South African
Health Care
A System in
Transition
Since the overthrow of Apartheid in 1994, the health care system in South Africa has been under an ongoing revolution to erase inequities in service and access, and to fund a higher level of health care. Their approach is to decentralize the health care system into a District Health System, and to assure that a standard Primary Health Care package is available to all. This system in transition has made commendable achievements, but there are still plenty of improvements to be made before South Africa attains the system it has envisioned. The most formidable adversary to their health care reform is the HIV/AIDS epidemic. The successes and shortcomings of this middle-income developing country’s approach to improving health care provide valuable lessons to other countries that face similar challenges to improving their health care systems.
South Africa, a middle income
nation with a GDP per capita of USD$7,555, and a population of 43,791,000, is a
nation in transition.[i] After four decades of minority apartheid
rule, a democratic government was established in 1994.[ii] This radical change in identity has called
for a great deal of policy adjustment.
This change, coupled with the emergence of the HIV/AIDS epidemic has
cornered South Africa into a national crisis; a crisis that is centered on
health care. The keystone of any
government is tending to the well being of its people. The well being of South Africans is
teetering on the edge, and the people are depending on the government to
respond by putting the majority of its efforts into improving national health.
Currently, the total health
expenditure per capita in South Africa is USD$530.00, and the total health
expenditure as a percentage of the GDP is 8.8%. These expenditures stand beside marginal quality health
indicators such as the life expectancy at birth of 47.7 years for men, and 50.3
years for women. Child mortality rates
are 103 deaths per 1000 births for males, and 90 deaths per 1000 births for
females.[iii] Unfortunately, these figures are worsening
in a landslide caused by HIV/AIDS. But
the government’s formidable approach to reforming health care, by starting anew
with a vision of health care equity, is on the right track.
South Africa’s vision for health
care is a decentralized system that offers an equally accessible and free basic
package of primary health care to all of its citizens.[iv] These goals are presented in the National
Health Bill of 2001, which establishes the structure for the implementation of
a national health care system based on Primary Health Care (PHC), and operated
by District Health Systems (DHS). For a
description of the government-funded services covered by the Primary Health
Care package in South Africa, visit this website
(http://www.doh.gov.za/docs/reports-f.html).
The national Department of Health, headed by Minister Mantombazana Edmie
Tshabalala-Msimang, oversees the system of nine provincial health
departments. Municipal boundaries for
local governments were demarcated in 2000.
Each provincial health department has its own ministers and leaders. However, the youth of this decentralized
system is resulting in predictable management issues.
The impetus behind creating a
decentralized health care delivery system was that provincial governments would
have the ability to customize the health systems to their unique cultural
groups, while the national department of health would balance out inequities to
assure that all districts conform to the national health policy. In such a culturally diverse nation, the
state would be mistaken to mandate a one-size-fits-all national health care
policy. Meanwhile, the districts are
presumably small enough, and carry enough social solidarity that the District
Health Systems are centralized into one department. Eric Buch of the School of Public Health of the University of
Pretoria praises the model of decentralization:
“Establishment
of a District Health System with provinces and local authorities starting to
pool their resources and integrate care, [offers] a more comprehensive service
under one roof. This not only improves
economies of scale and efficiency, but means that parents do not have to go to
two or more venues and face duplicate queues and examinations to get care for
themselves and their families.”[v]
He also explains that in order to
meet the goals for elevating clinics to fully functional levels, all clinics
must have infrastructural services, such as electricity, refrigeration, potable
water, sanitation, and roads by 2004.[vi] Not only are clinics to be improved, but
more clinics are to be built. The goal
is to provide equal accessibility to health care for all South Africans. This primary objective of the South African
health care system is to ensure that all South Sfrican citizens are able to
realize their fundamental rights to health care as enshrined in Section 27 of
the Constitution. However, Dr. David McCoy, the Director of Research at the
Health Systems Trust in South Africa, explains why the South African system is
not yet a “universal” health care system:
“In order
to define the nature of people’s rights to health care, the national DoH has
defined ‘package of Primary Health Care’ that is expected to be available
through the public sector. It lists the scope of services to be provided in
clinics and district hospitals. In addition, we have a variety of clinical
policies that define national policy on standards of treatment and care in the
country. For example, we have official national HIV treatment guidelines. However, while everyone essentially has
unimpeded access to PHC, in practice, many people have physical and financial
barriers to getting to health facilities, and when they do attend a health
facility, there is a significant gap between what is set out in the policies
with what is actually being delivered.”[vii]
The definition of “universal”
health care that is generally subscribed to is a system in which the government
covers the costs and administration of the entire health sector, such as in the
Canadian Health Care system. But this
kind of system is highly unlikely to be instituted in South Africa. The obstacles are that the health system is
already saturated with issues demanding attention, there is an entrenched
private health sector, HIV/AIDS is churning up any continuity in health system
development, it is not an upper wealth nation, and there is not enough social
solidarity.
