Use of entomopathogenic nematodes as biological control agentsa [37].
\r\n\tThis necessitated a need to understand control theoretical concepts and system analysis in a discrete time domain, which gave rise to the area of discrete time control systems. This has helped control engineers and designers to theoretically ascertain the possibilities and limitations of a control system design implemented in a digital framework, whereas continuous time designs suffer from the essential mismatch in the nature of the underlying independent time variable in theoretical studies and practical implementation. Also, many practical systems are inherently discrete time in nature, sensors and transducers sample data only at fixed time intervals, and computers calculate the control input only in some finite time.
\r\n\tTraditionally, fundamental concepts of discrete time control systems are derived from the continuous time counterpart upon time discretization of the latter and subsequent formal analysis. This gave rise to discrete time counterparts of system models and controllers in z-domain as well as in state space form. However, discrete time control system design and analysis matured as a discipline in itself with the advent of optimal and adaptive techniques solely based on discrete time approach. Robust nonlinear discrete time controllers were also developed utilizing the ideas of sliding modes, model predictive control, etc.
\r\n\tThe techniques for parameter estimation and system identification are largely dominated by discrete time methods. Well-established Kalman filter and extended Kalman filters are developed in discrete time. Many discrete time stochastic filters are utilized in control systems to reduce the impact of noise and disturbance during practical implementation.
\r\n\tDespite the developments in discrete time control designs and their usefulness in control system implementation, there are a few challenges like discretization effect on systems stability, communication loss, etc. which are also areas of serious research. With all its usefulness and limitations, discrete time control systems have found vast areas of application from process control and automation, robotics, network control systems and internet of things, control of networks and multi-agent systems, etc.
\r\n\tThis book intends to provide the reader with an overview of detailed control system design methodologies in discrete time which are well-established in literature. Emerging areas of interest in discrete time systems catering to new and existing challenges are also welcomed.
Entomopathogenic nematodes (EPNs) are soil-inhabiting, lethal insect parasites that belong to the Phylum Nematoda from the families Steinernematidae and Heterorhabditidae, and they have proven to be the most effective as biological control organisms of soil and above-ground pests [1, 2]. They have been known since the seventeenth century [3], but it was only in the 1930s that serious care was given by using nematodes for pest control.
\nSo far, the family Steinernematidae is comprised of two genera, Steinernema Travassos, 1927 [4] (Poinar, 1990) and Neosteinernema (Nguyen and Smart, 1994) [5]. Neosteinernema contains only one species Neosteinernema longicurvicauda that isolated from the termite Reticulitermes flavipes (Koller). The family Heterorhabditidae contains only one genus, Heterorhabditis Poinar, 1976 [6].
\nEPNs are mutually associated with bacteria of the family Enterobacteriaceae; the bacterium carried by Steinernematidae is usually a species of the genus Xenorhabdus, and that carried by Heterorhabditidae is a species of Photorhabdus. The third juvenile stage of EPNs is referred to as the “infective juvenile” (IJ) or the “dauer” stage. IJs of both genera release their bacterial symbionts in the insect host body and develop into fourth-stage juveniles and adults. The insects die mainly due to a septicemia. Sometimes a bacterial toxaemia precedes the resulting septicemia [7].
\nInfective juvenile is the only free-living stage and can survive in soil for several months until susceptible insects are encountered. IJs locate and infect suitable insect hosts by entering the insect host through the mouth, anus, spiracles or thin parts of the host cuticle. After infection, the symbiotic bacteria are released into the insect haemocoel, causing septicaemia and death of the insect [1, 8]. When an insect host is infected in the soil by an EPN, development and reproduction within the cadaver can take 1–3 weeks [9].
\nSurveys for EPNs have been conducted in temperate, subtropical and tropical regions and found that EPNs have a worldwide distribution; the only continent where they have not been found is Antarctica [10]. Soil texture, temperature and host availability are thought to be important factors in determining their distribution [11–13].
\nNearly 70 valid species of Steinernema [14–16] and 25 species of Heterorhabditis [17, 18] have been described worldwide and still surveys for EPNs have been conducted in many parts of the world.
\nThrough all nematodes studied to control insects, the families Steinernematidae and Heterorhabditidae have made a sensation and information about them is increasing exponentially. Steinernematids and Heterorhabditids from these families have similar life cycles, and the only difference between the life cycles of Heterorhabditis and Steinernema is occurred in the first generation. Steinernema species are amphimictic; this means that for successful reproduction they require the presence of males and females, whereas Heterorhabditis species are hermaphroditic and able to reproduce in the absence of conspecifics.
