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FAD/EUO Joint Conference on Public Health Care Reforms: Challenges and Lessons for Advanced and Emerging Europe




Keynote Address by Mr. Naoyuki Shinohara, Deputy Managing Director, IMF

Ladies and gentlemen, I am delighted to be here and to participate in this important conference on public health care reform in Europe. This morning’s discussion has already been extremely enlightening and productive, and I look forward to learning more this afternoon.
Despite a temporary slowing of economic activity, we expect the global recovery to continue, with world GDP growth projected at 4.3 percent this year and 4.6 percent in 2012. Downside risks, however, have increased again, and the global expansion remains unbalanced. Growth in many advanced economies is still weak, while growth in most emerging and developing economies continues to be strong. Greater-than-anticipated weakness in U.S. activity and renewed financial volatility from concerns about the fiscal challenges in the euro area periphery pose greater downside risks. There are also risks from persistent fiscal and financial sector imbalances in many advanced economies, while signs of overheating are becoming increasingly apparent in many emerging and developing economies. Against this background, my remarks today will concentrate on the fiscal policy challenges facing our member countries, and the potential role of public health care reform in helping countries meet these fiscal challenges.

The Fiscal Situation
In advanced economies, fiscal deficits remain very large, and the average public debt ratio by end-year will breach 100 percent of GDP for the first time since the aftermath of World War II. These fiscal trends are clearly not sustainable. Although countercyclical fiscal policy helped to save the global economy from a far deeper downturn, the fiscal fallout of the crisis now needs to be addressed if the recovery is to be sustained. The central challenge is to avert potential future fiscal crises, while at the same time maintaining social cohesion.
Fiscal consolidation is proceeding at a broadly appropriate pace in many advanced economies, notably in most of Europe and in Canada. Fiscal adjustment in Europe is also being accompanied by a strengthening of institutions and rules. In the United States, strong revenue growth and a slower pacae of spending mean that the 2011 budget deficit is now expected to be similar to 2010 in cyclically-adjusted terms, rather than expansionary as originally expected. This will make the planned adjustment in 2012 less abrupt, reducing the risk that it could negatively affect growth prospects. Nevertheless, consensus on a credible medium-term adjustment plan is still urgently needed. Similarly, a detailed medium-term adjustment plan is still missing in Japan, where the humanitarian costs of the recent natural disaster has led to a significant weakening of the fiscal accounts.
In some prominent adjustment cases in Europe, mostly notably Greece, Ireland, and Portugal, risk perceptions are rising, as reflected in sharp increases in bond spreads. This underscores the need for the European countries to work cooperatively to develop a comprehensive and consistent approach to crisis management in the euro area.
Against the backdrop of this historic fiscal challenge in the advanced economies, spending pressures from health care have been rising steadily. Since 1970, total health spending as a share of GDP has nearly doubled in the advanced economies, to almost 12 percent of GDP. Two-thirds of this increase was due to higher public health spending. As we heard this morning, prospects going forward are worrisome: with unchanged policies, IMF staff expects annual spending on public health in the advanced economies to increase by an average of 3 percentage points of GDP over the next 20 years, and by 6½ percentage points of GDP over the next 40 years.
These baseline projections assume no changes in the present roles of the public and private sector in financing and providing health care. Of course, these roles vary widely across countries, reflecting differences in country preferences and constraints. Indeed, there is no optimal level of public health spending that can provide a benchmark for comparing countries. Nevertheless, there is a need to ensure that whatever model a country adopts, public health care services are provided in an efficient way.
In this context, the projected increase in public health spending is also a concern because in most countries, this spending is not very efficient. This can be illustrated by examining the gains countries could achieve by getting rid of these “efficiency gaps” in health spending. This efficiency gap provides an estimate of the difference between the life expectancy countries currently achieve and the best performing countries at similar levels of spending. Based on the recent work by the OECD, cutting the efficiency gap in half could increase life expectancy by over one year. Achieving this through higher spending, in contrast, would require an increase in spending of 30 percent.
Turning to the emerging economies, the overall fiscal outlook appears more favorable, although this in part reflects the tail winds of high asset and commodity prices, low interest rates, and strong capital inflows. Their reversal could leave fiscal positions exposed in many cases. Further, some of these economies may be overheating, and need to make faster progress in reducing deficits to help offset pressures from rising domestic demand. For many emerging economies, the adverse fiscal impact of high fuel and food prices is also a major challenge.
Of course, in many emerging economies, including in emerging Europe, fiscal consolidation is also proceeding at an appropriate pace, and financial markets have recognized this. Further fiscal consolidation will nevertheless be needed in the years to come. Emerging Europe also faces long-term pressures on public health care and pension spending. This spending is projected to rise by an average of 4 percentage points of GDP over the next 20 years, compared with 2 percentage points of GDP in the emerging economies as a whole. In Russia, Turkey, and Ukraine, for example, this spending would rise by 4½ percentage points of GDP or more over the next 20 years, adding substantially to the burden of fiscal adjustment.

