Organisation of health care
Ministry in charge
- Ministry for the Interior
- Ministry for Health (in Catalonia and the Basque Country)
Social organisations are campaigning for the responsibility for healthcare to be transferred to the Autonomous Communities. This would facilitate the co-ordination of healthcare programmes (transfer of medical records, continuity of care, etc.). Legislation enacted in 2003 would allow this transfer to take place, however this has only happened in Catalonia and the Basque Country.
Every prison facility has a health care unit
Number of medical staff (FTE)
The teams of health professionals working in detention are composed, in 2015, of 600 general practitioners, 30 psychiatrists and 300 psychologists.
The European Committee for the Prevention of Torture (CPT) reports a lack of health care staff. The 2020 report highlights the lack of nurses and doctors in detention as well as the lack of psychiatrists and psychologists. Overall, the report states poor working conditions for medical staff.
Doctors have called attention to the lack of health professionals. They criticised the instability of temporary contracts, the lack of qualifications and training among temporary workers, and the stress generated by the challenging working environment.
In August 2022, 67% of the positions for prison doctors remained vacant. There were 148 regular posts filled, 40 interim positions and three interns, for a total of under 200 doctors for over 55,000 prisoners. The Ministry of the Interior created 80 new posts for health workers in 2021 and 2022, but only 11 have been filled.
The Ministry of the Interior oversees health care in the country’s prison facilities, except in Catalonia, the Basque Country, and Navarre. The Spanish government acknowledged, in an official document from the General Secretariat of Penitentiary Institutions, that due to a “shortage of medical professionals in certain prisons”, it was not possible to “guarantee medical care around the clock”. In response to this shortage, the government implemented a system for remote consultations with medical professionals assigned to other facilities.
A primary care team1 is present in each prison, providing outpatient services. The team consists of at least one general medical practitioner and two nurses. Psychiatrists, dentists and occasionally pharmacists may also be available. Other specialists (e.g. ophthalmologists, gynaecologists, dermatologists etc.) are rarely present. Patients suffering from certain conditions are taken to hospital. There are insufficient doctors available. Requests for medical consultations are subject to delays. Sixteen out of 82 establishments have a pharmacy on site.
Ombudsman, “[Annual Report and Court Cases 2017](https://www.defensordelpueblo.es/wp-content/uploads/2018/03 /Informe_anual_2017_vol.I.1_Gestion.pdf)”, 2018, pp. 197-198. (in Spanish) ↩
Each prison is attached to a particular hospital, which must be equipped with a secure unit to receive patients (hospital beds with a police guard).
Access to health care
Health care is free
A medical examination is performed upon admission
An examination is carried out on arrival in detention. New inmates undergo blood tests and other medical examinations. An assessment with a doctor must be carried out within 24 hours of admission.[^euc] A doctor and a nurse review the medical history and carry out a “risk assessment”: suicide risk, drug use (type of drug, frequency, method of consumption, withdrawal symptoms, etc.), mental disorders. Risk behaviours such as sharing injection equipment, unprotected sex and tattooing are also taken into account. The communicable disease assessment covers infections such as tuberculosis, HIV, HCV, HBV and syphilis. This assessment provides guidance on the appropriate treatment (substitution treatment or care) to be provided.
The CPT recommends that all establishments keep a register of injuries sustained by inmates before their admission or during their detention.
[^euc]: European Commission, Mentally Disordered Persons in European Prison Systems - Needs, Programmes and Outcome (EUPRIS), October 2007, p. 28.
A medical file is opened upon admission
Prisoners can access health care units after
an oral request
Verbal requests addressed to the prison guards are not dealt with promptly. The CPT delegation received complaints from inmates in all of the prisons they visited. The CPT recommends that inmates should be able to engage directly and confidentially with healthcare service providers. They suggest the installation of a letterbox, managed by the healthcare provider.
Medical examinations are carried out on a confidential basis
in most cases
Medical confidentiality is not guaranteed when the patient is examined in the hospital setting. The presence of police officers during diagnostic consultations has been reported. Results of tests are not given directly to the patient. There are cases of female inmates refusing to have a gynaecological examination due to the presence of prison guards in the consultation room.
Inmates must be allowed access to the same care that they would receive in the outside world. Social organisations have revealed that these rights are not respected. There is a clear inequality of access in this area.
The prison administration is responsible for the health of prisoners, according to the legislation, and must provide them with medication.
Detainees with mental health problems are mostly treated with medication. The lack of psychiatrists and psychologists in detention could explain this trend. Some detainees suffering from schizophrenia are reportedly overmedicated, according to the CPT. The Committee questions the consent to be given to medication, which seems to be sometimes imposed on the detainee.