\nBoth nematode genera reproduction is amphimictic in the second generation [4]. However, a hermaphroditic Steinernematid species was isolated from Indonesia [19]. Only the free-living, IJ stage is able to target insect host and the only form found outside of the host. EPNs occur naturally in soil and locate their host in response to carbon dioxide, vibration and other chemical cues, and they react to chemical stimuli or sense the physical structure of insect’s integument [1].
\nIJs penetrate the host insect via the spiracles, mouth, anus, or in some species through intersegmental membranes of the cuticle, and then enter into the haemocoel [20]. IJs release cells of their symbiotic bacteria from their intestines into the haemocoel. The bacteria multiply rapidly in the insect hemolymph, provide nematode with nutrition and prevent secondary invaders from contaminating the host cadaver, and the infected host usually dies within 24–48 hours by bacterial toxins.
\nNematodes reproduce until the food supply becomes limiting at which time they turn into IJs. The progeny nematodes go through four juvenile stages to the adult. Based on the available resources, one or more generations may occur within the host cadaver, and a great number of IJs are released into environment to infect other host insects and continue their life [1].
\nThe insect cadaver becomes red if the insects are killed by Heterorhabditids and brown or tan if killed by Steinernematids (Figure 1). The colour of the insect host body is indicative of the pigments produced by the monoculture of mutualistic bacteria growing in the host insects [1].
\nDifferent colours of the dead Curculio nucum larvae on white traps after EPNs infection.
The foraging strategies of EPNs change between species, and they use two main foraging strategies: ambushers or cruisers [21]. Steinernema carpocapsae is an example of ambushers, which have an energy-conserving approach and lie in wait to attack mobile insects (nictitating) in the upper layer of the soil. Steinernema glaseri and Heterorhabditis bacteriophora are examples of cruisers are highly active and generally subterranean, moving significant distances using volatile cues and other methods to find their host underground. But they are also successful to attack white grubs (Scarab beetles), which are less mobile. Other species, such as Steinernema feltiae and Steinernema riobrave, use an intermediate foraging strategy (combination of ambush and cruiser type) to find their host.
\nSelection of an EPN to control a particular pest insect is based on various factors: the nematode’s host range, host finding or foraging strategy, tolerance of environmental factors and their effects on survival and efficacy. The most critical factors are moisture, temperature, pathogenicity for the targeted pest insect and foraging strategy [1, 22–24]. The activity, infectivity and survival of EPNs can be profoundly influenced by soil composition, through its effects on moisture retention, oxygen supply and texture [25–27].
\nWithin a favourable range of temperatures, adequate moisture and a susceptible host, those EPNs with a mobile foraging strategy (cruisers and intermediate foraging strategies) could be considered for use in subterranean and certain above-ground habitats (foliar, epigeal and cryptic habitats). Those EPNs with a sit and wait foraging strategy (ambushers) will be most effective in cryptic and soil surface habitats [28].
\nThese nematodes have many advantages; EPNs and their associated bacterial symbionts have been proven safe to warm-blooded vertebrates, including humans [29, 30]. Cold-blooded species have been found to be susceptible to EPNs under experimental conditions at very high dosages [31, 32]. However, under field conditions, the negative results could not be reproduced [33, 34].
\nMost biological agents require days or weeks to kill the host, yet nematodes can kill insects usually in 24–48 hours. They are easy and relatively inexpensive to culture, live from several weeks up to months in the infective stage, are able to infect numerous insect species, occur in soil and have been recovered from all continents except Antarctica [1, 35].
\nFoliar applications of nematodes have been successfully used to control the quarantine leaf-eating caterpillars as Tuta absoluta, Spodoptera littoralis, Helicoverpa armigera, Pieris brassicae on several crops and have the potential for controlling various other insect pests. Application of EPNs does not require masks or other safety equipment like chemicals. EPNs and their associated bacteria have no detrimental effect to mammals or plants [29, 30, 36].
\n\nPotential of EPNs as insecticidal agents has been tested against a wide range insect species by many researchers all over the world. They have been used with different success against insect pests occurred in different habitats. Much success has been obtained against soil-dwelling pests or pests in cryptic habitats such as inside galleries in plants where IJs find excellent atmosphere to survive and protect themselves from environmental factors. Commercial use of EPNs against some pest insects is given in Table 1.
