Health Economics of Prisons – The Jury is Out!
Rachael Maree Hunter1, Nick Freemantle1 & Stephen Morris2
1. Research Department of Primary Care and Population Health
2. Department of Applied Health Research
Economics of Prison Health Care
• Worldwide there are more than 10million people in prison, 95,000 in the UK. The highest per head of population is the US with 2.4mil.
• Physical and mental health care needs are greater in prisons than in non-incarcerated groups:
• 90% have a mental health problem;
• 60% have a substance misuse problem;
• Higher prevalence and incidence of blood borne viruses and other communicable diseases including Tuberculosis (TB)1 .
• In the US prison health care costs are growing at a faster rate than any other correctional cost. Similar concerns about the
sustainability of prison health care finances has also been expressed in the UK.
• The aging population in prison is of increasing fiscal concern2.
Systematic Review
Economic Theory of Health
Care in Prison
Method
Search Strategy
Comprehensive search of medical and social science databases: MEDLINE (Ovid), the NHS Economic
Evaluations Database, Econlit, Embase, Scopus, Cochrane Database of Systematic Reviews and the
Offender Health Research Network. General search using Google and Google Scholar. Hand searching of
references.
Incarceration; prevent
crime; public safety
Search Terms
Search terms used were from one of three categories:
(i) prisons, criminality, offenders or incarceration;
(ii) costs, economic evaluations or value for money; and
(iii) health or drug treatment interventions.
Inefficiency
Inclusion Criteria
(i) At least one intervention group or the control group were incarcerated.
(ii) Included an economic evaluation or costing analysis of an intervention, i.e. an assessment of the
economic impact of an intervention, policy or programme.
(iii) The aim of the intervention was to address a health need in an adult (over 18 years old) incarcerated
population.
(iv) The analysis could be a decision analytic model or an analysis using data from an observational study
or clinical trial.
(v) The article is available in English
No publication year exclusion criteria were applied and searches were conducted on 12 August 2013. Grey
literature was included to increase the scope.
Results
Detected
citations
n=2,115
Studies excluded
by title and
abstract
n=1,926
Additional
studies excluded
n=143
Full text for
studies retrieved
n=188
Studies included
in the review
n=72
Identified by
hand searching
n=28
CUA
0
CEA
3
CBA
0
Costing
12
CC
1
Total
16
Addiction
0
9
6
4
0
19
Communicable
diseases
4
14
2
3
0
23
Telemedicine
1
1
1
4
0
7
Other
0
0
2
5
0
7
Total
5
27
11
28
1
72
Mental Health
Improve health and
well being; prevent
crime
Papers were grouped into the most common clinical areas. The
most common area was communicable diseases (32%) and the
most common type of economic evaluation was costings (39%).
The effectiveness of the intervention for the majority of studies
was based on observational studies and mechanisms for
reducing bias were rarely considered. The costs and
consequences included meant that unless the intervention was
clearly cost saving it is hard to compare the cost-effectiveness or
value for money of different prison health care programmes.
As health care is not an a prior aim of
prison, and prisons are not conducive
to good health, providing health care
in prison creates inefficiency. An
overlap exists in that both can prevent
crime, but by different mechanisms:
 Prison: deterrent and while in
prison ability to commit crime
reduced.
 Health care: prevention and
treatment of health problems
related to crime such as mental
illness and addiction.
Other market failures include:
• Externalities: If left untreated
prisoners can go on to infect and
harm others, including those in the
community when released. The
public can have strong positive and
negative opinions about prisoner
rights to health care that differ to
views about other groups in society.
• Duty of care: prisoners are a
vulnerable population where a
special duty of care exists.
• The nature of prison restricts
access to health care and market
competition. This can result in
monopoly of power with single
purchaser (the state) and provider
relationships and poor quality,
access to and supply of care
including access to physicians, with
prisoners’ unable to act as
informed consumers.
Conclusion
Finding innovative and financially efficient ways of delivering health care in prisons is of increasing interest to governments worldwide. The quality and
content
of economic
Collaborators
logos evaluations of prison health care interventions though is variable and poor. Guidance on conducting health related economic
evaluations in prisons should be produced so as to improve the quality, comparability, theoretical basis and rigour of future analyses.
References: (1) Fazel & Baillargeon (2011) The health of prisoners. Lancet, 377. pp. 956-965. (2) Watson et al (2004) Prison health care: a review of the literature. International Journal of Nursing Studies, 41. pp. 119-128.
Table: CUA - Cost-utility analysis; CEA- Cost-effectiveness analysis; CBA- Cost-benefit analysis; CC- Cost-consequences.