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Achieving universal health coverage in Africa: is there a role for formal for-profit providers? By Jane Doherty, School of Public Health, University of the Witwatersrand, South Africa

There is increasing consensus that public financing is required to achieve the financial protection from the costs of using health care that is an essential component of the concept of universal health coverage. However, the other dimension of universal health coverage is access for all to health care services that are both needed and of sufficient quality to be effective (World Health Organisation 2010).

Some donors and international agencies, such as the International Finance Corporation, argue that private, formal, for-profit providers should play some role in extending access to quality care (International Finance Corporation 2007). There are initiatives by international agencies, donors, African governments and others to expand the for-profit private sector in Africa. These include efforts to attract new local and international investors, encourage bank loans to private practitioners, and subsidise for-profit health care businesses (Doherty 2011).

Can this expansion support the principles of universal health coverage? In low- and middle-income countries, for-profit private providers, especially private hospitals, are often costly and located in more urbanised areas. For-profit services are seldom comprehensive and, while they are often perceived to offer superior and more convenient care, there is minimal public monitoring of their quality (Doherty 2015).

There is also evidence that private care is subject to incentives that distort treatment decisions (Berer 2011, Ravindran and de Pinho 2005, Hanson, Gilson et al. 2008, Doherty and McIntyre 2013). The existence of private facilities contributes to the brain drain from the public sector and aggravates the fragmentation of the health system. Further, fair competition is obstructed through unfair practices (such as collusion) as well as unregulated practices such as the ownership by single companies of health insurance companies, health care providers and pharmacies (which makes patients vulnerable to exploitation) (Shamu et al. 2010).

Lastly, powerful private sector alliances compromise governments’ ability to regulate the sector in the interests of national health objectives.

This is not to argue against the fact that some for-profit private providers make very particular contributions to the health systems in which they are located. Some patients prefer some forms of private provision, so private provision should remain an option to complement strengthened public services (Balabanova, McKee et al. 2011). However, in most health systems in developing countries, the private sector is poorly regulated and monitored. Therefore, the perceived benefits of private provision are often offset by the distortions that are introduced by the private sector overall. In particular, for-profit private provision is simply unaffordable for the vast majority of the populations in developing countries.

In the current environment of donors pushing for a strong role for the private sector, policy-makers in Africa (and in other low- and middle-income countries) need to embark on a programme of action to strengthen regulatory frameworks. Such a programme includes policies, legislation and reimbursement mechanisms that incentivize appropriate behaviours by for-profit providers (Hongoro and Kumaranayake 2000, Doherty 2015). Without these actions, investment by donors and funders in the expansion of the private sector will only serve to increase inequality in health care.

The range of actions should address the failings of the health insurance and health provision industries in tandem, as well as the interplay between them. They should include:

  1. developing a sound evidence base on the nature and extent of the private sector, differentiating clearly between different components of the sector and their existing or potential impacts
  1. assembling country-based evidence on where particular arrangements have allowed private provision to be incorporated successfully in universal health coverage strategies (together with the factors explaining the strengths and weaknesses of these arrangements);
  1. exercising greater stewardship over the for-profit private sector by demonstrating the political will and leadership to regulate effectively and in the interests of national health objectives;
  1. developing an over-arching policy on the private sector’s roles and responsibilities in support of the achievement of universal health coverage;
  1. raising the awareness of Competition Commissions regarding the reasons why some behaviours of the private health sector can have an adverse impact on the health system, and necessary strategies to protect national health objectives;
  1. conscientising Ministries of Trade and Development regarding the damaging impact on public health and health systems strengthening of some of their policies that seek to attract investment into the private health sector and stimulate private health businesses;
  1. strengthening government capacity to develop, implement and monitor legislation and other regulations;
  1. making efforts to rationalise, harmonise and strengthen existing regulators;
  1. addressing important gaps in the legislation (including that relevant to health insurers, health providers, health professionals, fair competition and consumer protection);
  1. building strategic alliances with key stakeholders to counteract regulatory capture by groups with vested interests;
  1. introducing a range of price controls for services;
  1. strengthening sanctions against non-compliance with regulations;
  1. ensuring greater transparency on the part of private providers with respect to their underlying costs and quality; and
  1. monitoring and evaluating the impact of the private health sector and its regulation on the health system, including on equitable access, affordability, quality of care and efficiency.

