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Interface - Comunicação, Saúde, Educação

versão On-line ISSN 1807-5762

Interface (Botucatu) vol.21  supl.1 Botucatu  2017

http://dx.doi.org/10.1590/1807-57622016.0233 

Open Space

Immersion in reality: the Brazilian National Health System and the organization of the More Doctors Program in São Paulo, Brazil

Vinícius Pena de Alencar(a) 

Maria Sortênia Alves Guimarães(b) 

Talita Buttarello Mucari(c) 

(a) Programa Saúde da Família Carlos Aldrovandi. Avenida Ângelo Bertelli Netto, 1000. Núcleo Residencial Professor Carlos Aldrovandi. Indaiatuba, SP, Brasil. 13.337-149. viniciuspena1@gmail.com

(b) Núcleo de Estudos da Saúde do Tocantins, Universidade Federal do Tocantins (UFT). Palmas, TO, Brasil. msortenia@uft.edu.br

(c) Curso de graduação em Medicina, Universidade Federal do Tocantins (UFT). Palmas, TO, Brasil. tmucari@mail.uft.edu.br


ABSTRACT

Since 2003, the program Experiences and Internships in the Reality of the Brazilian National Health System (VER-SUS) has given university students the opportunity to experience the reality of the SUS. These experiences are part of the More Doctors Program framework, involving its organization in the reality of the Brazilian healthcare system. A group of students from several health areas spent seven days at planning and implementation meetings for the program in the state of São Paulo. The activities carried out included participation in meetings, tours to healthcare units, assessment of program implementation, and spaces for discussion. This paper is a report on the experience from the perspective of a student who participated in the experience, by means of a chronological and reflective narrative and theoretical grounds within the context of each issue raised.

Key words: More Doctors Program; SUS; VER-SUS

RESUMO

Desde 2003, o Vivências e Estágios na Realidade do Sistema Único de Saúde (VER-SUS) tem dado oportunidade a universitários de vivenciar a realidade do Sistema Único de Saúde (SUS). Com essa finalidade, surge a vivência em questão, ocorrida no âmbito do Programa Mais Médicos, envolvendo sua organização na realidade do Sistema de Saúde brasileiro. Para isso, um grupo composto por estudantes de várias áreas da Saúde esteve por sete dias em ambientes de planejamento e execução do programa no Estado de São Paulo. As atividades realizadas incluíram participação em reuniões, visita a unidades de Saúde, avaliação sobre a implementação do programa e espaços para debate. Assim, relata-se a experiência sob a perspectiva de um acadêmico que participou da vivência, em uma narrativa cronológica e reflexiva, com fundamentações teóricas inseridas no contexto de cada questão abordada.

Palavras-Chave: Programa Mais Médicos; SUS; VER-SUS

RESUMEN

Desde 2003, el VER-SUS ha proporcionado a universitarios la oportunidad de vivir la realidad del Sistema Brasileño de Salud. Con esta finalidad, surge la experiencia en cuestión, ocurrida en el ámbito del Programa Más Médicos, envolviendo a su organización en la realidad del sistema de salud brasileño. Para tanto, un grupo formado por estudiantes de varias áreas de la salud estuvo durante siete días en ambientes de planificación y realización del programa en el Estado de São Paulo. Las actividades realizadas incluyeron participación en reuniones, visita a unidades de salud, evaluación sobre la implementación del programa y espacios para debate. De esa forma, se relata la experiencia bajo la perspectiva de un académico que participó de la vivencia, en una narrativa cronológica y reflexiva con fundamentaciones teóricas inseridas en el contexto de cada cuestión abordada.

Palabras-clave: Programa Más Médicos; SUS; VER-SUS

Introduction

The first version of the program Experiences and Internships in the Reality of the Brazilian National Health System (VER-SUS) was created in 2003. It was designed with the participation of student representatives from undergraduate health care courses and the Ministry of Health, in partnership with the United Network and several other entities. This program allows students to experience contact with the Brazilian National Health System (SUS), stimulating them to think about what they observe. The entire process was designed in an immersion format, in which the group of students lives together for a period of seven to fifteen days in the same physical space, with the expectation that their daily interactions will lead to dialogue and serve as a major milestone in their experience. Active teaching and learning methods are applied, supported by a facilitator, who is a student qualified by prior internship experience or their own experience. Hence, VER-SUS stands out as a stimulation tool for the formation of professionals who are committed to the SUS principles and guidelines and are capable of acting as agents for social change1.

