Liver diseases account for 1 in 25 deaths worldwide. Owing to the asymptomatic nature across the dynamic spectrum of steatotic liver disease (SLD) and the absence of targeted screening programmes, individuals at risk of progression to cirrhosis or hepatocellular carcinoma (HCC) are unlikely to pursue liver disease testing. Historically, hepatitis B and C were the leading causes of liver injury that can progress to cirrhosis or HCC. Global efforts to implement screening and vaccination programmes, expand testing and treatment, and encourage active viral hepatitis case finding followed the widespread availability of curative treatment for hepatitis C and effective suppressive therapy and vaccines for hepatitis B, further supported by changes in law, regulation and public policy. With encouraging declines in new viral hepatitis infections in many countries, greater attention should turn to SLD, now the leading global indicator for cirrhosis and HCC. Screening and active case finding for SLD lag far behind its increasing prevalence, leaving most people undiagnosed. This Expert Recommendation draws on lessons learned from legal, regulatory and policy changes required to combat the viral hepatitis public health threat. Our recommendations can contribute to a concerted shift in legal frameworks and policies to enhance screening programmes, increase testing and improve health outcomes.
Long-term survivors (LTS) of HIV, including individuals diagnosed before the availability of effective antiretroviral therapy (ART), have played a pivotal role in shaping the HIV response. Despite an increase in their number in the United States, their unique medical, social and economic challenges remain underrepresented in HIV policy and research, particularly in the context of HIV cure advancements. While an HIV cure may alleviate ART-related burdens, LTS fear unintended consequences, including the potential loss of critical social benefits, economic support and healthcare access. This study explores the policy priorities of LTS, addressing their current unmet needs and the broader implications of an HIV cure. We conducted qualitative interviews with 32 LTS across diverse racial, gender and geographic backgrounds, recruited through community-based organizations and research networks from 2023 to 2024. Using inductive thematic analysis, we identified key policy concerns and recommendations based on participants' lived experiences. Data collection continued until thematic saturation was reached. LTS emphasized four pressing policy domains: (1) Persistent Healthcare Disparities: Participants reported fragmented Medicare and Medicaid coverage, limited access to essential services (e.g. dental, vision and mental healthcare), and ongoing stigma and discrimination in healthcare settings. (2) Social and Economic Precarity: Housing instability, financial insecurity and employment barriers disproportionately affect LTS, many of whom face systemic barriers to re-entering the workforce. (3) Policy Implications of an HIV Cure: Participants voiced concerns that an HIV cure, while promising, could result in disqualification from disability and social assistance programmes, exacerbating socio-economic vulnerabilities. (4) Structural Reforms for LTS Inclusion: LTS underscored the urgent need for their direct involvement in HIV research, policy development and decision-making to ensure equitable, community-driven solutions. Policymakers must address comprehensive healthcare access, economic stability and social protections for LTS of HIV. HIV cure research must not undermine existing benefits or widen disparities. Ensuring LTS representation in decision-making is critical to developing equitable policies that safeguard their wellbeing before and after a cure.
The HIV and AIDS Act was enacted in India in 2017 to protect the right to privacy, bodily autonomy, and non-discrimination of Persons Living with HIV (PLHIV). Prior to the Act, HIV/AIDS-related jurisprudence in India developed largely through judicial decisions on privacy, health care, queer rights, and marriage. This jurisprudence stigmatised PLHIV and constructed them as threats to society. The Act sought to respond to such characterisations and affirmed several rights of PLHIV that were previously denied. This article uses the reproductive justice framework to analyse the scope and potential of the Act in furthering sexual and reproductive freedoms of PLHIV and their partners. The article argues that despite the various rights and anti-discrimination protections under the Act, the law is insufficient to address the systemic and structural issues affecting PLHIV. The Act is premised on the problematic assumption that PLHIV are 'risky' sexual subjects, which affects the construction of rights and benefits. Furthermore, the Act does not, and arguably cannot, holistically address the problems faced by PLHIV in sexual, marital, and familial relationships. These constraints are a crucial reminder of the larger limitation of law as a blunt policy tool that is unable to comprehensively address complex socio-legal issues.
