Responding to Inmates' Health Needs in Zambia: A Policy Analysis


 Introduction{Fazel, 2011 #25}Worldwide, the rates of infectious and non-infectious diseases in prisons is generally higher than that of the general population. Although Zambia has adopted international and local guidelines to address prisoners’ health, the disease burden remains high in Zambian prisons. This study therefore explored barriers to translation and implementation of the legislative acts and guidelines that deal with health for inmates in correctional facilities. MethodsThis was a case study. Data was gathered through key informant interviews with stakeholders supporting inmates’ health in Zambia. These included the Ministry of Home Affairs, Ministry of Health (MoH), Ministry of Justice, Zambia Correctional Service, NGOs and UN agencies. The policy triangle was used to guide data collection, organization and analysis. Data was analysed using thematic analysis. Nvivo software version 12 was used for data coding. ResultsContext: There was political will and commitment to address inmate’s health in Zambia but was constrained by inadequate resources, infrastructure and trained Health Care Workers. Actors: Many key actors were not aware of key policy documents and guidelines addressing inmates’ health in Zambia. Coordination among partners was poor and efforts were underway to address lack of coordination in providing good health services to inmates. The role of the Ministry of health, as the lead partner, was emphasised going forward. Process: It was revealed that the policy development and implementation process was not consultative. There was weak inter-ministerial collaboration and lack of completion of the domestication process of the international guidelines, and this resulted in poor coordination and implementation of legal provision on inmates’ health.ConclusionDespite the existence of key legal and policy guidelines to address prisoners’ health in Zambia, there remain several barriers to implementation. These include lack of resources, lack of awareness and poor coordination among partners working in this sector. It will be important for the Ministry of Health to provide leadership and resources to raise awareness about prisoners’ health and a policy provision to support this process. Resources and infrastructure will be key to addressing the current challenges related to providing quality care for inmates in Zambia.


Introduction
{Fazel, 2011 #25}Worldwide, the rates of infectious and non-infectious diseases in prisons is generally higher than that of the general population. Although Zambia has adopted international and local guidelines to address prisoners' health, the disease burden remains high in Zambian prisons. This study therefore explored barriers to translation and implementation of the legislative acts and guidelines that deal with health for inmates in correctional facilities.

Methods
This was a case study. Data was gathered through key informant interviews with stakeholders supporting inmates' health in Zambia. These included the Ministry of Home Affairs, Ministry of Health (MoH), Ministry of Justice, Zambia Correctional Service, NGOs and UN agencies. The policy triangle was used to guide data collection, organization and analysis. Data was analysed using thematic analysis. Nvivo software version 12 was used for data coding.

Results
Context: There was political will and commitment to address inmate's health in Zambia but was constrained by inadequate resources, infrastructure and trained Health Care Workers.
Actors: Many key actors were not aware of key policy documents and guidelines addressing inmates' health in Zambia. Coordination among partners was poor and efforts were underway to address lack of coordination in providing good health services to inmates. The role of the Ministry of health, as the lead partner, was emphasised going forward.
Process: It was revealed that the policy development and implementation process was not consultative. There was weak inter-ministerial collaboration and lack of completion of the domestication process of the international guidelines, and this resulted in poor coordination and implementation of legal provision on inmates' health.

Conclusion
Despite the existence of key legal and policy guidelines to address prisoners' health in Zambia, there remain several barriers to implementation. These include lack of resources, lack of awareness and poor coordination among partners working in this sector. It will be important for the Ministry of Health to provide leadership and resources to raise awareness about prisoners' health and a policy provision to support this process. Resources and infrastructure will be key to addressing the current challenges related to providing quality care for inmates in Zambia.