A Fiscal Strategy for Advanced Economies
What is needed to address the fiscal problems of advanced economies? First, I believe it is important to be clear about the final goal of any fiscal adjustment strategy. In my mind, there is no doubt that it should be to lower public debt ratios to more prudent levels, not just to stabilize them at post-crisis levels. The April Fiscal Monitor underscores that the magnitude of the adjustment needed to lower debt ratios is daunting. But the task is not impossible. The necessary ingredients include the right combination of expenditure cuts and revenue increases and reforms of age-related spending, including health.
Expenditure cuts will need to dominate the required adjustment process, but some revenue increases are likely to be necessary in several countries, given the magnitude of the necessary adjustment. This is especially true in countries with relatively low spending ratios. Consumption taxes may prove to be an important source of potential revenues. More generally, classic tax reforms—encompassing broadening tax bases while simplifying rules and rates—would be appropriate in many advanced economies. A key goal should be rolling back tax expenditures, as this would bring in substantial revenue while also improving both the efficiency and fairness of tax systems.
Expenditure reform should be guided by the desire to improve the efficiency of spending while ensuring equity. Cutting spending across the board has not proven to be very effective in the past, except in the very short run. A more strategic approach is needed when the adjustment effort is large and expected to be sustained over time. In many countries, better targeting of social welfare spending could provide substantial fiscal savings. There is also scope to reduce spending on subsidies, including agricultural subsidies, which are still large in some advanced economies. An effort is also needed to lower military spending over the medium term.
As part of the adjustment strategy, fiscal consolidations must also deal with the long-term spending pressures from age-related spending. Given the projected increases in both pensions and health spending, an ambitious goal for countries would be to stabilize this spending as a ratio of GDP. On pensions, many countries have already undertaken reforms, such as raising retirement ages. Pension spending is projected to rise by 1 percentage point of GDP over the next 20 years. This increase will need to be offset through further reforms.
Challenges are even more daunting in the health care area. Providing access to affordable health care is of paramount importance. At the same time, spending on health care is putting enormous pressure on public budgets. Most countries have yet to commit to deep reforms that promise long-lasting effects on spending. Still, it is important to recognize that some countries have been successful in containing the growth of health spending in the past, and for others this success is expected to continue. For example, Germany, Japan, and Sweden have managed to control spending increases over the longer term. As we heard this morning, we know from the experience of these and other countries that reforms can help slow the growth of health care spending while preserving equity and efficiency. The most promising strategies involve a mix of both macro-level instruments to contain costs and more micro-level reforms to improve the efficiency of spending. Among macro instruments, budget caps can be a powerful tool for reducing spending growth. Among micro reforms, strengthening market mechanisms by increasing patient choice, allowing greater competition between insurers and providers, and relying on a greater degree of private provision can help contain costs. Public management and contracting reforms, such as extending the use of managed care or shifting toward case-based payments, are also central to improving the efficiency of spending. Demand-side reforms, such as greater reliance on private financing and increased cost-sharing, can also be effective. A greater role for the private sector, however, should be accompanied by measures to ensure that the poor and chronically ill retain access to basic health services. Finally, supply constraints, such as those that ration high-technology equipment, can help reduce the growth of public health spending. The appropriate mix of these reforms options, of course, will vary by country and depend on the projected outlook for public health spending.
Health care reform has important implications for the range of services or products financed by the public sector. If containing public health spending growth is a priority, countries may face difficult choices regarding which services will be covered by the public benefit package and the role of the private sector in financing these services, including through private insurance. However, there are considerable market failures associated with private insurance markets. Thus, an expansion of private insurance would need to be accompanied by appropriate regulations to ensure access, equity, and efficiency.
In sum, containing health care spending will be an essential ingredient for successful fiscal adjustment in the advanced economies. However, even with extensive reforms, some countries may not be able to prevent an increase in health spending as a share of GDP, given the strong pressures from aging and the continued effects of technological improvements on health care costs. For these countries, even more ambitious cuts in other programs may be necessary to achieve their goals for fiscal adjustment.