\nCrops (targeted) | \nPest common name | \nPest scientific name | \nEffective nematodesb | \n
---|---|---|---|
Artichokes | \nArtichoke plume moth | \nPlatyptilia carduidactyla | \nSc | \n
Vegetables | \nArmyworm | \nLep: Noctuidae | \nSc, Sf, Sr | \n
Ornamentals | \nBanana moth | \nOpogona sacchari | \nHb, Sc | \n
Bananas | \nBanana root borer | \nCosmopolites sordidus | \nSc, Sf, Sg | \n
Turf | \nBillbug | \nSphenophorus spp. (Col: Curculionidae) | \nHb, Sc | \n
Turf, vegetables | \nBlack cutworm | \nAgrotis ipsilon | \nSc | \n
Berries, ornamentals | \nBlack vine weevil | \nOtiorhynchus sulcatus | \nHb, Hd, Hm, Hmeg, Sc, Sg | \n
Fruit trees, ornamentals | \nBorer | \nSynanthedon spp. and other sesiids | \nHb, Sc, Sf | \n
Home yard, turf | \nCat flea | \nCtenocephalides felis | \nSc | \n
Citrus, ornamentals | \nCitrus root weevil | \nPachnaeus spp. (Col: Curculionidae) | \nSr, Hb | \n
Pome fruit | \nCodling moth | \nCydia pomonella | \nSc, Sf | \n
Vegetables | \nCorn earworm | \nHelicoverpa zea | \nSc, Sf, Sr | \n
Vegetables | \nCorn rootworm | \nDiabrotica spp. | \nHb, Sc | \n
Cranberries | \nCranberry girdler | \nChrysoteuchia topiaria | \nSc | \n
Turf | \nCrane fly | \nDip: Tipulidae | \nSc | \n
Citrus, ornamentals | \nDiaprepes root weevil | \nDiaprepes abbreviatus | \nHb, Sr | \n
Mushrooms | \nFungus gnat | \nDip: Sciaridae | \nSf, Hb | \n
Grapes | \nGrape root borer | \nVitacea polistiformis | \nHz, Hb | \n
Iris | \nIris borer | \nMacronoctua onusta | \nHb, Sc | \n
Forest plantings | \nLarge pine weevil | \nHylobius abietis | \nHd, Sc | \n
Vegetables, ornamentals | \nLeafminer | \nLiriomyza spp. (Dip: Agromyzidae) | \nSc, Sf | \n
Turf | \nMole cricket | \nScapteriscus spp. | \nSc, Sr, Sscap | \n
Nut and fruit trees | \nNavel orangeworm | \nAmyelois transitella | \nSc | \n
Fruit trees | \nPlum curculio | \nConotrachelus nenuphar | \nSr | \n
Turf, ornamentals | \nScarab grubc | \nCol: Scarabaeidae | \nHb, Sc, Sg, Ss, Hz | \n
Ornamentals | \nShore fly | \nScatella spp. | \nSc, Sf | \n
Berries strawberry | \nRoot weevil | \nOtiorhynchus ovatus | \nHm | \n
Bee hives | \nSmall hive beetle | \nAethina tumida | \nHi, Sr | \n
Sweet potato | \nSweetpotato weevil | \nCylas formicarius | \nHb, Sc, Sf | \n
Use of entomopathogenic nematodes as biological control agentsa [37].
aNematodes listed provided at least 75% suppression of these pests in field or greenhouse experiments.
bAbbreviations of nematode species; Hb: Heterorhabditis bacteriophora, Hd: H. downesi, Hi: H. indica, Hm: H. marelata, Hmeg: H. megidis, Hz: H. zealandica, Sc: Steinernema carpocapsae, Sf: S. feltiae, Sg: S. glaseri, Sk: S. kushidai, Sr: S. riobrave, Sscap: S. scapterisci, Ss: S. scarabaei.
cEfficacy against various pest species within this group varies among nematode species.
In our laboratory, we investigated the use of native EPN isolates to control various pest insects, and one of these pests was tomato leaf miner. The tomato leafminer, T. absoluta (Meyrick) (Lepidoptera: Gelechiidae), is a very devastating pest and was first recorded in 2009 in the Urla District of Izmir Province in Turkey [38]. It has been a serious problem to tomato production in Çanakkale since the first detection in our country [39]. T. absoluta can attack all parts and stages of the tomato plant, overwinter in the egg, pupal or adult stage and can cause up to 100% losses in tomato crops [40].