Dr. McCoy explains the funding
mechanisms of the South African health system:
“We don’t
have a dedicated health insurance system. The public sector is mainly funded
from the general tax base and to a much lesser degree from user fees. There are proposals for social health
insurance for the poor but employed, [leaving the poor and unemployed
unattended], which may segment the health care system between the unemployed
and the employed, as happens in South America.
While this offers opportunities for more people to access the private
sector, it could entrench a weak health care system for the poor who are
excluded from social health insurance.
Outside of the public sector, is a large private health care sector
which outstrips public health expenditure.”[viii]
In the private sector, prepaid
health plans accounted for 76.6% of the private expenditure on health in 2000.[ix] Medical Schemes are the dominant third-party
intermediary with 73% of the private expenditure.[x] And out-of-pocket expenditure on health as a
percentage of the total expenditure on health in 2000 was 12.6%.[xi] Antoinette Ntuli of the Health Systems Trust
proclaims: “The greatest health sector inequity continues to be the imbalance
of resources available to the public and private sectors.”[xii] Such inequities are inherent in a young
system that is developing rapidly on a macro scale. Eric Buch explains the development pattern in South Africa:
“In other
middle income countries the issues are more around constant improvement off the
baseline. In South Africa they are
around providing services for all that were previously available to a few.”[xiii]
This approach has been necessary
given South Africa’s impending health crisis, yet it has left much room for
improvement. The mission statement of
the Department of Health’s “1999-2004 Health Sector Strategic Framework” is:
“While the
first five years focussed on increasing access to health care, especially for
those who did not have access, … the next five years will focus on accelerating
quality health service delivery.”[xiv]
This optimistic outlook passes
over the need to improve on areas missed in the initial surge of health sector
reform. It inappropriately implies that
an end has been reached for achieving equal access to health care. Let us now look at the issues that have
challenged health sector reform, address suggested improvements, and present
the direction in which South Africa is moving toward achieving its envisioned
socialized health care system.
If the vitality of the health care
services were related to water supply, then the health care system would be the
dam, and the reservoir would be the resources that power the system. In South Africa, the reservoir is running
dry. There is inadequate funding, poor
access to information, a outward migration of medical professionals, and
insufficient leadership to sustain the system.
The most basic resource that the
health care system relies on is funding.
In light of the HIV/AIDS crisis, it is promising that the government
spends 11.2% of its budget on public health.[xv] However, this will need to increase. In the medical sector, it appears that even
if all efficiency measures are achieved, current public sector funding will not
satisfy the costs of providing the care desired.[xvi] Eric Buch suggests:
“There are
two places that significant additional funds could come from. The first is a budget that grows
significantly in real terms, and the second through raising more funds from
users.”[xvii]
These are not dynamic
solutions. But perhaps what is most
needed is more resources from the conduits built into the system. However, the funding mechanisms built into
the system are also problematic.
