Canada Health Act

*Canada Health Act*
Canada Health Act
Parliament of Canada
	show Long title
Citation	Canada Health Act
Enacted by	Parliament of Canada
Assented to	April 17, 1984
Legislative history
Introduced by	Monique Bégin, Minister of Health
First reading	December 12, 1983
Second reading	March 26, 1984
Third reading	April 9, 1984

The Canada Health Act (CHA) (French: Loi canadienne sur la santé), commonly known simply as the Act, is a piece of Government of Canada legislation, adopted in 1984, which specifies the conditions and criteria with which the provincial and territorial health insurance programs must conform in order to receive federal transfer payments under the Canada Health Transfer. These criteria require universal coverage of all insured services (for all "insured persons").^[1]

"Insured health services" include hospital services, physician services, and surgical-dental services provided to insured persons, if they are not otherwise covered, for example by provincial workers' compensation programmes.^[2]

The Act deals only with how the system is financed. Because of the constitutional division of powers among levels of government in Canadian federalism, adherence to CHA conditions is voluntary (enforceable by Health Canada). However, the fiscal levers have helped to ensure a relatively consistent level of coverage across the country. Although there are disputes as to the details, the Act remains highly popular.

Another cause for debate is the scope of what should be included as "insured services". For historical reasons, the CHA's definition of insured services is largely restricted to care delivered in hospitals or by physicians. As care has moved from hospitals to home and community, it increasingly has been moving beyond the terms of the Act. International data shows that approximately 70% of Canadian health expenditures are paid from public sources,^[3] placing Canada below the OECD average.^[4] However, health insurance covers surgery and services, including psychotherapy, in clinics and doctors' offices as well as dental surgery at dental offices and laboratory tests.

Overview of the Health Act[]

On December 12, 1983, the Canada Health Act was introduced by the Liberal government, under Prime Minister Pierre Trudeau, spearheaded by then Minister of Health Monique Bégin. As she noted, the government decided not to expand coverage (e.g., to mental health and public health), but instead to incorporate much of the language from the HIDS and Medical Care Acts.^[5] The Canada Health Act was passed unanimously in the House of Commons on April 9, 1984, and received Royal Assent from the Senate on April 17, 1984. Following election of a Conservative government under Brian Mulroney in September 1984, in June 1985, after consultation with the provinces, new federal Health Minister Jake Epp wrote a letter to his provincial counterparts that clarified and interpreted the criteria points and other parts of the new act.

The main objective of the Canada Health Act regarding healthcare policy in Canada, was to facilitate reasonable, continued access to quality healthcare to all Canadians, regardless of income or geographic location by establishing criteria and conditions in respect of insured health services and extended health care services.^[6]

CHA conditions and criteria[]

In order to receive federal transfer payments, the provinces and territories must follow these criteria and conditions related to public administration, comprehensiveness, universality, portability, and accessibility. There is also a requirement that the provinces ensure recognition of the federal payments and provide information to the federal government.^[6]

Public administration[]

The health insurance plans must be "administered and operated on a non-profit basis by a public authority, responsible to the provincial/territorial governments and subject to audits of their accounts and financial transactions." (Section 8). This condition is the most frequently misunderstood; it does not deal with delivery, but with insurance. However, it does reduce the scope for private insurers to cover insured services (although they are still able to cover non-insured services, and/or non-insured persons).

Comprehensiveness[]

The health care insurance plans must cover "all insured health services provided by hospitals, medical practitioners or dentists" (Section 9). The Act lists, in the Definitions (Section 2), what is meant by insured services - in general, this retains the restriction to hospital and physician services arising from the earlier legislation. The provinces are allowed, but not required, to insure additional services. Note that the CHA refers to "surgical dental services" but only if these must be provided within a hospital. In practice, this almost never occurs, and the annual health expenditure data published by the Canadian Institute for Health Information (CIHI) confirm that Canadian dental services are almost entirely financed privately. Lobbying by other providers, including nurses, led the act to speak of 'practitioners' rather than physicians; physician services had to be covered, but provinces were allowed, but not required, to define other health professions as qualifying under the Act. To date, this provision has been used only occasionally; for example, some provinces have added Midwifery, which means that their services are also fully publicly paid for.

