Minister of Health Budget speech & response by DA
16 May 2017
Minister of Health, Dr Aaron Motsoaledi, gave his Budget Vote Speech on the 16 May 2017.
Madam Speaker/Deputy Speaker/House Chairperson
My Colleague Deputy Minister of Health, Dr Joe Phaahla
Cabinet Colleagues and Deputy Ministers present
Chairperson of the Portfolio Committee on Health, Honourable Lindelwa Dunjwa and
Honourable Members of the Portfolio Committee on Health
Representatives of UN agencies
Representatives of development agencies and Donor Partners
Ladies and Gentlemen
Honourable Speaker, Honourable Members of the House as you know, this year we celebrate the 100th birthday of one of the most revered icons of our revolution, Oliver Reginald Tambo. The year has been accordingly declared the year of Oliver Tambo.
Tambo has dedicated his entire life to the creation of a democratic, non-racial, non-sexist and prosperous South Africa where all people regardless of their economic or social status would have equal rights.
Tambo once declared "we have a vision of South Africa in which black and white shall live together as equals in conditions of peace and prosperity.
To me Honourable Speaker, the best tribute we can pay to this gallant hero of our liberation struggle is to ensure that we translate our Constitution into reality - into a living organism.
While we have made huge progress in health as observed by the Statistician General yesterday, when releasing the results of the South African Demographic and Health Survey (I will visit this point later), we still have not translated very important parts of the Constitution into health reality.
Only when our people enjoy the health dividends of democracy through the provisions enshrined in the Constitution, shall we say our work is done and Oliver Tambo has indeed been honoured.
The Bill of Rights in Section 27 of the Constitution states unequivocally that healthcare is a right. Subsection (2) then goes on to say: "The State must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of each of these rights." And subsection (3) says: "No one may be refused emergency medical treatment".
Honourable Speaker, the most important aspects of these provisions have not yet been operationalised. The time has now eventually arrived for us to do so. In the second phase of our transition to democracy, the phase of radical economic transformation, we have no option but to do so.
It is for this very reason that we have no option but to implement the United Nations programme of Universal Health Coverage which in South Africa we call NHI.
To those not yet fully initiated, we define NHI as a health financing system that pools funds to provide access to quality health services for all South Africans, based on their health needs and irrespective of their socio-economic status.
This definition may as well fit in very well in the definition of a medical aid scheme. But there are two main very notable exceptions that make NHI and medical aid schemes to look like chalk and cheese.
The first exception is the word "all". Under NHI we intend to pool funds for all South Africans. In medical aids, the word "all" does not exist. Medical aids are designed for a selected privileged few and pretends the majority of South Africans do not exist.
Yes, the system of medical aids is designed for only 16% of the population. According to this system, 84% of South Africans have no right to access to good quality health services and they can be served through alternative means.
The second notable exception are the words "irrespective of their socio-economic status".
Under the medical aid system even the selected privileged few are stratified according to their economic status. The more senior the job you do, the more you earn and the better the quality of health services you get. The more junior your job status, the lesser you earn, the lesser the quality of health services you get.
We can no longer allow this to go on. It is a flagrant disregard of our Constitution because the Constitution does not recognise economic status in the provision of health services. It is also a flagrant disregard of the Constitution because it makes healthcare a condition of service rather than a right.
Contrary to nay sayers, the NHI is the one which is in line with the Constitution because it puts the healthcare of all South Africans on an equal footing.That is why the United Nations used the word "Universal" because nobody should be left behind.
This year, we are at the end of the 5 years, which we regard as a preparatory phase of NHI. Time and again reports have emerged in the media that nothing happened in the NHI pilot districts.
Our 5 year preparatory phase was guided by Section 2 of the NHI White Paper which states that "NHI represents a substantial policy shift that will necessitate a massive reorganisation of the current health system, both public and private ...."
In this massive reorganisation of the healthcare system, we did what is commonly known as piloting to try and figure out and learn how the healthcare system can be massively reorganised, based on values of justice, fairness and social solidarity.
The time is now, for me to provide a short report back about this reorganisation.
(1)Infrastructure and Equipment
Within the 10 pilot districts, we have completed the building of 34 new and replacement clinics and we are busy with 48 others. This will be a total of 82 new and replacement clinics.