The length of this list underlines the extent to which extensive interventions are required to ensure that the for-profit private sector meets, rather than undermines, national health objectives, including equitable universal coverage and access to quality services. It also underlines the current weaknesses of governments in developing countries in exercising oversight of the private sector.

Accordingly, extreme caution should be exercised, by both governments and development agencies, with respect to promoting further expansion of private provision or health insurance, until solid strategies such as those proposed above can be put in place. Given the capacity constraints facing governments in Africa and other developing countries, it can be expected that progress on these interventions will be slow.

A greater priority than expanding the private sector is surely the strengthening of public sector provision, not only to meet the needs of the majority but also to provide stiffer competition with private providers. Public provision must remain the core function of the public sector.

Equally importantly, it is a priority for governments in Africa to strengthen mandatory prepayment for health care, especially through general taxation but also, where appropriate, through earmarked taxes, including payroll-based payments. The leverage provided by this instrument in incentivizing providers to comply with quality controls and contain costs is arguably far greater than through legislation alone.


Balabanova D, McKee M, Mills A (eds). 2011. ‘Good health at low cost’ 25 years on: what makes a successful health system? London: London School of Hygiene and Tropical Medicine.

Berer M. 2011. Privatisation in health systems in developing countries: what’s in a name? Reprod Health Matters; 19(37): 4-9.

Doherty J. 2011. Expansion of the private health sector in East and Southern Africa. EQUINET Discussion Paper 87. Harare: EQUINET.

Doherty J, McIntyre D. 2013. Addressing the failings of public health systems: should the private sector be an instrument of choice? In: Surender D, Walker R. Social policy in a developing world. Cheltenham, UK: Edward Elgar: 101-124.

Doherty J. 2015. Regulating the for-profit private health sector: lessons from East and Southern Africa. Health Policy and Planning; 30: i93-i102.

Hanson K, Gilson L, Goodman C, Mills A, Smith R, Feachem R, Feachem N, Koehlmoos T, Kinlaw H. 2008. Is private health care the answer to the health problems of the world’s poor? PLOS Medicine; 5(11): e233

Hongoro C, Kumaranayake L. 2000. Do they work? Regulating for-profit providers in Zimbabwe. Health Policy and Planning; 15(4): 368-377.

International Finance Corporation. 2007. The business of health in Africa:  partnering with the private sector to improve people’s lives. Washington, D.C.: International Finance Corporation, the World Bank Group.

Marriott A. 2009. Blind Optimism:  Challenging the myths about private health care in poor countries. Briefing Paper 125. Oxfam International.

Ravindran T, de Pinho H. 2005. The Right Reforms? Health Sector Reforms and Sexual and Reproductive Health. Johannesburg: Women’s Health Project, School of Public Health, University of the Witwatersrand.

Shamu S, Loewenson R, Machemedze R, Mabika A. 2010. Capital flows through medical aid societies in Zimbabwe’s health sector. EQUINET Discussion Paper 82 Serie. Harare: Training and Research Support Centre, SEATINI, Rhodes University, EQUINET.

World Health Organisation. 2010. World Health Report. Health systems financing: the path to universal coverage. Geneva: World Health Organisation.


Dengue in Delhi – fighting an outbreak with the wrong numbers and an unwilling private sector by Anna Marriott, Public Services Policy Manager

A recent dengue outbreak in Delhi has once again revealed the shortcomings of the massively underfunded Indian public health system, alongside the unacceptable and illegal exclusion of poor patients by the city’s private hospitals. This blog steals the excellent analysis by my colleague Oommen Kurian from Oxfam India, recently published in the British Medical Journal, as well as the post-dengue prognosis of well known commentators, Reddy and Murphy.

Oommen Kurian’s BMJ blog outlined how the current dengue outbreak in Delhi came to international prominence following the unfortunate incident of a young couple who committed suicide after their son was rejected treatment by many prominent private sector hospitals in Delhi. Treatment was denied despite the government saying on 28 August that patients should not be denied admission to hospital on account of a lack of beds. Responding to such cases, the Government of Delhi has issued show-cause notices to five private hospitals asking them to explain why they refused to admit the boy and why their registration should not be cancelled.