Background
Page 3 /23 It has been documented that {Fazel, 2011 #25}worldwide, about 10.2 million people are held in prisons [1] with four to six times this number passing through the world's prisons every year. This population keeps increasing leading to the world's notorious problem of overcrowding in prisons [2], and inevitably resulting in higher rates of both infectious and non-infectious diseases among prisoners than that of the general population [1].
To address this challenge, international bodies have developed several policies and guidelines to protect prisoners against inhumane and degrading treatment and uphold their right to health [3]. These international bodies prescribe that prisoners retain their fundamental right to enjoy good health, both physically and mentally. For instance, the Human Rights Watch [4] explains that, article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) -which establishes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health [5], should equally apply to prisoners. Further, the WHO Guide to the Essentials in Prison Health [6], UN Nelson Mandela Rules [7], WHO Moscow Declaration [8], and Good Governance for Prison Health in the 21st Century [9] all acknowledge that prison health affects public health and that, Government Ministries responsible for public health should also be responsible for prison health services.
Zambia is a signatory to most international guidelines. In an attempt to operationalize the international guidelines, Zambia has enacted the National Health Services Act 17 of 2005, Prisons Act (Chapter 97) repealed by Act 16 of 2004, the Public Health Act (Chapter 295), Prisons Health Strategic Plan and National Health Policy to enable deliverance of an adequate and e cient internationally acceptable health system for inmates. Moreover, the Constitution of the Republic of Zambia guarantees human rights and equal treatment to all citizens irrespective of whether they are incarcerated or not [10].
Despite the available policy documents and guidelines aimed at supporting delivery of adequate and e cient internationally acceptable healthcare to inmates, which is equal in standard to that available in the community [11], the rates of infectious and non-infectious diseases in Zambia's Correctional Centres remain higher than those of the general population [12,13].
This study, therefore, used the policy triangle by Watt and Gilson that consists of Content, Actors, Process and context to provide insights into the enablers and challenges in translation of legislative Acts and Policies. [14]. Exploration of the process led to understanding of how legal provisions were developed and communicated. The actors involved in formulation and those responsible in implementation were identi ed and these were the determinants of the content. Content of the national laws and policies governing inmates' health and their translation were examined. Contextual factors also play a big role in the success of the translation, to this effect, the contextual factors were explored.

Study Design
Page 4/23 The study used a qualitative case study design because it sought to understand complex social phenomena [15]. The case in this study was the existing legislative acts, policies and how they are translated to respond to health needs of inmates. The case study design also allowed for an exhaustive examination of the different aspects of healthcare provision in Zambia's Correctional Service.
To examine the gap, the study analysed the inmates' health aspect of the legislative Acts, National Health Policy and National Health Strategic Plan. The primary unit of analysis in this study were the Zambia Correctional Service, Ministry of Home Affairs, Ministry of Justice, Ministry of Health and cooperating partners (see table 2) with an interest in inmates' healthcare.

Data Collection
Document review: Data collection for the study was done between 24 th November, 2017 and 2 nd March 2018 which included a review of policy documents in relation to prison health ( Table 1). The major documents reviewed included legislative Acts, policies and strategic Plans that contained inmate's health. These documents are readily available online except for the Prison Health Strategic Plan that was obtained from the Zambia Correctional Service. other remaining 3 were phone interviews. The study used an interview guide adapted from Creswell [16] and the interviews were conducted at participants' o ces. For rigor and validity, the study used multiple sources of data collection (16) that is, document review and key informants. Informed consent was obtained prior to the interview and permission to record the interviews was sought. This study used a Policy triangle by Walt and Gilson [17] to provide insights into the enablers and challenges in translation of legal provision on inmates' health. The policy triangle has four main components which are; Content, Process, Context and Actors. Content is part of translation because it is the content of the legal provision that needs to cascade at different stages to nally get to intended bene ciaries. Similarly, the Process is an integral part of the translation as the content of the Legislative Act have to be initiated, developed and communicated across different platforms. Contextual factors also play a big role in the success of the translation. Finally, Actors are determinants of the content that has to be translated and are, therefore, key players that ultimately decide whether or not certain issues, such as inmates' health, should be included in the document.

Data analysis
The analysis approach used in this study was thematic analysis. All documents were read for familiarization and special focus was on parts in the documents that were addressing inmates' health. Recorded interviews were transcribed verbatim. Content relating to inmates health were consolidated, after which codes were developed. The codes were developed from document analysis and interviews. Further analysis was done on the codes to establish the subthemes. New codes that came up during analysis were incorporated to the existing subthemes. Subthemes were then analysed and aggregated in correlation to the predetermined major themes obtained from the policy triangle. The data was coded, subsequently categorized according to the broad idea that they represented. Categories were then analysed and grouped according to the predetermined themes that were derived from the policy triangle. Table 3 shows examples of the codes, categories and themes from the analysis.

