MINISTERS’ DEPUTIES

Notes on the Agenda

CM/Notes/1514/H46-26

5 December 2024

1514th meeting, 3-5 December 2024 (DH) Human rights   H46-26 Cosovan group v. Republic of Moldova (Application No. 13472/18) Supervision of the execution of the European Court’s judgments Reference documents DH-DD(2024)1148, CM/Del/Dec(2023)1483/H46-20

Application	Case	Judgment of	Final on	Indicator for the classification
13472/18	COSOVAN	22/03/2022	22/06/2022	Complex problem
69086/14	MACHINA	17/01/2023	17/04/2023
11272/16	NIȚU	11/06/2024	11/06/2024

·  Cooperation project: VC2840 – “Strengthening the prison and probation reforms, provision of health care and the treatment of patients in closed institutions in the Republic of Moldova” ·  Cooperation project: VC3679 – “Further strengthening the prison and probation reforms, provision of health care and the treatment of patients in closed institutions in the Republic of Moldova” ·  Cooperation project: VC 2846 – “Strengthening the Human Rights Compliant Criminal Justice System in the Republic of Moldova”

Case description

This group of cases concerns inadequate medical treatment and specialised medical care in detention between 2008 and 2019, and lack of effective domestic remedies in this respect (violations of Article 3 and 13).

The Court established serious shortcomings in dispensing medical care in detention, in particular:

-       lack of official accreditation of the prison hospital as a health institution;

-       absence of certain specialist doctors in the prison hospital and the fact that a treatment could be denied or only partially carried out simply because no appropriate treatment was available in prison or because the resources were too scarce;

-       logistical and financial complications for guarding detainees transferred to civil hospitals;

-       lack of access of detainees to the general medical insurance scheme;

-       subordination of prison doctors to the prison administration;

-       unavailability of humanitarian release of seriously ill persons detained pending trial;

-       State’s failure to prevent transmission of HCV in prison;

-       lack of screenings upon admission in detention; and

-       lack of special diet.

Furthermore, the Nițu case concerns a lack of appropriate medical assistance in prison to treat the applicant’s mental health problems, resulting in harm to himself and frequent application of force against him.

The Cosovan case also concerns the domestic courts’ failure to provide relevant and sufficient reasons in court decisions justifying the applicant’s detention pending trial and its extension (violation of Article 5 § 3).[1]

Status of execution

The Committee of Ministers examined this group of cases at its 1483^rd meeting (DH) in December 2023. In response, the authorities submitted an action plan on 9 October 2024 (DH-DD(2024)1148).

Individual measures:

By its decisions from December 2023, the Committee ended its supervision of the individual measures in Cosovan. It encouraged the authorities to promptly bring to an end the domestic proceedings into the complaint on conditions of detention lodged by the applicant in the Machina case.

In their latest action plan, as concerns the Machina case the authorities submitted that the applicant was released from detention on 7 July 2016.[2] On 28 February 2024, the Chișinău Court dismissed the applicant’s complaint as regards conditions of detention in Prison No. 7 and partially admitted her complaint concerning conditions of detention in Prison No. 13. It awarded the applicant MDL 85 300 (about EUR 4 400) for
non-pecuniary damage. This ruling was challenged before the Court of Appeal, which will decide this case on 13 November 2024.

In the new Nițu case, the just satisfaction awarded by the Court was paid. Following the events described in the Court’s judgments, on 2 May 2024 the applicant was detained in the context of new criminal proceedings initiated against him. On 30 July 2024, he was convicted of robbery and sentenced to four years of imprisonment. He is being detained in Prison No. 13, awaiting a final court decision in his case. In the period between 2 May to 5 June 2024, he resorted to self-mutilation on several occasions. Individual psychological counselling and outpatient medication treatment is being provided in response.

General measures:

In its decisions from December 2023, the Committee noted the efforts undertaken by the authorities to address the deficiencies in prison healthcare, and stressed that the extent of these deficiencies, their complexity and systemic character require continued resolute action and a holistic approach on the part of the authorities, including with support from the Council of Europe cooperation activities. The Committee invited the authorities to develop a comprehensive strategy to address the deficiencies in prison healthcare within national health policies, including transferring prison healthcare to the Ministry of Health, achieving the accreditation of the Prison Hospital, improving detainees' access to specialist medical treatment, and ensuring sufficient medical staff and funding for prison healthcare. It noted with interest the establishment of the Quality Council and its audits of prison medical units and requested information on how they ensure the Council experts' independence, and implementation of their recommendations by the prison administration. Further, it noted with interest the measures adopted to prevent the spread of transmissible diseases in prisons and encouraged the authorities to ensure proper implementation of the procedures to that effect. Also, it invited the authorities to provide information on medical insurance coverage to detainees; possibility of humanitarian release of seriously ill detainees on remand; dietary policy; examples of case-law on the application of domestic remedy challenging lack of medical assistance.