The program process begins with a call for submission of projects carried out by the United Network, which is the nationwide association responsible for the executive office of the VER-SUS/Brazil project. This entity publishes weekly selection processes aimed at the creation of projects and proposes holding seminars, workshops, and experiences focused on key topics in VER-SUS and its prospects for continuing health education. After the submission of projects by state and municipal institutions and already-established organizing committees, selection of proposals takes place, followed by release of the list of places that will be awarded the funding for the execution of the projects.

With the intention of including the most current and relevant public health issues, VER-SUS has oriented its topics toward health policies that have greater impact on the population. Among these actions, medical provision in Brazil has been the main focus of discussions in recent years. However, before elaborating on the discussion and addressing the need to import medical professionals, it is necessary to understand the context for the creation of a medical provision program in the country.

Historically, Brazil has suffered from a shortage of medical professionals in remote regions where there is extreme poverty. Combined with the vulnerable situation of the populations that live in these areas, whether they are located in urban settlements or in isolated communities in inhospitable regions of the country, this situation markedly increases the health risks of these populations.

In contrast to what it has been seen in these regions, increases in the number of physicians per person has been confirmed every decade in Brazil. In 1980, it was 1.15 physician per 1,000 people. this followed a steady upward trend until reaching 2 professionals per 1,000 individuals in 2012, representing an increase of 73.92% in the rate of physicians per person in the country2. All of this is the result of a complex configuration in which issues related to education are intertwined that are still echoes of a recent past. In this context, learning processes focused on hospital services are seen as a fragile method of integration that leads to a fragmented education process that basically encourages specialization3.

The reconciliatory approach between healthcare learning activities and healthcare services involves both work management and education, which is initially addressed by analyses that see medical workers as a labor force, aimed at diversification of specializations within the hospital setting. In this context, growing fragmentation of medical education is noted, leading to the concept of professionals as mere resources to be managed. Subsequently, an increase in the number of jobs due to the expansion of primary care coverage led to an increase in the need for strategies aimed at the provision and securing of professionals in these jobs in order to improve thee training process.

This is the context in which the More Doctors Program (MDP) emerged; it was enacted by Law 12.871 on October 22, 2013, with the aim of training human resources in the medical field for the SUS and reducing the shortage of professionals in priority regions, in order to reduce regional inequalities in the healthcare area4. The program was structured around three areas of action: investments in improvement of healthcare network infrastructure; expansion and educational reforms in undergraduate medical courses and medical residency; programs in the country; and emergency provision of physicians for vulnerable areas5.

Since its creation, the MDP has reached a dimension capable of meeting a considerable portion of the demand for medical professionals in Brazilian cities. In less than one year, the program recruited and allocated 14,462 physicians in 3,785 cities. Most of these professionals were hired through a partnership between the Brazilian Ministry of Health and the Pan American Health Organization (PAHO), which mediated an agreement with the Cuban government, allowing physicians from that county to come to work in Brazil5. At two years after its creation, the program relied on approximately 18,000 physicians working in more than 4,000 Brazilian cities. In the state of São Paulo, the increase in the number of physicians after implementation of the MDP corresponded to 14.1% as of June 20156.

Given the size of the contingent in charge of providing Primary Health Care attained by the MDP, it is of utmost importance that the settings in which the program is implemented be included in the VER-SUS area of activity. This integration not only entails coordination between the teaching environment and the space for performing the duties, but also provides a broader view of what a complex healthcare system is all about.

To meet these precepts, the goal of the experience was to provide students with direct contact with the reality of the healthcare system in the Primary Health Care field and foster knowledge of how the medical provision program is organized, from planning to execution.

Method of building the experience

At the end of the recruiting process carried out by the United Network, implementation of the experiences began once the proposals were approved. This procedure involved local committees consisting of teaching staff, managers, healthcare professionals, and social movement representatives, who coordinated the project together with several bodies in the locality, in constant and continued dialogue with the VER-SUS national coordination7.