Fiscal Adjustments in Emerging Economies
Turning to the emerging economies, a tighter fiscal stance than currently envisaged will be needed in the near term in many cases. Emerging economy deficits are falling, but in some countries the fiscal buffers eroded by the crisis need to be rebuilt to protect against sudden reversals in recent capital flows. At a minimum, the temptation should be resisted to use the current favorable tailwinds to boost spending.
Over the medium term, for many emerging markets a general increase in government spending is likely and is often even desirable. But the budgetary needs differ across countries: some will need reforms to help boost consumption; others need greater investment in infrastructure and other growth-enhancing spending.
In this context, health care reform is a critical issue, although the current challenges are a bit different from the ones facing advanced economies. Increases in health spending have been moderate over the past decades, and spending pressures are expected to be less severe than in advanced economies. At the same time, many countries need to further expand access to high quality health care. For the most part, health outcomes such as life expectancy and infant mortality continue to lag behind the advanced economies, and significant parts of the population are still uninsured and do not have access to adequate medical care.
Emerging Europe forms a special group, of course: spending is relatively high by emerging economy standards and coverage is nearly universal, but the challenge here remains to enhance the efficiency of spending to improve lagging health outcomes and the quality of service delivery. Like in the advanced economies, fiscal space is also limited in much of emerging Europe, placing a premium on reforms that improve health outcomes without raising public spending.
In conclusion, containing the growth of public health spending in an equitable and efficient manner will be a key ingredient for successful fiscal consolidation in advanced economies. There will thus be strong pressure on health systems to improve their efficiency to continue delivering improvements in health outcomes. Emerging Europe, which also has limited fiscal space, faces a similar situation. Despite this daunting challenge, there are grounds for optimism, given the successful reform experience of many countries. I hope and expect that today’s conference will provide a fruitful opportunity to exchange views on these experiences, to draw lessons from them, and to advance our knowledge on how best to approach the remaining challenges in health care reform in this region and beyond. I wish you a very productive and interesting remainder of the conference. Thank you very much.

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Three questions the financial services industry must answer in 2021



Three questions the financial services industry must answer in 2021 1

Xformative, a Mastercard Start Path recipient, shares what these questions mean for fintech partners and their innovations

This year, fintechs and institutions alike pushed the limit on how fast, innovative, and digitally-savvy they could be. Buzzwords like cloud and faster payments made headlines, but 2021 will be about refining best practices and putting them into action. Xformative believes that more industries should benefit from digital payments and that it’s not just about faster payments, but the option to offer multiple methods.

  • Which industries are lagging in the digital payments space and why? The pandemic forced financial institutions and their partners to move digital transformation into a new phase of maturity. But this doesn’t mean every industry has transformed, there are still laggards. According to a survey of more than 1,400 American freelancers and contractors, conducted by, more than half said they were still receiving their money in the form of a physical check. Checks still exist in spaces like Property and Casualty, though we did see some reassuring industry changes this year. The year ahead will require businesses to offer more payments flexibility outside of physical checks to meet the payment needs of their gig workers, freelancers, and contractors. Businesses will rely on technology partners to bring them up to speed and simplify the payments process.
  • How can fintechs overcome the challenges of building in the cloud? Most businesses want to architect using a select cloud provider, or at least offer cloud-based services, to remain competitive in today’s fast-paced, disruptive landscape. There are assumptions that cloud architecture will inherently be less expensive to operate than legacy mainframe systems, but for many, these assumptions have turned upside down when developers fail to understand cloud cost optimization principles. As fintechs look to build in the cloud, they should ensure their technology is highly optimized, only leveraging real-time capabilities and transactions when required. Responsible fintechs should focus on balancing customer experience and economics with a mix of batch and real-time capabilities, constantly asking themselves, “is real-time the best choice?” Just because real-time can be offered doesn’t mean it should, and 2021 will be about drawing the line between utilization and optimization.
  • Why is offering more payment choices important? Emerging faster payments are working in parallel, not as a replacement for other methods. People want options to be able to pay however they like, whether it’s with Zelle, Venmo, Apple Pay, or traditional methods like cash or card, and financial institutions need to be prepared to meet this demand. The card that consumers once kept in their wallet was a key component of the bank’s and/or program manager’s brand value, as well as potentially communicating the cardholder’s lifestyle and socioeconomic status. 2021 will reinforce the value of financial institutions having partnerships with fintechs who can help them evolve their brand value to include the broad scope of emerging payments.