To improve the diagnosis of undetected infections with the Human Immunodeficiency Virus (HIV), the Hepatitis C Virus (HCV) and syphilis infections among key populations, Section 24 of the Infection Protection Act was amended. Since 1 March 2020, non-medical staff have also been permitted to perform rapid tests. This study aims to examine the impact of the legal change in low-threshold AIDS and drug services as well as in public health offices. In a cross-sectional survey, 274 drug services, 100 member organisations of the German AIDS Service Organisation and 342 public health offices were invited to take part in an online questionnaire. Topics included facility structure, service provision and the acceptance, implementation and effects of the legal change. Data were analysed descriptively; where sample size allowed, results were differentiated by facility type. Of the 716 facilities contacted, 286 participated. After the legal change, 80 (28%) introduced rapid testing by non-medical staff. Facilities with existing testing services were more likely to adopt testing by non-medical staff than those without prior experience (56.8% vs. 13.6%). The average monthly number of HIV, HCV, and syphilis rapid tests increased significantly. The number of reactive test results remained unchanged. The legal change shows positive effects but there is still potential for broader implementation. Existing test infrastructure appears to support uptake. Additional support measures are needed to expand testing by non-medical staff. However, this alone is not sufficient to detect undiagnosed infections. Expansion and promotion of outreach testing services remain essential. HINTERGRUND: Zur besseren Diagnostik bislang unerkannter Infektionen mit dem Humanen Immunschwäche-Virus (HIV), dem Hepatitis-C-Virus (HCV) und mit Syphilis in besonders betroffenen Gruppen wurde § 24 Infektionsschutzgesetz geändert. Seit dem 01.03.2020 darf auch nichtärztliches Personal Schnelltests durchführen. Ziel der Studie ist es, die Auswirkungen dieser Gesetzesänderung in niedrigschwelligen Aids- und Drogenhilfeeinrichtungen sowie im öffentlichen Gesundheitsdienst (ÖGD) zu untersuchen. In einer Querschnittsbefragung wurden 274 Drogenhilfen, 100 Mitgliedsorganisationen der Deutschen Aidshilfe und 342 ÖGD-Einrichtungen zur Teilnahme an einer Online-Befragung eingeladen. Themen waren Einrichtungsstruktur, Leistungsangebot sowie Akzeptanz, Umsetzung und Auswirkungen der Gesetzesänderung. Die Daten wurden deskriptiv ausgewertet, bei ausreichender Fallzahl auch nach Einrichtungstyp differenziert. Von 716 kontaktierten Einrichtungen nahmen 286 teil. 80 (28 %) führten nach der Gesetzesänderung Schnelltests durch nichtärztliches Personal ein. Einrichtungen mit bereits bestehendem Testangebot implementierten dies deutlich häufiger als solche ohne Vorerfahrung (56,8 % vs. 13,6 %). Die durchschnittliche Anzahl monatlich durchgeführter HIV-, HCV- und Syphilis-Tests stieg signifikant an. Die Zahl reaktiver Tests blieb unverändert. Die Gesetzesänderung zeigt positive Effekte, jedoch besteht weiteres Potenzial. Eine vorhandene Testinfrastruktur begünstigt die Umsetzung. Es bedarf zusätzlicher Unterstützung, um Schnelltests flächendeckend zu etablieren. Allein reichen sie jedoch nicht aus – insbesondere aufsuchende Testangebote müssen ausgebaut und gefördert werden.
Countries around the world have committed to universal health coverage (UHC), a global vision that affirms the right for all people to access essential healthcare, when and where they need it and regardless of their ability to pay. UHC, as a political commitment, developed as part of the Sustainable Development Agenda in 2015 and, more recently, at the United Nations High-Level meeting on UHC in 2019. A policy commitment to UHC means translating the broad vision of UHC into nationally appropriate, locally relevant health policies. The aim of this work is to develop an analytical framework for describing the key features of UHC to assess how UHC is conceptualised and translated at the national health policy level. We analysed purposively collected documents on UHC and conducted case studies of relevant health policies in three countries: South Africa, Botswana, and Kenya. We propose a framework that includes five components we consider central to a UHC approach, namely: population coverage, healthcare service provision, health financing, health equity, and leadership and governance. The framework was applied to health policies in three countries in Africa (Botswana, Kenya, and South Africa) to test its relevance and applicability. Analysing policy commitments for UHC is central to understanding how countries are translating the broad aspiration into action. Our framework provides a useful tool by breaking down UHC into five core components and proposes questions to guide how policy commitments can be identified.