Kurian’s blog focussed primarily on two major problems:  the shamefully inaccurate ‘official’ data on incidence and deaths from dengue fever, and inappropriate profiteering by Delhi’s private health sector during the Dengue outbreak. Reddy and Murthy, two prominent commentators, also argue in their post-dengue prognosis that once the media hype and finger pointing of the current dengue fever crisis passes, citizens of India are left with the same long-term problem of a chronically underfunded public health system that causes unreported tragedy on a daily basis.

The numbers

Kurian’s quick comparison of different sources of data on deaths from dengue fever show that only 29 of the 1221 deaths from dengue registered in Delhi between 2010 and 2014 entered the official system (see graph below). Official estimates of the annual incidence of dengue fever nationwide are a staggering 282 times lower than the actual number.

Dengue fever affects most of the metropolitan cities and towns in India, where the healthcare delivery systems are better than the rural areas. However, the preparedness of the system against it may be impacted by the level of massive under-reporting of cases and deaths.

Profiteering or serving?
Delhi has a large number of private hospitals, which have received free land and other subsidies from the government to provide a set percentage of their services free to poor patients. Over time, these charitable hospitals have become purely commercial entities, dishonouring the commitments made to the government.

A high level committee assigned by the Government of Delhi, headed by Justice AS Qureshi, took a bleak view of the nature of such hospitals which claim to be charitable just to lap up subsidies and have become “selfish, greedy, and exploitative” moneymaking machines. Data from 2014 show that the average total medical expenditure for treatment per case of hospitalisation is higher in Delhi than any other state in India, at Rs 34,658. The India average is Rs 18,268.

Profiteering in times of distress is nothing new to Delhi’s private health sector: even those which claim to be private “charitable” hospitals are notorious. For these very reasons, midway through the dengue outbreak, the Union Health Ministry decided to ask the Delhi government to take action against any overcharging by the private hospitals. On 16 September, Delhi’s Directorate of Health Services issued an order against private hospitals and laboratories overcharging, and implemented ceiling prices for dengue testing. Another advisory on the same day allowed the private hospitals and nursing homes to increase their bed strength by up to 20 per cent on a temporary basis for two months.

And now?

As of 21 September this year, the press has reported that while the death toll has “risen” to 22 this season, the deputy chief minister announced that the health situation is now better and the government is winning the battle against dengue. Activists do not take these numbers seriously. Advocate Ashok Agarwal, a member of a Delhi high court-appointed panel to oversee the implementation of the EWS scheme (beds reserved for patients from “economically weaker sections”) in private hospitals announced on social media that the Delhi Government’s dengue death figures are incorrect and that 23 dengue deaths have happened in one hospital alone. The director of another hospital in Delhi is on record saying that at least seven dengue deaths had taken place in his hospital alone, as of 17 September.

A look at civil registration data reveals that dengue strikes Delhi at regular intervals. With more money already put into health, the current Delhi government—only in its first year of rule—may be better placed to fight any dengue outbreak in the future. However, any effort towards containing contagion should begin with having correct numbers—of cases and deaths—and a long term plan to align the private sector in the state with the broader public health goals of society.

Once the current media hype has passed….

In their post-dengue prognosis Reddy and Murphy write that there is ‘justified outrage at the tragic deaths of children from dengue under deplorable conditions of apathy and neglect in the capital of India. But say the underlying causes of the crisis, namely chronic and long-term underfunding, poor co-ordination and planning, remain unaddressed and the daily tragedies facing citizens in the rest of the country, especially in rural areas, go unreported. They give the heartrending example of a tribal in Odisha who allegedly felt forced to sell his two-month-old son for Rs 700 to buy medicines for his sick wife. Reddy and Murphy conclude that:

Public health systems cannot function as a motley crowd of disconnected actors ad libbing their way through an unscripted play in chaotic fashion. The different actors involved require a script, coordination, direction, and need to work as a team. It is time India got its act together to create strong, well-resourced, responsive and responsible health systems. Or else, terrible things will continue to happen to innocent children, expectant mothers, poor tribals, disabled persons — and to your family and ours. We will all be responsible when such terrible wrongs happen.


Oommen C. Kurian is research coordinator, Oxfam India.

