INTER-SECTORAL COORDINATION INTER-SECTORAL COORDINATION IN HEALTH CARE DELIVERYIN HEALTH CARE DELIVERY

Yade Lal TekhreYade Lal TekhreFormer ProfessorFormer Professor

Department of Social SciencesDepartment of Social SciencesNational Institute of HealthNational Institute of Health

and Family Welfare,and Family Welfare,New Delhi, IndiaNew Delhi, India

yadelal20@yahoo.cayadelal20@yahoo.ca

INTER-SECTORAL INTER-SECTORAL COORDINATION COORDINATION

IN HEALTH CARE DELIVERYIN HEALTH CARE DELIVERY

What to doWhat to do

• Discuss the concept of inter- Discuss the concept of inter- sectoral coordinationsectoral coordination

• List out of the various List out of the various organizations for ISC at district organizations for ISC at district levellevel

• Describe likely mechanism of Describe likely mechanism of coordinationcoordination

WHY INTER-SECTORAL WHY INTER-SECTORAL COORDINATION IS NEEDEDCOORDINATION IS NEEDED

ISCISC for achieving health for achieving health goals has been accepted as goals has been accepted as one of the one of the guiding principles guiding principles of the health strategyof the health strategy that that was adopted at the was adopted at the international conference on international conference on primary health care.primary health care. (Alma-Ata, USSR, 1978)(Alma-Ata, USSR, 1978)

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There are many There are many governmental governmental departments and departments and agencies working for agencies working for people whose people whose activities activities are closely linkedare closely linked with with healthhealth, as health itself is , as health itself is a multi-sectoral subjecta multi-sectoral subject

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1.1. Clean waterClean water2.2. SanitationSanitation3.3. Pollution free environmentPollution free environment4.4. Economic conditionsEconomic conditions5.5. Food production etc.Food production etc.

Health is an essential component of Health is an essential component of all developmental activities. all developmental activities. Multilateral linkages exist between Multilateral linkages exist between health, socio-cultural, political and health, socio-cultural, political and economic spheres.economic spheres.

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Earlier health care system Earlier health care system focused more on focused more on ’curative’curative’ rather ’ rather than ‘than ‘preventivepreventive’ aspects’ aspects

The coordinated health care The coordinated health care activities involved activities involved working with working with peoplepeople, , PRIPRI member, local member, local groups, groups, youthyouth clubs, clubs, Mahila Mahila MandalsMandals, , self-helps groupsself-helps groups, and , and NGOsNGOs etc. etc.

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COLLABORATION IS COLLABORATION IS

–More More participativeparticipative–Implies Implies commitmentcommitment–EconomizesEconomizes efforts efforts–Improves Improves qualityquality of work of work–Avoid Avoid duplicationduplication and wastage and wastage–OptimizesOptimizes output output

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‘‘Willing cooperation and Willing cooperation and agreement to agreement to collaborate leads to collaborate leads to effective coordinationeffective coordination’ ’ the ultimate aim of the ultimate aim of coordination is coordination is convergenceconvergence of health care of health care services in the communityservices in the community

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MEANING:MEANING:

Coordination is an Coordination is an administrative administrative processprocess which seeks to bring about unity which seeks to bring about unity of purpose in order to of purpose in order to achieve common achieve common objectivesobjectives. Coordination implies a . Coordination implies a cooperative situationcooperative situation where two or more where two or more participants have a common goal and participants have a common goal and where where each has sufficient informationeach has sufficient information as as to what others are going to do to enable to what others are going to do to enable him to make him to make correct decisioncorrect decision..

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Convergence is a process--- that Convergence is a process--- that facilitatesfacilitates different functionariesdifferent functionaries and and communitycommunity to work together for to work together for efficient service delivery.efficient service delivery.

CONVERGENCE LEADSCONVERGENCE LEADS THIRSTTHIRSTTT = = TIME SAVINGTIME SAVINGHH = = HELPS IN BUILDING RAPPORT WITH OTHERSHELPS IN BUILDING RAPPORT WITH OTHERS

II = = INCREASES EFFICIENCYINCREASES EFFICIENCYRR = = REDUCES WORKLOADREDUCES WORKLOADSS = = SHARING OF IDEASSHARING OF IDEASTT = = TRUSTWORTHYTRUSTWORTHY

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NEED FOR COORDINATION IN NEED FOR COORDINATION IN HEALTH CARE DELIVER SYSTEMHEALTH CARE DELIVER SYSTEM