Universality[]

All insured persons must be covered for insured health services "provided for by the plan on uniform terms and conditions" (Section 10). This definition of insured persons excludes those who may be covered by other federal or provincial legislation, such as serving members of the Canadian Forces or Royal Canadian Mounted Police, inmates of federal penitentiaries, persons covered by provincial workers' compensation, and some Aboriginal people. Some categories of resident, such as landed immigrants and Canadians returning to live in Canada from other countries, may be subject to a waiting period by a province or territory, not to exceed three months, before they are classified as insured persons; this waiting period arises from the portability provisions.^[7]

Portability[]

Because plans are organized on a provincial basis, provisions are required for covering individuals who are in another province. The conditions attempt to separate temporary from more permanent absences by using three months as the maximum cut-off. As the above-mentioned summary clarifies, "Residents moving from one province or territory to another must continue to be covered for insured health care services by the "home" province during any minimum waiting period, not to exceed three months, imposed by the new province of residence. After the waiting period, the new province or territory of residence assumes health care coverage." The portability provisions are subject to inter-provincial agreements; there is variation in what is considered emergency (since the portability requirement does not extend to elective services), in how out-of-country care is covered (since there is no 'receiving' province), in how longer absences are dealt with (e.g., students studying in another province), whether the care will be paid for at home province or host province rates, and so on.

Accessibility[]

Finally, the insurance plan must provide for "reasonable access" to insured services by insured persons, "on uniform terms and conditions, unprecluded, unimpeded, either directly or indirectly, by charges (user charges or extra-billing) or other means (age, health status or financial circumstances);" (Section 12.a). This section also provides for "reasonable compensation for...services rendered by medical practitioners or dentists" and payments to hospitals that cover the cost of the health services provided. Note that neither reasonable access nor reasonable compensation are defined by the Act, although there is a presupposition that certain processes (e.g., negotiations between the provincial governments and organizations representing the providers) satisfy the condition. The Act allows for dollar-for-dollar withholding of contributions from any provinces allowing user charges or extra-billing to insured persons for insured services. As noted below, this provision was effective in 'solving' the extra-billing issue.

Additional conditions[]

Section 13 lists two additional conditions which must be met by the province in order to receive its full share of the federal transfers. The first condition is that the federal Minister of Health is entitled to specific information relating to a province's insured & extended health care services. This information is used in drafting annual reports, presented to parliament, on how the province administered its health care services over the previous year.

The second condition is that the province must "give recognition" to the federal government "in any public documents, or in any advertising or promotional material, relating to insured health services and extended health care services in the province" (Section 13.b).^[8]

Background[]

Division of power over healthcare in Canada[]

The division of power in Canada between the federal, provincial, and territorial governments was originally established through the British North America Act 1867 , which was renamed the Constitution Act, 1867 in 1982. In 1867, specific clauses of Act, gave the federal government some powers over aspects of health care, for example quarantine. According to Section 92, "provincial legislatures" have "exclusive powers" over the "establishment, maintenance, and management" of "hospitals, asylums, charities, and eleemosynary institutions in and for the province, other than marine hospitals."^[9]

In 1948, the federal government introduced a series of National Health Grants to directly provide funds to the provinces and territories to construct hospitals, to provide professional training and for public health. This increased the number of hospital beds but did not address the issue of how their operating costs would be covered.

Various Senate Committees have reported on the division of power between the federal, provincial, and territorial governments, including the March 2001 report entitled, "The Health of Canadians: The Federal Role".^[10] The report described how the federal government assisted the provinces by providing federal funding to the provinces and territories to health services, and that tensions arose when the federal government attempted to set national standards on health along with the federal transfers.^[10]

The challenge of ensuring equal access to the same level of services to all provinces and territories—which have differing fiscal resources and fiscal capacities—by implementing federal programs, encountered resistance from the provinces and territories. The implementation of different iterations of equalization payment plans, became increasingly problematic. This resulted in several legal battles. In a few cases, where there was agreement that the federal government should take the lead, adverse court decisions were handled by amending the constitution.^{[Notes 1]}

Health insurance before the CHA[]

