A summary of this committee meeting is not yet available.
IMPROVEMENT OF QUALITY OF LIFE AND STATUS OF WOMEN JOINT COMMITTEE
2 October 2001
HUMAN SCIENCE RESEARCH COUNCIL & WESTERN CAPE DEPARTMENT OF HEALTH ON HIV/AIDS: BRIEFING
Chairperson: Ms P Govender
Documents handed out:
Opportunities and Challenges in implementing evidence-based prevention and care programmes in developing countries – Dr O Shisana (See Appendix)
Public Policy Making Process PowerPoint Version
The Executive Director of the Human Science Research Council stated that research results seldom have an immediate impact on government policy but understanding the complexities in policy making will help in addressing opportunities and challenges of HIV/AIDS in South Africa.
The introduction of anti-retroviral drugs has led to a dramatic decline in mortality of HIV/AIDS related deaths.The transmission of HIV from mother to child could be prevented safely through low cost drugs. Government needs to establish sustainable financing mechanisms to ensure reliable distribution and access of these drugs.
The Western Cape Department of Health expected a dramatic drop in mother to child transmission by the end of this year. It was anticipated that by the end of the year 2004 no child should be born HIV positive in the Western Cape.
Briefing by Dr Shisana, Executive Director, Social Aspects of HIV/AIDS and Health, Human Sciences Research Council (HSRC)
Dr Shisana, discussed Aids in South Africa. She presented three possible interventions
-treatment of sexually transmitted infections to reduce HIV incidence
-use of highly active anti-retroviral therapy
-prevention of mother to child transmission (MTCT) of HIV
Aids was preventable, this is according to her, as has been the case in democratic societies such as North America and Western Europe where the scourge of Aids has been contained.
More than 34 million people are globally infected with HIV/AIDS out of which 67 percent were in developing countries. South Africa has 4.7 million HIV infected people.Half of those people were women while in some places one woman out of three women was HIV/AIDS positive.
In 1999, 1.3 million children were infected with HIV/AIDS out of which about 90 percent were through mother-to-child transmission (MTCT). In the same year, more than 2 million Africans died of AIDS.
Dr Shisana said out of 10.7 million people infected with HIV in the SADC region half of them were South Africans which makes South Africa the leading country with the number of people infected with HIV in the region.
Armed with this kind of evidence, Dr Shisana asked what could government do? Delay implementation or go for intervention?
There are many areas were government could intervene. Government could train health workers to be more empathetic towards patients, which was part of service delivery. The government could also step up the testing of HIV/AIDS in women who are "especially vulnerable to the HIV/AIDS epidemic".
Sexually Transmitted Infections
Most women depended on men for their livelihood, she told the committee, which gives them no choice to tell men to use a condom, or not because of their status in the community.The other area of intervention could be to increase the health budget to better combat the disease. She went into details about the causes of this disease saying that sores in genital organs were the main culprits. She stated that having sexual intercourse involves blood and a sore from a person infected makes the transmission more easier.
Dr Shisana said with the introduction of the antiretroviral (ARV) drug in the United States in 1996, there was a dramatic decline in mortality or HIV/AIDS related deaths. This was the same case in Canada and Western Europe were new Aids cases were declining.
However, she pointed out that the cost factor played an important role here in the sense that in the US there was a marked decline in AIDS related deaths among white men while amongst black women, "who come from low income groups", the trend of decline was more slower. So too among black men who were ‘poor and marginalized’.
Highly Active Anti-Retroviral Therapy (HAART)
Dr Shisana said drug companies in the United States were among the leading Fortune 500 Companies in profit making whose profit increased between 1998-1999 by $4.8 billion, exceeding the profits of companies like the automotive industry, oil companies, security firms and airlines.
These drugs become too costly for developing countries to access these drugs. For instance, she mentioned the high cost of infrastructure of these drugs cost between $20-$187 per unit which is out of reach for Aids patients in developing countries.
Dr Shisana stated there was hope though for developing countries. Before leaving office former US President Bill Clinton’s Executive Order that encourages Sub-Saharan countries to use the options in the TRIPS agreement to use private licences to gain access to drugs for the treatment of HIV/AIDS. The Bush Administration has been pressurized by activists to keep that Executive Order but unfortunately many governments are not using that option except for a few.
