The number of people in prison in Africa is continually growing, resulting in worsening prison overcrowding. The occupancy rate of prisons in several Africa 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, 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 and makes 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.

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.

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 framework of norms needs to be modified? As more international standardsare 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 stakeholder s 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 year. ¹