The development of Canadian health insurance^[11] has been well described by Malcolm Taylor, who participated in many of the negotiations in addition to studying it as an academic.^[12] Health care is delivered privately but largely administered and funded publicly by provinces, consistent with their jurisdictional authority. Funded privately until the mid-to-late 20th century, Taylor notes that many Canadians "daily faced the potentially catastrophic physical and financial consequence of unpredictable illness, accident, and disability," and providers, unwilling to deny needed care, had growing bad debts. A number of efforts to establish social insurance systems failed due to provincial opposition to federal incursion into their jurisdiction. These included the 1937 Rowell-Sirois Commission on Dominion-Provincial Relations, and the 1945 Green Book proposals of Prime Minister Mackenzie King as part of the post-World War II reconstruction. At the same time, Canada resembled other developed economies in its receptivity to a more expansive government role in improving social welfare, particularly given the widespread sacrifices during World War II and the still active memories of the Great Depression.

Following the collapse of the conference proposals in 1946, in 1947, the social democratic premier of Saskatchewan, Tommy Douglas of the Co-operative Commonwealth Federation (CCF) established Canada's first publicly funded hospital insurance plan. Other provinces - including British Columbia, Alberta, and Ontario, introduced their own insurance plans, with varying degrees of coverage, and varying degrees of success. When Newfoundland joined Canada, it brought along its system of cottage hospitals. These policy initiatives increased pressure on the federal government, flush with post-war financial resources, to buy in to health care for its electoral appeal and to extend public financing to provinces whose citizens did not yet have full coverage for hospital care.

The result was that the Progressive Conservative government of John Diefenbaker, who also happened to represent Saskatchewan, introduced and passed (with all-party approval) the Hospital Insurance and Diagnostic Services Act of 1957. This shared the costs of covering hospital services. By the start date (July 1, 1958) five provinces—Newfoundland, Manitoba, Saskatchewan, Alberta, and British Columbia—had programs in place which could receive the federal funds. By January 1, 1961, when Quebec finally joined, all provinces had universal coverage for hospital care.

Saskatchewan decided to take the money released by the federal contributions to pioneer again, and following lengthy consultations with but also strong opposition from the provincial medical association, introduced a plan to insure physician costs (The Saskatchewan Medical Care Insurance Plan). By this time, Douglas had moved to national politics, as leader of the federal New Democratic Party (NDP), The provincial plan precipitated a strike by the province's physicians (1962). It was eventually settled, but the CCF lost the 1964 election to Liberal Ross Thatcher. The plan, however, remained popular, and encouraged other provinces to examine similar programs. A policy debate ensued, with some arguing for universal coverage, and others (particularly the Canadian Medical Association) arguing for an emphasis on voluntary coverage, with the government assisting only those who could not afford the premiums. Three provinces - BC, Alberta, and Ontario - introduced such programs.

The federal reaction was to appoint a Royal Commission on Health Services. First announced by Prime Minister Diefenbaker in December 1960, it was activated in the following June. Its chair was Justice Emmett Hall, the chief justice of Saskatchewan, and a lifelong friend of Mr. Diefenbaker. Three years later, following extensive hearings and deliberations, it released an influential report, which recommended that Canada establish agreements with all provinces to assist them in setting up comprehensive, universal programs for insuring medical services, on the Saskatchewan model, but also recommended adding coverage for prescription drugs, prosthetic services, home care services, as well as optical and dental services for children and those on public assistance. (None of these have yet been added to the formal national conditions, although most provinces do have some sort of coverage for these services.)

By this time, the Liberals, under Lester B. Pearson were in power. Following intense debate, the Pearson government introduced the Medical Care Act which was passed in 1966 by a vote of 177 to two. These two Acts established a formula whereby the federal government paid approximately 50% of approved expenditures for hospital and physician services. (The actual formula was a complex one, based on a combination of average national expenditures and spending by each province. In practice, this meant that higher-spending provinces received more federal money, but that it represented a lower proportion of their expenditures, and vice versa for lower-spending provinces.) By 1972, all provinces and territories had complying plans. However, the fiscal arrangements were seen as both cumbersome and inflexible. By 1977, a new fiscal regimen was in place.

Change in fiscal arrangements: the 1977 act[]

In 1977, HIDS, the Medical Care Act, and federal funds for post-secondary education (also under provincial jurisdiction) were combined into a new Federal-Provincial Fiscal Arrangements and Established Programs Financing Act of 1977 (known as EPF). This legislation de-coupled the legislation governing the amount of the federal transfer from the legislation establishing the terms and conditions to be met to receive it.