K Srinath Reddy is president and N R Narayana Murthy is chairman of Public Health Foundation of India



Healthcare for all in India: Is dependence on private sector and insurance the way forward? By Oommen Kurian, Research Coordinator, Oxfam India

India’s health care delivery system portrays many contradictions. Enthusiastic policy discourse on Universal Health Coverage (UHC) and user charges co-exist. Grand plans for international health tourism focusing on super-specialty hospitals in the cities are made, while health payments push 60 million Indians below the poverty line every year. The overall public expenditure on health is at just over 1% of GDP but more budget cuts and insurance-based financing are being proposed. Oxfam India’s new Working Paper, “Financing Healthcare for All in India: Towards a Common Goal” highlights some of these contradictions and explores the challenges facing India’s health sector.

Sengupta (2013) observes that one reason for the unified support of UHC among international agencies was the global rise in catastrophic Out Of Pocket Spending (OOPS) on healthcare. This is in the backdrop of crumbling public health systems, which in turn was a consequence of a prolonged period of neglect of public healthcare and privatisation of health systems, as prescribed by the World Bank reports in 1987 and 1993.

Because of the devastating effects of payments during health shocks, OOPS became politically untenable and UHC was seen as a solution. Evidence of adverse effects of user charges was mounting too.   In a way, for many international institutions, promotion of UHC meant a reversal of some of their previously held policy positions.

In 2014, the World Bank president Jim Yong Kim admitted : “There’s now just overwhelming evidence that those user fees actually worsened health outcomes. There’s no question about it. So did the bank get it wrong before? Yeah. I think the bank was ideological”.

Unfortunately, this new consensus has not yet shown much policy impact in India. The Indian public healthcare delivery system still has user charges, and exemptions for low-income groups are known to be extremely ineffective. The system is also being pushed towards an insurance-based model, which promotes private sector providers. Reportedly, India’s efforts towards UHC is to be based on the experience of Rashtriya Swasthya Bima Yojana (RSBY)– an insurance-based scheme targeting households below the poverty line.

This centrally sponsored scheme – which has been in operation for seven years – gives selected poor families (up to five members) an annual coverage of up to $470 worth of secondary level care for an annual fee of less than half a US dollar. RSBY, and several similar regional schemes operating in the last ten years have failed to significantly expand coverage – official data just released indicate that as much as 86% of the rural population and 82% of the urban population are still not covered under any government sponsored insurance scheme.

Despite the inconclusive and generally negative evidence on its impact, the high praise given to RSBY and other health insurance schemes by influential agencies including the World Bank and the International Labour Organisation (ILO) has contributed significantly to its policy popularity. An Oxfam paper described such praise as “both premature and dangerously misleading”.

Evidence-based policymaking?

Despite the popularity of government- funded insurance schemes at the highest levels of policymaking, there is resistance within the government structures to objectively evaluate the performance and impact of the schemes. Fan and Mahal (2011) observed that politicians and administrators often presume that independent evaluations cause more damage than benefit, and governments in India are known to be hesitant towards conducting independent evaluations of health insurance schemes such as RSBY. It is often claimed that some “rigorous assessment” of its impact is done, but RSBY shares the scheme data “only with a carefully selected group of researchers” – this lack of transparency prevents public scrutiny.

Until now there is no disaggregated data available on government’s reimbursement to the health providers through RSBY. Simply put, we do not know how much money is going to the private sector, or how much is flowing back to the public sector. After it was quoted as a successful international UHC case study, and a potential model to expedite India’s UHC, the RSBY data portal stopped uploading even the basic state level data, which was being infrequently updated earlier.

The latest data available on the portal is from the first quarter of 2014. The latest evaluation published is from the first quarter of 2013. For many states like Bihar, latest data from many districts are from 2012. The allegation that RSBY is a private sector subsidy scheme still stands, particularly in the light of high prevalence of corruption and the limited or even negative impact that the scheme seems to have on OOP spending.

In the light of latest government’ evidence showing that a decade of promoting health insurance schemes across the country has resulted in only about 12% urban and 13% rural population getting covered, there is dire need of a rethink about how India can really achieve UHC. It needs to start with strengthening the public system that India already has rather than reinventing the wheel.



