Since 2014, the Brazilian Prison system has been covered by the National Policy for Comprehensive Health Care for Persons Deprived of Liberty (PNAISP). Through the PNAISP, each basic prison health unit became a point of the Health Care Network, giving the prison population access to the Unified Health System (SUS). While such a policy exists, its implementation is heavily influenced by the beliefs, ideas and value judgments of those responsible for its implementation in prisons.

“These street-level bureaucrats can act influenced by contexts and by their own references. In the case of the prison system, a space still heavily permeated by prejudice, individual references – which include moral issues and value judgments – can further influence the implementation of policies.” That’s what Mariana Scaff says, a doctoral candidate at the Department of Politics, Management and Health at the USP School of Public Health. The researcher published a special editorial for the Journal of Public Health . The article is part of the Young Researcher Editorial series , on the challenges and perspectives of public health in Latin America.

In his article entitled Access to Healthcare in Brazilian Prisons: Why is it Important to Look at the Bureaucracy and Policy Implementation? (in free translation, Access to Health in Brazilian Prisons: Why is it Important to Look at Bureaucracy and Policy Implementation? ), the author explains that those responsible for implementing the PNAISP are multidisciplinary professionals from prison primary care teams . According to Mariana, these teams can be organized into different compositions, depending on criteria such as the number of people in custody and their epidemiological profiles. “At a minimum, its composition must have a doctor, a nurse, a nursing technician or nursing assistant, a dental surgeon and an oral health technician or assistant”, she describes.

The author brings together other publications that discuss the concept, such as the article by USP professor Marta Arretche entitled A Contribution to Making Less Naive Assessments . For her, the performance of these professionals who work directly with the public is influenced by political, economic and institutional conditions, along with their own prejudices, interests and ideologies.

“These street-level bureaucrats are essential for policy to happen. They need to stay in the system, but of course taking into account that they can transform the way policies are designed. It is essential, therefore, to recognize that there is a dynamic of interactions between users of the policy – ​​people deprived of liberty – and the implementers – prison primary care teams”, says Mariana to Jornal da USP .

The researcher proposes that the performance of the street-level bureaucracy be recognized beyond the criteria of neutrality. “We must look beyond formal policy specifications to improve prison health. Institutional rules and guidelines are often abstract and can be interpreted broadly, which gives the implementing bureaucrat a lot of freedom of action”, he suggests in the article.

Mariana concludes that, by understanding these circumstances and mechanisms, it will be possible to improve health policies that affect the prison system.

prison community
The prison population in Latin America has grown exponentially in recent decades, reaching 1.4 million people deprived of their liberty. With more than 835,000 prisoners, Brazil leads the ranking on the continent and continues to have the third largest prison population in the world. In addition to these numbers, there is a lack of publicly available data on the health situation in Brazilian prisons.

In June 2022, during a public hearing at the Social Security and Family Commission of the Chamber of Deputies, the Health coordinator of the National Penitentiary Department (Depen) of the Ministry of Justice and Public Security, Rodrigo Pereira, informed around 33,000 private people of freedom were diagnosed with the most prevalent infectious diseases in the prison system: HIV/AIDS, hepatitis, syphilis and tuberculosis. In two years, HIV cases went from around 8,500 to 10,100.

About 77 thousand cases of tuberculosis are registered per year in Brazil. Approximately 11% occur in prison units, according to the thesis carried out by USP researcher Daniele Maria Pelissari, recognized in the 2020 Capes de Tese Award in the field of Collective Health. According to the expert, transmission is airborne and, despite health efforts to control tuberculosis in some prisons, overcrowding is the main spreading factor.