Brazil and Thailand have learnt the technology to produce drugs for HIV/AIDS. Recently Brazil has decided to produce the drugs in Brazil by using their own patent legislation. Dr Shisana said it would be a good idea for South Africa to emulate their counterparts in Brazil.
Government needs to negotiate cheaper prices for diagnostic kits and reagents. Sustainable financing mechanisms have to be established to ensure reliable distribution and access to drugs.
Prevention of Mother to Child transmission (MTCT)
The transmission of HIV from mother to child can be prevented safely through the use of low cost AZT. A study conducted by the Paediatric AIDS Clinical Trial Group shows that the risk of transmission has been reduced by 67.5 percent when zidovudine is given antepartum and intrapartum. However, this remedy is complex and expensive for developing countries to adopt. It was more appropriate for developed countries where women can afford not to breast feed.
Implementing interventions meanwhile for developing countries requires family planning (such as the use of condoms to prevent pregnancies, STDs, and HIV, early access to quality anti-natal clinical treatment, trained health workers, counseling, HIV/AIDS testing, and ARV for those mothers who are HIV positive.
Many developing countries claim that their Ministries of Finance cannot provide them with adequate budget to provide these services. Governments need to prioritize the services they provide to people in order to improve the quality of life.
Many health workers were overworked, had low moral and some were ill due to HIV/AIDS related illnesses. They needed training in order to "provide further prevention transmission."
There was need for government to prioritize intervention by subsiding infants and HIV positive mothers. There was a possibility of drinking contaminated water, which threatens the survival of children. South Africa may want a solution of producing ready-made instant formula which women may be able to use.
Ms C September (ANC) asked if the World Health Organisation (WHO) approached the WTO about TRIPS. As the HIV/AIDS issue was highly politicized in this country, how was it being handled in other countries?
Dr Shisana replied that she left the WHO a year ago and was not informed of developments there. HIV/AIDS was politicized everywhere in the world. It started in the United States in the early 1980s when the gay community was ostracized because of the virus. She however said the debate on the issue was vital in order to reach a common response.
Ms D Nhlengethwa (ANC) asked if the AZT had any side effects?
Dr Shisana answered that there was no drug that had no side effects and that the AZT had the backing of the WHO.
Rev P Moatshe (ANC) asked if South Africa was classified as a developing country or developed country?
Dr Shisana replied that South Africa was a developing country with few certain areas resembling the first world but overwhelmingly third world in the majority of the areas. As such, it was viewed as a middle-income country or an emerging market.
Ms N Twala (ANC) asked for clarification on the Brazil and US saga over TRIPS.
Dr Shisana said the USA took Brazil to the WTO where it argued that Brazil was violating the WTO rules of patent laws and intellectual property by manufacturing HIV/AIDS products in Brazil. For five years the two countries locked horns over this issue but at the end Brazil won.
Ms P Govender (ANC) asked for clarification on the linear approach to policy making.
Dr Shisana responded that when scientific evidence says that this thing works, policy makers have the right to test it by putting it into implementation. Unfortunately in reality this was not the case. Before that evidence can be tested it goes through long discourses before it is approved or discarded to the detrimental of the patients involved.
Ms Lamani (ANC) inquired what measures were being taken to train health workers?
Dr Shisana replied that it was unfortunate that HIV/AIDS patients were not well treated in hospitals but the worst scenario was from the private sector, which was notorious for not treating sexually transmitted diseases effectively. The Department of Health has been trying to look at the issue of health workers in general and several issues have been raised especially after the post-Durban Aids conference.
She said that issues were related to the fact that not much was being done amongst the gay community to raise the awareness of HIV/AIDS. Secondly, ARV therapy should be started at a small scale and be expanded gradually, and thirdly, social factors that facilitate the spread of HIV/AIDS should be examined.
Some of these social factors are issues like polygamy and the culture of multiple partners. Messages like abstinence, faithfulness and condomising have to be examined to study their effectiveness. Lastly, HIV/AIDS awareness should be recognised in the socialization of young people.
Presentation by Dr F Abdullah: Mother to Child Transmission in the Western Cape
Ms Z Mazwi and Dr N T Naledi accompanied Dr Abdullah the leader of the delegation. The main focus of Dr Abdullah’s presentation was based on Khayelitsha statistics. The population of Khayelitsha was about 325,000 people with 70 percent of the people living in shacks and 40 percent unemployed. The infant mortality rate was between 35-45 per 1 000 life births.