Accreditation of medical services of the prison system: The authorities submitted that continued efforts are undertaken to obtain accreditation of the Prison Hospital. Thus, in 2023, to improve its sanitary condition, an investment of about EUR 541 000 was made for capital refurbishment of the roof of the TB block and its ventilation system. Additionally, 37 patient rooms and all medical treatment rooms have been repaired. Currently, 13 out of 15 outpatient medical units in the prison system are accredited, with the accreditation process underway for medical units in Prisons Nos. 6 and 10.

Access to specialised medical treatment in prisons and public health institutions: In 2024, penitentiary institutions signed 16 public procurement contracts for external medical services in the amount of EUR  144 000. The authorities attribute the budget decrease for external medical services compared to previous years to a decline in the prison population (from 6 429 detainees in 2021 to 5 695 in 2024), fewer detainees with serious illnesses, and the end of the COVID-19 pandemic. From January to September 2024, 295 detainees received consultations and 89 patients were hospitalised in public health institutions.

Medical insurance for detainees: Articles 230 and 231 of the Code of Execution provide the right to free medical care in detention, fully covered by the state budget. Medical assistance is provided both through the Prison Hospital and prison medical units. Emergency and specialised care is available through public health institutions, similar to the services provided under the national health insurance system. If services not covered by the National Health Insurance Company are required, detainees may access private medical services at their own expense, regulated by the National Prison Administration (NPA) Order No. 272 of 17 May 2024.

Control over the quality of medical services: The Quality Council’s audit reports with recommendations and deadlines are sent to prison directors for the follow-up action. Their implementation is reviewed in follow-up audits, with decisions approved by the director of the NPA, making them either mandatory or advisory. On 17 January 2024, the Quality Council released an audit report on 20 internal audits conducted in 2023 across nine medical units. The audits revealed 87 cases of non-compliance, compared to 123 in 2022, and issued 175 recommendations (down from 269 in 2022), suggesting progress, but emphasising the need for continued improvement.

Supply of medicines, consumables and medical devices: All purchases are made through centralised public tenders. Between September 2023 and July 2024, the Prison Hospital was equipped with medical devices funded from the state budget in the amount of EUR 2 100 and from external sources in the amount of EUR 70 400. In 2024, EUR 495 600 was allocated for medical supplies. In April 2024 the NPA was provided EUR 105 000 worth of medical equipment from the Council of Europe (CoE), which was distributed across all 16 penitentiaries.

Measure to address understaffing:As of January 2023, salaries for civil servants with special status were increased by three successive grades for management positions and by six successive grades for executive positions. Additionally, a fixed monthly bonus of EUR 70 was established for all civil servants. The Prison Hospital is currently staffed with a variety of specialists, including 1 surgeon, 1 endoscopist, 1 therapist, 1 dentist, 1 gynaecologist and 43 nurses. Moreover, new medical specialists were recruited, including a medical laboratory technician, medical sonographer, endoscopist, dermato-venerologist and oncologist. Three agreements were also concluded with resident doctors to join the team after completing their studies.

Transfer of responsibility for healthcare in prisons from the Ministry of Justice to the Ministry of Health: In October 2024, the CoE conducted a fact-finding mission to the Republic of Moldova to assess healthcare organisation and management in prisons and explore its integration into the public healthcare system.[3] The CoE will provide the authorities with a comparative analysis of existing models of health care organisation in prisons in different CoE member States, including those that were transferred from the Ministry of Justice to the Ministry of Health, with recommendations on feasible models for the Republic of Moldova.

Psychological and psychiatric care in the penitentiary system: Following an expert opinion provided by the CoE,^[4] on 16 May 2024, the Parliament adopted Law No. 114 on mental health and well-being, designating the Ministry of Justice to oversee mental health care for detainees. The Prison Hospital has a dedicated psychoneurological ward and contracts are in place for emergencies with external hospitals. Ongoing psychological counselling aims to manage aggressive behaviour and ensure treatment compliance. Transfer to specialised facilities in ensured in case of necessity.

