about HIV and AIDS, either with their friends during their sentence (41 per cent) or with a prison health officer (23 per cent), NGO officer (18.8 per cent), friends outside the prison (15.9 per cent), parents (13 per cent), prison officer (5.8 per cent) or with a sibling (11.6 per cent). All participants reported having a medical complaint whilst in prison. These included: headaches (69.5 per cent), a sore back (40.6 per cent), cough or flu (34.7 per cent), problems with their digestive tract (23 per cent) and pruritus or scabies (23 per cent). For illnesses of the reproductive system, most said that they had excessive menstrual pain (33.3 per cent) or irregular menstruation (27.5 per cent). Other issues were vaginal bleeding (4 per cent), itchiness
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in the genital area (5.8 per cent), leucorrhoea (5.8 per cent) or complications of pregnancy (2 per cent). Women prisoners and health-seeking behaviour A thematic analysis of the data highlighted both “formal” and “informal” coping strategies around health. The access to the various aspects of these coping strategies depended on a number of factors both internal and external to the prison or detention centre. “Formal”: access to health services. As the clinic is the only health service available in prison, a common theme according to the clinical officers interviewed was the inadequate number of doctors and nurses allocated to service prisons. Each prison visited usually had only one medical officer, one doctor and one nurse although many prisons have no doctor or no health staff at all and must rely upon monthly visits from their supervising prison’s doctor (Ministry of Justice and Human Rights, 2014). Most prisoners with health complaints reported they had attended the prison clinic (84 per cent). Even though, on average, 60-80 patients attended each clinic per day, study participants indicated they were not confident that the service provided was of high quality. During FGDs female prisoners expressed a low opinion of the service provided by prison clinics. They reported that clinics often prescribed the same medicine for different symptoms: [y] whether it is diarrhoea or a sore back, the medicine [given] is the same. Same colour, same shape, same brand [y] (Female prisoner, Surabaya). [y] to go to the clinic is not about getting well, it is just so that the illness will not become more severe. Even though we go there repeatedly, we do not get well. But we don’t have any other choice [y] (Female prisoner, Jakarta). [y] where else can we go, there is no choice. I only go to the clinic if the illness is severe. If not, I still prefer a traditional coin massage [y] (Female prisoner, Semarang). [y] at the clinic everything is limited. I understand that they are busy and also that we are a burden to the state but it is their responsibility. If they put us in here and then they neglect us, I think it’s better if we are outside [y] (Female prisoner, Surabaya).
FGDs and interviews explored the referral and health support system. A system for referral to health services outside of prison exists with prisons usually having established their own network with a local hospital. For cancer, asthma or other common problems, referral is relatively easy and well established. However, referral for illnesses related to HIV and AIDS is more complex. Even though almost all prisons have a referral hospital designated to provide treatment with antiretroviral therapy, this did not mean that referral to these services could be easily arranged. For example, the women at Tangerang women’s prison reported difficulty in being referred to Tangerang General Hospital. This was related to the need for prisons to give a guarantee regarding payment for external health services. Consequently, the hospital was unwilling to treat PLWH. Clinic staff commented on the need for a better system for dealing with each hospital administration to facilitate this process, especially regarding the payment guarantee, the supply of medicines and guarding of female prisoners while they were in the hospital. According to the heads of prisons, the problem with hospital referral was not limited to the higher cost of the treatment in hospital. Problems also arose due to additional costs for the meals, transport and scheduling of guards, when a police officer had to be hired to guard a patient. The problems associated with referral were exacerbated when the prisoner had no relatives to contribute to treatment costs. Prison heads stated that there was no specific budget for health treatment. Rather, there was a general budget to cover all prisoner-related expenses. As such, allocation of funds to support referral depended upon each situation and the policy adopted at each prison. “Formal”: access to drug substitution therapy. A methadone service for drug-dependent opioid users was established in some hospitals in 2004. At Kerobokan Prison, Bali, a referral system operated if a prisoner had previously been a methadone patient outside of prison. These
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prisoners would automatically obtain routine treatment inside prison by producing a referral letter from their regular clinic (i.e. community health centre or hospital). When a prisoner nears the end of his or her sentence, the methadone officer prepares a referral for treatment to be continued outside the prison. This model of providing prisoners with the same treatment they were accessing in the community, does not apply in all cases. Prison officials reported endeavouring to obtain additional resources, such as additional staff, medicines, reagents or laboratory equipment from the local community health centre or hospital. Problems and obstacles can arise because community health centres and prisons fall under different government departments and are often located in different geographical areas. Even though insufficient coordination between departments constrains the effort to obtain additional resources, prisoners qualify for support under the national scheme which guarantees health services for the poor: [y] we already tried to cooperate with the local health service to get additional medicines, but they have difficulty accounting for medicine they give to prisons [y] (Doctor, Jakarta). [y] it’s difficult to ask for additional resources (like doctors and nurses) from a community health centre. They also have their own patients to look after every day, it could be hundreds, so I have to treat them all by myself [y] (Doctor, Bandung).