There are no hospitals in Khayelitsha but there are three community health clinics and eight clinics with facilities for child health, TB and STD. About 60 percent of deliveries are done at a community setting.
Mother to Child Tranmission therapy in Khayelitsha started in June 1999. AZT is offered up to 36 weeks while in labour. Formula feed is provided for up to six months.
So far up to 18,788 women have been attended to, a number that Dr Abdullah said was more than the number of women treated in Uganda over the last two years. Out of that number 13,945 (about 74%) accepted the testing and 2,674 (19.2%) were HIV positive. Dr Abdullah said the latter figure was an alarming figure. Of the remaining women, about 11,271 tested negative.
About 791 infants were tested at age nine months and out of that number ninety-four (11.9%) tested positive or "indetermined". He said nine out of ten babies in the Western Cape are born negative.
Expansion of Programme
The Western Cape Provincial Health Department has found that individual counseling was better than group counseling. Rapid tests were better because they give results in ten minutes. AZT was given for 34-36 weeks and was self-administered.
They were now expanding to other areas such as George, Paarl, Worcester, KTC, Guguletu, Langa, Hout Bay and Plettenberg Bay. By June next year they hope to reach 95 percent women and the remaining 5 percent being based in remote areas.
He said every year there were 70 000 pregnancies in the Western Cape alone.
Effects of the MTCT
Dr Abdullah said they expected a dramatic drop in MTCT therapy by the end of next year and that by the end of the year 2004 a child should not be born HIV positive. It was now easier to implement the MTCT therapy because the Department has its own budget. It has community support and the Western Cape is mostly urban with clean water. Breastfeeding is low in the province.
Ms C September (ANC) noted that there was a gross infrastructure inadequacy in Khayelitsha where deliveries are often performed on the floor. Was there a provincial coordinator? What was the implementation programme for the Department?
Ms Mazwi replied that there were deliveries taking place on the floor but the reason for that could be varied. For instance she said deliveries were at times taking place in the car while the patient was on the way to the clinic. She was the provincial coordinator and two other coordinators on site have been appointed. Future appointments would be made in due course. On the implementation programme she said it was not in the hands of the coordinators but lay with the Maternal Obstetric Units (MOU) and baby clinics.
Ms Morule-Maine (ANC) stated that services provided in Khayelitsha were not enough in view of the population there.
Dr Abdullah agreed and said that they were planning to build another clinic at Site C.
Ms Govender (ANC) asked whether they were monitoring other people from other places coming to make deliveries in Khayelitsha.
Ms Mazwi said it was difficult to monitor them because when coming to make deliveries they give residential addresses in Khayelitsha.
Ms Maloney (ANC) asked if there were follow-ups for babies for formula feeding.
Dr Naledi responded that they provided free formula feeding for six months at local authority clinics in the surrounding areas.
The meeting was adjourned.
OPPORTUNITIES AND CHALLENGES IN IMPLEMENTING EVIDENCE-BASED PREVENTION AND CARE PROGRAMMES IN DEVELOPING COUNTRIES
Dr. Olive Shisana, Executive Director, Social Aspects of HIV/AIDS and Health, Human Sciences Research Council
The path from generation of evidence to knowledge utilization in policy formulation is not as straightforward as it may appear. It seldom results from a rational process of conducting a study, analysing the findings, preparing policy options and politicians choosing among the given options and then mandating their departments to implement the chosen option. It may result from a political process that involves negotiation, bargaining and accommodating different interests. The process involves interest groups, often with varying agendas. These partners include politicians, members of the executives, scientists and academicians, NGO’s, activists, donors, private sector and multilateral organizations. For us who are scientists it is vital for us to understand the process of policy formulation so we should know when and how to engage in this process. For parliamentarians it is crucial that you understand what the scientific evidence is, so that you can contribute to policy development and also evaluate policies and legislation.
There is substantial literature on making public policy. Several issues stand out from this literature (SLIDE 1):
Research results with policy implications seldom have an immediate impact on government decisions, but may have a slow and indirect impact on framing the context within which policy debate takes place;
The political system in the country determines the policy making process;
The nature of problems, proposed solutions and politics may determine the policy making process, and
Because there are many players involved in the policy making process, a linear approach to policymaking is unlikely to succeed.