Examining evidence: the private for-profit healthcare sector and Universal Health Coverage (UHC) Jessica Hamer, Health Policy Adviser, Oxfam GB

On 2nd July 2015 at the International Conference on Public Policy (ICPP), Oxfam, together with Dr. Anuj Kapilashrami of the Global Public Health Unit, University of Edinburgh, convened a session entitled ‘Private sector and Universal Health Coverage: Examining evidence and deconstructing rhetoric’.

As an earlier blog explained, the session aimed to look at new and existing evidence on the role of the private for-profit sector in health, and to critically evaluate this in the context of achieving UHC in low- and middle-income countries. The five papers presented at the session looked at a wide range of private sector actors in health care delivery but raised a number of common themes and challenges.


High costs, and continued challenges around out-of-pocket spending (OOPS), was a common theme across the papers. One paper presented by Asha Kilaru, examined state insurance schemes in Karnataka, India, and found that OOPS were prevalent across the schemes, even where all costs should be covered. The study found 93% of those insured by at least one government scheme sought care from a private hospital, but only 8% reported receiving completely free care. Where healthcare was provided for free, additional costs (such as multiple hospital referrals for different tests and treatment) meant OOPS still occurred.  It seems that this was a problem particularly associated with private provision of healthcare, as evidenced by one respondents’ interview:

‘Only the operation [C-section] was free. At the government hospital, a C-section would be only Rs3-4000, but we went to a private hospital since we had insurance and wound up spending so much. It seems like government are agents that send us to a private hospital. In this yojana [Yeshasvini insurance scheme] the government spends and we also spend’.[i]

Difficulties faced in controlling the level of fees charged by private providers were also highlighted. In a paper by Jane Doherty examining the for-profit private healthcare sector in East and Southern Africa, it was noted that out of sixteen countries, ‘no country places a ceiling on the prices that its private hospitals may charge’ (although there may be some limitations to reimbursement payments made by insurers in two of the countries). The paper also explained that ‘there is little control of the fees charged by health professionals or limits placed on their total incomes, except in Kenya’.

Equity and access for the poorest

Challenges in controlling OOPS and the overall costs of private healthcare present significant obstacles to achieving UHC, and especially to ensuring access to healthcare for the poorest. Another recurring barrier to equitable access highlighted is the location of private services. A paper mapping India’s private healthcare provision by Mukhopadhyay et al highlighted that urban, metropolitan areas benefit from the majority of private hospitals, while in rural areas, disproportionately populated by poorer people, the private sector is largely comprised of individual practitioners. Moreover, almost half of India’s private hospitals were located in cities with a population of more than 5 million. Mumbai alone has 16% of all India’s private hospitals.

Poor quality and regulatory challenges

Usar’s paper investigating perceptions of shops selling medicines in Nigeria highlighted major concerns around their ‘pervasive regulatory infringements’ – and especially the selling of drugs beyond the scope of their licenses – as well as the lack of training of staff. The same paper pointed to the challenges of regulating medicine vendors in Nigeria in order to improve their quality, highlighting that regulation has been constrained by inadequate funding, weak institutional capacity, the often-remote location of the shops, and inter-regulatory agency conflicts.

Doherty’s research examining East and Southern Africa’s for-profit private providers pointed out that both an absence of regulation, and poor enforcement of regulation where it exists, contribute to problematic dynamics around private sector healthcare actors there. We have already heard how little legislation exists to control costs within the sector, but the study also found that that there is almost no regulation that guards against anti-competitive behaviour. Furthermore, ‘there is little monitoring by governments of quality and health outcomes, or attention to how the private health sector supports national health objectives’.

The same paper flags additional challenges to regulation, including patchy regulatory frameworks, the high cost of introducing new regulation, limited available information on the private sector, and the resistance of key stakeholders to regulation, or their “capture” of regulation to safeguard their own interests. In South Africa, for example, attempts to regulate dispensing fees for pharmacists have been resisted heavily.

Impact on the public system

Doherty concludes that ‘legislative gaps and enforcement problems, together with the fact that prices are not contained in any meaningful way, either through price controls or active reimbursement mechanisms, mean that for-profit private care in the region is likely to become increasingly unaffordable for any but the wealthiest’. Yet, if the for-profit private sector is poorly regulated and potentially growing, what impact could this have on the public health system left for the majority of the population?