“Informal”: health-seeking behaviour. Individual relationships in a block or cell had different dynamics, but were important in accessing resources. Members who had served the longest sentences were reported as having the best chance of managing resources and were often the ones more dominant in enforcing rules in the block. Appointment of people of responsibility within the block was usually carried out by discussion although they were sometimes self-appointed. FGD results showed that block leaders were usually appointed as a result of: block members feeling able to share their problems with them; seniority (due to age or how long they have been in prison); their ability to manage conflict. However, it was noted that appointment of block leaders was not related to economic status, physical power or access to special facilities in prisons and was an informal arrangement. As well as relying on the support of the block leader and attending the prison clinic for health services, 46 per cent women reported asking their friends in their block for help. Others bought off-the-shelf medicines (16 per cent) or consulted a hospital or doctor outside prison (7 per cent). Almost all participants thought that the clinic was the easiest way to access help with health issues whilst inside prison (64 per cent), and the next easiest option was to consult a friend (13 per cent). Female prisoners reported being able to afford to get pregnancy check-ups with a specialist outside of the prison. This option was easier for women in detention centres to arrange, as most detainees are only on remand, which makes it easier for them to access services outside the prison. “Informal”: pregnant prisoners and babies. Interviews and other data revealed that it is not uncommon for women to give birth while in prison. New mothers tend to receive advice from other prisoners about getting enough rest and eating healthier food. It is common for all of the cell block to participate in the raising of a baby, including bathing, changing nappies or washing the clothes of baby and mother. New mothers reported that: [y] here, I didn’t really feel tired after delivering a baby. My friends helped me. Some help me to carry the baby while I wash my clothes, change diapers, prepare milk [y] (Female prisoner, Surabaya). [y] when I had a baby, everyone helped me, the prison officers, my friend in the block. I just sleep in the room. If my baby cries because it’s hungry, then they give the baby to me [y] (Female prisoner, Malang). [y] ten days after the delivery, my friend helped me wash my clothes and the baby’s. Free. I just sleep in my room [y] (Female prisoner, Malang).
“Informal”: health-seeking support networks. If a block member needed treatment, the health official usually receives this request via another member of the cell block. This route of communication was common across the prisons that were assessed. Block members often facilitated the process of getting the patient to the clinic officer. In an emergency situation, usually
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one block member will tell the block guard who will get the clinical officer. If the clinic is open, the clinical officer will come to the block, but if the clinic is closed, extra effort is needed to contact the health officer if they live at the prison. This system of support is most evident when the prisoner is pregnant or has recently delivered a baby, or if a baby or infant needs help: [y] usually if someone has a serious illness we are the first to know, usually we call for the guards and they make the arrangements with the clinic [y] (Female prisoner, Surabaya).