Understanding the complexities in policy making process will assist in examining opportunities and challenges South Africa faces in applying evidence to address HIV/AIDS--a major public health and development problem in our country. In this paper I will start by identifying key evidence to demonstrate that HIV/AIDS can be prevented and care can be provided effectively.
Three examples of effective and safe interventions are presented. These are (a) treatment of sexually transmitted infections to reduce HIV incidence, (b) use of HAART to reduce new AIDS cases and prolong life, and (c) use of zidovudine to prevent transmission of HIV from mother to child. Having presented the evidence we will then examine opportunities and challenges for South Africa to readily embrace these scientific breakthroughs and develop appropriate policies and programmes.
A brief background to the problem will place this presentation within context. HIV/AIDS is now the most serious epidemic facing developing countries, with an estimated 34 million people infected. The majority of these people live in developing countries, particularly Sub-Saharan Africa, where more than 67% of infected people are residing. (SLIDE 2). South Africa is home to 4.7 million HIV positive people.
WHO estimates that 250 000 South Africans died from HIV/AIDS-related illnesses in 2000. The National AIDS Foundation estimates that by 2008 half a million South Africans will be dying of HIV/AIDS-related illnesses. Instead of increasing to approach the levels in developed countries, life expectancy of South Africans is expected to decline. Projections based on the Metropolitan Doyle Model indicate that life expectancy will drop as follows:
No other country besides South Africa has such large numbers of people living with HIV/AIDS. South Africa leads the SADC region in being home to so many people living with the HI virus. The pie chart below supports this observation, and shows that of the 10,7 million people estimated to be living with HIV/AIDS in the SADC region in 2000, nearly half are South Africans. (SADC SLIDE).
Globally, women comprise a sizeable number, with approximately 15,7 million living with HIV/AIDS. In some high prevalence areas one in three pregnant women are infected with HIV. In South Africa, we also have gender differences, where women have higher infection rates than men. This is not a surprise. HIV is more efficiently transmitted from men to women. This is because of the biological make-up of women, which increases their susceptibility.
Globally, about 1.3 million children were infected with HIV in 1999, and 90% of these resulted from transmission of the virus from mother to child (MTCT). HIV/AIDS is reversing key development goals achieved over the last fifty years. Life expectancy and child survival are declining. South Africa is not an exception. In 1999 more than 2 million Africans died from AIDS. With limited resources and impending disaster looming over developing countries, it has become imperative that countries implement evidence-based policies to urgently curb the spread of this epidemic.
Sexually Transmitted Infections as co-Factors in HIV Transmission
There is now ample evidence from both non-randomised and randomised studies based on epidemiological and biological evidence that new HIV infections can be prevented through appropriate management of sexually transmitted infections. A series of studies, involving heterosexuals and men who have sex with men in developed and developing countries, have demonstrated that STI is a significant risk factor in HIV infection. In non-randomised studies the relative risk range from 1.5 to 8.5 (SLIDE 3).
In a randomized intervention study in Mwanzaa Tanzania, the researchers found that improved STI treatment reduced HIV incidence by approximately 38% after adjusting for co-factors (Lancet REFERENCEE USE TRANSPERANCY). However the results from the Rakai randomised controlled study did not show any impact of HIV incidence. The differences in the two randomised controlled studies include the differences in the prevalence of HIV infection and differences in the treatment approaches (syndromic vs. mass treatment).
Biological evidence is solid. The presence of STI increases HIV infectiousness due to the increased viral load in genital secretions. Secondly, the presence of STI increases susceptibility to HIV due to disruption of epithelial barrier and increased cell receptivity to HIV (in vitro data). Finally genital ulcers and other non-ulcerative STI’s are associated with increased shedding of HIV.
Armed with this evidence, what opportunities exist for governments to implement this strategy? In this case research has influenced policy makers in adopting the policy, the delay is in implementation. Many governments are implementing the intervention but usually on a small scale and even then STI patients are still not well managed. The opportunities for implementing the strategy could be increased if health workers are trained first to adopt empathic attitude towards patients. Secondly they should be trained to use correctly the syndromic management of STI among men and diagnose and treat STI among women. Thirdly, countries should have essential drugs programmes that ensure rational use, timely and adequate distribution of medicines. Unfortunately many developing country health systems are woefully ill-equipped to support neither cost-effective evidence-based nor low cost interventions such as correct management of STI’s. Reallocating resources to strengthen health systems to respond adequately to health problems could change this.