Results
Results are organised in line with the Policy triangle described above with a focus on the content, context, actors and process

Process of policy initiation, development and implementation
This study endeavoured to nd out the ways in which legal provisions on inmates' health were translated, that is, how legal provisions cascaded from formulation to the actual bene ciary. This was done by reviewing health legal provisions with a focus on inmates' health and through key informant interviews. Some of the issues that arose included; stakeholder consultation during formulation of legal provisions of health on inmates, fragmented legal provisions, delayed court hearings, lack of correctional training at Zambia Correctional Service Training School and inequality in public health care delivery and Accountability and Reporting on inmates' health. Each of these issues are presented below.
Stakeholder's involvement in formulation and sensitisation on inmates' healthcare laws.
Informants reported that the existing legal documents on inmates' health were formulated using topdown approach and that it is the reason why implementation has been di cult. They stated that, due to this, other important stakeholders have not owned these legal documents and they feel alienated from what the documents demand.
Top-down approach also suggest that the bottom stakeholders, inter-alia, bene ciaries were not consulted. Some informants expressed lack of full consultation during formation of some Legislative Acts that are currently existing, therefore, some health workers were not aware of any guidelines while others stated that the guidelines were non-existence. It was revealed that this process made some key implementers not to attach importance or take time to know what is expected of them.
"…it was a bit di cult to implement what was in the Prisons Act because some o cers were not able to understand what the Prisons Act says in terms of health of inmates…" (KI 02 Zambia Correctional Service 24-11-17) "…health facilities ...don't have guidelines or they are completely ignorant on how they should treat inmates that's why others may even refuse to attend to them…" (KI 04 Ministry of  Nevertheless, some informants stated that there are a few documents such as the Zambia Correctional Health Strategic Plan whose formulation was very consultative and there is belief it might be successfully implemented because key stakeholders are likely to own the documents and ensure its success. The only problem they anticipate is the fact that it was formulated when the National Health Policy, the National Health Strategic Plan and the 6 th National Development Plan had expired. This means that it did not buy in from any of these cardinal national documents. "…the process of coming up with the ZCHSP was quite inclusive and it was representative…" (KI 12 Cooperation Partner 29-11-17) Fragmented legal provisions A number of informants said that the process of implementation had been a challenge due to fragmented policies, strategies and guidelines. They added that people and institutions were working in silos, this led to stretching of the already scarce resources, impacting negatively on effectiveness and inability to achieve intended goals. They further stated that most of the Legislative Acts, policies, strategies and guidelines lacked frameworks to be implemented.

Political Environment
According to respondents, there was political will to improve health conditions in Zambia Correctional Service as shown by the president assenting to the constitution on 5th January 2016. They further stated that government had given attention to the needs of Zambia Correctional Service. They also added that government was also working on harmonising salaries for correctional staff, this would motivate them to execute their duties diligently.
"... there is support from the government currently, government is in support of the ZCS that's why in the PF manifesto they said they will change the name from prisons to ZCS just that is very, very important such that you can even tell that there is support from the government so even this the revised act I know it will be supported it will go through" (KII 03 ZCS 07/12/2017).

Stakeholders involvement in the translation and awareness of the law on inmates health
Due to nancial constraints alluded to above, not all key stakeholders were involved in the formulation process of the legal provisions on inmates' health. Consequently, some informants stated that some Ministry of Health staff are not aware of inmates' entitlement to healthcare. A respondents said the following; "I don't know anything about prison health guidelines or policy I have never seen anything written or any document on them" (KI 13 UTH 01-11-18).
On the other hand, some informants felt that Ministry of Health (MoH) by virtue of being charged with the responsibility of providing health for all, are expected to take up the supervisory role even if they were not actively involved in the formulation process of legal provisions on inmates' health. They added that they expect MoH to take the rst step in collaborating with Zambia Correctional Service (ZCS) not vice versa, as is the status quo. They gave an example of the cholera outbreak where they expected MoH to be in the forefront ensuring that ZCS had the necessary equipment and doing the right thing. To their dismay, ZCS had to nd its way of participating in the national committee to ensure that prevention of the infectious and water borne disease was addressed in correctional centres. Below is what an informant said; "…the collaboration with MoH is not yet 100%, there are still challenges, they are not proactive when it comes to some public health issues in Prisons that can threaten the health of the entire country, for example the cholera outbreak we had to push ourselves to the national committee…" (KI 07 ZCS 21-02-18)