The CoE provides important assistance to the authorities, including on the following:

Ø  Mental Health Strategy for the prison system and an Action Plan;[5]

Ø  Draft Code of Ethics for the medical staff in prisons;[6]

Ø  Concept Note and a Plan of Actions for the psychosocial rehabilitation of patients in psychiatric institutions;[7]

Ø  Assessment of the Psychoneurological Section of the Prison Hospital and developing recommendations on ensuring an integrated approach to psychosocial rehabilitation of patients, and on the minimum staffing level and incentives for staff recruitment;[8]

Ø  Regulation on Psychosocial Rehabilitation Services for people with Mental Disorders and Quality Standards for the implementation of the integrated model of psychosocial rehabilitation for patients in psychiatric hospitals;

Ø  Developing a concept on integrated specialised mental health services in prisons will be piloted in three prisons;

Ø  Adaptation of the Risk and Needs Assessment tool for health needs assessment and inclusion of health care / criminogenic needs into the Individual Sentence execution Plans;

Ø  Further training of medical and non-medical staff in prisons on medical examination upon admission to prison and managing patients’ individual files and on medical ethics;

Ø  Developing a handbook on psychiatric care in detention and materials on suicide prevention in closed environments.

Exclusion of disciplinary sanctions for self-mutilation: On 28 December 2023, the Parliament amended the Code of Execution to eliminate disciplinary sanctions and the requirement for prisoners to cover medical expenses related to acts of self-harm. This legislation reflects a shift in addressing self-inflicted harm as a mental health issue rather than a punishable act, promoting a more humane environment in prisons.

Measures to prevent transmission of HCV and other transmissible diseases: In the last 12 months, 142 detainees underwent medical investigations at the Republican Medical Diagnostic Centre in the context of the national treatment program for hepatitis C. As a result, the NPA submitted 108 files to the Ministry of Health, leading to 78 prisoners being included in the treatment program. In 2023, the prison administration received 1 600 doses of flu and anti-hepatitis vaccines for at-risk groups. In July 2024, an evaluation team of the World Health Organisation (WHO) and the National Agency for Public Health visited the Moldovan penitentiary institutions to assess the state of affairs and identify challenges in prevention and control of viral hepatitis. It concluded that testing, vaccination and treatment of hepatitis in prisons is in line with the WHO recommendations and the European standards on prison health and that the penitentiary system is working to eliminate viral hepatitis by 2030, in line with WHO global hepatitis strategy.

Humanitarian release of seriously ill persons held in pre-trial detention: Following an expert opinion provided by the CoE,[9] on 12 June 2024 the Government adopted the Decision No. 417, which introduced new rules for medical examination of seriously ill detainees, streamlining the procedure for their release on probation or replacement of pre-trial detention with alternative measures. The Consultative Medical Council of the Prison Hospital oversees medical assessments and makes recommendations for release. The decision expanded the list of serious illnesses which can serve as grounds for release.

Ensuring a balanced and varied diet in prison, including for detainees with health issues: On 26 March 2024, with CoE support,[10] the Government adopted Decision No. 228, setting minimum standards for food and hygiene products in prisons, focusing on improving nutrition and introducing special provisions for individuals with health issues, pregnant women, and nursing mothers. In July 2024, the CoE provided the NPA with standardised menus and detailed nutritional specifications for proper food preparation. These regulations will take effect on 1 January 2025.

Training aimed at increasing the quality of medical care in prisons: The authorities reported on training activities organised in 2024 and in previous years, including with the CoE assistance and in cooperation with State University of Medicine and Pharmacy “Nicolae Testemițeanu”. About 219 prison staff benefited of this training, including doctors, nurses, psychologists, psychiatrists and social workers.

Domestic remedy to challenge lack of medical assistance in detention: On 23 May 2024, with the CoE support, a workshop was held on the functioning of the domestic remedy.[11] It gathered judges, NPA and civil society. The participants observed that the preventive remedy for inadequate medical assistance in detention was ineffective due to vague regulations and lack of priority for urgent cases. Recommendations included amending the legal framework for quicker processing of medical cases. In November 2023, the Advisory Council of the Government Agent emphasised the need to amend the Code of Criminal Procedure to establish uniform compensation practices and ensure timely processing of claims related to medical assistance.

Analysis of the Secretariat

Individual measures:

In the Machina case, it is a matter of concern that the applicant’s complaint challenging conditions of detention has been pending with the domestic courts since May 2019, i.e. long beyond the statutory three-month time limit. The authorities could be urged to promptly bring these proceedings to an end and keep the Committee informed of their outcome.