\nSince its dispersal in the 1970s, chemical control has been the main method to control T. absoluta. Producers have tried to decrease its damages by using insecticides twice a week during a cultivation period, sometimes every 4–5 days/season with 8–25 sprays [41]. Although with the many applications of chemicals, effective control is difficult due to the behaviour of these mine-feeding larvae.
\nMoreover, the use of pesticides in plant production has numerous disadvantages as pesticide residues on human health and on the environment so biological control may be considered as an alternative method to chemical control [42]. In this respect, EPNs can be an alternative to chemicals. The aims of the work were to determine the efficacy of native EPN isolates against T. absoluta in tomato field and to reduce the use of pesticides.
\nFour native species of nematodes: Steinernema affine (Bovien) (isolate 46) S. carpocapsae (Weiser) (isolate 1133), S. feltiae (Filipjev) (isolate 879) and H. bacteriophora (Poinar) (isolate 1144), were tested against T. absoluta larvae. Each isolates was reared in the last instar of wax moth larvae Galleria mellonella L., which is the most commonly used insect host for in vivo production of EPNs because of its rich nutrient source available in body and easy to multiply in economical diet source [43, 44].
\nNematode-infected G. mellonella larvae were placed on white traps [45] at 25°C and IJs that emerged from cadavers were harvested.
\nLarvae, pupae and adults of T. absoluta used in the trials were obtained from infested tomato fields in Çanakkale. They reared in wooden rearing cages (50 × 50 × 50 cm) on tomato plants at 25 ± 1°C, 65 ± 5% RH, with a 16:8 L:D photoperiod in climate room.
\nField trials were carried out in the training and research area of Agriculture Faculty in Çanakkale between 2012 and 2013. In both seasons, nearly 1000 m2 area was cultivated with tomato and seedlings were controlled periodically and closed by a cage when they reached 20 cm height. Each tomato plant was grown in a single cage (50 × 50 × 50 cm). After 30 days, two males and two females were put into each cage.
\nEPNs were applied at dusk to utilise the higher air humidity for the nematodes with a conventional airblast sprayer at a rate of 50 IJs/cm2. Tomato plants remained wet in cages after application for 2 hours and that provides EPNs enough time with perfect condition to find and infect the target pest. The experiment was carried out with two replicates per nematode species and exposure day and repeated twice.
\nAfter releasing the adults of T. absoluta, EPNs were sprayed on tomato plants at the 7th, 14th and 21st days. Tomato plants were cut from the soil line at the 3rd, 5th 7th, 9th, 11th, 13th and 15th days after EPN applications and analysed to determine the mortality of T. absoluta. Dead T. absoluta larvae were immediately dissected and checked for nematode infection (Figure 2). EPNs most likely entered feeding canals in the leaves of tomatoes. Many larvae of T. absoluta died inside these galleries, which indicate that IJs were able to find and infect them.
\nEmerged EPNs from infected Tuta absoluta larvae.
The efficacy of EPNs in field in 2012 changed between 0 and 90.7 ± 1.5%. The least efficient species was S. affine and the most efficient species was S. feltiae with the mortality of 39.3 ± 1.5% and 90.7 ± 1.5%, respectively. S. affine caused 0–39.3 ± 1.5% mortality and found as the least efficient species. S. carpocapsae caused 0–43.7 ± 1.5% mortality, while S. feltiae caused 0–90.7 ± 1.5% mortality. H. bacteriophora caused 0–81 ± 3.5% mortality and was the second efficient species after S. feltiae against T. absoluta in tomato field in 2012.
\nThe efficacy of EPNs in field in 2013 changed between 0 and 94.3 ± 2.0%. The least efficient species was S. affine and the most efficient species was S. feltiae with the mortality of 43.7 ± 2.3% and 94.3 ± 2.0%, respectively. S. affine caused 0–43.7 ± 2.3% mortality and was the least efficient species. S. carpocapsae caused 0–49.3 ± 2.4% mortality, while S. feltiae caused 0–94.3 ± 2.0% mortality. H. bacteriophora caused 0–83.0 ± 2.1% mortality and was the second efficient species after S. feltiae against T. absoluta in field in 2013.
\nThe tomato leafminer, T. absoluta, is one of the most important lepidopteran moth associated with tomato plants and because of its biology and behaviour, it is difficult to control. Effective chemical control of T. absoluta is not possible because it feeds internally within the plant tissues. Resistance to insecticides is another significant problem in chemical control of this pest because of its high reproduction capacity, short generation cycle and intensive use of insecticides [46–50].
