24/11/2009| Prison health reforms - the situation in Norway | 1 Prison Health Reforms in Norway - The “Import Model” Dr. Jon Hilmar Iversen Head of Division for Primary Health Care Services

24/11/2009| Prison health reforms - the situation in Norway | 2 Disposition 1. Facts about Norwegian prisons and the prison population in Norwegian 2. Organisation of the Norwegian prison health services 3. The ”Import Model” 4. Implementing the Revised European Prison Rules from Competence building regarding health care service in prisons

24/11/2009| Prison health reforms - the situation in Norway | 3 Facts about prisons and the prison population in Norway (2007) 44 prisons, with different security levels 34 % of prisoners served at low security prison departments 20 % of prison capacity was pre-trial detainees prison cells (prison population) 54 % of inmates served less than 60 days people were imprisoned during 2007

24/11/2009| Prison health reforms - the situation in Norway | 4 Health problems among inmates (Norway 2004) Mental disorders - Men 3 times more frequent than general population - Women4 times more frequent than general population Chronic diseases - All2 times more frequent than general population Drug problems - All60 % have drug problems Fafo-report 429,2004: Living conditions among inmates (Norwegian)

24/11/2009| Prison health reforms - the situation in Norway | 5 The organization of prison health care services 1969: The import model regarding education is implemented! 1988: The import model regarding health care services is implemented! The responsibility for health services in prisons was transferred from the Ministry of Justice to the Ministry of Health (state level) 1994: The municipalities (430 local political entities) became responsible for primary health care services in prisons 2002: The regional health authorities (5, now 4 state owned authorities) became responsible for specialized health care (hospitals and policlinics) The counties (19 regional political entities) are responsible for dental services.

24/11/2009| Prison health reforms - the situation in Norway | 6 Cooperation and financing The municipalities are responsible for primary health care services in prisons and referral to specialized care when needed. The Government supplies special funds for prison health services run by the municipalities and the counties. The regional state owned health authorities deliver their services as part of their budget.

24/11/2009| Prison health reforms - the situation in Norway | 7 The Import Model – The philosphy Prisoners are imprisoned, but have equal right as the general population to health services, education,, social services and and culture activities. Prisoners are served by the same health care services as the general population. Primary health care services inside the prison and specialised services when needed in the prison or in a hospital or at a policlinic.

24/11/2009| Prison health reforms - the situation in Norway | 8 The Import Model - Challenges Good cooperation between the prison and other sectors of society which are needed inside prisons. Well tailored and smooth transitions to the services in the community when inmates are released to their home municipality Wise tackling of conflicts between prison needs for penalty enforcement and inmates needs of services.

24/11/2009| Prison health reforms - the situation in Norway | 9 The Revised European Prison Rules (2006) A European Council Recommendation. Adopted by the Committee of Ministers on the 11th of January Signed by our Minister of Foreign Affairs Jonas Gahr Støre. Under implementation in Norway in the judicial sector and in the health sector.

24/11/2009| Prison health reforms - the situation in Norway | 10 Part II - Health Article 45.1: The director shall consider the reports and advice that the medical practitioner or other competent authority submits (and) when in agreement with the recommendations made, shall take immediate steps to implement them. Article 45.2: If the recommendations of the medical practitioner are not within the director's competence or if the director does not agree with them, the director shall immediately submit the advice of the medical practitioner and a personal report to higher authority.

24/11/2009| Prison health reforms - the situation in Norway | 11 Framework for conflict negotiations according to the Revised European Prison Rules 1. Self-Sufficiency Model One line takes the decisions 2. Import Model Two lines have to cooperate and agree on decisions

24/11/2009| Prison health reforms - the situation in Norway | 12 The Import Model – Possible Routines for Conflict Management The prison director and the prison doctor present the case for a separate prison health commission with representatives from both the correctional services and the health authorities This commission should have opportunities for immediate decisions when needed in matters about life and death.

24/11/2009| Prison health reforms - the situation in Norway | 13 Three possible higher levels for appeals 1. County medical officer and Regional Correctional Services (both at regional level) 2. Norwegian Directorate of Health and Norwegian Correctional Service (both directorates at national level) 3. Ministry of Health and Care Services and Ministry of Justice and the Police (ministries at national level)

24/11/2009| Prison health reforms - the situation in Norway | 14 Competence Building - eLearning for Doctors Working in Prisons - Human Rights and Ethical Dilemmas Present relevant international statements regulating medical treatment of prisoners, and raise the prison doctors’ awareness on their role in various areas of conflicting interests between the prisoner (patient) and the prison administration, for example during hunger strikes, the patient's right to confidentiality, certifying prisoners for special punishment etc.

24/11/2009| Prison health reforms - the situation in Norway | 15 Editors Bjørn Oscar Hoftvedt The Norwegian Medical Association and Hernan Reyes, International Committee of Red Cross The Norwegian Medical Association has accredited the course with 12 hours/points in post-graduate and continuing education.

24/11/2009| Prison health reforms - the situation in Norway | 16 Etc, etc, etc! End of thinking capacity!