Antoinette Ntuli outlines the funding paradox:
“Current
mechanisms for funding local government health services are problematic. From the provincial perspective they do not
allow for adequate monitoring, while local governments are concerned about the
cash flow problems resulting from payments that are paid quarterly in arrears.”[xviii]
In parallel, the private sector is
also experiencing funding problems.
Eric Buch reports:
“The
private sector model of guaranteed fee-for-service payment to providers through
for-profit medical administration companies, together with other factors, kept
private health inflation well above that prevailing in the economy.”[xix]
The above passage may imply that
excessive expenditures are the results of overproviding by health care
professionals, however Buch clarifies that this is not the primary cause of
expense:
“Excessive expenditure on
health care is not only driven by the lack of constraints on members due to
third party payer insurance, but more importantly due to an asymmetry of
information between provider and patient on what interventions are required and
suitable.”[xx]
Effective information
dissemination is crucial to operating an efficient health care system. In South Africa, information is in short
supply. Ninety-seven percent of
provincial expenditures on health information goes to hospitals, with the
districts getting only three percent.[xxi] In order for inequities of access to be
neutralized, this ratio must be reduced so that rural clinics are given, and
return enough information to enable them to deliver care of acceptable quality. When asked if South Africa is doing a good
job of information dissemination, Dr. David McCoy responded:
“I guess
it’s all relative. The Department of Health does take the need to disseminate
information seriously. The Health Systems Trust is one of the main sources of
information [in South Africa] to health care workers, and they are partially
funded by the DoH. ”[xxii]
The other side of information
dissemination is information gathering.
Dr. McCoy elaborates on this theme:
“Research
is very important, but it can also be very distracting. What is important is relevant research and
research that targets policy makers and managers as the consumers (not academic
journal editors). South Africa also
needs to invest time in face-to-face communication of research findings, and
not rely on passive paper-based dissemination.
The bureaucracy is reasonably receptive to constructive criticism, but
this culture needs to be carefully nurtured and protected.”[xxiii]
One way any government bureaucracy
can be culturally sensitive and open to civil input is to empower
nongovernmental organizations (NGO’s) to perform some of the work on the
ground. Eric Buch makes a case for NGO
support in this passage:
“It is
generally agreed that NGO’s working in, and with, communities and those
focussing on a health problem e.g. cancer, tuberculosis, or a disability, have
the ability to achieve results and mobilize energy and volunteerism in a manner
that is difficult for formal health services to match. This energy seems to be dissipating in our
society, with people waiting for government to do things for them. The Health Department needs to intervene to
create an enabling environment for NGO’s, facilitate the emergence of local
NGO’s and provide seed funding in hitherto unserved areas.”[xxiv]
NGO’s tend to have an ability to
feel the pulse of the people. They also
tend to access areas that would normally be overlooked by government. One of the major challenges to the South
African health care system is bringing health care to rural underserved
populations. These people often forego
health services that would be deemed necessary by health professionals because
they don’t have access to services, or because they lack the funds for
services. There are also many
traditional healers throughout South Africa, who should not be dismissed in the
new health care system, but should be allowed their niche alongside modern
health care services. NGO's are crucial
to mediating sensitive issues like traditional healing, and helping to
facilitate new measures in underserved areas.