\nPesticides are so widely used and that destroys populations of natural enemies and consequently decreases biological control of T. absoluta. Because of these negative effects of insecticides, other approaches need to be considered seriously for this devastating pest.
\nSome insects can be controlled by a combination of methods, which are not totally effective when used alone. T. absoluta is one of these insects, which requires more than one method to be controlled successfully. For this reason, integrated pest management (IPM) programmes are continuously being progressed in different countries to control infestations of tomato leaf miner. EPNs have been considered as potential biocontrol agents for leafminers in recent years [50]. They can be applied, in combination with other biological and chemical pesticides, fertilisers and soil amendments and in the form of adjuvants or antidesiccants [51, 52].
\nVarious studies about EPNs have been conducted all over the world, but only few research has been carried out on the efficacy of EPNs against T. absoluta. This is the first study conducted both in çanakkale and in Turkey based on the efficacy of native EPN isolates to T. absoluta in a tomato field.
\nThe efficacy of the three EPNs after foliar application to potted tomato was tested under greenhouse conditions. High larval mortality (78.6–100%) and low pupal mortality (<10%) in laboratory were reported. In the leaf bioassay, high larval parasitisation (77.1–91.7%) was recorded. In the pot experiments, it was found that nematode application decreased insect infestation of tomato by 87–95%. These results showed the suitability of EPNs to control T. absoluta [53].
\nThe efficacy of soil treatments of three native EPNs (S. carpocapsae, S. feltiae and H. bacteriophora) against T. absoluta larvae, pupae and adults was determined under laboratory conditions in another study [54]. The effect of three commonly used insecticides against T. absoluta was also evaluated in the survival, infectivity and reproduction of these EPNs. When the larvae dropped into the soil to become pupa, soil application of nematodes resulted in a high larval mortality: 100, 52.3 and 96.7% efficacy for S. carpocapsae, S. feltiae and H. bacteriophora, respectively. No mortality of pupae was recorded, and mortality of adults emerging from soil was 79.1% for S. carpocapsae and 0.5% for S. feltiae. An insignificant effect of the insecticides tested was reported on nematode survival, infectivity and reproduction. No sublethal effects were observed. These findings proved that larvae of T. absoluta, falling from leaves following insecticide application, could be favourable hosts for nematodes, thereby increasing their concentration and persistence in the soil.
\nThe efficacy of S. feltiae, S. carpocapsae and H. bacteriophora was evaluated against larvae of T. absoluta inside leaf mines in tomato leaf discs by means of an automated spray boom. They reported that all EPNs used in the study were effective to all four larval instars of T. absoluta but caused higher mortality in the later instars (fourth instar: 77.1–97.4%) than in the first instars (36.8–60.0%). S. feltiae and S. carpocapsae showed better results than H. bacteriophora. S. carpocapsae and H. bacteriophora performed better at 25°C (55.3 and 97.4% mortality, respectively) than at 18°C (12.5 and 34.2% mortality, respectively), while S. feltiae caused 100% mortality at both temperatures. Their results demonstrated that under laboratory conditions, S. feltiae and S. carpocapsae showed effective performance against the larvae of T. absoluta inside tomato leaf mines [55].
\nOur results agree with other reports showing that larvae of T. absoluta were highly susceptible to the EPNs tested and these EPNs can be used as efficient biological control agents against T. absoluta. All EPNs used in the study showed efficacy at different rates against T. absoluta. They were able to find and infect T. absoluta larvae both inside and outside of the tomato leaf. According to these findings, it could be suggested that EPNs have a great potential to use as biocontrol agents for the management of T. absoluta.
\nIt should be noted that to understand their life cycles and functions, match the correct species of EPNs with the correct species of insect pests, apply them under optimum environmental conditions, such as soil temperature, soil moisture, angle of sun rays, and apply only with compatible pesticides are the keys to success with EPNs.
\nBiological control is an action that involves the use of natural enemies of insect pests to increase negative effects of insect pest as destroying important crops and plantation, plant growth destruction or development infections caused by pests [56].
\n\nAdvantages | \nDisadvantages | \n
---|---|
Broad host range of pest insect | \nHigh cost in production | \n
Able to seek or ambush the host and can kill rapidly the host | \nLack of labour, knowledge and skills required in nematology | \n
Mass produced by in vivo and in vitro (solid and liquid culture medium) | \nLimited shelf life and refrigerated storage required | \n
Can be used with conventional application equipment | \nDifficulties in formulation and quality control | \n
Safety for all vertebrates, most non-target invertebrates and the food sources | \nEnvironmental limitations; for survival and infectivity adequate moisture and temperatures are needed, sensitivity to UV radiation, lethal effect of several pesticides (nematicides, fumigants and others) lethal or restrictive soil properties (high salinity, high or low pH, etc.) | \n
Little or no registration required | \n\n |
Advantages and disadvantages of entomopathogenic nematodes [58].