MOST of the times these programme MOST of the times these programme pursue the achievement of their pursue the achievement of their specific objectives in a specific objectives in a vertical mannervertical manner loosing sight of the ultimate goal of loosing sight of the ultimate goal of primary health careprimary health care. It is to ensure . It is to ensure unity of purpose and direction and to unity of purpose and direction and to encourage team workencourage team work to deliver primary to deliver primary health care at various levelshealth care at various levels

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TYPES OF COORDINATIONTYPES OF COORDINATIONWITHIN the department – WITHIN the department – Intra-sectoralIntra-sectoralBETWEEN the department – BETWEEN the department – Inter-sectoral coordinationInter-sectoral coordination

Intra-sectoral coordinationIntra-sectoral coordination:: AT the district AT the district level- number of programme such as level- number of programme such as malaria control, leprosy, blindness malaria control, leprosy, blindness control, MCH, Immunization, NRHM control, MCH, Immunization, NRHM etc. is implementing. Many of these etc. is implementing. Many of these programmes are adopting similar programmes are adopting similar strategies but they go on their strategies but they go on their separate ways in the field.separate ways in the field. 1212

FREQUENTFREQUENT meetings, sharing of meetings, sharing of experience and success stories etc. experience and success stories etc. will be helpful in fostering will be helpful in fostering intra-intra-sectoral coordination sectoral coordination INTER-SECTORAL COORDINATION: INTER-SECTORAL COORDINATION: Alma-Ata declaration has also Alma-Ata declaration has also suggested suggested multi sectoral approachmulti sectoral approach as as one of the basic principles underlying one of the basic principles underlying primary health careprimary health care. The changes in . The changes in other sectors affect health and other sectors affect health and similarly health affects the similarly health affects the development in other sectors alsodevelopment in other sectors also

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CONSTRAINTS IN INTER-CONSTRAINTS IN INTER-SECTORAL COORDINATIONSECTORAL COORDINATION

THREE THREE LEVELLEVEL PROBLEMS: PROBLEMS:

1.1. At the At the KNOWLEDGEKNOWLEDGE level level2.2. At the At the ATTITUDINALATTITUDINAL level level3.3. At the At the PRACTICEPRACTICE level level

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KNOWLEDGEKNOWLEDGE - -

Lack ofLack of knowledge of knowledge of other other programmes and goalsprogrammes and goals of other of other sectors. Each programme is sectors. Each programme is implemented in an isolated manner. implemented in an isolated manner. For example Health Deptt. may not For example Health Deptt. may not know the goals of know the goals of ICDS programmeICDS programme, , which in turn may not be aware of which in turn may not be aware of the goals of RCH programme etc. the goals of RCH programme etc. This leads to This leads to misunderstandingmisunderstanding, , repetition and some times even repetition and some times even contradictions, which contradictions, which affect the affect the credibility.credibility. 1515

ATTITUDEATTITUDE - -

POWER conflict and egoist attitudes POWER conflict and egoist attitudes based on the dogmatic belief of based on the dogmatic belief of ‘my ‘my programmeprogramme’’, ‘, ‘why shouldwhy should I I’’ and and ‘could not care less’ act as a barrier ‘could not care less’ act as a barrier in the way of mutual understanding in the way of mutual understanding and team work. The feeling of and team work. The feeling of ‘why ‘why should I go, the other person should should I go, the other person should come forward’come forward’.. The attitudes are The attitudes are often based on misconception—often based on misconception—coordination means more work and coordination means more work and assuming responsibility for others assuming responsibility for others work. work.

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Clear understanding of the concept Clear understanding of the concept of coordination is required to change of coordination is required to change the the mind setmind set of functionaries. The of functionaries. The personality of the leader is also of personality of the leader is also of critical importance in this case. critical importance in this case. Authoritarian leadership will not be Authoritarian leadership will not be useful. Democratic leadership useful. Democratic leadership encouraging encouraging frequent participative frequent participative consultations and decision makingconsultations and decision making will foster coordination.will foster coordination.