This article reports new legal data on state syringe services program (SSP) and drug paraphernalia laws in the United States. Scientific legal mapping methods were used to develop a longitudinal legal dataset capturing state-level SSP and drug paraphernalia laws in effect from January 1, 2010, through June 1, 2024. During that period, the number of states with a legal mechanism allowing for syringe distribution from SSPs nearly doubled. However, legal barriers to SSP operations remain in many states.
Hearing loss affects approximately two thirds of adults in the United States aged 70 years or older and frequently remains untreated despite its well-documented harms, including accelerated cognitive decline, increased caregiver burden, and higher health care expenditures. We examine the major barriers to accessing high-quality hearing care, with particular attention to the complex and fragmented landscape of insurance coverage across Medicare, Medicaid, the US Department of Veterans Affairs, private plans, and over-the-counter (OTC) products. We review key legislative and regulatory developments over the past decade, most notably the 2022 establishment of OTC hearing aids, and summarize early opportunities and remaining gaps. We then propose targeted reforms to improve access and affordability, including more consistent Medicaid benefits, selective Medicare expansion, integration of teleaudiology, and strengthened oversight and consumer protections for OTC devices. Finally, we advance a technology-driven policy framework that integrates artificial intelligence-supported risk prediction, teleaudiology, real-time insurance verification, and a transparent device marketplace to modernize delivery and evaluation. Together, these strategies can catalyze a fundamental rethinking of how hearing health is prioritized and managed within the broader United States health care ecosystem. (Am J Public Health. 2026;116(3):387-396. https://doi.org/10.2105/AJPH.2025.308298).
The price of antiretrovirals (ARVs) continues to be a challenge to guarantee universal, comprehensive, and equitable pharmaceutical services. This article aimed to analyze the acquisition of the most widely used ARV in Brazil, comparing national and international prices. Our study conducted a documentary analysis of the history of the national procurement of dolutegravir (DTG) from 2017 to 2023. The price comparison was based on reports from the Clinton Health Access Initiative (CHAI), considering exchange rate and inflation variations. In 2022, generic versions from Farmanguinhos and Lafepe were distributed, but a patent barrier restricted the procurement from Lafepe. A major difference was found between national and international prices, even with the entry of generics into the Brazilian market; in 2023, the price of international generics was almost 12 times lower than that of the national procurement. The DTG case highlights the importance of monitoring prices, patent barriers, and local production, and of becoming familiar with the structure of production costs in order to negotiate fair prices and ensure the sustainability of the national pharmaceutical assistance policy. O preço dos antirretrovirais (ARV) continua sendo um desafio para a garantia da assistência farmacêutica universal, integral e igualitária. O artigo teve como objetivo analisar a aquisição do ARV mais utilizado atualmente no Brasil, comparando preços nacionais e internacionais. Foi realizada análise documental do histórico de aquisição nacional do dolutegravir (DTG) entre 2017 e 2023. A comparação de preços baseou-se em relatórios da Clinton Health Access Initiative (CHAI), considerando variações cambiais e da inflação. Em 2022, versões genéricas de Farmanguinhos e Lafepe foram distribuídas, mas uma barreira patentária restringiu a aquisição junto ao Lafepe. Houve grande diferença entre preços nacionais e internacionais, mesmo com a entrada de genéricos no mercado brasileiro: em 2023, o preço de genéricos internacionais foi quase 12 vezes menor que o de aquisição nacional. O caso do DTG evidencia a importância do monitoramento dos preços, das barreiras patentárias, da produção local e do conhecimento da estrutura dos custos de produção para a negociação de preços justos e garantia da sustentabilidade da política nacional de assistência farmacêutica. El precio de los antirretrovirales (ARV) sigue siendo un obstáculo significativo para asegurar la asistencia farmacéutica universal, integral y equitativa. Este artículo se propuso analizar la adquisición del ARV más utilizado actualmente en Brasil, comparando sus precios a nivel nacional e internacional. Se llevó a cabo un análisis documental del historial de adquisición nacional de dolutegravir (DTG) entre 2017 y 2023. La comparación de precios se basó en informes de la Clinton Health Access Initiative (CHAI), tomando en cuenta las fluctuaciones cambiarias y la inflación. En 2022, se distribuyeron versiones genéricas de Farmanguinhos y Lafepe; sin embargo, una barrera de patente limitó la adquisición a través de Lafepe. Se observó una disparidad considerable entre los precios nacionales e internacionales, incluso con la introducción de genéricos en el mercado brasileño: en 2023, el precio de adquisición de los genéricos internacionales fue casi 12 veces inferior al de la adquisición nacional. El caso del DTG pone de manifiesto la relevancia de monitorear los precios, las barreras de patentes, la producción local y el conocimiento de la estructura de costos de producción. Estos elementos son cruciales para negociar precios justos y garantizar la sostenibilidad de la política nacional de asistencia farmacéutica.