It’s time fintechs and institutions partner to digitize payments and offer choices. 2021 is about building smart and partnering for capabilities that can open the door to new opportunities at a financial institution.

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2020: The paradoxical year that has reshaped the future of motor insurance and related sectors



2020: The paradoxical year that has reshaped the future of motor insurance and related sectors 2

By Alan Inskip, Tempcover CEO & Founder

There’s no doubt that 2020 will be remembered as the year that changed the world. Whether that overall change was for the better or for the worse is a matter of perspective. One thing is for certain, 2020 has been the year of immense innovation and adaptability in the face of seemingly insurmountable adversity caused by the COVID-19 pandemic. In this piece, I’ll touch on some of the greatest challenges that could have had a potentially crippling effect on the economy but instead were overcome and ultimately paved the way for increased resilience and innovation.

Public transport shunned in favour of private vehicles, but driving patterns dramatically shift

With ten months of varying national and regional lockdown restrictions, passenger numbers on public transport have plummeted[1] as many people continue to work remotely, and with most opting for the safety of travelling by private vehicle when they do need to get out and about. But because of restrictive travel measures, motorists have been using their vehicles far less frequently.

This posed a major challenge for traditional motor insurers that were not able to swiftly adapt to this change, with many coming under fire for failing to adjust annual premiums in line with new driver trends[2]. As motorists became increasingly frustrated having to pay the same premiums or sometimes even more despite their vehicle usage being substantially minimised, the relatively new and still largely unfamiliar InsurTech industry was able to rise to the occasion.

In short, InsurTech involves the utilisation of the latest technological innovations such as data analysis, cloud computing, artificial intelligence and machine learning to enable insurance products to become more agile and flexible in line with modern consumer demand – all while remaining price competitive.

Being fully-digital and technology-driven, InsurTechs demonstrated the flexibility and agility that enabled them to adapt to the huge shift in customer demand and step change in how insurance is purchased and consumed. They did this by offering an entirely digital user experience in near real-time, with temporary policies tailored to the time actually needed – anywhere from 1 hour to 28 days.

In a time of furlough and economic uncertainty, this meant that many motorists who were not using their vehicles regularly did not have to take drastic action like declaring their vehicle SORN to achieve short-term financial relief. Nor did they have to risk driving uninsured or committing to an annual policy that they could ill afford at the time.

The rise of the digital dealership offering temporary insurance as part of the purchase journey

In the automotive retail market, dealerships were forced to make drastic changes to their operating models to comply with social distancing guidelines. Showroom footfall and subsequent sales initially plummeted[3]. But in the face of this immense adversity, we witnessed the rise of the digital dealership, a concept that would have been unfathomable even just a year ago.

Cazoo was the first fully-digital platform to enter the vehicle dealership market in late 2019, and there has also been significant investment this year in new entrants such as Cinch and Carwow. Traditional dealerships such as Arnold Clark, Cargiant and Motorpoint have extended the digital aspects of their purchase journeys with services including home delivery and Click and Collect as alternative options to the full show room experience.

InsurTech has been instrumental in ensuring that car insurance supports this shift to digital, as several national blue-chip dealerships, with both physical and digital showroom floors, now offer temporary driveaway insurance policies that cover the vehicle for a fixed-term, usually between five to seven days.