EPNs are a group of soil-dwelling organisms that attack soilborne insect pests that live in, on or near the soil surface and can be used effectively to control economically important insect pests. Different nematode species and strains exhibit differences in survival, search behaviour and infectivity, which make them more or less suitable for particular insect pest control programmes [57]. As the other biological control agents, also EPNs have advantages and disadvantages (Table 2).
\nThere is a great interest in finding wild populations to obtain new species and strains for possible use in biological control. The use of EPNs is one potential non-chemical approach to control insect pests. EPNs are widely spread geographically and have many hosts. They are currently used as biological control agents in many studies to control several important insect pests worldwide [59–61].
\nIt is highlighted that there is a need for more in-depth basic information on EPNs biology, including ecology, behaviour and genetics, to help understand the underlying reasons for their successes and failures as biological control organisms. Most appropriate nematode species/strain, abiotic factors such as soil type, soil temperature and moisture are important for getting success [1].
\nProper match of the nematode to the host entails virulence, host finding and ecological factors are essential before application to the field. Matching the appropriate nematode host-seeking strategy with the pest is essential, because poor host suitability has been the most common mistake occurred in application of EPNs [62]. Also application strategies, such as field dosage, volume, irrigation and appropriate application methods, are very important. Furthermore, plant morphology and phenology must be considered in predicting whether nematodes are viable control candidates [63].
\nUniversal health coverage (UHC) has been gaining a wider attention since the beginning of the 2000s, and it has become an ideological reference for health systems across the world. UHC stands for ensuring that health services, needed by people, are of sufficient quality, and that people may access them without exposing themselves to financial hardship.
\nThe historical background of UHC goes back to the period immediately after World War II. In 1948, WHO’s constitution considered health as a human right; in 1978, the Alma Ata declaration sustained the importance of primary healthcare to grant “Health for All”; in 2005, members of WHO signed a resolution aiming at the implementation of universal coverage [1]; recently, in 2018, in the Declaration of Astana governments recommitted to the importance of primary healthcare as a major pillar of UHC. Additionally, the UN has set UHC as a target for Sustainable Development Goal (SDG 3.8 [2]) to be achieved by 2030 [3].
\nFunding UHC has been one of the major challenges faced by governments. Not only funding has to be efficient to guarantee people’s access to health services when they are needed but it also has to ensure equity across people in the country.
\nToday governments have to deal with the new reality of aging societies. This demographic phenomenon is taking place all over the world, although some countries are aging more rapidly than others. For instance, in EU, it is expected that within five decades, the number of elderly aged over 80 will triple and there be only two active people (15–64 y.o.1) for each older person (+65 y.o.) [4].
\nAging implies a new constraint to funding as more people contribute less to the collection of financial revenues and more people are in need of healthcare, due to morbidity and end-of-life needs.
\nIn this chapter, we aim to present the concept of universal health coverage and LTC and also to discuss how it may be financed under the present scenario of demographic aging and increasing demand for long-term care.
\nUniversal healthcare coverage is the natural evolution of health systems since the World War II. UHC may be described as a general coverage framework where people receive health services needed with quality, without suffering financial hardship [5]. So, the two main objectives may be listed. First, all people should have access to a package of services in wide range of healthcare spectrum, including treatment, promotion, prevention, rehabilitation, long-term care, and palliative care. This objective guarantees that healthcare services may be available to everybody, with quality when they are needed. Therefore, quality and equity are core to this objective.
\nThe second objective ensures that people do not get bankruptcy because of health-care expenditures. The best way to prevent this financial hardship on people is by compulsory prepayment to a fund. The payments done by people are according to their ability to pay, which implies that there are always some people in the population who need to be subsidized because they are poor or cannot contribute to the fund.
\nUHC requires efficient management and fairness-sustainability trade-offs because UHC does not mean unlimited resources nor services provided. The general long-lasting aim of UHC is to expand coverage on a three- dimensional cube (Figure 1): breadth, depth, and height. Breadth of coverage measures the proportion of people who are covered or entitled; depth reflects the healthcare services that are included in the package of UHC; and finally, height shows the proportion of costs that are shared between people and the health system.