Prisoners willing and able to treat their sick friends constitute a strong form of social capital. To support this, routine, agreed-upon contributions are collected by and from prisoners in most cell blocks and used for the common benefit of the block including: paying for health services; treating babies; or paying for child-birth delivery. These fees are also used to buy necessities such as sanitary napkins, soap, sugar, tea and other common goods: [y] this fee is used for people who get sick. Sometimes if there is a need to refer to hospital, we use this money [y] (Female prisoner, Tangerang).
“Informal”: maintaining harmony and conflict management between prisoners. Disputes between prisoners are common, usually over simple matters related to the tidiness of the block, such as disposal of used sanitary napkins, untidy beds, glasses or plates left unwashed after use, or the daily sentry (block member responsible for maintaining order) not doing her job. However, physical violence is rare, which is probably related to the strong emotional bonds that were reported between prisoners: [y] I often say, “you live together here. Get on together, face your difficulties together, don’t fight. Usually they follow this advice” [y] (Warden, Tangerang). [y] often they fight but usually it’s just a quarrel, there are no fist fights [y] (Female prisoner, Surabaya). [y] we never fight here, it’s a quiet life [y] (Female prisoner, Malang).
A baby or a child in the prison can be a catalyst for creating harmony between female prisoners. A baby is the responsibility of all members of the cell block which includes ensuring that the baby has a decent living environment while in prison e.g. providing comfortable bedding, ensuring there’s no smoking nearby, keeping those with transmissible diseases at a safe distance. Prisoners reported taking turns to look after a baby while the mother washes clothes, prepares milk or rests: [y] if there is a baby or a child, we will be more tidy. If someone has a cough, we separate them from the baby, our room is also cleaner [y] (Female prisoner, Tangerang).
“Informal”: social relationships between female prisoners and prison officials. Despite the reluctance to be open with prison guards, prisoners had a different attitude towards health officers. This relative openness was reportedly because prisoners considered health officers to be more concerned with prisoners’ well-being: [y] if we tell something to the guard, sometimes it can come back to us if something happens [y] (Female prisoner, Surabaya). [y] I feel closer to the women from the clinic, they care about our health and are more relaxed and not so strict [y] (Female prisoner, Malang). [y] they could talk to me more easily compared to the security staff, maybe because they feel it’s safer here in the clinic and we do not deal with discipline [y] (Doctor, Jakarta). [y] they are more relaxed with health officers, they can share their story with me even though I’m a man [y] (Doctor, Bandung).
Relationships between prisoners and health officers can act as a bridge for creating personal and social relationships between prisoners in a block. Depression, stress and other psychological symptoms were reportedly reduced after consulting with health officers: [y] it’s better to share with people from the clinic, they will not tell each other [y] (Female prisoner, Surabaya).
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I give advice even though I don’t have a psychology background, but giving advice to others is a basic skill. Usually they change and begin to accept their condition, but my time is usually limited because I have other patients [y] (Doctor, Jakarta).
Even though prisoners reported good relations with health officers, most reported that they kept certain confidences from them, did not communicate regularly with health officers, and that their closest friend and confidante was another prisoner.
Conclusion and discussion This study has identified a number of issues that exacerbate health problems for women in prison and correctional facilities in Indonesia. These include: ’
Overcrowding. As of March 2014 only 27 per cent of provinces had prisons which were collectively not overcrowded. The total prison system currently contains 164,000 inmates, but was designed for o111,000, representing 148 per cent overcapacity (Ministry of Justice and Human Rights, 2014).
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Lack of female-focused health facilities. Prisoners interviewed reported low quality services which were usually unable to respond adequately to their basic health needs.
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Staff and resources. The responses reported by clinical officers are backed up by current data: as of February 2014 only 679 doctors and paramedics were allocated to care for the 164,000 inmates. The budget to cover non-food services (which must include health services) is o6 per cent of the total budget to run the prison system. However, even this small budget is currently under pressure (Ministry of Justice and Human Rights, 2014).