The same process led, as a result of a call for the summer project that was issued in January 2016, to the experience in question. The project was called “More Primary Health Care for the State of São Paulo”; it was published under a proper term of reference, and was similar to a public notice on the platform of the Observatory of Information Technology and Communication in Health Services and System (OTICS). On this platform, any healthcare student in the country can fill out an application to participate in the experience. The group of participants (experiencing and facilitators) was selected by the organizing committee by preliminary analysis of an essay and an audio or video piece recorded by each student.

After selection, a group of ten students (eight experiencing and two facilitators) was formed from different educational areas, including: nursing, pharmacy, physical therapy, public health, and psychology. To provide support for the participants, an organizing committee was created, consisting of representatives from the Ministry of Health and Ministry of Education, who were responsible for monitoring the MDP and providing qualification support for Primary Health Care in the state of São Paulo.

The experience took place from February 15 to 22, 2016, in the cities of São Paulo, Embu-Guaçu, Limeira, and Sorocaba, with the More Doctors Program of the federal government as an experience, theoretical, and practical immersion within the local healthcare system. The activities carried out included participation in planning meetings with managers, visits to healthcare units, rounds of talks with healthcare teams, and local assessment of program implementation, and spaces were opened for debate and analysis of MDP strategies at the state level. As a means of integration, daily interaction among participants in the same setting was proposed with the aim of stimulating sharing of ideas by each individual about the current moment being experienced, in order to build collective knowledge.

The report below describes the entire experience, from the perspective of a student from the medical course at the Federal University of Tocantins (UFT), who was selected as a live participant for this iteration of VER-SUS. The narrative is presented in a chronological and reflexive fashion. The theoretical foundations will be inserted in the context of each issue addressed, with guidance from the professors who make up the UFT teaching staff.

Report on the experience and reflections

First day

The experience began with a welcome for the participants by the National Health Ministry Council (NEMS) organizing committee. After the reception, a round of talks was held with Primary Health Care and MDP professionals from the state of São Paulo. In this early stage, the context for the creation of the MDP was described as a way to meet the great demand for physicians in the Primary Health Care, driven by a local governance movement that relied on mayors from several localities.

This movement emerged in January 2013, during the National Meeting of Mayors, held in Brasilia, when the National Front of Mayors created the campaign “Where is the Doctor?” One of the issues raised was a demand for federal government measures to provide physicians for the cities, along with a proposal to loosen the rules for hiring foreign physicians who are willing to work in the Primary Health Care. The justification given by the federal government for meeting these demands was based on the rate of physicians per resident in Brazil compared to other countries and the unequal distribution of these professionals in the national territory8.

Presumably, the main argument in favor of the creation of a medical provision program in Brazil at that time was the unequal distribution of professionals. This is supported by another statistic that showed that the number of physicians was lower than in other countries worldwide, even among some nations in South America, such as Argentina8. However, it is worth mentioning that there is large concentration of physicians in certain Brazilian regions, including the state of São Paulo itself. Conversely, even with the presumable rise in competition for work places in these localities, job offers in regions with shortages of professionals were not enough to attract physicians who were willing to commit themselves to Primary Health Care, whether for lack of infrastructure in these working areas or for mere financial reasons.

Second day

Looking at the territory, the second day of experience made it possible to learn a little about the reality of Primary Health Care in Embu-Guaçu, a city located 48 km from the capital, with an estimated population of 67,000, that relies on 18 authorized jobs for physicians of the program. A local municipal health office team provided a brief background on the difficulties experienced by their healthcare system prior to the implementation of the MDP, indicating the improvements observed up to that time.

The city, which used to depend on only four Primary Health Care units (UBS), obtained an increase to 13 facilities through federal government subsidies provided for by the MDP law. Pharmaceutical care, which was initially provided on a decentralized basis, began delivery of drugs from a central pharmacy, because of the difficulty of local management with relying on one pharmacist per unit.

The MDP established a five-year plan for supplying Primary Health Care units with quality equipment and infrastructure, tripling the existing budget for the UBS Requalification Program, which defines the allocation of resources to the cities according to the presentation of proposals related to the modernization of the infrastructure and the units. With this measure, more than R$ 5 billion was invested by the Ministry of Health for this purpose6.