Under this new arrangement, cost sharing was no more. Provinces/territories now had more flexibility, as long as the federal terms and conditions continued to be met. The federal government had more predictability. Rather than an open-ended commitment, EPF established a per capita entitlement (not adjusted for age-sex or other demographic factors) which would be indexed to inflation. This money would go into provincial general revenues. To simplify a complex formula, the EPF entitlement could be seen as consisting of two components. Part of the funds were in the form of "tax transfers" whereby "the federal government agreed with provincial and territorial governments to reduce its personal and corporate income tax rates, thus allowing them to raise their tax rates by the same amount. As a result, revenue that would have flowed to the federal government began to flow directly to provincial and territorial governments."^[13] This transfer could not be reversed by subsequent governments, meaning that the federal government had no fiscal leverage over this component of the transfer. (Indeed, there has been an ongoing controversy as to whether this component should even be considered part of the federal contribution.)^[14] The remainder of the entitlement was in the form of cash grants. Although the per capita amount was intended to be escalated to inflation, subsequently, the federal government tried to deal with its fiscal position by unilaterally first reducing and then freezing the inflation escalator. As the cash portion threatened to disappear, in 1996, the federal government combined the EPF transfers with another cost-shared program, the Canada Assistance Plan (CAP), to form the Canada Health and Social Transfer (CHST). This enabled the federal government to both cut the total transfers (by approximately the amount in the CAP) while retaining a 'cash floor' on the total amount. In 2004, these transfers were split into the Canada Health Transfer (CHT) and the Canada Social Transfer. The federal Department of Finance publishes brief guides to these programs.^[15] Nonetheless, many argue that there has been no explicit federal transfer for health care since 1977, since these programs are no longer tied to specific spending.

The second component of the federal plan, specification of the terms and conditions which provincial/territorial insurance plans must meet, continued to be those established in HIDS and the Medical Care Act. (Note that there were almost no conditions attached to the CAP or post-secondary education components of the transfers.) The genesis of the CHA was recognition of the extent to which the federal ability to control provincial behaviour had been reduced. One particular problem was the absence of any provision for graduated withholding of the federal contribution. Because there was little desire to withhold the full contribution for minor violations of terms and conditions, provinces increasingly were permitting extra billing for insured services. In response to the resulting political uproar, the federal government again turned to Justice Emmett Hall and asked him to report on the future of medicare. His 1979 report, 'Canada's National-Provincial Health Program for the 1980s' noted some of the areas recommended in his earlier report which had not yet been acted on, and warned that accessibility to health care was being threatened through rising user fees. The federal response was to pass the 1984 Canada Health Act which replaced both HIDS and the Medical Care Act and clarified the federal conditions.

Violations and penalties[]

In order to document compliance with the Act, the federal Minister of Health annually reports to the Parliament of Canada on how the Act has been administered by each province over the course of the previous fiscal year.

For non-compliance with any of the five criteria listed above, the federal government may withhold all or a part of the transfer payment with "regard to the gravity of the default" (Section 15). Thus far all non-compliance issues have been settled through discussion or negotiation. Some^[who?] argue that the federal government has not actively attempted to enforce these conditions, with particular concerns about handling of portability (e.g., the reduction of coverage for residents while traveling abroad) and comprehensiveness (e.g., de-insuring of some medical procedures).

In accordance with section 20, if a province were to violate the prohibition on extra-billing or user charges, the corresponding amount of that collected would be deducted from the transfer payment. Details about these amounts are available from the Canadian government websites.

One aspect of the Act was provision for reimbursement of funds withheld for extra-billing and user charges if these were eliminated within three years. Although often contentious (e.g., Ontario's physicians went on strike), all provinces complied with the provisions of the Act. Although the amounts withheld were relatively modest—financial penalties totaling $246,732,000 were withheld from the provinces in the first two years—provinces found it difficult to resist the pressure. (They found that many interest groups seeking additional funds would argue that it could be afforded if the province/territory eliminated their extra billing/user fees. Faced with multiple claims on the same pot, most provinces decided that the easiest path was to eliminate these charges.)

In 1993, British Columbia allowed approximately 40 medical practitioners to use extra-billing in their practices. In response, the federal government reduced B.C.'s EPF payments by a total of $2,025,000 over the course of four years.

