1. Introduction has served to demonstrate the limited value of criminal justice interventions in tackling criminal conduct and the complex social, psychological, economic and other factors which tend to underlie it. We know that people with health problems are greatly over-represented among those who are arrested, prosecuted and imprisoned; and we know that their entry into the criminal justice system frequently worsens health, thereby hindering rehabilitation and increasing the risk of reoffending. It is from this perspective that we approach the topic of prisoner health and healthcare and propose a health-informed approach to penal reform. 1.2 Structure of the report The report has three main chapters. Following this introduction, Chapter 2 considers the health problems with which people enter prison. We note that prison populations are disproportionately drawn from the poorest and most marginalised sections of society, within which mental and physical health problems tend to be more prevalent than in the general population. We also note the ease with which certain kinds of mental health conditions can, in themselves, propel individuals into the criminal justice system and ultimately into custody. Chapter 3 considers some of the ways in which being in prison can worsen existing mental and physical health problems and create new ones. This chapter includes discussion of the interlinked problems of poor material conditions, social and psychological stresses, availability of illicit substances, violence and mistreatment among prisoners and staff, and suicide and self-harm. We also look at the scale of overcrowding in prisons around the world and the associated health risks. In Chapter 4, we highlight the urgent need to address the health-related harms associated with over-use of imprisonment, and propose some ways of doing so. We argue for a two-pronged approach which emphasises, first, reduced use of custody – in general, and for those with significant mental health conditions in particular – and, secondly, improved health provision within prisons. In preparing this report, we have largely – although not exclusively – used evidence from the ten countries in which we are currently conducting research. The issues addressed, however, have relevance across most of the globe. Figure 2: Communal cell, Pollsmoor Maximum Security Prison, Cape Town, South Africa © Mikhael Subotzky, courtesy Goodman Gallery 3