Highly Active Anti-Retroviral Therapy
Sub-Saharan Africa has seen in the last year more than 2 million of its residents dying prematurely from AIDS. With South Africa accounting for 12% of all African infections, this country must have contributed significantly to these deaths. HIV/AIDS was the leading cause of death in this continent. These deaths occur in spite of availability of highly effective anti-retroviral therapy in developed countries. On the other hand, countries in the north have used the evidence from clinical trials to intervene through highly active antiretroviral therapy to significantly (a) reduce new HIV infections, (b) reduce occurrence of opportunistic infections, (c) new AIDS cases and (d) AIDS deaths. (SLIDES 4-11). Evidence exists in Uganda and Cote dÍvoire that AIDS patients in developing country settings can also be managed successfully—i.e., they do take their medications regularly and are responding to treatment.’ Yet, this evidence is still not translated into daily medical care practice in Africa, including South Africa. Botswana is well on its way to providing care for its infected population. The most frequent and legitimate reasons developing countries cite are:
The high cost of ARV’s charged by Pharmaceuticals Companies. The latest Report by Public Citizen in the United States show that the 10 most profitable drug companies increased their profits by $4.8 billion, or 20 percent, from 1998 to 1999; and show data revealing that the 1999 profits of major drug companies far exceeded the profits of other Fortune 500 industries such as auto, oil, securities and airlines. (SLIDE 12)
The high cost of infrastructure necessary to use these drugs (including cost for testing and monitoring CD4 cell counts, viral load, to monitor adherence to treatment regimen, training, development and implementation of treatment guidelines. (SLIDE 13).
Voluntary Counselling and Testing not routinely available in most facilities
Poor health systems’ capacity to cope with the epidemics of HIV and AIDS.
It would not be useful to focus on challenges without examining opportunities for intervention.
Given that the cost of drugs are unaffordable, it is necessary for developing country governments to use the provisions in the TRIPS agreement and remove some of these obstacles. This would allow more than 20% of the populations of the heavily affected countries to be saved in time. The governments of these countries have an opportunity to (SLIDE 14):
Implement President Clinton’s Executive Order that encourages Sub-Saharan countries to use the options in the TRIPS agreement to import or use compulsory licensing to gain access to drugs for HIV/AIDS-related illnesses.
Import ARV’s and other drugs from countries like Brazil and Thailand without being sanctioned, given that many poor governments in developing countries do not have to comply with the TRIPS agreement until year 2006 (unfortunately some are rushing to comply with the restrictive trade policies that deprive them cheaper drugs)
Work with countries such as Brazil and Thailand to learn the technology to produce these drugs..
Negotiate cheaper prices for diagnostic kits and reagents (or even bulk purchase for regions).
Establish sustainable financing mechanisms to ensure reliable distribution and access to drugs.
Begin providing these locally produced or imported ARV’s in all tertiary facilities, which by definition have the necessary infrastructure
Scientific evidence on the effectiveness of triple therapy, the price of drugs and the growing grassroots and advocacy movements to gain access to drugs have framed the context within which the debate on access to ARVs is taking place. This will eventually influence the policies that developing country governments will take. Moreover, the type of political system, the ensuing politics in each country and the closeness to elections determine the policies taken on ARVs.
Prevention of Mother to Child Transmission of HIV
We now know that transmission of HIV type 1 from mother to child can be prevented safely through the use of long course zidovudine. This evidence emanates from a study based on the most rigorous scientific method, i.e., randomised, double blind, placebo-control clinical trial conducted by the Paediatric AIDS Clinical Trials Group Protocol 076. This study demonstrated conclusively that the risk of transmission of HIV could be reduced to 67.5% when zidovudine is given antepartum and intrapartum. However, this regimen is complex and expensive for developing countries to adopt. It is most appropriate for developed countries where women can afford not to breast-feed and the health system is adequately equipped to routinely administer this intervention.
Since this landmark study there have been several randomised controlled studies, which have demonstrated conclusively that short course zidovudine is both effective and safe in preventing transmission of HIV type 1 from mother to child. These studies include the the Bangkok Collaborative Perinatal HIV Transmission Study Group, and DITRAME Group in Burkina Faso and Cote dÍvoire. The effectiveness of the regimen range from 50% to 30% depending on whether women do or do not breast-feed their babies and also on when the measurement was taken. The longer women breast-feed, the less effective the antiretroviral regimen.