Outside the 10 pilot districts, work has also been going on and we have just completed 96 clinics and are still busy with 132 others, to give a total of 228 new and replacement clinics.
Once all are completed, it will be a total of 310 new and replacement clinics.
In the same period within the pilot districts we have completed the refurbishment of 154 clinics and are still busy with refurbishing 192 others. This will give a total of 346 refurbished clinics in the 10 pilot districts.
Outside the pilot districts, we have completed refurbishing 135 clinics and are busy with 220 others. This will give a total of 355 refurbished clinics.
As you can see Honourable Speaker, the grand total will yield 701 clinics - new or refurbished.
This report is since piloting started in 2012.
We have also separately put up consulting rooms for doctors who visit our clinics on a contract basis. We have completed 142 of them and are still busy with 21 others to give a total of 163 doctor consulting rooms.
There are also new and refurbished hospitals, refurbished nursing colleges within and outside the pilot districts.
Within this preparatory period we have spent a total of R40, 342, 973,108.00 on infrastructure only. We have spent another R1, 706, 562,156.00 on all equipment within this preparatory phase.
(2)Access to medicines
You may remember the phenomenon of drug or medicine stock-out which used to bedevil the health system. We have, within this preparatory phase, undertaken three 3 initiatives:
(i)SVS or stock visibility system.
This is an electronic way of measuring stock at the clinic by scanning the back code on the package or bottle with a specially-supplied cellphone with a special application. When the nurse scans at the clinic the stock level is automatically and in real time, reported to an electronic map of all clinics in our country at the central tower in Pretoria. We are proud to announce that we have SVS in 3 163 clinics, 658 of which are within the NHI pilots - since we started implementing in July 2014. We did this project in partnership with the Vodacom Foundation and it is very successful in controlling medicine stocks.
(ii)Rx Solution and other electronic stock management systems (ESMS).
This system has been installed in 80% of our 10 Central Hospitals, in 94% of our 18Provincial Tertiary Hospitals, 83% of our 47 Regional Hospitals and 71% of our 254 District Hospitals. This system also works by reporting levels of stock electronically from each of these hospitals to the central control tower in Pretoria. If the stock levels are low, it automatically sends in an order.
With the SVS alone, stocks in our clinics have improved as follows:
ARVs from 69,5% to 92,5%.
TB medication from 65,7% to 88,5% and
Vaccines from 64,5% to 94,5%
(iii)Central Chronic Medicines and Dispensing and Distribution Programme
In this programme, patients who are stable on chronic medication do not have to visit our clinics anymore - except maybe after 6 months for check-up. They collect their medicines in 401 pickup points around the country and 1,300,000 patients are using this system, relieving congestion in our clinics or hospitals.
(3)Record management and Unique Patient Identifier
Honourable Speaker, pre- or post Apartheid, South Africa has never had a patient information system that allows as to follow a patient from one facility to the other. This means that one patient can visit as many facilities like on any one day and collect medicine and receive similar services without us knowing because there is no system to detect it.
Working with CSIR, Department of Science and Technology and Department of Home Affairs, I am happy to announce that our preparatory period has gone very well in this regard. We now have a system being implemented that will be ready for NHI. This programme as of 10 May 2017, has now reached 1 859 clinics, 705 of which are in the NHI pilots. Honourable Speaker, as I am speaking now, 6,355,759 South Africans have registered in this system in preparation for NHI.
We are registering people in these 1 859 facilities at the rate of 80 000 to 100 000 per day.
Honourable Members, this Unique Patient Identifier is linked to your ID number in Home Affairs and is a cradle-to-the-grave number. This means as soon as you register, you will keep it until you die. If a newborn baby is registered today, that is their number in our health facilities for the rest of their life.
Each South Africa is going to have their own number and if you visit any one of the 1 855facilities, you may register. It would take you 5 minutes when you register for the first time. But after having registered, it will take you only 45 seconds, not minutes, to retrieve your file in subsequent visits.
The 6 million South Africans are already enjoying that type of quick service. You however do not have to be in a hurry, it will reach all health facilities in due course. Under NHI, you are going to need this number which will link you from facility to facility in the public sector, from your GP to any facility and from your private hospital to your public hospital.Creating this was a massive operation done by a team of 25 officials from National office. A member of the team had to spend a minimum of 5 days in each of the 1 855 facilities to come up with a completed system.