Alan Inskip

Alan Inskip

The entirely online one-step user experience is the first of its kind in the traditionally outdated and inflexible driveaway insurance industry and it is dramatically simplifying the process of how insurance is purchased and consumed. Due to the flexibility and agility of the digital solution, each retailer has its own unique URL, where the customer can obtain a simple single-cost policy in just 90 seconds through an entirely digital process, which fits in line with the evolving consumer purchase trends.

This takes the stress out of searching for annual insurance on the spot and provides the driver with near instant cover so that they can immediately drive their new car while giving them the opportunity to thoroughly research the best annual policy to suit their needs. It’s also an ideal solution while the car is under its money-back warranty, as the driver does not have to commit to an annual policy on a car that might be returned. Another benefit is there’s no risk to any existing No Claims Discount, as it’s a separate and standalone policy.

Declining brand loyalty and a demand for a more personalised and convenient user experience

Insurance has an unenviable reputation for being inflexible and even unwilling to adapt to shifting consumer trends – making it confusing for most customers. Even pre-COVID, there was a clear trend that brand loyalty was in decline, as modern day consumers are no longer prepared to remain blindly loyal to any company for a long-term period. Instead, they will reward businesses that offer a simple and convenient user experience at best value. COVID accelerated this trend and many large insurers have struggled to adapt accordingly.

Conversely, this has enabled InsurTech to thrive, as the products and user journeys are developed with direct input from customers to ensure that they are receiving a straightforward and fit-for-purpose solution that best fits their needs and requirements. Just some examples of this are simplified terms and conditions, near-instant and paperless policy documentation via the web or dedicated app, and data-driven customer engagement initiatives that offer personalised discounts and communication via email and text messaging. The end result is a user experience that is easier, more convenient and better value for potential consumers in the market.

Cautiously optimistic (if somewhat uncertain) future

Even in the most stable periods, it’s a challenge to accurately predict future market trends. And with 2020 completely rewriting the rulebook on how business is conducted, it would be remiss of me to make outright predictions. One thing is for certain, the days of slow, inflexible and costly motor insurance are numbered. It is important to note that this doesn’t mean that InsurTech is gaining the upper hand at the expense of the traditional insurers in a bid to replace them.

Instead it is there to fill a gap and act as a complementary add-on to provide the best possible value to the consumer. Industry players that enter new collaborative partnerships will dramatically improve the consumer experience, leading to new business wins and return custom, which ultimately impacts positively on the bottom line. But those that fail to adapt will be left behind.

I believe that we can look forward to a futuristic economy in 2021, where ground breaking technology continues to advance at an unprecedented rate to adapt to rapidly evolving consumer lifestyles and subsequent purchasing habits. The real winner will be the consumer and that is in everyone’s best interest.

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Leadership and management in a WFH world



Leadership and management in a WFH world 3

By Carolyn Moore, SVP of People at Auth0

Although many of us will have settled into some kind of groove, having worked away from the office for the best part of a year, there are still numerous challenges that businesses and their workforces face in this new reality.

One particularly pertinent challenge is the one faced by people managers, especially those managing virtually for the first time. How can you ensure productivity from those in your charge when you don’t have direct oversight? How do you have those more difficult conversations over a video call? Some of your team may be handling remote working better than others, so how differently should you be handling them day-to-day?

For the majority of businesses these will be questions they’re still grappling with. When the pandemic hit, we happened to be in the fortunate position of being a remote-first business, where 60% of our nearly 700 employees were already working from home. As a result, the uptick to 100% was far less taxing for us. In seven years of working from home, we’ve learned a lot about managing teams remotely, a few of which may help leaders who are still navigating the transition.

Keeping communication channels open to build trust

Leading a remote team is wholly different to the usual, in-office set up. Strict hierarchy, and any notion of presenteeism do not translate well into the remote working environment. You have to accept that your employees’ domestic life will necessarily overlap with their professional one.

Leading a virtual team requires trust and a philosophy of work based on results, and managers need to learn to give them more freedom to do work on their own terms, as long as they produce the intended results.

Building trust is best managed with regular communication. Frequent written communications from leaders regarding strategy, objectives, and organisational learning is crucial. It’s natural when working remotely for team members to isolate themselves and get wrapped up in their own workload. Managers need to help their teams understand how their work impacts on the broader corporate objectives. At Auth0, we adopted and adapted a technique created by Google called ‘Objectives and Key Results’ (OKRs) to enable this.