Considered an extremely poor city, Embu-Guaçu took advantage of the offer provided by the government program, which anticipated the expansion of the Primary Health Care network of the federal participating bodies. However, it was clear that the health actions taken by the previous city administration regarding the program were shown to be insufficient. The actual organizational structure of the administrative office, along with constant resignations, did not allow continuation of the work. That was because it is known when leadership changes, all personnel often end up being replaced as well, resulting in dropping out of previous ideas and returning to ground zero.

It became clear that distributing, providing and securing health professionals in a region have an inversely proportional relationship with the health condition of the population. In the city of São Paulo, for instance, there are areas with high a concentration of physicians and others where the rate of physicians per inhabitant is comparable to remote areas. It is known that precarious employment bonds are also an issue related to the difficulty of providing physicians in certain areas. This is the result of the hiring conditions made by city managers, the wages offered, and poor working conditions, which results in turnover, instead of securing them in their jobs3.

With the aim of coming to better understand the implementation of the MDP in Embu-Guaçu, a field experience was carried out in one UBS of the city that is responsible for providing care to users in a neighborhood and some from an adjacent rural area. The entire UBS structure was presented by the management, which was followed by a talk with the family health care team, which consisted of Cuban physicians from the MDP who worked in the unit.

The group learned that the UBS has a good physical structure and material resources to serve the population, including a successfully installed dental clinic. The spaces are adequate for reception, screening, medical appointments, and procedures. During a conversation with the team, one contradiction was detected, when it was noticed that part of what had been confirmed in the meeting with the city management diverged from the reality of the care. Some UBS professionals reported that most users were having difficulty receiving prescribed drugs, because of the distance between their homes and the central pharmacy.

Third day

At this point, the experiencers and facilitators participated in two meetings with the state coordination committee of the MDP in state of São Paulo. The meetings focused on work scheduling and the development of institutional and matrix support. To understand the purpose of the discussions that took place during these meetings, it is first necessary to understand how state committees are constituted and the role played by tutors and supervisors in the program.

The MDP ministerial coordination body includes three representatives from the Ministry of Health Ministry three from the Ministry of Education. The state committees made up of representatives of the Ministry of Health, state health office, Council of Municipal Health Secretaries (COSEMS) and supervising institutions. These committees are responsible for coordinating, guiding, and carrying out the activities needed to establish the program in the state. Two agents are essential to making this task possible: the supervisor (a physician who is in charge of ongoing supervision of the participating professionals) and the academic tutor (a professor in the medical area who is in charge of the educational guidance and planning activities of the supervisor). Both agents are linked to public institutions of higher education, public health schools, or private parties who are participating in the program9.

During the meeting, some of the supervisors explained that the role played by supervisors with physicians in the program is not monitoring, but guidance. Therefore, these agents are responsible for providing appropriate technical support within the planning determined by tutors and overseeing the progress of the work carried out by the professionals in the city. This proximity between educational institutions and the physicians who work in the program is of fundamental importance. The support offered allows improvement of the service provided and qualification of professionals in the same working environment.

The introduction of ongoing educational actions serves as an important strategy for putting an end to the existing opposition between education and service, aiming at improving the primary care model for the population. The maintenance of supervision with the help of teams, in a multiprofessional and cooperative fashion, is seen as an extraordinary driver of change in healthcare practices. The main challenges in this area are maintaining dialogue on the design of professional training models, and defining a regulatory standard of work and educational management for Brazil8.

Fourth day

The fourth day of the experience took place in the city of Limeira, where it was possible encounter a different reality in terms of public healthcare administration. Limeira has a population of about 294,000 and is located 143 km from the capital. It is one of the cities in the state of São Paulo that has a higher number of professionals from the MDP, with 57 authorized jobs for physicians from the program. The group of VER-SUS participants was welcomed by local managers. This was at a time when the city administration was facing difficulties in securing physicians in the UBS, before the effects of implementation of the MDP were seen. It was also pointed out that this situation lasted for several years, even in a city known for strong economic activity, driven by the agricultural, industrial, and trade sectors, and a high Human Development Index (HDI). The city intends to keep this contingent of physicians from the program, because the managers believe that, without the program, it would not be possible to continue with the care.

In this context, it is important to highlight the criteria for the city to receive professionals from the MDP. They are based on profiles marked by parameters that include: percentage of the local population living in extreme poverty; low per capita level of public revenue; high social vulnerability; and an area of activity located in a Special Indigenous Health District5.