Extending service to underserved
areas is one of the most significant challenges to the health care system. Not only must new clinics be built, and
basic utilities and resources provided, but also there need to be health professionals
to work in underserved areas. Doctors
will need to commit to working regularly in clinics. Moreover, supporting health services staff such as nurses and
assistants will need to be enticed into working in underserved areas, and will
require specific training for working in these new environments. This will be a costly and demanding
measure. Eric Buch offers one
suggestion for alleviating the financial burden and pressing demand for sending
health professionals to work in underserved areas:
“Large
numbers of rehabilitation, pharmacy, environmental and other assistant
categories (mid-level health workers), with one to two years of tertiary
education, need to be rapidly but effectively trained and deployed…One
conclusion drawn by the Human Resources planning process is that the current
staffing model, based on professionals alone, is unaffordable, and that
extensive use should be made of mid-level health workers.”[xxv]
This advice, while sensible, may
sound grating to many South African health analysts who are pressing for a more
professional work force. Amid the
rapid, but necessary changes to the health sector, the health work force is
overburdened by changing values in the jobs, and unreasonable work loads.[xxvi] Dr. Graham Bresick comments:
“Urgent
attention needs to be paid to the low morale, disillusionment, and high levels
of stress and burnout among health service staff. We can’t hope to build a reformed and improved health sector on a
spent work force.”[xxvii]
Difficult working conditions, few
incentives, and low morale are causing health professionals to leave their jobs
or seek work in other countries. South
Africa has an enormous problem with the colloquially termed phenomenon of
“Brain-Drain.” Many health care
professionals, who have received their training in South Africa, emigrate to
countries with more inviting health care systems. South African Department of Health Minister Manto
Tshabalala-Msimang states in her speech, “Health Department’s Multi-Pronged
Health Staffing Strategy”:
“We
believe that if there is a major – and insidious – threat to our overall health
effort, it is the continued outward migration of key health professionals,
particularly professional nurses, with a consequent de-skilling of the
professional base in both the public and private sector.”[xxviii]
Antoinette Ntuli illustrates the
magnitude of this threat with the following statistics:
“In 2001
there were 19.8 medical practitioners per 100,000 population as compared with
21.9 in 2000. For professional nurses
the ratio reduced from 120.3 in 2000 to 111.9 in 2001.”[xxix]
The Department of Health has taken
a few measures to combat this readily apparent threat. It developed a Code of Conduct for other
Commonwealth Nations in their recruitment of South African professionals. It created a new “Community Service” program to encourage professionals to work in
underserved areas. And it sent 254
students to Cuba to train to become physicians. These students have committed to return to South Africa to offer
four years of service to underserved areas.[xxx]
Dr. David McCoy comments on these
incentive programs:
“This is a
major priority of the health system and we have been talking about incentive
schemes for the last six years. There
has been a recent resurgence of interest in policy-making circles, but we await
some positive outcomes. The only
program that has been put in place is a compulsory community service program
for medical graduates of one year, and a program to place Cuban doctors in
rural areas. Both initiatives have been partially successful, but are
insufficient to address the “brain drain” and the inadequate levels of staffing
in the rural areas.”[xxxi]
It is not only the doctors and
nurses who are strained by the needs of the health care systems; it is also the
administrators. In the early stages of
the new decentralized health care system, leadership was given to those who may
not have had proper training, avenues of decision making were unclear, and the
responsibilities of the leaders were too burdensome. Antoinette Ntuli elaborates on these problems:
“Worryingly,
many health services managers have a low sense of personal accomplishment. Huge demands, difficulties in prioritizing,
inadequate management skills, lack of rewards for competence or sanctions for
incompetence, and hierarchies that are too rigid all impact upon their ability
to deliver quality health care. Other
difficulties include inappropriate organograms, lack of financial delegation,
unsatisfactory communication between provinces and districts and inconclusive
appointments of staff, (especially to strategic positions) many of whom are in
acting positions.”[xxxii]
Dr. David McCoy echoes her
concerns:
“There are
inadequate management skills amongst managers and policy makers who set the
operational priorities for transforming the health care system in a rational
sequence of steps. One cannot put the
roof on before building the walls. This
is technical work.”[xxxiii]
Building a national health system
is not easy, and South Africa has only had eight years in which to do it. The nation has certainly made a commendable
effort at health care reform. The
problems that arose are all problems that can be solved, and were virtually
inherent in developing a new health care system. South Africa provides an example of a nation doing fairly well in
transforming their health care system under pressure.
However, that pressure is immense
and must be confronted. When asked if
South Africa was doing a good job with its health care reform, David McCoy gave
this response:
“Is the glass half empty or
half full? Relative to many developing
countries we are doing okay. Given the
history of the country and the relative inexperience of the government, we are
also doing okay. However, relative to our health needs and the emergency that
is AIDS, we are doing poorly. AIDS threatens
to wipe out all gains made since 1994.