HIV criminalisation is a global phenomenon undermining both public health and human rights. Although scientific advances have transformed HIV into a manageable condition, legal systems have not kept pace. This paper traces the evolution of community-led responses to HIV criminalisation over nearly two decades, demonstrating how science, advocacy, and storytelling have collectively reshaped legal and policy frameworks. It describes the formation and strategic interventions of the HIV Justice Network and, later, the HIV JUSTICE WORLDWIDE coalition; highlights methodological innovations such as legal monitoring and community-based documentation; and emphasises the centrality of human rights principles. Case examples - including the legacy of Ugandan nurse Rosemary Namubiru - illustrate the impact of HIV criminalisation and the power of resilience. While challenges persist amidst growing authoritarianism and disinformation, coordinated global efforts continue to advance evidence-informed, rights-based alternatives. This paper calls for a humanisation of the law that centres lived experiences, elevates scientific understanding, and fosters justice for people living with HIV. Ultimately, this paper argues for a paradigm shift from punitive legal responses to approaches rooted in care, dignity, and justice.
Equitable access to health care is a major issue in the United States of America. For young adults and adolescents who identify as being part of the lesbian, gay, bisexual, transgender, queer or questioning their gender, intersex, asexual, and other identities (LGBTQIA+) community, accessing gender-affirming care can be challenging in states with unsupportive legislation. Analysis of current legislation and state funding for South Carolina has focused on providing health care to vulnerable populations, while legally prohibiting gender-affirming care to the LGBTQIA+ community. Health care access issues faced by the LGBTQIA+ community in southeastern states such as South Carolina are exacerbated by recent legislative policies that restrict care and punish providers. The lack of access to care for this marginalized population in the restrictive southeastern region of the United States, legislation exacerbating the health care disparities, and recommendations from national health care organizations on how to bridge the gap in care are reviewed.
On May 20, 2025, the World Health Assembly adopted the WHO Pandemic Agreement, complementing 2024 amendments to the International Health Regulations (IHR). While these reforms aim to strengthen pandemic preparedness, address inequities, and support resilient health systems, their final texts fall short of embedding human rights as a central pillar. Despite rights violations during COVID-19 prompting global calls for reform, the instruments soften explicit rights commitments with broader principles of "equity" and "solidarity," which lack the legal precision and accountability of human rights law. We examine the implications of this shift, assessing how it may limit rights-based accountability in pandemic governance. Without deliberate institutional design-particularly within the Conference of the Parties (COP) process-these reforms risk an "implementation trap" where ambitious goals lack enforceable follow-through. We propose concrete measures to integrate human rights into governance, monitoring, and reporting to ensure the Pandemic Agreement fulfills its equity, solidarity, and rights promise.
Trans-women in Ghana experience stigma from institutions, social groups, and individuals. Yet, studies are needed to provide a comprehensive understanding of the nature of stigma experienced by trans-women, especially in Ghana and West Africa. This study employs an ecological model to qualitatively explore the ecology of stigma experiences of trans-women living in urban slums in Accra, Ghana (N = 20). Findings revealed stigma across various ecological levels. At the public policy level, the LGBTQ+ bill emerged as a key driver of stigma. Various subcategories related to this bill included: (a) Restricted freedoms of expression and isolation from harm, (b) LGBTQ+ bill potential for facilitating violence, and (c) fear of arrest and jail time. At the institutional level, trans-women encountered stigma in three areas. The first was in the healthcare sector involving rude gestures and behaviors. The second was from law enforcement officers and included (a) harassing attitudes from law officers, and (b) extortion. Community-level stigma encompassed: (a) insults, name-calling, (b) possible harm from gender expression, and (c) fear of attacks. At the interpersonal level, Trans-women experienced: (a) invasion of privacy, (b) leaving home due to safety, (c) threat of bodily harm, and (d) rejection. At the individual/self-stigma level, trans-women experienced (a) self-doubt and internal struggles, and (b) sense of regret and guilt. Findings highlight the unique experiences and pervasive and multi-layered stigma faced by trans-women across different levels of society. Addressing stigma experiences requires a multi-tiered approach that tackles issues from public policy to individual self-acceptance.