A discrepancy can be seen between the proportion of physicians from the program working in Limeira, compared to other, poorer cities. The explanation given was that some cities that had initially joined the program withdrew or refused to receive foreign professionals, who were then assigned to work in Limeira, in with the full agreement of the city government.

From the city hall, the group was led by the Health on Wheels program team to a rural settlement located on the outskirts of Limeira. This is an area of approximately 700 hectares occupied by families from the Brazilian Landless Rural Workers’ Movement (MST). When they arrived, they were met by a settler. She offered to show them a small literacy school facility built by the settlers, and then she briefly told them about the health problems they were facing.

The VER-SUS group was also authorized to join a home visit inside the settlement. The team was composed of one nursing professional, one social worker, one community health agent, and one MDP physician from Cuba. During the visit, certain communication difficulties were noticed between the physician and the patient, so much so that sometimes there was a need for mediation from the members of the team. Maybe this difficulty occurred, not only because of the language difference, but also because the patient was an elderly person with a hearing deficit. The patient presented a venous insufficiency diagnosis with lesions on the lower limbs. He was properly evaluated by the physician and received some recommendations. The visit finished with advice on general wound care, without the need for prescribing a specific drug.

Discussions about the provision of physicians to work in rural and remote areas in Brazil gained momentum when the MDP was implemented. Despite the divergences in this debate, there is a consensus that inequality of distribution of physicians in different regions of the country contributes to the so-called rural-urban gap in supplying physicians. Reform of the health system for rural areas requires the training of skilled professionals to work in these locations. This involves changes in medical education and its curriculum and the decentralization of health education, measures aiming to facilitate access to the courses by students from the hinterland. Another path to be followed is the improvement of family and community medicine residency programs, which will qualify decisive specialists who are capable of handling the most frequent problems seen in rural areas10.

Fifth day

In an MDP local regional supervision meeting, held in Sorocaba, the VER-SUS group worked with tutors, supervisors, health residency coordinators, and physicians from the program who work in the cities in the Vale do Ribeira region in the state of São Paulo. At that time, lectures and presentations on care protocols for prenatal and sexually transmitted diseases were presented to professionals working for the MDP. The presentations were technically oriented, and were taught in a class format, using slides.

This format for medical care protocols that specific for each clinical situation helps define the behavior of professionals. However, what is determined by flowcharts and algorithms does not always correspond to the actual availability of the system. Sometimes, imposition of these measures minimizes the autonomy of the professionals when they are trying to establish their own treatment plans based on evidence observed on a daily basis.

After the presentations, a dialogue took place with the program personnel regarding the work carried out in educational support provided to the physicians who worked in the cities in the Vale do Paraíba region. This gave the group a change to deepen their knowledge of the way tutors and supervisors carry out their duties. However, the most interesting part of the talk was hearing the accounts of some supervisors about the characteristics of areas where the physicians from the program work. One was Cananéia, a city of more than 12,000 inhabitants located on the southern coast of the state of São Paul; it encompasses fishing villages far from the city that require physicians to travel up to two hours by ship in order to provide care to these communities.

Continuing education activities are characterized by teaching-service integration with the purpose of contributing to, supporting, and assisting the professionals in reaching qualification and improving the service provided. Educational opportunities are provided by public institutions of higher education that are part of SUS Open University (UNA-SUS) and through educational activities offered by supervising institutions that have joined the project. The physicians in the program also receive clinical and educational support from the Brazilian Telehealth Network, with unlimited access to the Evidence-Based Health Portal and to the Community of Practice, a collaborative network that allows these physicians to dialogue and exchange experiences with health professionals from various fields and localities6.

Sixth day

A visit was made to a mixed health unit located in the northern area of São Paulo. This is a health facility that included one UBS and one outpatient medical care unit (AMA), both set up inside the same physical structure. The UBS is located on the upper floor and the AMA on the ground floor. Upon arrival, the VER-SUS group received an invitation to meet the community leaders who participate in the organization of local care.