In 1996, Alberta had their EPF payment reduced by a total of $3,585,000 over the course of a few years due to the use of private clinics that charged user fees. Newfoundland suffered the loss of $323,000 until 1998 and Manitoba lost a total of $2,056,000 until 1999 from user fees being charged at private clinics. Nova Scotia has also forgone EPF payment for their use of user fees in private clinics.

As required by section 23 of the Canada Health Act, the Government of Canada publishes a yearly report describing the extent to which each province and territory has complied with the Act.

Reports: Canada Health Act Annual Reports

Criticism[]

Pro-choice advocates have pointed out that the Canada Health Act fails to meet its criteria in providing access to abortion. Abortion, as a medical service, does not meet the basic principles of the Act: public administration, comprehensiveness, universality, portability, and accessibility. Joyce Arthur concludes that "Abortion services fail at least 4 out 5 of these tests." The delivery of abortion services fails comprehensiveness because clinics are not equally funded, universality because of lack of equal access across the country and especially in rural areas, portability because abortion is excluded from the standard reciprocal billing between provinces, accessibility because of lack of clinics in some provinces, and possibly public administration because private clinics are forced to administer its costs.^[16]

In Canada, general oral health care is not included in the Act. Most Canadians receive oral health care through privately operated dental clinics and pay for services through insurance or by paying for it themselves. Some dental services are covered through government dental programs.

A 2016 Huffington Post article quoting Saskatchewan Member of the Legislative Assembly Ryan Meili stated: "Extra-billing in Ontario, private MRIs in Saskatchewan and user fees in Quebec: violations of the Canada Health Act are on the rise across the country. Canadian doctors are concerned about the impact of this trend not only on their patients, but on our public health care system as well".^[17]

Popular discussion[]

In popular discussion, the Act is often conflated with the health care system in general. However, the Act is silent about how care should be organized and delivered, as long as its criteria are met. The Act states that "the primary objective of Canadian health care policy is to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers."^[18]

Notes[]

^ In the case of unemployment insurance, For example, in 1940, in response to a court decision that federal unemployment insurance was unconstitutional, the Constitution Act, 1867 was amended to give the national Parliament jurisdiction over unemployment insurance).Reference Archived November 21, 2007, at the Wayback Machine re Employment Insurance Act (Can.), ss. 22 and 23, 2005 SCC 56, [2005] 2 Supreme Court of Canada 669.

References[]

^ "Canada Health Act, Section 9". Government of Canada. 1984-04-01. Retrieved 2012-12-14.
^ "Canada Health Act, Section 2". Government of Canada. 1984-04-01. Retrieved 2012-12-14.
^ Canadian Institute for Health Information (September 27, 2005), CIHI exploring the 70-30 split, ISBN 1-55392-655-2, archived from the original on July 6, 2011, retrieved 2010-12-15.
^ Organisation for Economic Co-operation and Development (2010), OECD Health Data 2010: How Does Canada Compare (PDF), retrieved 2010-12-15.
^ Monique Begin. Medicare: Canada's Right to Health. 1988 ISBN 978-0-88890-219-1
^ Jump up to: ^a ^b Health Canada (November 25, 2002). "Canada Health Act Overview, 2002". About Health Canada. Canada. Archived from the original on December 17, 2007. Retrieved 2007-12-26.
^ "Canada Health Act, Section 10". Government of Canada. 1984-04-01. Retrieved 2012-12-14.
^ Branch, Legislative Services (2017-12-12). "Consolidated federal laws of canada, Canada Health Act". laws-lois.justice.gc.ca. Retrieved 2021-05-20.
^ Canada, "Archived copy". Archived from the original on 2011-06-05. Retrieved 2010-11-07.CS1 maint: archived copy as title (link)
^ Jump up to: ^a ^b Standing Senate Committee on Social Affairs, Science and Technology (March 2001), The Health of Canadians – The Federal Role, Interim Report, Volume One – The Story So Far (PDF), Canada, retrieved 2007-12-26
^ [1]
^ Malcolm G. Taylor. The Seven Decisions That Created the Canadian Health Insurance System and Their Outcomes. Second edition. McGill-Queen's University Press, 1987. ISBN 978-0-7735-0629-9
^ Health Canada (2002), The Canada Health and Social Transfer, Canada, archived from the original (– ^{Scholar search}) on December 18, 2007, retrieved 2007-12-26
^ Raisa Deber (July 11, 2000), "Who Wants To Pay For Health Care", Canadian Medical Association Journal, 163 (1): 43–44, PMC 1232551, PMID 10920731, retrieved 2007-12-26
^ Department of Finance. "A Brief History of the Health and Social Transfers". Federal provincial cost sharing programs. Canada. Archived from the original on 2007-12-17. Retrieved 2007-12-27.
^ Arthur, Joyce (November 2001). "Canada Health Act Violates Abortion Services: Five Basic Principles Not Met". Pro Choice Action Network. Retrieved 2012-12-14.
^ "It's Time for the Federal Government to Enforce the Canada Health Act". 4 April 2016.
^ "Canada Health Act, Section 3". Government of Canada. 1984-04-01. Retrieved 2012-12-14.

