A/HRC/38/36 Accountability 43. Accountability for the realization of the right to health requires three elements: monitoring; review, including by judicial, quasi-judicial and political or administrative bodies and social accountability mechanisms; and remedies and redress. Accountability is vital if the right to health inside prisons and other confinement settings is to be realized in practice. 44. Despite the commendable efforts of several monitoring mechanisms, human rights violations in prison and other centres of detention and confinement continue to be committed with impunity in a widespread and systematic manner. Individuals held in such centres often have limited or no access to independent accountability mechanisms, frequently because no monitoring body exists. Mechanisms charged with monitoring centres of deprivation of liberty rarely consider structural barriers, such as the disproportional detention of people in situations of vulnerability, including medical vulnerability, the existence of unequal power structures, often rooted in racist and violent pasts, and the little to no access to channels through which to voice demands, including health-care related demands. 45. The Special Rapporteur encourages national human rights institutions and national preventive mechanisms to give attention to those structural challenges. A right-to-health approach can be a useful tool in their monitoring and promotion functions. Persons formerly or currently deprived of liberty or confined, their families and civil society should be engaged in the development and implementation of accountability arrangements. III. Relationship between mental health and forced confinement and deprivation of liberty 46. Actual and de facto deprivation of liberty has adverse effects on mental health, which may amount to violations of the right to health. Solitary confinement and protracted or indefinite detainment, including decades of detention in prisons or other closed settings, negatively influence mental health and well-being. The rates of poor mental health in prisons worldwide far exceed the rates in the general population. Being deprived of liberty itself is an emotionally fraught experience, carrying with it potential exposure to inhumane and crowded conditions, violence and abuse, separation from family and community, the loss of autonomy and control over daily living and an environment of fear and humiliation, and the absence of constructive, stimulating activities. Suicide rates in prisons are at least three times higher than those in the general community. 23 47. While there has been a surge in research on mental health in prisons, it has been mostly limited to academic psychiatry and focused on disease prevalence and on improving services during confinement. There remains a dearth of research on how the constraints of a closed environment itself, particularly a punitive one, presents significant obstacles to the delivery of quality health care to those who are most in need. 48. Apart from recognizing that many people who are currently detained or confined should not be, there is an emerging consensus that prisons are not conducive to effective mental health treatment and that they are not the place for people identified as having a mental condition. This view, however, has led to forced confinement in mental health facilities, sometimes for indefinite periods, without meaningful safeguards to protect the right to health, to build on recovery or to guard against arbitrariness. For example, persons with intellectual and psychosocial disabilities who are in conflict with the law and who are deemed incapable of forming a rational judgment about their conduct (“insanity” defence) end up being held in custody in medical or security facilities instead. 49. The Convention on the Rights of Persons with Disabilities includes relevant provisions in this connection (arts. 12 and 14). The Committee on the Rights of Persons with Disabilities has established that the provisions represent an absolute prohibition on 23 10 Seena Fazel and Jacques Baillargeon, “The health of prisoners”, The Lancet, vol. 377 (2010).