As regards the Nițu case, while noting with interest the exclusion of sanctions for self-mutilation and the fact that the applicant ceased to self-mutilate, a systemic approach is required to improve the applicant’s condition and prevent reoccurrence of the harmful behaviour. The Committee might wish to encourage the authorities to continue providing the applicant with regular psychiatric treatment and constant medical follow-up and to consider therapeutic and rehabilitative, including occupational, psychosocial and recreational activities, tailored to his specific needs. Information is awaited in this connection by 1 March 2025.

General measures:

Medical care in prison system

At the outset, the Committee might wish to note a large range of measures reported by the authorities, which indicate efforts undertaken with a view to improving healthcare in prisons. Improvements were noted by the National Preventive Mechanism (NPM) in 2023, in particular as concerns supply of medicines and equipment.[12]

At the same time, a number of important challenges require continuous resolute action on the part of the authorities, in particular as follows.

While welcoming the refurbishments carried out in the Prison Hospital to improve sanitary conditions, it is noted that it still lacks its accreditation as a medical institution. The information provided by the authorities makes it difficult to assess the progress achieved in this process. The Committee might thus wish to invite the authorities to put in place a strategy with clear benchmarks and deadlines, which would provide a clear picture on the situation surrounding the accreditation of Prison Hospital.

It appears that understaffing continues to be a pressing issue affecting the provision of adequate medical care and hindering the accreditation process, in particular of the medical units in Prisons Nos. 6 and 10. As observed in the 2023 Annual Report of the NPM, on 31 December 2023, 52,5 medical posts in prisons were vacant.[13] The 2023 Ombudsman’s Annual Report also noted an acute shortage of psychologists and therapists, which drastically undermines any efforts by the prison administration to improve the quality of the re-education and resocialisation process for detainees.[14] As concerns the psychiatric care in prisons, it is noted that the Execution Code provides that all prisons should have at least a psychiatrist. The authorities are invited to give the highest priority to filling in the vacant posts, rapidly reflecting on the measures to address the understaffing of medical professionals in the prison system and considering additional incentives for staff recruitment, to make these positions more attractive.

The authorities submitted that detainees benefit from medical assistance free of charge in prison or in public hospitals if needed, under the same conditions as provided by the general medical insurance scheme. The Committee might wish to invite the authorities to provide a detailed list of medical services, treatment and medications covered by the state for detainees.

The authorities also reported that the decrease of budgetary allocations for external medical services is due, inter alia, to fewer detainees with serious illnesses. However, the NPM reported that in 2023 there was an increase by 21% in the general morbidity in prison population when compared to 2022.[15] It can be also noted from the figures provided by the authorities, that only about 5% of detainees received medical consultations and only 1.5% were hospitalised in the public healthcare institutions. In this context, the authorities are invited to explain why the public healthcare facilities are used so rarely, despite available budget, and clarify the practical aspects of decisions to make recourse to public healthcare, including logistical and financial implications for escorting and guarding detainees.

It is to be noted the authorities’ readiness to address the issue of responsibility over the healthcare in prisons and consider different models of organisation and management thereof, including those which imply its transfer to the Ministry of Health. The Committee might wish to invite them to make full use of the CoE expertise in choosing a model suitable to their national specifics and setting a roadmap, and keep it informed on the progress in this process.

The Committee might wish to welcome that it is now possible to grant humanitarian release to detainees on remand. The authorities are invited to provide examples of domestic case-law on the application of this mechanism.

The adoption of the new dietary policy and the measures to address transmissible diseases by means of screening, vaccination and treatment should also be noted with interest. The authorities should be encouraged to continue their efforts and inform the Committee on further progress in these areas, including on how dietary needs of detainees suffering from illnesses are met in practice.

Likewise, the exclusion of sanctions for detainees who engage in self-mutilation, as well as the removal of the requirement for them to cover related medical expenses, is welcomed. As it can be inferred from the Nitu case, following the applicant’s renewed detention after the Court’s judgment, this approach reduces the likelihood of reoccurrence of acts of self-mutilation. The authorities are thus encouraged to ensure the consistent application of these legislative amendments, in line with their intended objectives.

Domestic remedy to challenge inadequate medical assistance in prisons

The authorities’ intention to consider legislative amendments to ensure the effectiveness of the remedy in the part related to the medical assistance is noted. The Committee might wish to invite them to take a prompt action in this regard and keep the Committee informed on the progress.

Financing assured: YES