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PRACTICEPRACTICE - -

Lack of knowledge about the Lack of knowledge about the mechanismsmechanisms. People do not know . People do not know how to go about it and how to how to go about it and how to formalize it. The formal mechanism formalize it. The formal mechanism such as such as constitution of Advisory constitution of Advisory Committees, Coordination Committees, Coordination Committees, Task-forcesCommittees, Task-forces etc. foster etc. foster coordination. People feel that coordination. People feel that coordination means ‘coordination means ‘additional additional responsibilitiesresponsibilities’ ’

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Pre-requisites for Effective Pre-requisites for Effective ISCISC

leadershipleadership style and willingness style and willingnessHealth Health policies and prioritiespolicies and prioritiesSharing of a Sharing of a common visioncommon vision and and perspectiveperspectiveDefiningDefining role and responsibilities of role and responsibilities of participatory agenciesparticipatory agenciesParticipatoryParticipatory decision making decision makingDevelopingDeveloping informal contacts with involved informal contacts with involved groupsgroupsLearningLearning more about quality of services more about quality of servicesSpelling out Spelling out strategiesstrategies and procedures and proceduresConductingConducting joint monitoring and evaluation joint monitoring and evaluationTaking Taking immediateimmediate remedial measures in solving remedial measures in solving problems related to coordination/resource problems related to coordination/resource mobilizationmobilization 1919

Areas of Inter Sectoral Areas of Inter Sectoral CoordinationCoordination

PROMOTION OF NUTRITIONPROMOTION OF NUTRITIONAgricultureAgricultureEducationEducationSocial Welfare/Women and Social Welfare/Women and Child DevelopmentChild DevelopmentPanchayatsPanchayatsAnimal HusbandryAnimal HusbandryCooperativeCooperativeBanksBanks

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Some of the activities of health Some of the activities of health department providing scope for department providing scope for inter-sectoral coordination are:inter-sectoral coordination are:– Supply of safe water, Supply of safe water, – Excreta disposal and refuse disposal, Excreta disposal and refuse disposal, – Waste water disposal, Waste water disposal, – Maternal and child health, Maternal and child health, – Family welfare, immunization against Family welfare, immunization against

major infectious diseases, major infectious diseases, – Prevention and control of locally Prevention and control of locally

endemic diseases, and health education endemic diseases, and health education on prevailing health problems.on prevailing health problems.

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MECHANISM OF COORDINATIONMECHANISM OF COORDINATIONLISTINGLISTING out the programmes which need joint out the programmes which need joint effortseffortsIDENTIFYINGIDENTIFYING the areas where coordination is the areas where coordination is requiredrequiredKNOWINGKNOWING the categories of health personnel the categories of health personnel whose activities should be integratedwhose activities should be integratedLOCATINGLOCATING the level of health systems where the level of health systems where joint efforts are neededjoint efforts are neededFORMINGFORMING coordination committee of members coordination committee of members of district health team which includes all the of district health team which includes all the middle level supervisors and specialized middle level supervisors and specialized functionariesfunctionariesFORMINGFORMING of operation teams at field level of operation teams at field level

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Steps in Planning Inter-Steps in Planning Inter-sectoral Coordinationsectoral Coordination

LISTINGLISTING THE PROGRAMMES, THE PROGRAMMES, IDENTIFYINGIDENTIFYING - THE AREAS/ - THE AREAS/

ACTIVITIES; ACTIVITIES; DIFFERENTDIFFERENT ORGANIZATIONS AND ORGANIZATIONS AND

AGENCIES; AGENCIES; GOODGOOD LOCAL NGOs to facilitate LOCAL NGOs to facilitate

community’s involvement;community’s involvement; DEVELOPING AN ACTION PLAN FOR:DEVELOPING AN ACTION PLAN FOR:

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–Independent tasksIndependent tasks–Joint tasksJoint tasks–Sharing of resourcesSharing of resources–Field work teamsField work teams

Create informal forum for Create informal forum for meetings; acknowledgement and meetings; acknowledgement and appreciation of all partners’ appreciation of all partners’ efforts in achieving the targets.efforts in achieving the targets.

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INVOLVING THE COMMUNITY FOR INVOLVING THE COMMUNITY FOR

COMMUNITY PARTICIPATIONCOMMUNITY PARTICIPATION

Community participation has been Community participation has been identified as an important means of identified as an important means of overcoming sectoral barriersovercoming sectoral barriers. It is . It is the community and its involvement the community and its involvement that best motivates that best motivates collaboration collaboration between sectors through the between sectors through the communitycommunity, health goals can be , health goals can be linked to and reinforces other goals linked to and reinforces other goals of well being.of well being.

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THE process of community THE process of community participation is therefore by participation is therefore by no means easyno means easy. .

It is a long arduous task It is a long arduous task but but results are good and results are good and lastinglasting. The ranges of . The ranges of activities of community activities of community participation therefore participation therefore include the following:include the following:

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1.1. HelpingHelping community to analyze their problems community to analyze their problems and their causes.and their causes.

