Africa: informal governance and healthcare access in prison

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Carole Berrih, a lawyer specialising in public law, is the director of Synergies Coopération. She studies and evaluates international programmes and projects. She has been active in the prison sector for 20 years and is currently carrying out doctoral research at the Université Grenoble Alpes. Her research focuses on the role of prisoners in the maintenance of order in Nigerian prisons.

Here, Carole discusses the impact of informal governance on prisoners’ access to healthcare.

According to international norms on the treatment of prisoners, the prison service alone is solely responsible for prison management and discipline. However, these norms also recognise and permit “systems based on self-government, under which specified social, educational or sports activities or responsibilities are entrusted, under supervision, to prisoners who are formed into groups for the purposes of treatment.”[1]

In practice, many prisons, especially in Africa, are jointly governed by the official prison service and an informal hierarchical organisation of prisoners. This goes beyond the self-government recognised by international norms. Several historians have highlighted that this system, in which “super-prisoners”[2] play a role in the surveillance and management of prisons, began in colonial times to compensate for the limited resources allocated to prisons. Now, this system has become further entrenched as a result of overpopulation in some prisons and a serious shortage of guards. As such, the internal organisation of many prisons, from searches to cell allocation to healthcare access, is in the hands of prisoners.

Does this system facilitate or restrict prisoners’ access to healthcare? My research, which focuses in particular on the men’s sections of several African prisons, indicates that the informal organisation of prisoners does compensate to some extent for the limitations of the prison service. However, it can also foster discrimination.

Overcrowding and understaffing

The number of people in prison in Africa is continually growing, resulting in worsening prison overcrowding. The occupancy rate of prisons in several African capital cities is over 300%. For example, in 2020 the prison of Makala in Kinshasa had an occupancy rate of 570% and the civil prison in Niamey had an occupancy rate of 340%.

This level of overcrowding means that it is not uncommon for prisoners to sleep on the floor, sitting down or pressed against each other or head to toe “like sardines”, as it is described in prison. This situation has a major impact on prisoners’ physical and mental health, leading to the spread of infectious diseases (tuberculosis, HIV/AIDS), a high incidence of skin conditions (abscesses, scabies) and widespread depression.

Given the density of the prison population, the number of guards provided by the prison service is completely inadequate, making  it impossible to organise infirmary access for prisoners. The internal management of the prison is therefore carried out by prisoners. In theory, the system works as follows: each cell has a “leader” who notes the names of sick people; the following morning, this information is passed up the hierarchy and the sick prisoners can then access the infirmary to receive treatment. However, the system does not work in the same way for all prisoners.

The importance of social capital in access to healthcare

Some infirmaries are located in the prison grounds, but outside the prisoners’ quarters. To get to the infirmary, prisoners must leave their quarters, and they can only do this via those running the informal system. In the civil prison in Niamey, the “super-prisoners” restrict infirmary access to a maximum of 10 or 20 people per day, for “security reasons”. According to prisoners, only those who “know someone” – in other words, those who have the trust of the “super-prisoners” – can access healthcare. Unless they are seriously ill, prisoners with limited social or relational capital must sometimes wait for several weeks before they can go to the infirmary. Some reportedly pretend to faint so that they can see the medical staff.

In general, the infirmaries have nowhere near enough medication to meet the prison population’s needs. Sometimes they only have a few basic items, such as paracetamol. In the DRC, Niger, Chad and Cameroon, the medical staff write prescriptions so that prisoners’ families can get medication for them outside the prison. However, in some prisons, “super-prisoners” do not allow medication coming from outside in case this leads to narcotics entering the prison. The situation therefore depends on the extent to which the representatives of the informal governance system trust the other prisoners.

Change needed on the ground

This informal organisation enables prisons to function in spite of the very limited number of guards. However, this system has major shortcomings, especially for “ordinary” prisoners who do not have a large network.

Does this mean that the normative framework needs to be modified? As more international standards are adopted, the disparity between formal norms and the situation on the ground continues to grow. Rather than adopting new texts which will not be applied in practice, a better approach would be to work to remove the obstacles to healthcare access in prison. Concrete change at ground level would ensure measures are context-specific, and more likely to bear fruit than a purely normative approach. To achieve this, governments and stakeholders in the prison sector could draw on the extensive research on modes of government and public policy analysis in Africa that has been carried out in the last ten or so years[3].