We have to run fast to keep still.”[xxxiv]
“South Africa has more HIV
positive people than any other country in the world.”[xxxv] Two years ago the South African government
reported that 4.7 million, which is one in nine, South Africans was HIV
positive. Today that number is expected
to be far higher. The South African
government is starting to acknowledge its massive HIV/AIDS crisis. “This year the government almost tripled its
anti-AIDS budget to USD$108 million, and plans to up to $194 million in the
next financial year.”[xxxvi] “Tony Leon, leader of the main opposition
Democratic Alliance said, ‘South Africa’s fight against AIDS has been massively
hampered and harmed by government’s dithering, denial and dissent from the
orthodoxies associated with the disease.”
He also pointed out that women’s life expectancy will fall from 54 to 38
in the next decade, and more than 2 million children will be orphaned by AIDS
in this time.[xxxvii]
Not only are children being
orphaned, but also:
“Each
year, more than 600,000 infants [worldwide] become infected with HIV, mainly
through mother-to-child transmission.
WHO and the UNAIDS Secretariat recommend that the prevention of
mother-to-child transmission of HIV, including antiretroviral regimens such as
nevirapine, should be included in the minimum standard package of care for
HIV-positive women and their children.”[xxxviii]
The article by WHO and UNAIDS also
explains: “The simplest regimen [of PMTCT drug therapy] requires a single dose
of nevirapine to the mother at delivery and a single dose to the newborn within
72 hours of birth.”[xxxix]
Yet despite the World Health
Organization and UNAIDS endorsements of nevirapine therapy, the South African
government was reluctant to distribute the drug to health providers. Instead the Department of Health set up an
eighteen-site test of the effectiveness and risks of Intrapartum Nevirapine
treatment, because as Minister Manto Tshabalala-Msimang explained:
“The
public sector cannot afford to provide the drugs, while nevirapine did not
guarantee the virus could not be passed from mother to child.”[xl]
This is a clear example of the
Department of Health’s reluctance to give HIV/AIDS the attention it has
warranted. It is this kind of
negligence that prompted Dr. Peter Berman of the Harvard School of Public
Health to say; “South Africa could be an example of what to avoid in AIDS
policy.”[xli]
Dr. David McCoy issued the
following statement on what other countries can learn from South Africa’s HIV/AIDS
policy:
“Political
leadership is critical [to an effective HIV/AIDS policy]. Openness is critical, as is making the
problem a national priority at the early stages of the epidemic.
Ensuring
that the basic primary health care infrastructure is capable of providing
correct treatment of sexually transmitted infections (STI’s), condoms, family
planning, and TB control…in other words, getting the basics in place. This then provides a foundation for the
implementation of more complex treatment programs.
Human
resource training is critical – especially of community lay workers who can act
as agents of community mobilization.
Prevention intervention is not just a health care system responsibility,
but needs to be planned and implemented from a broad base of government and
non-governmental institutions.
Understanding
local culture and beliefs is very important.
Social science research must be employed from the beginning to inform
prevention interventions in particular.
The western model of individual-based counseling is inappropriate and
has been a millstone around our neck.”[xlii]
These words of advice are poignant
especially to countries that are now just starting to be infiltrated by
HIV/AIDS. India, China and other
countries in Asia, where the virus is spreading most rapidly should learn from
South Africa’s shortcomings in HIV/AIDS policy.
The South African health care
system has many implications for developing countries. The model of social equity in health care
that South Africa envisions is appropriate to the needs of its people, and can
be achieved given the nation’s wealth, infrastructure, and relative social
solidarity. Decentralization beneath a
governing body seems to be the most effective design in a socialized health
care system. Public provision of
primary health care services without interfering with privatized secondary and
tertiary health care services achieves a balance of government control while
allowing for the private market to drive progress. South Africa’s approach to reform was on the macro scale. This may not be possible for more diverse
and impoverished nations, and as seen here, can leave holes, which require
repairing. Perhaps a more thorough
approach to health care reform would be to start small in a pilot program
format, and through the work of both government and non-governmental
organizations, build up to a national system while attending to the
complications that arrive along the way.