General references

[11] In the case of unemployment insurance, For example, in 1940, in response to a court decision that federal unemployment insurance was unconstitutional, the Constitution Act, 1867 was amended to give the national Parliament jurisdiction over unemployment insurance).Reference Archived November 21, 2007, at the Wayback Machine re Employment Insurance Act (Can.), ss. 22 and 23, 2005 SCC 56, [2005] 2 Supreme Court of Canada 669.

[chal9-1] "Canada Health Act, Section 9". Government of Canada. 1984-04-01. Retrieved 2012-12-14.

[chal2-2] "Canada Health Act, Section 2". Government of Canada. 1984-04-01. Retrieved 2012-12-14.

[3] Canadian Institute for Health Information (September 27, 2005), CIHI exploring the 70-30 split, ISBN 1-55392-655-2, archived from the original on July 6, 2011, retrieved 2010-12-15.

[4] Organisation for Economic Co-operation and Development (2010), OECD Health Data 2010: How Does Canada Compare (PDF), retrieved 2010-12-15.

[5] Monique Begin. Medicare: Canada's Right to Health. 1988 ISBN 978-0-88890-219-1

[HC_2002-6] Jump up to: ^a ^b Health Canada (November 25, 2002). "Canada Health Act Overview, 2002". About Health Canada. Canada. Archived from the original on December 17, 2007. Retrieved 2007-12-26.

[chal10-7] "Canada Health Act, Section 10". Government of Canada. 1984-04-01. Retrieved 2012-12-14.

[8] Branch, Legislative Services (2017-12-12). "Consolidated federal laws of canada, Canada Health Act". laws-lois.justice.gc.ca. Retrieved 2021-05-20.

[9] Canada, "Archived copy". Archived from the original on 2011-06-05. Retrieved 2010-11-07.CS1 maint: archived copy as title (link)

[sencanada_200103-10] Jump up to: ^a ^b Standing Senate Committee on Social Affairs, Science and Technology (March 2001), The Health of Canadians – The Federal Role, Interim Report, Volume One – The Story So Far (PDF), Canada, retrieved 2007-12-26

[12] [1]

[13] Malcolm G. Taylor. The Seven Decisions That Created the Canadian Health Insurance System and Their Outcomes. Second edition. McGill-Queen's University Press, 1987. ISBN 978-0-7735-0629-9

[14] Health Canada (2002), The Canada Health and Social Transfer, Canada, archived from the original (– ^{Scholar search}) on December 18, 2007, retrieved 2007-12-26

[15] Raisa Deber (July 11, 2000), "Who Wants To Pay For Health Care", Canadian Medical Association Journal, 163 (1): 43–44, PMC 1232551, PMID 10920731, retrieved 2007-12-26

[16] Department of Finance. "A Brief History of the Health and Social Transfers". Federal provincial cost sharing programs. Canada. Archived from the original on 2007-12-17. Retrieved 2007-12-27.

[cha-fail-17] Arthur, Joyce (November 2001). "Canada Health Act Violates Abortion Services: Five Basic Principles Not Met". Pro Choice Action Network. Retrieved 2012-12-14.

[18] "It's Time for the Federal Government to Enforce the Canada Health Act". 4 April 2016.

[chal3-19] "Canada Health Act, Section 3". Government of Canada. 1984-04-01. Retrieved 2012-12-14.

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[11]

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[13]

[14]

[15]

[16]

[17]

[18]

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