Social support is known to influence pregnancy outcomes. We explored the sources of social support available to pregnant women in a rural setting in south India. We conducted 13 focus group discussions (FGDs) among women of child-bearing age, husbands, mothers/ mothers-in-law, community health workers, and community leaders. FGDs were transcribed and analysed using thematic analysis. Support received during pregnancy were mainly in three domains; tangible, informational and emotional support. Tangible support refers to providing practical support such as cooking nutritious food for the pregnant women, helping them with household chores, and accompanying pregnant women for hospital visits. Informational support refers to measures aimed at improving awareness during pregnancy and promoting informed decision making such as advice on dietary practices and remedies for common ailments. Emotional support refers to the support provided by family members and CHWs in fulfilling women’s desires during pregnancy and allowing them a safe space to share their problems. Sources of support identified include husbands, elders in the family, friends, the local community, and health service providers. In general, perceptions were similar across participant groups, age and gender. While tribal participants sought elders’ advice and relied on traditional remedies compared to non-tribal participants, they were more likely to access nutritional aids offered by the government. CHWs provide additional support to tribal communities in identifying pregnant women, closely monitoring them and extending informal support during pregnancy and delivery by taking them to the hospital. Members of the joint family including mothers-in-law and sisters-in-law actively helped in chores, nutrition and newborn care compared to the nuclear family. In general, women felt that they received valuable support from family and community. Participants felt that support from husbands, families and neighbours had an influence on women’s health and behaviour during pregnancy. The findings were used to develop intervention modules to promote maternal health and the health of their offspring. The online version contains supplementary material available at 10.1186/s12884-026-08888-7.
In Zimbabwe, pregnancy termination is generally prohibited unless and only if the circumstances are in sync with the conditions stipulated in the Termination of Pregnancy (ToP) Act of 1977. This raises questions about the modern-day rights of bodily autonomy and integrity (BAI). Funded by the AIDS and Rights Alliance for Southern Africa, this study, therefore, seeks to review and analyse sexual and reproductive health and rights policies and how they relate to the ToP Act (1977) and BAI. This study will use a concurrent multimethod approach. First, policies related to the ToP and bodily autonomy and integration will be reviewed and analysed using the policy analysis triangle. Concurrently, a qualitative and quantitative survey will be conducted on purposively selected key informants and focus group discussions with purposively selected women and men, as well as 200 stratified selected women. Qualitative findings will be recorded, transcribed and thematically analysed using MAXQDA V.20 Pro. Simultaneously, the quantitative output will be collected using KoboCollect, exported into Excel and analysed using both Excel and STATA. The strengths, weaknesses, opportunities and threats (SWOT) framework and the Basic Logic Model will guide the triangulation of the findings and development of a policy brief. Ethical approval for this study was obtained from the National University of Science and Technology Institutional Review Board at Bulawayo, Zimbabwe (Ethics Number: NUST/IRB/2023/23). Written consent would also be sought from the participants. A policy brief would be developed and shared with key stakeholders. At least three manuscripts would emanate from this study and will be submitted for publication in reputable peer-reviewed journals.