Physical health care
The most prevalent diseases are :
- Hepatitis C
Inmates undergo a medical examination on arrival at the institution. The prevention of epidemic and communicable diseases is of utmost importance. An x-ray is performed on all inmates who show the first symptoms of tuberculosis. A doctor performs this examination.
Risk minimisation programmes in prison aim to reduce drug-related risk of harm. Programmes include testing, vaccination and provision of safe injecting equipment, protection and hygiene products such as bleach.
A needle exchange programme has been in place since 1997. Condoms are made available. The review of this programme shows that:
- Drug use and injection does not increase
- Risk behaviours and transmission of diseases (HIV, Hepatitis C) decrease
- Positive health outcomes have been observed (drastic reduction in overdose cases)
- A number of establishments vouch for the effectiveness of the programme.
Mental health care
Psychiatric units within prisons are few and far between, despite the legal measures put in place.
The two psychiatric prison facilities are in Seville and Alicante, under the control of the Ministry of the Interior. Brians 1 prison, in Catalonia, has a psychiatric hospital unit. Brians II has a psychiatric rehabilitation unit that can house 22 patients. This prison also has an arrangement with the Sant Joan de Déu hospital, for the treatment of prisoners with serious mental health problems. These institutions are under the control of the Catalan Department for Justice.
A specific programme for people suffering from certain mental health issues (PAIEM, “Programa de Atención Integral a Enfermos Mentales”) was set up in 2005 by the prison administration. The number of prisoners taking part in this programme in 2017 was 2,029 (1,892 of which are in SGIP prisons and 137 in Catalonia). This represents 3.4% of the prison population. The PAIEM programme is present in the majority of prisons. NGOs are involved in delivering the programme.
The Ombudsman has remarked on the programme’s deficiencies in most of the prisons it visited. Care is limited to diagnosis and drug therapy. Tailored therapy is not often provided.
In 2017, the Ministries for Health and Justice signed an agreement for the integration of mental health teams in all institutions. The Catalan Penitentiary Administration has promised to invest an additional 6.5 million euros from 2018 (18.5 million per year in total) to mental health.
Around 8% of inmates in Spain suffer from serious psychological problems (around 4,700 people)1.
The Association for Human Rights of Andalusia (APDHA), “Health in Prison, Robbed of health within four walls”, 2016, p.23. (in Spanish)“ ↩
In 2020, the infirmaries in prison facilities held 7,432 prisoners with mental illnesses. The percentage of the prison population dealing with serious and chronic mental disorders is estimated at 5%. The prison system only has two hospitals specialised in psychiatry. The union ACAIP-UGT decried the shortage of available doctors and reiterated that the suicide rate is eight times higher in prison, often due to psychological distress.
More than 200 charities and associations specialising in mental health came together to oppose the proposed development of a super-psychiatric prison unit at Siete Aguas (Valence). The unit was designed to hold 500 prisoners. The campaigning organisations, under the collective banner “mental health beyond prison” demanded that construction be stopped. The vice-president of Valencia was also opposed to the new centre.
Critics of the two existing ‘psychiatric prison’ facilities in Séville and Fontcalent claimed they were overcrowded, poorly run and lacked sufficient medical staff. It was also claimed that they were run more for punishment than psychiatric care: *“Nearly ten years ago, prison authorities were already cautioning that these facilities must not become substitutes for the old asylums, which were banned under psychiatric reforms of the 1980s”, said the campaigners.
They stressed that the proposed facilities contravened national mental health strategy: prisons cannot and should not support people suffering severe mental ill health. The super psychiatric prison unit would not meet international standards, and they were concerned it would also be too remote.
The Ombudsman has noticed a lack of specialist personnel, notably in the prison psychiatric hospital in Seville. There are four vacancies for psychiatrists in the institution. At the time of the delegation’s visit in 2017, there was only one psychiatrist available to meet the needs of 169 inmates1.
Inmates with addictions receive special monitoring.
Inmates with addictions have particular services available:
Smoking: the percentage of smokers among prisoners is higher than in the outside population. The prison administration has been increasing smoking information and awareness campaigns since 2012. It has organised conferences and individual cessation programmes. The length of the programmes varies between two and three months and the participants have a follow-up assessment at the end of their programme. In 2016, the programme was in place in 18 establishments and was involved in the treatment of 315 inmates.
Alcoholism: a programme provides awareness of the risks of excessive consumption of alcohol, suggests strategies to abstain and organises group workshops to motivate the patients. The average number of participants in the programme is 1,300 inmates per quarter.
Drug addiction: the war on drugs is one of the key priorities of prison health programmes. Many intervention programmes have been developed around three fundamentally interdependent areas: prevention, assistance and social reintegration. Dedicated therapy areas have been set up. Inmates with drug dependencies can access substitute treatments, like methadone.