The question arises. Given this impressive scientific evidence on the effectiveness of zidovudine in preventing HIV transmission from mother to child, why then are developing country governments reluctant to implement this intervention? Well, to implement this intervention, according to WHO draft guidelines for Mother to Child Transmission Programme, requires: (SLIDE 15)
expansion and strengthening of family planning and STI/HIV information and services, especially approaches providing dual protection;
early access to quality antenatal care from trained health workers;
counselling and HIV testing for women and their partners;
provision of antiretroviral therapy during pregnancy and delivery for HIV positive women;
improved care during labour, delivery and the postpartum period; and
counselling for HIV positive women on infant feeding choices and supporting them in whatever option they chose.
Many governments argue that their health services are under-funded and hence they are unable to provide this package of services, which in any case is vital to the primary health care service provision. The pillars of good primary health care in each country include quality family planning, maternity and child care services. Ministries of Health maintain that the Ministry of Finance has not provided them with adequate budget to provide the service. If possible, they may very well have to prioritise the services they currently provide to determine which ones will improve the quality of life and save more lives given the limited resources available.
The second barrier to introducing MTCT programmes is establishing Voluntary Counselling and Testing (VCT) services throughout the country. For effective VCT it is essential to have counsellors who are trained specifically to deal with HIV/AIDS, addressing issues of stigma., social isolation, partner counselling, prevention of further transmission, etc. Many health workers are currently overworked, have low morale, and some are ill due to HIV/AIDS related illness. Developed countries are also aggressively recruiting health workers from developing countries, thus further increasing staff shortages in the public sector. To ensure the adequate provision of VCT services requires infusion of new staff to do counselling; training of existing staff to ensure testing is done properly and encouraging many women to agree to undergo VCT services. The cooperation of staff and patients is vital to policy adoption and implementation.
With regard to formula feeding, this policy is frequently not implemented as the cost is high. There is a need for government to prioritise this intervention by subsidising infant formula feeding for HIV positive women who choose not to breast-feed. Further, for those who use replacement feeding, the possibilities of using contaminated water threaten the survival of children. The solution may be ready to feed infant formula. This is an option that developing country governments may wish to adopt. The state may produce or contract with the generic manufacturers or other parties to produce ready -made generic infant formula. The role of NGO’s opposed to this strategy cannot be ignored. There are those who would argue that exclusive breast-feeding is the solution, in spite of the observation that in many developing countries with high HIV prevalence mothers may be undernourished and therefore feed infants at the expense of their health.
The model of social policy making focusing on legitimacy, feasibility and support that Hall and his colleagues outlined is applicable in understanding why governments may or may not intervene even if there is evidence to show benefit. While policy makers may consider HIV/AIDS a legitimate issue to address given strong public support, they may find that it is not feasible to implement evidence-based interventions because of unavailability of skilled persons throughout the whole country, inadequacy of health services and insufficient budget. All of this point to the importance of negotiation skills in pioneering policy development; skills Ministries of Health need to effectively engage labour, NGO’s, donors, Ministries of Finance and Trade, etc. If all fails, Ministries of Health may need to refocus their attention, not so much on the barriers, but on how to remove the barriers and implement programmes for the benefit of the population.
From the information presented it is clear that the path from evidence generation to use in policy making is complex. There are many opportunities for intervening, however there are many obstacles that need to be cleared first. The barriers are not impossible as developing country governments have the muscle they have not sufficiently or speedily flexed. In the case of sexually transmitted infections, training staff to provide quality and acceptable service, coupled with ensuring timely distribution of drugs is crucial.
With respect to HAART, the situation is a lot more complex. Evidence is overwhelming to show the benefits of triple therapy in improving the quality of life of HIV infected persons and prolonging life. However, the barriers related to cost of drugs and infrastructure are high. There are solutions that developing countries can use to remove these barriers; these were outlined in this paper. Technical support to countries needs to be increased to enable these developing country governments to overcome the obstacles.
Finally, with respect to prevention of mother to child transmission of HIV, it is possible to implement the evidence-based policies. The current pilot studies going on in developing countries are being increased in numbers in some countries. However, as with all large-scale policy introductions, a phased approach seems to be a realistic approach to implementation.
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