2.2. To To identifyidentify the needs and prioritize them in a the needs and prioritize them in a logical manner. Sometimes felt needs of the logical manner. Sometimes felt needs of the community may be different from the community may be different from the perceived need of the health professional.perceived need of the health professional.

3.3. To To planplan activities to meet these needs/solve activities to meet these needs/solve the problems and to find resources for them.the problems and to find resources for them.

4.4. To To monitormonitor closely the implementation of closely the implementation of programmes.programmes.

5.5. Last but not the least to own the programme by Last but not the least to own the programme by assumingassuming full responsibilityfull responsibility for its for its implementation.implementation.

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Advantages of Community Advantages of Community ParticipationParticipation

MORE achievement at MORE achievement at lower costlower costCATALYSTCATALYST for further development for further developmentDEVELOPS a DEVELOPS a sense of ownershipsense of ownership and and subsequently responsibility in subsequently responsibility in utilization and maintenance of health utilization and maintenance of health care servicescare servicesINCULCATES INCULCATES self-relianceself-reliance by by enhancing the use of local indigenous enhancing the use of local indigenous expertiseexpertise

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IMPEDIMENT/OBSTRUCTION/BARRIER/BLOCKAGE TO IMPEDIMENT/OBSTRUCTION/BARRIER/BLOCKAGE TO

COMMUNITY PARTICIPATION IN HEALTH CARECOMMUNITY PARTICIPATION IN HEALTH CARE

THE health care system in the country is THE health care system in the country is not having not having roots in the cultureroots in the culture and traditions of our people. and traditions of our people.

HEALTH need not be viewed in an isolated mannerHEALTH need not be viewed in an isolated manner

HEALTH personnel do HEALTH personnel do not have the requisite attitudesnot have the requisite attitudes and and skills to work with the communityskills to work with the community. There is a gap . There is a gap between ‘providers’ and ‘users’.between ‘providers’ and ‘users’.

PRE-OCCUPATION with targets and infra-structural PRE-OCCUPATION with targets and infra-structural issues, issues, bureaucratizationbureaucratization and compartmentalization of and compartmentalization of various departments and sectors, and lack of various departments and sectors, and lack of coordination among them.coordination among them.

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Innovative Projects In Community Innovative Projects In Community Participation In HealthParticipation In Health

Rangabela project, West BengalRangabela project, West Bengal

Comprehensive Rural Development Comprehensive Rural Development Project, Jamkhed, MaharashtraProject, Jamkhed, Maharashtra

RUSHA Integrated Health and RUSHA Integrated Health and Community Development Project, Community Development Project, Vallur, Tamil Nadu.Vallur, Tamil Nadu.

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AN ANALYSIS of successful AN ANALYSIS of successful community based projects highlights community based projects highlights the following learning experiences:the following learning experiences:

An attempt to An attempt to integrate health with integrate health with development activitiesdevelopment activitiesPreventive and promotive orientationsPreventive and promotive orientationsSearch for an Search for an appropriate technologyappropriate technologyPromotion and utilization of Promotion and utilization of local local resourcesresourcesTraining of Training of locallocal health workers health workersInvolvingInvolving people’s groups and people’s groups and organizationsorganizations

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Some Significant Strategies For Enhancing Some Significant Strategies For Enhancing Community ParticipationCommunity Participation

Recruitment of local frontline health Recruitment of local frontline health workersworkersWorking with local groupsWorking with local groupsWorking with NGOsWorking with NGOsUse of PRA/PLA techniquesUse of PRA/PLA techniquesDevelopment and use of simple Development and use of simple indigenous technologiesindigenous technologiesDemand driven approach rather than Demand driven approach rather than supply driven approachsupply driven approach

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Role of Panchayati Raj Role of Panchayati Raj Institutions in Health and FWInstitutions in Health and FW

7373rdrd Constitutional amendment given Constitutional amendment given adequate adequate powers to Gram Panchayatpowers to Gram Panchayat for the development of its village and for the development of its village and health is one of the major componentshealth is one of the major componentsThe Village Health Plan is considered The Village Health Plan is considered as the first step in enabling village as the first step in enabling village communities to take charge of their communities to take charge of their own health needsown health needs

The 73rd constitutional The 73rd constitutional amendment, which prescribes amendment, which prescribes uniform structureuniform structure of local of local governments throughout the governments throughout the country, provides the basis country, provides the basis for conceptualising the role of for conceptualising the role of PRIs for local PRIs for local self-governance self-governance and developmentand development