During the conversation with community leaders, it was possible to confirm how the history of the struggle for and development of improvements in health care is similar to the process that led to the creation of the SUS. The accounts of countless difficulties faced in the past and obstacles that remain and prevent improvements in service set the emotional tone for the conversation at times. An elderly lady who was part of the group complained of the strain imposed during the entire process, and said that she had lost her hope because of lack of interest in continuing to fight on the part of younger people.

Popular participation in health management is guaranteed by the Federal Constitution, which highlights guidelines for community participation in the development of the SUS. This is shown in action by citizens, who actively participated in the policymaking process, taking action and orienting the public administration on the best measures to be adopted. Their main tools are the health councils and conferences, spaces that are opened up for the exercise of so-called social control over the implementation of health policies. Although determined by law, social participation is under constant construction, and depends on widespread mobilization of the community in defense of their rights. Therefore, in order for participative democracy to become effective, it is necessary to provide conditions that allow civil society to become a protagonist in the process11.

Seventh day

For this last day of activities, the organizing committee defined the activities as the formulation of the theoretical and reflexive components of the experience, using concepts of dynamics based on what was experienced. To accomplish this task, the participants and facilitators defined a dynamic approach to freely expressing their impressions on the experience. The group of students chose to build a ballot box, where they placed their answers to the following questions: How did I get here? How has it been? Where do I go next? This kind of reflection (retrospective, present, and prospective) allowed for demonstration of the evolution of thoughts from the so-called “immersion” in the experience process.

After the ballots were created and the members’ ideas were placed in the ballot box, the group went to a meeting with the organizing committee in the NEMS headquarters. First, acknowledgment was given to the entire committee for holding the experience, followed by the opening of the ballot box to check the ideas. At this time, each organizer retrieved a ballot and read it aloud. The various opinions expressed by the students were similar and were based on the idea of fighting for improvement of public health in the country. The activities were closed by the experience by the participants in an exchange of perceptions and subjectivities.

Final considerations

The professional training model supported by daily care experiences and practices provided by VER-SUS is in line with the principle of continuing education in health, and introduces spaces and topics that lead to self-analysis and changes in realities. Its dissociation from the traditional model of capacitation is based on building links and awareness about the topic, through a substantial and participative learning process, including horizontality in the construction of knowledge. The varied realities presented during the experience include diversities and characteristics of population groups living in the country11.

The opening of experience fields in this iteration of VER-SUS provided the participants with broader knowledge of the way the More Doctors Program is organized, from the initial project to its realization. It became clear that the biggest challenge to the integration of the program with health management in the cities is that the managers need to understand the local reality and have the ability to face existing problems.

In contrast, it also became evident during the experience that, despite the broad scope in the provision of medical care attained by the MDP, the Brazilian healthcare system still needs revisions. These reforms demand not only human resources, but also structure and organization, which are basic requirements for achieving quality health care.

The experience also made it possible to ascertain that one of the major difficulties to be overcome after the program ends will be securing the physicians in the regions currently assisted by the MDP. Considering the increase in the number of graduated medical professionals in Brazil, in order to solve this problem, the focused must be on the quality of medical education with an emphasis on the actual needs of the country, shifting the focus of the program from acquiring more physicians to acquiring better physicians.

The MDP was established in an emergency context and was motivated by poor health access conditions for a considerable portion of the Brazilian population, and has shown its importance by providing care to those who need it the most. However, there are many obstacles to be overcome, some of which extend beyond the domain of the program, requiring the mobilization of society for the improvement of the health care system as a whole.

The immersion process developed during the experience allowed the broadening of concepts based on working environments, making it possible for the students to understand the reality of the SUS. Thus, VER-SUS served as a highly valuable tool to help in training professionals who are capable of changing the overall public health situation of the country.

Referências

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7. Ferla AA, Dall’Alba R, Andres B, Leal MB, Barnart F, Assimos R, et al. Vivências e estágios na realidade do SUS: educação permanente em saúde e aprendizagem de uma saúde que requer integralidade e trabalho em redes colaborativas. RECIIS (Rio de Janeiro). 2013; 7(4):32-43. [ Links ]

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Received: April 04, 2016; Accepted: May 22, 2017

Collaborators

All the authors participated actively in the production stages of the manuscript. The first author was responsible for manuscript production, and the co-authors participated actively in discussion of the results, proofreading, and approval of the final version of the.

Translated by Teodoro Lorent

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