Primary healthcare services must be provided at the same standard provided in free society (Regulations to the Correctional Services Act, Regulation 7.1a). The Department of Correctional Services sets out which types of care are provided and under which category they fall. Comprehensive primary health care services are provided to all categories of prisoners, including those in pre-trial, and infants incarcerated with their mothers. The majority of the health care services and programmes provided are primary care.

Secondary and tertiary health care specialists must also be available. Basic and specialist, as well as emergency oral and dental health care services must be provided.¹ In practice, access to specific healthcare is virtually non-existent. Prisoners at Pollsmoor filed complaints regarding the lack of dental services due to the expiration of the contract with the service provider.²

The prison administration reports that care services suffer from poor management, a lack of facilities and equipment, and a neglect of environmental and nutritional care, which are provided sporadically by security officials.³

Each facility must be linked to a 24-hour public health care facility to ensure access to secondary and tertiary care.¹

Prisoners may refer to a medical practitioner as often as necessary (Regulations to the Correctional Services Act, Regulation 7.3). A registered nurse must attend to all sick prisoners at least once a day (Regulation 7.4). The prison administration further states that any care that began prior to detention will continue throughout the duration of sentence. Each facility is attributed a medical practitioner that comes in, for example, for health check-ups, to manage medication, and respond to suicidal ideation or other emergencies. Frequency varies from one facility to another. On-call medical practitioners are not present in the facility at all times.

In 2022, the JICS reported that prisoners did not benefit from regular access to nurses and doctors.

The Department of Correctional Services’ data systems are not linked to the Department of Health (DoH), which prevents them from obtaining proper medical history.

The DCS Health Care Policy and Procedures Manual details the procedures for handling medication,¹ which must always be distributed by a competent healthcare provider. Personal treatment medication in a prisoner’s possession upon admission must be used until the medical practitioner can provide a prescription (B-Orders, chapter 1, paragraph 33.2).

Over the years, the JICS has observed that medication is often distributed in bulk, increasing the risk of overdose.² They are not always distributed on time, and some are even expired. Prisoners are advised to renew their prescriptions well in advance, given the delays in distribution.³

Civil society organisations and scholars note that hospitalisation generally only occurs in case of emergencies. Prisoners are rarely granted permission without recommendation from a medical practitioner. It can be very difficult to get the attention of a correctional official in case of emergency due to staff shortages.

The prison governor must inform the prisoner partner or relative in case of hospitalisation (Regulations to the Correctional Services Act, Regulation 7.6).

Prisoners may not be forced to undergo medical intervention or treatment without informed consent (Correctional Services Act 111 of 1998, Section 43.3), or written consent from a parent or guardian in the case of a minor. The procedure, duration, benefits and side effects must be explained beforehand. In case of emergency, informed consent may be bypassed. Prisoners may refuse treatment, unless mentally ill or suffering from a transmissible disease.¹ Prisoners may not be subjected to any medical or scientific experimentation even with their consent. They may participate in clinical trials with the National Commissioner’s approval (Regulations to the Correctional Services Act, Regulation 7.7).

Tuberculosis and HIV are rampant, but extensive provisions are in place to treat prisoners that are affected. In 2021, the organisation TB HIV Care identified 2,133 prisoners, around 8.5% of the prison population, as HIV positive.¹

The medical practitioner, environmental health officer or registered nurse must inspect all facilities at least once a month and report to the National Commissioner on any potential concerns (Regulations to the Correctional Services Act Regulation 7.11).

TB HIV Care partners with the prison administration Social Work Services to provide:

• HIV prevention services (education, awareness, testing services, self-screening using oral swabs and pre-exposure prophylaxis PrEP)

• voluntary medical male circumcision services across five regions (Gauteng, Free State, KwaZulu Natal, Limpopo, Mpumalanga, North West and Western Cape). A total of 1,540 circumcisions were carried out in 2021.

TB HIV Care also supports the prison administration in the prevention of tuberculosis and hepatitis (HBV and HCV).¹

South Africa Partners also collaborates with the prison administration to implement prevention measures and raise awareness among prisoners and staff about HIV and other infectious diseases, stigma, sexual violence, substance abuse, as well as LGBTIQ+ specific issues. They carry out screenings for HIV and tuberculosis in eight facilities.

In practice, available resources and infrastructure considerably limit prophylactic capabilities for all diseases. The JICS reports dilapidated infrastructure in the majority of prisons and warns against the potential spreading of disease, mainly as a result of dysfunctional drains and sanitary facilities.²

Condoms and water-based lubricants must be provided in dispensers accessible across all facilities.¹ TB HIV Care assists in providing condoms and lubricants in some regions.² Consistent distribution is not ensured by the prison administration.

Prisoners must be screened on admission for current and past suicidal ideation or mental illness.¹ A person showing signs of mental health issues must be detained in a single cell or a correctional health facility for observation by a medical practitioner (Correctional Services Act 111 of 1998, Section 49.D). Prisoners may also use their own psychologist at their own expense (Regulations to the Correctional Services Act, Regulation 10.3).

The prison administration states needs-based psychological services are provided. These aim to assist prisoners in adjusting to prison life, developing coping skills and preventing re-offending behaviour. Participation is voluntary, unless required by the Court.

Prisoners may undergo an assessment by a psychologist. The evaluation consists of interviews, psychometric tests, observing the prisoner in group settings, feedback from personnel, as well as consultation with family members and/or other relevant persons. Due to a general lack of psychologists in the country, psychological care cannot be offered to all prisoners. As such, the following groups are prioritised:

• previous history of mental illness and/or psychiatric or psychological treatment

• at-risk of suicide

• referred by a court

• youth and women

• violent and/or sexual offenders

• persons who request a psychologist

The following treatment methods are used:

• individual psychotherapy

• group therapy (8-12 persons)

• couples and/or family therapy

• structured programmes (e.g. anger management programmes) managed by psychologists and other professionals (e.g. social workers)

Access to mental health care varies considerably from one facility to another. Prisoners can wait for months before being able to see a psychiatrist. Medication such as antidepressants is provided but there remains a lack of psychologists and follow-up. Some civil society organisations and faith-based organisations provide basic non-qualified mental health support and auxiliary counselling.

People found not criminally responsible by reason of mental illness or intellectual disability are known as ‘state patients’ (Criminal Procedure Act 51 of 1977. These people may be temporarily placed in correctional centres under the care of a medical practitioner while awaiting placement in a psychiatric facility managed by the Department of Health (Regulation 7.13). Due to insufficient space in psychiatric facilities, they sometimes find themselves waiting in correctional centres for indefinite periods. Correctional officials are not trained to deal with ‘state patients’. As of September 2022, there are 113 declared state patients, of which seven are women.²

Civil society organisations observe that the mental health of prisoners often deteriorates during detention, leading some to become more violent. They are often placed in segregation units, given chemical restraints such as medication, or dragged into submission. Medical practitioners frequently use antipsychotics or other medication to calm them down and make them easier to control. This is a particular problem in remand centres where staff are not trained to deal with these issues. Support for women with a history of abuse, trauma and/or violence is not provided. The SAHRC reports a systemic failure to provide adequate standards of mental health care and support services.¹

The prison administration provides a substance abuse programme managed by the Social Work Services. This is sometimes done alongside civil society organisations. Some prisons have discussion groups where prisoners suffering from addiction can share their experiences and struggles.