Honourable Speaker, one of the recommendations of the Health Ombud's report on Life Esidimeni reads as follows:
"The development of information systems with patient registers and a data by which to make evidence-based decisions, monitor and evaluate healthcare delivery must be a priority of the Gauteng Department of Health. This recommendation is strongly endorsed by StatsSA".
If the Ombud was conducting his investigation in any other province other than Gauteng, he will have made exactly a similar observation.
I am very happy to announce that now was the Ombud to visit the 1 855 facilities and investigated the 6,355,759 patients by last week, he would not have to make this recommendation. He would have found all the data he needed.
The 6 million will soon be 55 million with you and me included - as long as you are a South African.
In the massive reorganisation of School Health, we have also completed screening 3,2 million school kids for physical barriers to learning, i.e eyesight, hearing, speech and oral health. We can report that a total of 500 004 school kids specially in the NHI pilots have the following problems:
• 8 891 have speech problems that will need a Speech Therapist;
• 34 094 have hearing problems that will need an Audiologist or maybe hearing aids;
• 119 340 have eyesight problems that will need an Optometrist, Ophthalmologist or maybe spectacles;
• 337 679 have oral health problems that may need a Dentist, Dental Therapist or Oral Hygienists.
I do not have to point to you how these problems negatively affect their studies.
In putting up solutions to the problems, I have just stated, I wish to first quote from the Budget Speech of the Minister of Finance in February this year:
"The service package financed by the NHI Fund will be progressively expanded. In setting up the Fund, we will look at various funding options, including possible adjustments to the tax credit on medical scheme contributions. Full details will be provided in the adjustments Budget in October this year, and in the course of the legislative programme.
Honourable Speaker, the tax credits mentioned in the February 2017 Budget Speech by Treasury is a whooping R20 billion. Yes, R20 billion that in 2015 and annually will leave the fiscus through SARS back to the pockets of people simply because they are members of a medical aid scheme.
Honourable Speaker, taking so much money back to rich people is like sending coal back to New Castle when you have a neighbour without a simple fire to cook their food.
How do we as public representatives, honourable ones for that matter, justify this type of thing happening in our country under our watch?
As Honourable Members of the House, we are beneficiaries or recipients of this R20 billion. I am one of them. You are one of them.
This is the worst form of social injustice committed in the name of the cream of the South Africansociety with our full participation.
Therefore Honourable Speaker, we believe the time to change and move towards economic equity as O.R Tambo has declared, has now arrived.
We are proposing that the 1st step towards implementation of NHI is to pick up those who are outside the system of medical aids and provide services for them through the NHI Fund which must be created from among others the R20 billion tax credits.
Please note, this R20 billion credit given to all who have joined medical schemes is separate from the R26,7 billion which is the total of all medical aid subsidies due to all who work for the State - including the Honourable Members here. I have not as yet even touched that R26,7 billion but I am talking about the R20 billion tax credits.
We have identified the South African who will benefit from the NHI Fund once it is established:
• The 500 000 school kids who I have mentioned;
• We will provide free ante-natal care in the form of 8 visits to a Doctor to each of the 1,2 million women who fall pregnant annually. We would also provide them with family planning, provide for breast and cervical cancer screening as well as treatment where appropriate;
• We will be able to provide better services for mental health users - screening and subsequent services;
• We will help the elderly with assistive devices like spectacles, hearing aids and wheel chairs.
We will also deal with the backlog of blindness caused by cataract. The backlog is now 270 000 elderly people who are presently blind and are awaiting cataract removal. We can perform 90 000 operations a year for the next 3 years to clear the backlog;
• We will be able to provide assistive devices to people living with disabilities.
This to us will be the beginning of revolutionizing the way healthcare is provided in our country. Lastly Honourable Speaker, I do hear time and again that I am in the business of watering down NHI and diluting it through multipayer system. I am actually handing it over to private hands and betraying voters. These statements are usually issued by our partners in the Labour Movement. I am trying to contact them but since I saw such a statement just 30 minutes ago, I am unfortunately forced to use this platform to clarify matters.
There is nothing in our policy documents that says any of these things. I will never sell NHI and I know what NHI is all about. I am prepared to defend NHI with my life!!