Most significantly, developing countries should learn from South Africa’s
HIV/AIDS policy. As South Africa is
learning, while it is important to develop a strong national health care
system, the effort may be futile if the country doesn’t also address the
HIV/AIDS pandemic.
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[i] “WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
[ii] McIntyre, D. and Gilson, L. “Putting Equity in Health Back onto the Social Policy
Agenda: Experience from South
Africa.” Soc Sci Med 2002 Jun; 54(11):
1637-56.
[iii] “WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
[iv] Sait, Lynette. “Health Legislation: South African Health Review 2001.” http://www.hst.org.za/sahr/2001/chapter1.htm
[v] Buch, Eric. “SAHR 2000: The Health Sector Strategic Framework: A Review.” The Health Systems Trust. http://www.healthlink.org.za/sahr/2000/chapter2.htm.
[vi] Buch, Eric. “SAHR 2000: The Health Sector Strategic Framework: A Review.” The Health Systems Trust. http://www.healthlink.org.za/sahr/2000/chapter2.htm.
[vii] McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly – Nov. 25, 2002.”
[viii] Dr. David McCoy. Director of Research for the Health Systems Trust. “Email to Greg Connolly – Nov. 29, 2002.”
[ix] “WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
[x] Goudge, Jane, et Al. “Private Sector Funding: South African Health Review 2001.” http://www.hst.org.za/sahr/2001/chapter4.htm
[xi] “WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
[xii] Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report 2001.” http://www.hst.org.za/sahr/2001/preface.htm
[xiii] Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
[xiv] Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
[xv] “WHO Country Profile: South Africa.” http://www.who.int/country/zaf/en
[xvi] Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
[xvii] Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
[xviii] Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report 2001.” http://www.hst.org.za/sahr/2001/preface.htm
[xix] Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
[xx] Buch, Eric. “SAHR 2000: The Health Sector Strategic Framework: A Review.” The Health Systems Trust. http://www.healthlink.org.za/sahr/2000/chapter2.htm.
[xxi] Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report 2001.” http://www.hst.org.za/sahr/2001/preface.htm
[xxii] McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly – Nov. 29, 2002.”
[xxiii] McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly – Nov. 29, 2002.”
[xxiv] Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
[xxv] Buch, Eric. “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.” Http://www.healthlink.org.za/sahr/2000/chapter2.htm
[xxvi] Bresick, Graham. “Email to Greg Connolly – Dec. 13, 2002.”
[xxvii] Bresick, Graham. “Email to Greg Connolly – Dec. 13, 2002”
[xxviii] Minister Manto Tshabalala-Msimang. “Health Department’s Multi-Pronged Health Staffing Strategy.” http://www.doh.gov.za/docs/pr/2002/pr1023.html
[xxix] Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report 2001.” http://www.hst.org.za/sahr/2001/preface.htm
[xxx] Minister Manto Tshabalala-Msimang. “Health Department’s Multi-Pronged Health Staffing Strategy.” http://www.doh.gov.za/docs/pr/2002/pr1023.html
[xxxi] McCoy, Dr. David.
Director of Research at the Health Systems Trust. “Email to Greg Connolly – Nov. 25, 2002.”
[xxxii] Ntuli, Antoinette. “Listening to Voices: Preface to the South African Health Report 2001.” http://www.hst.org.za/sahr/2001/preface.htm
[xxxiii] McCoy, Dr. David. Director of Research at the Health Systems Trust. “Email to Greg Connolly – Nov. 29, 2002.”
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[xxxviii] “WHO and UNAIDS continue to support use of nevirapine for prevention of mother-to-child HIV transmission.” http://www.who.int/mediacentre/statements/unaids/en/print.html
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