Cryptococcal meningitis (CM) is an infection of the central nervous system that accounts for approximately 19% of AIDS-related mortality worldwide, with the highest burden being in sub-Saharan Africa (SSA). In 2022, the WHO released clinical guidelines on the prevention, diagnosis and treatment of CM, based on strong evidence-based studies. It is not known how these WHO guidelines are being integrated at the national level. This study aims to highlight national clinical guidelines for the prevention, diagnosis and management of CM across SSA and how these guidelines compare to WHO 2022 CM guidelines. A comprehensive search was conducted to gather the current national clinical CM guidelines from all 46 countries in SSA. Methods to acquire copies of national guidelines included using online search engines, official government websites, WHO country office websites, direct contact with WHO officials and officers in national ministries of health as well as surveying the data repository of the International AIDS Society and HIV Policy Lab's Advanced HIV Disease Dashboard. National CM guidelines were analysed to determine if they incorporated the recommendations in the 2022 WHO CM guidelines. Of the 46 countries in SSA, 37% (17/46) did not have established national CM screening and diagnostic guidelines and 35% (16/46) did not have established national CM treatment guidelines accessible through our methodology. Among the countries with CM guidelines, 21% (10/46) follow WHO recommendations for prevention, 30% (14/46) for diagnosis and 13% (6/46) for treatment. Despite recent evidence to support diagnostic techniques and treatment approaches to improve CM outcomes, most national CM guidelines in SSA are not in accordance with the updated WHO recommendations, stressing a persistent gap in national adoption of CM international evidence-based guidelines.
This commentary seeks to inform registered nurses how to participate in opioid abatement decision making. Legal structures of opioid abatement spending are presented, as well as spending limitations citing federal and state law. Areas of advocacy at the intersection of infectious disease (ID), substance use disorder (SUD), and nursing, including harm reduction, scope of practice policies, and billing laws are discussed. Examples of nurse-led ID prevention and SUD treatment programs are offered. Overall, nurses with ID and SUD expertise can influence opioid abatement spending and nurse-related health policy.
Human Immunodeficiency Virus (HIV) criminalization laws may discourage engagement in care. American Men's Internet Survey participants were randomized to disclosure, in which automatic public health reporting of antiretroviral resistance testing (ARVRT) was explained upfront, or non-disclosure, in which it was revealed later. Among 4,750 participants, 64.4% were unsure whether their state had an HIV criminalization law. ARVRT willingness was greater with non-disclosure (OR = 1.96, 95% CI: 1.41-2.71) and most pronounced among those believing no law existed (OR = 4.00, 95% CI: 1.10-14.54), with an interaction between legal perception and disclosure condition (χ² (2) = 7.14, p = 0.028).
Legal provisions, as a key component of social structures, have a significant impact on HIV prevention and control efforts. Article 12 of the "Interpretation of Law in Handling Criminal Cases on Organizing, Forcing, Luring, Sheltering, or Introducing Prostitution" [Prostitution Law], jointly issued by China's Supreme Court and Supreme Procuratorate in 2017, stipulates that sex workers and clients aware that they are living with HIV who engage in commercial sexual activities are to be heavily penalized for spreading sexually transmitted disease, regardless of their actual viral load or use of safety measures. Our study employs a case study methodology, aiming to explore the adverse impacts of the criminalizing provisions of China's Prostitution Law on HIV prevention efforts through the analysis of specific cases. An analysis of cases reveals that records of antiretroviral therapy for people living with HIV, intended to manage their illness and reduce transmission risk, have paradoxically been used as evidence for their convictions.
Our study provides a critical analysis and synthesis of the existing literature, public health data, and policy documents related to HIV stigma, legal barriers, and health care access in Tunisia. It examines complex challenges faced by people living with HIV (PLWH) in Tunisia, focusing on those three areas of concern. We identify persistent stigma and discrimination as critical obstacles, compounded by restrictive legal frameworks and health care access challenges, including workforce shortages and insufficient training. We highlight promising policy and advocacy efforts for improving care and social inclusion for PLWH. To improve health outcomes, we advocate for multifaceted reforms, including public education campaigns, legal protections, and enhanced health care services that address PLWH's unique needs. We emphasize the importance of training health care workers and creating an empathic health care environment. We provide recommendations for a comprehensive approach combining legal reform, stigma reduction, and health care improvements to uphold the rights and dignity of PLWH in Tunisia.
Factors such as structural racism and disinvestment in community mental health and social services have resulted in harmful interactions between law enforcement and individuals experiencing mental health crises. These harms are even more prevalent among racial and ethnic minorities, sexual and gender minorities, and individuals with a mental illness. Nationwide, municipalities are exploring ways to ameliorate the harms experienced during these interactions, with some implementing alternative crisis response units. In Durham, North Carolina, we conducted interviews with staff of one such program to better understand what aids and prevents successful program implementation. Participants reported that buy-in from program partners such as other first responders as well as from the broader community facilitated program operations. Barriers disclosed included inadequate funding of local social services and changing policies and procedures.