Honourable Members, the Nation is still in mourning about the terrible events that took place at Life Esidimeni in Gauteng.
We have had a parliamentary debate after the release of the Health Ombud's report.
Very soon, I will hand over a report to the Speaker's Office to outline progress made so far in implementing the 18 recommendations of the Health Ombud.
(1)The first recommendation is that the Gauteng Mental Health Marathon Project must be de-established - this has been done, Gauteng no longer has such a project;
(2)Recommendations 2, 3, 4, 5, and 6 on dealing with those who are fingered by the Ombud's report, disciplinary processes have commenced according to the legal framework of the country;
(3)Recommendation 7 on reporting to the Ombud after 90 days has been done in that the Ombud has received a preliminary report;
(4)Recommendation 8 on SAPS and forensic investigators. I can confirm that SAPS has started with investigations long ago. Yesterday, the NPA asked for all the files to start preparing them for an inquest for each and every person who passed on and to decide who must be prosecuted;
(5)Recommendation 9 on asking the South African Human Rights Commission (SAHRC) to investigate human rights violations has been done on the 9th February and the SAHRC has commenced with their work;
(6)Recommendation 10 on appropriate legal proceedings against NGOs that acted unlawfully is part of what SAPS and the NPA are doing right now;
(7)Recommendation 11 is about de-registering NGOs that do not meet the standard as well as closing them down and revoking licences.
I can hereby report that the Ombud cited 27 NGOs in his report. We have relocated all the Life Esidimeni patients from 20 NGOs.
There are 7 NGOs where we did not relocate patients because some families have refused that their loved ones be relocated, and in some cases, patients themselves because they were extremely agitated and refused to get into ambulances during the relocation process.
Fourteen (14) of the 20 NGOs where patients were removed have been closed down and the remaining 6 remain open because they are conducting other business other than Life Esidimeni business. We will deal with them in due course as part of a routine operation.
(8)Recommendation 12 on the Minister reviewing licensing regulation of NGOs I can report that I have already approved guidelines for the licencing regulation of Community-Based facilities I can report that I have already approved guidelines for the licencing of Community-Based facilities for people with mental and intellectual disabilities and those will be published in the Government Gazette on the 19th May 2017. The guidelines were drawn by a team consisting of Law Review Commission, State Law Advisers, National Mental Health Policy Unit and the Legal Unit of the National Department of Health.
(9)Recommendation 13 that all patients placed in unlawful NGOs be removed and be placed in appropriate Health establishments, I can report as follows:
• 391 relocated to hospitals, 398 back to Life Esidimeni and 461 are in Weskoppies, Sterkfontein, Cullinan Care and our general hospitals where 9 of the patients have been admitted. As I have mentioned families who refused their loved ones to be moved account for 19 patients and those who refused to get into ambulances are 4. Hence 23 not relocated yet.
(10)Recommendation 14 on reviewing National Health Act 2003 and Mental Health Act 2002 iswork-in-progress.
(11)Recommendation 15 and 16 are work-in-progress because indeed we have worked together with the Premier's Office in Gauteng and the Department of Health, instead of allowing the Department of Health to work alone as they did, which led to the disaster we are faced with. The teams of 60 worked in this project were led by the DG in the Premier's Office in Gauteng, the National DG of Health and Dr Ramokgopa. Three family members are part of this team on a fulltime basis.
(12)Recommendation 17 that the Premier and Minister of Health must lead and facilitate a process for a dispute resolution led by credible and prominent South Africans be undertaken. Indeed, together with the Premier we have worked around the clock with family representatives, who are present in the gallery today.
Both Government and family representatives have identified a very prominent retired Judge to lead this process. We will make an announcement after certain processes have been followed.
(13)Recommendation 18 on dealing with theGauteng Mental Health Review Board, the MEC had disbanded the Board and put up an Interim Board. The MEC has then advertised positions for a permanent Board and people will be selected in due course.
In addition to dealing with these recommendations, I can also report that I have appointed in terms of Section 88A of the National Health Act, as amended, appointed a Tribunal to hear cases of appeal by those who feel aggrieved by the Ombud's findings.