Role of cooperating partners
To ensure that inmates have access to healthcare like that of general community, Zambia Correctional prisoner's health, in any aspect, come together with the correctional service to strategize on health service provision in the correctional centre. This has enabled all stakeholders to be involved in health provision for inmates. Unfortunately, it emerged from informants that the platforms' full potential is not tapped due to lack of funding and its lack of legal backing. One informant explained; "Prisons Health Advisory Committee is a forum or a platform that can be used to generate ideas on how prisons can be run in totality because that forum was meant to bring ideas to fore but I think we are not making full use of it…" (KI 16 Cooperating partner 22-12-17) Informants stated that provision of comprehensive care by ZCS has been a challenge and they attributed it to insu cient funding from the central government. However, informants submitted that Zambia Correctional Service receives support from partners with the mandate to provide support to inmates through the Prisons Health Advisory Committee (PHAC) that has been discussed above. Through this coordinating platform, partners share work plans for increased collaboration and sourcing of additional legal, Nutritional, spiritual, counselling and advocacy support. "…ZLDC is collaborating with UNODC and CIDRZ in facilitating and funding the review of Zambia Correctional Service Regulations that is supposed to take place in May...UNODC is going to fund the activity while ZLDC will facilitate the process and CIDRZ will participate…"(KI 16 Cooperating partner 22-12-17 "They increased funding to ZCS by using a simple technique of visual change of mind set that actually worked. PAC committee organized a meeting for parliamentarians with the support of UNODC, they came to chimbokaila to see the way inmates were leaving from there we bene tted such that members of parliament supported the increment in terms of funding to the ZCS because they saw that there was really suffering in prison" (KII 14 Cooperating Partner 24-11-17).
Delayed court hearing Some informants stated that they applauded the government for building more prisons to reduce congestion that was notorious for spreading diseases. However, this was not a complete panacea to the problem. They added that the new prisons would be congested as well so long as other criminal justice system were not addressed, for example delayed cases. Therefore, they suggested a holistic approach to the problem.
"…how the police investigate their cases, if its shoddily done someone's case can languish in the judiciary for years and they end up in correctional facility even longer, so we need a holistic approach" (KI 16 Cooperating partner 22-12-17) Lack of correctional training at Zambia Correctional Service Training School It was revealed by informants that after the constitution was amended to change Zambia Prisons to Zambia Correctional Service, the curriculum at Zambia Correctional Service (ZCS) training school has remained punitive. They stressed how the process of implementation of the new constitution demands that they produce o cers who will respect inmate's right to health and ensure that the ZCS becomes a healthy environment to complete public health vision. to the patients in the general community. Informants identi ed inequality in treatment of sick inmates as a barrier to translation of legal provisions on inmate's health. Informant stated that some correctional health facilities were found attending to community members rst before inmates, and this was because of the misconception that inmates are not entitled to healthcare, contrary to the civilized approach that gives inmates entitlement to access the same quality of health services as the general community.
Informants suggested that o cers need training so that they can understand the paradigm shift to corrections. They further pointed out that o cers are one of the major facilitators of access to healthcare for inmates. An informants stated the following; "….after training and sensitising the o cers on Mandela Rules, staff realised that inmates' access to health is equally important as their own access to health." (KI 16 Cooperating partner 22-12-17) Accountability and reporting on inmates health Informants reported that the process of translation of legal provisions can only be fully complete if there is Monitoring and Evaluation (M&E). Some informants attributed lack of M&E in the translation of legal provision on inmate's health to insu cient funding. They suggested systems to be in place to Monitor and Evaluate all the stages of translation, that is, from initiation of the legal provision through to implementation. They further reported inaccurate reporting by juniors in Zambia Correctional Service, for example, in cases when they report the number of inmates they have in the morning when they open the cells (unlock) and the number of inmates they have in the afternoon when they lock the cells (lockup), stating that the situation is normal. They revealed that detailed information on inmates' health and nutrition is omitted. This is the report that is given to the Minister who also presents to Cabinet and consequently the president is made to believe that the situation in the correctional service is normal and good when it is actually not.
"…o cers should state things as they are so that the Minister will have what to say not just telling the president all is well…" (KI 08 Cooperating Partners 02-03-18)

Lack of domestication of international guidelines
Informants felt that domestication was one of the most cardinal step in the process of implementation of international legal provisions. They reported that international guidelines cannot be one size ts all, and further stated that developed and developing countries have different priorities, depending on the economic performance, therefore, cannot be expected to have the same approach. For example, contrary to international provisions, there were mixed feelings among informants on a correctional health personnel completely shunning away from disciplinary sanctions on inmates and only concentrating on health provision. Some informants felt o cers needed to perform any duty that befalls them, while others felt that o cers responsible for inmate's health were only supposed to concentrate solely on health.
Below is what they had to say; "…developing countries like Zambia with limited resources it's better to let an o cer multi task and as long as an inmate is working with inmates they cannot do away with security". (KI 02 ZCS 24-11-17) On the contrary, informants felt that because of security implications in dealing with inmates, disciplinary sanctions cannot be done away with. Therefore, correctional health workers perform both custodial and rehabilitation work "…correctional health workers do both custodial and rehabilitation duties but that is so unethical, they don't have to be involved in punishing prisoners…" (KI 16 Cooperating partner 22-12 17) Therefore, informants recommended domestication of international guidelines.