\nUHC cube. Source: Based on WHO [6].
Nowadays aging is a major demographic phenomenon taking placing. People are getting older, and so there is change in the age distribution pictures from a pyramidal shape to inverted pyramidal shape. The fast growing percentage of elderly in the population is expected to take place in the next decades, as shown in Figure 2, which displays the projected evolution of older age groups for Europe.
\nProjections of percentage of age group in population in Europe. Source: Based on UN data [7]—Based on medium variant projections of age groups for Europe.
There are three trends that may explain the current aging phenomenon [8]. They include (i) the increased longevity of people as people they live longer, (ii) the declined fertility as women have less children, and (iii) the aging of “baby boom” generations.
\nThis demographic scenario raises the concern of how living longer is related to people’s health, in particular, in later stages in life. In fact, the relationship between aging and health has been described from three different perspectives:
a compression of morbidity, proposed by Fries [9], where morbidity is condensed in the last part of the life cycle;
an expansion of morbidity, proposed by Gruenber [10] and Kramer [11], where the increased life years are unhealthy and spent with morbidity; and
a dynamic equilibrium, proposed by Manton [12], which is something in between the two previous proposals, meaning that, there is a constant proportion of healthy life in the overall life cycle of people. According to this proposal, the gains obtained of life span without disability are balanced by losses in healthy life span. The dynamic equilibrium may also be described by the balance between the decreasing/constant proportion of life span with serious illness or disability, and the increasing proportion of life span with moderate disability or illness severity.
Depending on the country or the region, these three perspectives may be found. However, in all of them, the increasing need of long-term care (LCT) is inevitable. What may differ across each of them is the kind of LCT needed and provided.
\nLTC may be defined as the range of services and assistance for people who, as a result of mental and/or physical frailty and/or disability over an extended period of time, depend on help with daily living activities and/or are in need of some permanent nursing care” [4]. The living activities for which people may need help include both activities of daily living (ADL) and instrumental activities of daily living (IADL). The ADL include basic self-care tasks such as healthcare and personal care (e.g., help with hygiene) and also household help (e.g., shopping). IADL include activities related to independent living and include preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, doing laundry, and using a telephone.
\nLong-term care is often under looked in the package of UHC, even though its provision has been increasing in several countries, in particular, in Northern Europe. The provision of LTC can take different forms: health or social nature, cash or in-kind benefits, and institutional/formal or home/informal care.
\nThe variability of long-term care systems across countries is so large that comparisons are difficult to perform. For instance, when comparing the long-term care expenditures (both social and health) as a share of current health expenditures across EU countries, it becomes clear that all LTC systems tend to be different (Figure 3).
\nShare of total current health expenditure (%CHE), 2016. Source: Based on Eurostat data [13].
Comparing different forms of LTC provided across countries becomes even harder as shown in Figure 4, when comparing expenditures in LTC per capita and the structure of expenditures in type of LTC.
\nExpenditures on different types of long-term care, 2016. Note: Includes government schemes and compulsory contributory health-care financing schemes; monetary unit: Purchasing power standard (PPS) per inhabitant. Source: Based on Eurostat data [13].
To overcome comparisons across countries, OECD [14] has proposed one classification of LTC systems. Two criteria are used to classify LTC coverage: one is the depth of the benefits and the other is the organization.
\nThe depth of the benefits measures the scope of the entitlement of the LTC benefits, i.e., either universal or means-tested; the organization criterion assesses how the LCT is covered, either by a single system or by a multiple benefits, services, and programs.
\nBased on these two criteria, three groups of countries are identified. The first group includes countries with a universal coverage based on a single program (e.g., Nordic countries, Belgium, and Japan). This system may be separate from the health system, or be part it, and LTC is provided to everyone eligible. This does not mean free provision because there may be means of payment such as co-payments or user charges subject to income thresholds.
\nThe second group considers mixed systems (e.g., Italy, Czech Republic, Ireland, Australia, France, Greece, Spain, and Switzerland), meaning a mixture of universal with means-tested LTC programs and benefits. In these countries, there is no single LTC system but rather multiple benefits and entitlements.
\nFinally, the third group includes countries with means-tested safety net schemes (e.g., USA). Under this type of LTC coverage organization, income and/or assets are used to assess the eligibility to publicly funded care. People with means lower than some established threshold are entitled to receive such coverage.