Now more than ever, make it a priority to regularly check in with your employees and always be up to date and aware of what their needs are. One of the first initiatives we kicked off in an effort to do so was our Slack ‘Coronabot’. This is a tool we integrated with our main form of communication that allows employees to self-identify if their work capacity was impacted by the pandemic. Another way that we tried to better understand the concerns and needs of our employees was holding listening sessions. From these listening sessions, we’ve rolled out a couple of initiatives to combat burnout, including Slack-free weekends and no internal meeting Fridays.

Make flexibility a priority

As the worlds of home life and work life collide, the traditional ‘9 to 5’ workday needs to evolve. Leaders need to encourage their team to devise their own schedules and complete work at those times when they’re most productive.

If in doubt, ask your employees how best you can help and trust that their answers will be honest. In our own experience we saw a need for a different approach when it came to supporting our employees who are caregivers. With childcare much less accessible, caregivers are doing double duty. We rolled out a survey to these individuals to hear directly how best we could support them and used the feedback to plan future programmes and supports.

We have encouraged these employees to take advantage of flexible working hours, should they need to adjust due to the pandemic, and are using tools like Clockwise or Slack that allow our employees to set their working hours and snooze notifications when they’re offline. This alleviates the pressure to respond, and we’ve found employees are actually happier and more productive this way, especially if you have a team spread across several time zones.

Put your culture front and centre

When you work remotely interactions between management and staff become increasingly transactional. Leaders need to avoid making decrees without explaining the reasoning behind them, and the thought process that led to them. Failure to do so can create a secondary culture within the workforce composed of rumours and hearsay, which can lead to mistrust.

Leaders therefore need to firstly be clear in the reasoning for their decisions, but also explicit about the culture they want to create. Your corporate culture must be written down and communicated frequently so employees can use them to guide their everyday work.

Carolyn Moore

Carolyn Moore

This is particularly beneficial for multinational companies spread across geographies and timezones and encompassing multiple cultures. Whether your teams are based in Singapore or San Francisco, they all have a code of conduct to adhere to This is crucial for dealing with conflict in a productive way and creating teams that collaborate and respect each other.

Create virtual spaces to socialise

Leaders mustn’t forget the more pastoral benefits of the workspace. Spontaneous water-cooler chats may seem trite, but they’re an essential means of colleagues building rapport and learning about one another’s lives outside of work.

Socialising should not disappear when you transition to remote work. That would be bad for business, productivity, and employee wellbeing. Instead, I would encourage you to get creative and use different functionalities of the collaboration tools you’re probably using daily. We use Donut within our Slack channels, that randomly pairs three employees together and schedules them for a meeting. The intention is to bring employees together that otherwise may never interact and have them connect on topics beyond the workplace, such as life, family, etc. Donut has been a fantastic aid in keeping our distributed workforce feeling connected. We’ve also utilised the results of both our semi-annual engagement survey and more frequent pulse surveys to give us insight into how effective these engagement programmes have been and where we could tweak them to make them even better.

Don’t neglect security

Security should always be a top priority, especially especially as people are logging into more services remotely. Your business’ IT and Security teams should have set up multi-factor authentication as the minimum standard. As new apps are connected to better enable any of the measures described above, your IT teams and managers should also be educating their teams about the access third-party providers have to their data.

Managers have a crucial role to play as evangelists of security best practice. They should be monitoring whether their teams are completing their security awareness training and, if new apps or technology are being introduced, ensuring that the appropriate channels are open for them to ask questions. The pandemic has been a lucrative time for cybercriminals, who have taken advantage of some lapses in security best practice. Ensuring security is everyone’s business, but it starts from the top.

Building for the future

For many businesses the move to remote working will have been, and is continuing to be, a difficult transition. Admittedly, remote work is not a perfect substitute for personal communication. When circumstances allow, we would recommend managers meet with their teams in-person at least once a year. managers meet with their teams at least once a year.

However, even whilst the pandemic still hampers our ability to travel and meet face to face, it is still possible to have a distributed team that is productive, collaborative, and happy. If leaders take the time and make the effort to foster a culture built on trust, it will open up opportunities for you in the long-term, no matter what that future may be.

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