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A male-dominated prison system. As of March 2014, 8,382 women represented only 5 per cent of prisoners. Consequently, female prisoners were forced to rely upon approaches developed for a service developed to incarcerate men (Ministry of Justice and Human Rights, 2014).
A range of formal and informal coping strategies are adopted by women in an attempt to address health issues experienced in prison including: accessing services internal and external to the prison; peer support within each block; developing relationships with prison staff; pooling of funds by prisoners; and communal childcare and shared responsibility. As noted in the introduction the Government of Indonesia has a policy whereby all female prisoners (regardless of their conviction) are able to keep their babies/infants with them in prison. However, once the child reaches two years of age it must be given to a family member for care in the community. There are no special facilities provided to support the rearing of children in prison although the policy does provide for supplementary food for infants (President of Indonesia, 1999). Many prisons adopt an informal system whereby each cell block has a leader or daily sentry to maintain order amongst the block’s inmates. There is no regulation that supports such a system. Indonesian cell blocks are usually designed for five to 40 inmates. However, the number of block residents may be far higher due to overcrowding of the prison system. Women in Indonesia’s prisons and detention centres adopt a range of health-seeking behaviours to meet their needs. Access to basic medication is often dependent on women’s ability to pay. If the formal clinic or health system is unable to provide appropriate health services, women must resort to a range of coping strategies, including informal networks of support within the prison or cell block. While this is beneficial in terms of prisoner morale and solidarity, it does not resolve the need for a health system that can provide women prisoners with the level of care that they can receive in the community, with commensurate budgeting, personnel and funding with access to referral to more specialised external services. Women prisoners have less access to health care and other services than men. Women have limited access to reproductive and post-natal health care and have a range of special needs that should be met while in prison.
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Health service access is limited by prison budgets and dependent upon the goodwill of external health providers. Addressing immediate health care and access to health services is urgent and achievable. However, this is reliant upon the authorities desire to fulfil the obligations under the health care system and also allocating appropriate funds. As an interim step to improving access to services ongoing capacity building is needed for prison staff to develop their knowledge on women prisoner’s health needs, including reproductive health and HIV prevention, treatment, care and support. This focus on improving the education and knowledge of those responsible for the care of women prisoners will improve the likelihood that those prisons that develop their own health plans will meet the needs of the inmates. Indonesian prisons reflect global trends as more women are being incarcerated. As the UNODC (2008) report notes, globally female prisoners represent about 5 per cent of the total prison population and this proportion is increasing, especially in countries with high levels of illicit drug use. UNAIDS (2008) has concluded that, ultimately, alternatives to imprisonment should be developed for women. This study supplements recent work conducted by Hinduan et al. (2013) on the HIV-related knowledge and attitudes of Indonesian prison officers and the Nelwan et al. (2010) study on the implications of HIV screening in Indonesian prisons, highlighting the importance of multi-method research in this field. Given the high proportion of women sentenced for drug possession, diversionary sentencing of drug offenders can have the dual benefits of responding to the overcrowding of prisons with people with drug problems and providing more access to effective treatment in the community. The potential for drug diversion programmes is currently under consideration in Indonesia, and, given the recent plans to release 27,000 inmates to reduce overcrowding (Perdani, 2013), such a strategy in dealing with drug using offenders could be of wide ranging benefit.
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Further reading available at: http://smslap.ditjenpas.go.id/public/sdm/current/monthly/kanwil/db59bd20-6bd1-1bd1badstudy’s9-313134333039/year/2014/month/1 (accessed 20 March 2014). available at: http://smslap.ditjenpas.go.id/public/grl/current/monthly/year/2014/month/3 (accessed 20 March 2014). available at: http://smslap.ditjenpas.go.id/public/sdm/current/monthly/year/2014/month/1 (accessed 20 March 2014).
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