The 3 persons Tribunal consists of:
• Judge Bernard Ngoepe, retired Judge President of North Gauteng High Court;
• Professor Hoosen Coovadia and Professor Brian Robertson, both retired Professors from the Universities of KwaZulu Natal and of Cape Town respectively.
They have been working around the clock exchanging legal documents with the lawyers of the appellants and I can confirm that as of yesterday, one case brought by two NGOs is ready for a hearing - it can take place anytime from now.
Two other cases brought by public servants who have been fingered by the Ombud are about to finalise the exchange of legal documents and those two will also be ready for a hearing in a few weeks or perhaps a few days' time.
Honourable Speaker, yesterday I was officially handed a report from the Statistician General on the findings of the South African Demographic and Health Survey.
The last time such a survey was done was in 1998.
As you might have learnt from the press conference held by the Statistician General in Pretoria yesterday, the overall findings are very positive in that mortalities have gone down, improvements in the health system have been successful, smoking rate has gone down and many other positive findings.
However he said that a lot of work still needs to be done in areas like stunting which is worsening as well as levels of Obesity which are going up, as well as people still keeping multiple sex partners despite all the teachings about HIV and AIDS.
The Statistician General emphasized that most of the problems picked up by the Survey, which affect health, actually do not stem from the health system itself but from social determinants of health and from socio-economic factors.
I wish to take this opportunity to thank my colleague Dr Joe Phaahla, the Deputy Minister of Health, the Portfolio Committee led by Honourable Dunjwa, and the Health team led by the DG, Ms Precious Matsoso, as well as my colleagues in the Provinces, the MECs.
I hereby present the Health Budget of R42, 625,723,000.00 for 2017/18 for adoption by this House.
I THANK YOU!!
Priority must be given to building a highly effective primary health care system that responds to those who are vulnerable to illness and disease
The following speech was delivered in Parliament today by the DA’s Shadow Minister of Health, Dr Wilmot James MP, during the Budget Vote on Health.
South Africa lives with the world’s highest epidemic of HIV/AIDS, a preventable disease that brought widespread death, extraordinary misery and great hardship to the people. Close to half of the 3.7 million orphaned South African children lost their parents to HIV/AIDS.
The reason for this calamity is the failure of political and moral leadership to promote responsible safe-sex practices under circumstances where a vaccine was, still is and likely will be unavailable for a while.
It did not have to be like this.
F.W. de Klerk’s last apartheid government did not know what they were dealing with. A University of Cape Town group led by Mamphela Ramphele went to see Nelson Mandela in 1999 to persuade him to declare a national emergency. He urged health Minister Nkosazana Dlamini-Zuma to declare a health emergency, but she failed to do so.
It was Barbara Hogan and the Honourable Aaron Motsoaledi who led South Africa out of what some have described it as quiet genocide – for which no one has been held accountable.
Dlamini-Zuma has a lot of explaining to do. On her watch, in an act of nepotism, a R14 million contract was awarded to Mbongeni Ngema – a ‘good friend’ he was called – to produce a sequel to the musical Sarafina.
Dlamini-Zuma was also criticised for supporting Virodene, a ‘quack’ remedy for HIV/AIDS, which was, in fact, a toxic industrial solvent rejected by the health science community as ineffective. I was personally present at the meeting with Nelson Mandela when he said that he will call on Dlamini-Zuma to declare HIV/AIDS an emergency and he, as we well know, always kept his word, but she did nothing.
May her soul rest in peace, Manto Tshabalala-Msimang is no longer with us and we will not speak ill of the dead. Thabo Mbeki on the other hand, whose stubborn anti-science denialism, following on Dlamini-Zuma, is the reason why Minister Motsoaledi inherited a budget organised around the health implications of the HIV/AIDS crisis and that stands in the way of implementing a much needed plan for health systems strengthening.
I recall this history because it is important that Honourable Members understand that a health budget should not be designed simply for a crisis. It should be designed to constantly address multiple disease and illness risks. The World Health Organisation (WHO) identified the six building blocks of a health system as follows:
1. Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those that need them;
2. A well-performing workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible;
3. A well-functioning health information system is one that ensures the use of reliable and timely information on health determinants, health system performance and health status;
4. A well-functioning health system ensures equitable access to essential medical products, vaccines and technology of assured quality;
5. A good health financing system raises adequate funds for health, in ways that ensure that people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them;
6. Leadership and governance involve ensuring strategic policy frameworks exist and are combined with effective oversight, regulation and accountability.