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Within the PRIs Village Health Within the PRIs Village Health Committee Committee ((Swasthya SamitiSwasthya Samiti)) is an is an important entity, it has to be important entity, it has to be strengthened and links have to be strengthened and links have to be established with block and District established with block and District level units with special reference to level units with special reference to capacity building; capacity building;

Role and responsibility has to be Role and responsibility has to be fixed at the other side towards fixed at the other side towards betterment of health of the villagersbetterment of health of the villagers

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Functions of Panchayati Raj Functions of Panchayati Raj Institutions ( XIth Schedule)Institutions ( XIth Schedule)

(11) Drinking Water;(11) Drinking Water;(16) Poverty Alleviation (16) Poverty Alleviation

Programmes; Programmes;(17) Education;(17) Education;(23) Health & Sanitation including (23) Health & Sanitation including

Hospitals; Primary Health Hospitals; Primary Health Centers & Dispensaries; Centers & Dispensaries;

(24) Family Welfare;(24) Family Welfare;(25) Women and Child Development;(25) Women and Child Development;(28) Public Distribution System.(28) Public Distribution System.

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According to PRI Act, out of According to PRI Act, out of 29 subjects29 subjects five five subjects are directly associated with the subjects are directly associated with the health and family welfare, which are: health and family welfare, which are:

1.1.Safe drinking water,Safe drinking water,2.2.Health and sanitation Health and sanitation

(including health centers)(including health centers)

3.3.Family welfare,Family welfare,4.4.Women and child development,Women and child development,5.5.Social welfare Social welfare (including Physically and (including Physically and

mentally challenged mentally challenged))

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"involvement of Panchayat Raj "involvement of Panchayat Raj institutions for ensuring inter sectoral institutions for ensuring inter sectoral coordination and community coordination and community participation in planning, monitoring participation in planning, monitoring and management", although medical and management", although medical practitioners in voluntary and joint practitioners in voluntary and joint sectors, industries in the organized sectors, industries in the organized and the unorganized sectors and and the unorganized sectors and labour representatives have also been labour representatives have also been bracketed with PRIs for such bracketed with PRIs for such involvement. Planning commissioninvolvement. Planning commission 3838

Health is a very critical sector in Health is a very critical sector in these arrangements. In the existing these arrangements. In the existing arrangement of allocation of arrangement of allocation of responsibilities, responsibilities, health system right health system right from sub-centers to the district from sub-centers to the district hospitals including family welfare hospitals including family welfare apparatus falls inapparatus falls in the domain of the domain of PRIsPRIs. It is expected that PRIs would . It is expected that PRIs would promote public participation in health promote public participation in health and family welfare management and and family welfare management and develop strong affinity and develop strong affinity and ownership feeling towards ownership feeling towards institutions and programmes institutions and programmes associated with themassociated with them

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The PRIs, therefore, would be The PRIs, therefore, would be policy making bodiespolicy making bodies in their in their own jurisdiction. To discharge own jurisdiction. To discharge this role, they would have to this role, they would have to gather necessary information, gather necessary information, interact with technical personnel, interact with technical personnel, consult local people through consult local people through various Institutionsvarious Institutions in which they in which they participate and associate experts participate and associate experts and non-experts outside the and non-experts outside the Government Government

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Basic characteristics of PRIs in Basic characteristics of PRIs in Health and Family WelfareHealth and Family Welfare

PRIs are a set of democratically elected PRIs are a set of democratically elected structures of self-governance at three structures of self-governance at three levelslevelsThe National Population Policy (NPP) The National Population Policy (NPP) 2000 has put a great deal of emphasis 2000 has put a great deal of emphasis on the role of PRIs in formulating and on the role of PRIs in formulating and implementing area specific policies and implementing area specific policies and programmers relevant for population programmers relevant for population stabilization and other programmesstabilization and other programmes

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Panchayats have been considered Panchayats have been considered useful for promotional and motivational useful for promotional and motivational activities in respect of activities in respect of small and small and healthier families healthier families PRIs could be rewarded for PRIs could be rewarded for universalizing universalizing small family normsmall family norm, , achieving reductions in infant mortality achieving reductions in infant mortality and birth rates and promoting literacy and birth rates and promoting literacy with completion of primary schooling with completion of primary schooling Panchayat should appoint a competent Panchayat should appoint a competent and mature midwife assisted by and mature midwife assisted by volunteers to look after volunteers to look after village village maternity hutmaternity hut

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Thank youThank you