Discussion
This paper analysed the legal provisions and policy framework that deal with health for inmates and how they are implemented. This was done by understanding the context in which the legal provisions on inmates were formulated and implemented, the actors involved and the process used in formulation and to ensure the existing legal provisions on inmates cascaded from formulation to the actual bene ciary [18]. Most of the ndings from this study are consistent with ndings from prison health studies done in Zambia [11,[18][19][20] as they all indicate that despite the existing legislation, policies and strategies on inmates health, translation has been a challenge.
Our study revealed that Zambia subscribes to international bodies that prescribe the minimum standards for an inmate's health [21]. Unfortunately, international legal documents have not been domesticated, this is in line with ndings by Mukanu et al., [22] who concluded that there was need for domestication of international guidelines and frameworks to match the disease burden, resources and capacities in the local context if policy measures are to be comprehensive, relevant and measurable [23]. Similar to ndings by Shiffman J [24] who attributed policy success to interaction of actors and process, this study's existing gap in provision of inmates healthcare were attributed to, inter-alia, lack of stakeholders involvement in formulation of policy, delayed court hearings, lack of correctional training at ZCS Training School, inequality in public health care delivery and Accountability and Reporting on inmates health. The identi ed gaps make implementation di cult, therefore, they need to be addressed so as to ensure inmates' smooth access to healthcare. Additionally, international provisions need to be domesticated to tailor them to the local needs.
This study supports other studies' by concluding that during formulation of any legal provision, it is vital to involve all necessary stakeholders because it determines success of implementation [25]. In particular, the study cited lack of involvement of inmates who are one of the key stakeholders in the formulation of legal provisions for inmates' health, as one of the reasons for unmet healthcare needs among inmates in Zambia Correctional Service. This is in line with ndings from other studies that emphasized how fruitful bottom-up approach was compared to top-down that usually leaves out key stakeholder in policy process [26,27]. Furthermore, the study stated that it could be the reason Ministry of Health does not have ownership of the legal provisions in the Prisons Act. Therefore, this study shows that attention should be paid to the extent of key stakeholder participation or else e ciency and effectiveness in implementation is affected, this is supported by Walt and Gilson [17] who state that focus on the content of policy neglecting the other proportions of process such as actors and context can make the difference between effective and ineffective policy choice and implementation [22,28].
It was noted that even though Ministry of Health (MoH) was supposed to provide leadership and direction for inmates' health as provided in Prisons Act (ROZ, 2004), most of its staff were oblivious of such obligation. This contributed to implementation challenge and is akin ndings by Canadian Journal of Public Health [29] that concluded that key stakeholders can be affected by policy decision or be in a position to affect policy. This was a lost opportunity that can be addressed.
Furthermore, the lack of involvement of bene ciaries of the policies during policy design and implementation meant that key stakeholders did not have a say and therefore were unable to participate fully and often felt betrayed by policy makers. Similar studies have reported the importance of stakeholder engagement in the formation process of legal provisions and disseminated of information, Mukanu et al., [22] stated how stakeholder engagement made legal documents comprehensive while others showed how di cult ownership of legal provisions and implementation was due to lack of stakeholder participation [23,30,31].
Although we noted some effort to address infrastructure limitations by building new and bigger Correctional Facilities, these were isolated and not comprehensive as they did not guarantee better access to health services. Therefore, this study suggest, in line with Topp et al., [11] , the need for a holistic approach that engages other stakeholders to develop a comprehensive package which addresses several but related barriers to provision of good health services in prisons.
It was revealed by informants that, in the process of trying to implement and align with international standards of prison care and translate the law accordingly, the constitution was amended to change Zambia Prisons to Zambia Correctional Service [19]. However, the change of name has not translated into improved services as intentioned. Some of the reasons that the study found were the curriculum at Zambia Correctional Service training school had not changed to training o cers in evidence based corrections and how to respect inmate's rights that included right to health, more so, the Prisons Act gives authority to an o cer without medical background to decide on inmates need for medical attention. This supports other similar studies and in particular Singh's study [32] that recognised the incompleteness in the transformation from prisons to corrections because of lack of coherence of paradigm, and the lack of a common understanding of the meaning of rehabilitation across the entire Correctional Service, this led to development of a concept documents called "Conceptualising Rehabilitation" to harmonise change of name with practice [32,33].