Doherty points to South Africa as an example, where one impact of a strong private sector has been the ‘brain drain’ of human resources away from the public sector to much more lucrative private providers. The final paper by Jisha C. J., examining a state health insurance scheme in India (Kerala), highlights an additional worrying trend, where some private hospitals register in the state insurance scheme, only to de-register themselves once they have attracted some new patients to their facility. It can be assumed this trend will waste public resources spent on administration, as well as raising serious concerns about both equitable access and the behaviour of private providers.


The evidence presented at the Oxfam-University of Edinburgh session makes a further contribution to the debates over the role of the private sector in achieving UHC. While the papers can only shed light on the specific areas they analyse, it is clear that the wider themes they highlight chime with the findings of broader studies on the comparative roles of the public and private sectors.

Oxfam hopes to continue these discussions further, and will be hosting additional blogs on Global Health Check from the contributing authors and discussants exploring the details of the evidence presented in the coming months.



[i] The paper notes that ‘while it is claimed that [the] Yeshasvini [scheme] is self-funded, it received Rs. 40 crore as a government grant in 2012-13 and Rs. 45 crore in the 2013-14 budget’. Rs 40 crore is equivalent to more than USD 6 million while Rs 45 crore is equivalent to almost USD 7 million.



Private for profit providers and UHC: a panel discussion at the International Conference on Public Policy, Milan 1-3 July 2015 by Mohga Kamal-Yanni

Private for profit and UHC: a panel discussion at the International Conference on Public Policy, Milan 1-3 July 2015

In 2012, the UN General Assembly unanimously adopted a resolution to encourage governments to transition towards universal access to affordable and quality health-care services. In 2013, the WHO Director-General described UHC as “the single most powerful concept that public health has to offer”.

A range of financing and delivery mechanisms have since been implemented in diverse international contexts, with limited empirical evaluation of their potential to achieve equitable access to universal health coverage. Financing health care will be negotiated as part of the Financing for Development conference in Addis Ababa in July 2015.

There is strong evidence that no country has achieved or made big strides towards achieving UHC without a strong public health system, yet the position of the private-for-profit sector in UHC reforms remains a subject of wide debate.

At the International Conference on Public Policy in Milan (1-4 July 2015), Oxfam and the University of Edinburgh are co-hosting panel discussion that seeks to examine new and existing evidence on the role of the private sector in health – and the paradigm of public- private partnerships. The session aims to enhance understanding and knowledge of the nature and scope of public-private interactions in health, and to critically evaluate the role of the private for-profit sector in health in the context of achieving UHC in low- and middle-income countries. The session will do this by:

  • Exploring a range of questions around for-profit private roles and interests in public health, focusing on UHC
  • Examining evidence on the role of the for-profit private sector in a range of health systems functions, and across different national contexts
  • Promoting discussion on theoretical and methodological frameworks that can be used to examine the implications of the private sector’s engagement with public healthcare systems

The session will have a strong focus on low- and middle-income country experiences, perspectives and debates, but will also welcome relevant evidence and experience from high-income countries.

Five papers will be presented covering the following:

  1. Achieving UHC in East and Southern Africa: What role for for-profit providers? Jane Doherty, School of Public Health, University of the Witwatersrand
  2. Changing landscape of private health care providers in India: implications for national level health policy, Indranil Mukhopadhyay, Public Health Foundation of India
  3. State insurance schemes in Karnataka and users’ experiences – issues and concerns, Asha Kilaru, independent researcher
  4. The Comprehensive health insurance scheme in Kerala: an exploratory study in Kollam district, Kerala, India, Jisha Jayasree, Jawahar Lal Nehru University
  5. Universal Health Coverage for rural communities in Nigeria:: How may patent medicine vendors be effectively engaged? Iornumbe Usar, University of Jos, Nigeria

The papers will be discussed by Dr. Mark Hellowell, University of Edinburgh and Professor Rama Baru from Jawaharlal Nehru University.

The session will be co-chaired by Anuj Kapilashrami from the University of Edinburgh and Mohga Kamal-Yanni from Oxfam. Chairs and discussants will also engage the audience through ‘question and answer sessions where panellists will reflect on substantive issues raised by the presentations, panellists’ own research and interjection from the audience.

Readers are invited to participate in the session via sending comments and questions via twitter. Please follow @MohgaKamalYanni @Akapilashrami

Look out for a follow up blog on the conclusions of the session and links to the presentations.

The research papers are available here.





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