There are no objective measures against which we can rate our standing against these goals because our Office of Health Standards Compliance and other research agencies are not geared to collect data on this scale.
Indeed, as we pointed out in Our Health Plan, there is no system in place to assess the performance of the public or private health sectors which means that policy-makers and the Honourable Motsoaledi are flying blind.
What we do know is that for the money we put in, the health outcomes are deeply disappointing. We do not spend small change. The consolidated expenditure for health at all levels of government was R168,4 billion (the second largest after education’s R297,5 billion) or 11,5 percent of our R1,46 trillion national expenditure in the 2016/17 financial year. This is impressive by any standard.
But, our health outcomes, though improving, are dreadful. Experts usually use the maternal mortality rate as a proxy indicator for the quality of a health system measured by its outcomes and ours is embarrassing for a country at our stage of development.
According to the 2014 Department of Health’s Saving Mothers annual report and detailed analysis of maternal deaths due to non-pregnancy related infections, our institutional maternal mortality rate is declining but still excessively high at 141 deaths per 100,000 live births.
The Free State does the worst at 203 deaths and the Western Cape the best at 66 deaths, but even this is simply not good enough. It should be under 50 per 100,000 live births, a millennium development goal we set for ourselves but missed by far.
The consequence of these trends is that the budget before Parliament is not designed to strengthen our health system but to deal with our HIV/AIDS crisis. It is quite simply, reactive.
Of the R42,63 billion set aside for the national ministry, R15,75 billion is for HIV and AIDS, R27,5 million for TB and R18,39 million for maternal and child health or 37 percent of what the Honourable Minister has to spend. There is no measure of the real cost to provinces of treating HIV/AIDS patients in all their clinical settings, but it must be considerable.
Saving lives is, of course, a moral obligation, and we will, therefore, spend, as we must, a monumental amount of money on HIV/AIDS until the epidemic burns itself out. The Honourable Minister has distinguished himself in delivering on this moral obligation, something one cannot say for most of the rest of the ANC Cabinet and certainly not for President Zuma who is everything but moral.
But HIV/AIDS will not burn out unless we stop the new infections, especially among young women. I do not believe that we are aggressive enough with our efforts and I challenge the Honourable Minister to tell us what he plans in this respect.
To deal with the ongoing HIV/AIDS/TB crisis and strengthen our health system will require both more money and better management.
The Honourable Minister is focused on the money. He wants to compel those on medical aid or health insurance to pay their monthly subscriptions to his National Health Insurance in return for services over which they have no control. He would like to have access to the medical aid reserves that run into billions, eliminate the medical aid tax credits and block the universal subsidy to middle to high-income earners.
But the Honourable Minister is not focused on management. He is running out of doctors and nurses. The average quality of hospitals is shocking. We have enough clinics in our country but can only staff half of them properly.
Bad governance and mismanagement is why the Esidimeni tragedy happened.
In any health system worthy of the name, an unusual pattern of deaths would be evident immediately and provoke an immediate response. The Gauteng Province may be the principal frontline offender but the ANC governance failures run wider and deeper, which is why the DA still believes that it is of the greatest importance for Presidential Zuma to appoint a judicial enquiry into the saga.
In South Africa, private and public health systems exist in parallel. The public system serves the vast majority of the population but is chronically mismanaged and understaffed. The better off 20 percent of the population use the private system and are better served.
When in national government, the DA will introduce strategic reforms to extend the coverage provided by medical aid and health insurance to serve 65 percent of the population, which will take off the pressure from and create the opportunity to upgrade the public health sector to meet WHO standards of care for those without jobs in a mixed health economy.
As an example of the DA’s commitment to improving healthcare, where we govern at Metro level in the City of Johannesburg for instance, we have ensured that 6 clinics are now open in the evenings, until 10 pm, and on the weekends to allow more people to access health care. In the new budget, the DA have proposed that millions be allocated to ensure that all other clinics in the City are also able to extend their hours.
The DA believes that every part of our health system should be modernised but priority must be given to building a highly effective primary health care system that responds to the needs of all those vulnerable to illness and disease.
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