Limitations
The study has several limitations; rstly, this was a qualitative case study and it is not designed to establish causal inference but to understand the process of Legislative Acts translation. Generalisation cannot be made from this study. Secondly, the researcher works for Zambia Correctional Service as well as some of the people who were interviewed, some were the researcher's seniors while others were juniors, these could have exaggerated their response either positive or negative and the researcher could have in uenced the response and report. To avoid preconception and bias, some participants were interviewed by the research assistant while others were interviewed by both the researcher and research assistant. To further counter preconception and bias, the researcher used a re exive journal [34], the researchers perspective and assumption were noted in the journal during interviews and discussed with the assistant to ensure reliability. Furthermore, triangulation techniques was employed to improve trustworthiness of the ndings. Thirdly, despite assurances of con dentiality, some responders were uncomfortable to say anything negative about Zambia Correctional Service probably due to the nature of their work which borders on security and classi ed information. Nonetheless others were happy to talk freely and we made efforts to re-assure those who expressed concerns of con dentiality.
Finally, our study was limited to supply side but future research should endeavour to include demand side as it was noted during the study that it is important to know how involved current or former inmates were in formulation of legal provisions that are related to them and how much they now about the existing ones in order to get a balanced picture.

Conclusion
In conclusion, in order to achieve a successful and well implemented legal provision, interaction of Process, Context, Actors and content (Policy Triangle) in policy making process is cardinal. The content, as noted by most of the studies done in Zambia on Prisoners legal provision on health, the major legal documents that contain health for inmates' have adequately addressed inmates' health. Nevertheless, inadequate knowledge of the content and limited resources for implementation negatively affected the extent to which these policies were translated. The study provided an insight on how the process of policy formulation was not very satisfactory as certain elements such as key stakeholder engagement was not satisfactory, for example Ministry of Health who were not engaged fully. It underlined how lack of leadership from the Ministry of health and limited resources were also labelled as major barriers to full implementation of the laws which provide for inmates' health services in Zambia, this was partially attributed to lack of involvement in formulation of some vital legal documents for inmates health as alluded to earlier and in some instances it was Ministry of Health shirking their responsibility. On the other hand, there was political will to improve inmates' access to healthcare. It is therefore cardinal to note that unless the challenges highlighted are addressed, inmates' health will remain poor in Correctional Centres in Zambia The study contributes to information necessary to improve policy making process that should ensure that all the complexities of interaction of Process, Content, Actors and Context are well taken care of. This study has also opened up to more studies on Policy Triangle on demand side that might bring out a different perspective of healthcare challenges in Zambia Correctional Service.

Declarations
Availability of data and materials The data from which these ndings were drawn is available from the corresponding author on reasonable request. Acknowledgements This paper is part of the Master of Public Health dissertation requirement. Many thanks to Zambia Correctional Service, Ministry of Home Affairs, Ministry of Health and Cooperating Partners for granting us permission to carry out interviews. We would like to thank supervisors for the guidance and whose valuable input made this work possible.
In addition, a thank you to all members of faculty and all the participants that consented to be interviewed. Finally, special thanks to our families for encouragement, understanding and unconditional support. Funding The authors declare that no funding was received for this research Authors Information Authorized Representatives as data on prisoners is involved in the study. Ethical clearance for the study was granted by the University of Zambia Biomedical Research and Ethics Committee, reference number 018-06-17. Prior to interviewing informants, o cial permission was sought from the organizations and informed consent was obtained from all the informants who participated in the study. Permission to audio record interviews was sought from participants and clear explanation why it was necessary was given. Identity con dentiality was assureds and all the interviews were conducted in private (informant's o ces). The researcher informed the informants that there were no direct bene ts to the researcher, however, it would bene t the Zambia Corrections Service (ZCS) by recommending necessary measures to be taken to translation of the law to nally bene t the inmates and enhance collaboration with stakeholders. All hard and soft copies of the data were kept securely. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests.