A/HRC/38/36 confinement often concentrate people from the most vulnerable situations, including those who are medically vulnerable. The centres are often characterized by inhumane physical and psychosocial environments and unequal structures of power frequently rooted within racist and violent pasts. The unpopularity and powerlessness of those deprived of liberty and confined leave them with no voice and few defenders to advocate for their dignity. These factors shape an ecology of deprivation that significantly compromises the ethical and effective organization and delivery of health care. 36. The availability of health-care services in detention and confinement centres is often compromised by managerial procurement decisions, particularly when those services are segregated from mainstream public-health infrastructure. Decisions to not make available certain health-care services are often taken by penal-oriented administrators instead of independent public-health actors, and security and punishment eclipse concerns for health. In many low-income settings, prison health systems lack the resources necessary to ensure the most basic provisions of health care. 37. In such settings, the accessibility of available health-care services is often dependent on negotiations with staff tasked with control and containment. Many people are denied access to appropriate medical services because of punitive or negligent actions of security staff. This has led to egregious violations of human rights, including preventable deaths. 38. In terms of acceptability, health-care services must: respect human rights and medical ethics; be culturally appropriate, sensitive to gender and life-cycle requirements and designed to respect confidentiality; and improve the health status of those concerned. Services in settings of confinement and deprivation of liberty must be culturally appropriate, as well as acceptable to adolescents, women, older persons, persons with disabilities, indigenous persons, minorities and lesbian, gay, bisexual, transgender and intersex persons. 39. As regards quality, evidence-based health-care protocols and practices must be used to support people who are deprived of liberty or confined, the majority of whom, because of their structural situation of disadvantage, will require significant provision of quality physical and mental health care. However, the delivery of such services faces systemic obstacles. The climate of deprivation and control adversely affects relationships, undermining the quality of health care. The absence of resources, particularly in lowincome settings, further exacerbates this environment. The inappropriate use or overprescription of psychotropic medications, common in prisons as a means of behaviour control, and the use of solitary confinement, isolation and forced medical treatment are issues of quality of care and do not promote and protect the right to health. In higherresource prison settings, cognitive-behavioural and other behaviour modification programmes raise serious questions of quality. Such programmes perpetuate individualistic approaches to offending as “abnormal”, masking the political and social contexts that shape the lives and choices of those who have been detained or confined. Participation 40. The effective realization of the right to health requires the participation of everyone, including those deprived of liberty or confined, or most at risk, in decision-making at the legal, policy and community levels, in particular in the area of health care. At the population level, enabling everyone to participate meaningfully in decisions about their right to health requires inclusive engagement, such as with those currently and formerly deprived of liberty and confined, their families, police, prison administrators, medical professionals, social workers, penal reformers and abolitionists and the wider community. 41. Health-care services in closed settings must empower users as rights holders to exercise autonomy and participate meaningfully and actively in all matters concerning them and to make their own choices about their health, with appropriate support where needed. 42. The inclusion of the voices of those directly affected must be encouraged, although this remains complicated owing to deeply unequal penal and medical power dynamics. Prisoner-led trade unions, voting rights movements and documentation projects, and movements of users and survivors of mental health systems, as well as the inclusive engagement of academia and the non-governmental sector, are powerful means for promoting meaningful participation. 9