\nThe allocation of LTC benefits varies across countries, and all countries end up facing the same trade-off between fair protection and fiscal sustainability. The allocation of resources to LTC usually does not provide full costs of LTC to all older people. Benefits are to be distributed according to the three vectors of UHC: eligibility or entitlement rules (breadth), depth of services covered, and the height of cost sharing.
\nHealth systems are expected to perform several functions, and funding is one of them. This function financially supports three aims of any health system: improving population health, responding to people expectations, and providing financial protection against the costs of ill health, including health decline due to age [15].
\nFunding health systems aims to “provide people with access to needed health services, including prevention, promotion, treatment, and rehabilitation, of sufficient quality to be effective and to ensure that the use of those services do not expose people to financial hardship” [15]. According to this definition, there are three roles that funding has to perform: (i) collecting funds, (ii) pooling funds and risk, and (iii) purchasing healthcare services.
\nCollecting funds means raising revenues, using several sources and contribution mechanisms; pooling funds and risk translates the arrangements to gather the prepaid funds and diversify the individual risk across the pool of participants; purchasing healthcare services comprises the way that the funds are transferred to providers, either by provider payment mechanisms (PPM) or by institutional structure of purchasers [16].
\nA more in-depth explanation is next presented for each of these roles of funding.
\nToday, it is widely accepted that the best way to fund healthcare systems is based on prepaid mechanism gathered from a large pool of contributing individuals. Funding mechanisms include the voluntary and the mandatory mechanisms (and some low- and medium-income countries (LMIC) may also find external sources of financing obtained from international donors).
\nVoluntary financing mechanisms account for the out-of-pocket payments and voluntary insurance. Out-of-pocket payments are the most regressive form of funding the health system, and they may contribute to catastrophic expenditures and poverty. Voluntary insurance may be a secondary layer of health insurance but it is inequitable as it does not extend to all people.
\nMandatory funding mechanisms are the most efficient mechanism to guarantee a prepaid healthcare expenditure and to finance UHC. There are, however, two basic forms of these mechanisms: social insurance and taxation, each rooted in its historical proponent. The former funding system was proposed by Otto von Bismark, who implemented the sickness funds system financed by payroll taxes in 1883, in Germany. The later funding proposal was given by William Beveridge, who suggested the national health system financed by taxes in 1948, in UK.
\nThese two approaches to finance health systems, either social insurance or tax based, are also the same financing mechanism of long-term healthcare. While the advantages of the tax-based system are the broader base of funding and greater flexibility and adaptability in providing benefits, the social insurance-based system ensures higher transparency and predictable revenues. On the other hand, the tax-based system has no link between the revenues and the provided benefits while the social insurance-based system is inflexible in the benefits awarded and ends up requiring public budget contribution for those who are not able to pay the for the social insurance contribution [17].
\nThe large majority of health systems nowadays is mainly or partially financed by taxes, either because the major financing source is taxes or because insurance funds do not cover the whole population and so complementary financial source is needed.
\nLow- and middle-income countries with high unequal income distribution face a taxing challenge: to tax the wealthy and powerful country elites to finance in an equitable way the health system of the country. Because in most cases these elites are also the political and governing ones, it ends up that equitable collecting funds for the health system do not occur.
\nUser fees are one source of funding which raise some controversy. While some argue that user fees reduce utilization by poorer people, others consider that user fees cannot be ignored as an important funding source in some countries. In particular, in countries where resources are limited and institutions are weak, as happens in several LMIC. It is argued that if there is a well-designed user’s fee policy, which includes waiver mechanisms and compensating procedures to providers, and as long as those public fees are lower than private fees, then user fees may be an efficient and less inequitable source of funding.
\nFunding LTC either by taxes or by social contribution may not be enough to accommodate all the people in need of care. So other funding alternatives, which may complement taxes or social contributions, are required to be collected.
\nWouterse and Smid [18] have proposed four LTC funding mechanisms: (i) pay-as-you-go system, (ii) collective saving funds, (iii) pensioner tax, and (iv) cohort-specific savings. The differences across these alternatives are the distribution of costs along time and across age groups.
The pay-as-you-go system is described as a financing system where contributions come from actual workers to pay the current retirement benefits. So the additional spending available for LTC in some year is matched by the additional premium payments collected in that year.
The second funding mechanism is saving fund which is created by the contribution of people. Collective saving funds are a form of pooled funds which aim to generate a steady level of income without threatening the initial value. This idea is basically creating a pre-funding mechanism to be used in the future [19]. Pre-funding may be full or partial. By partial it is meant that LTC contributions are expected to cover only part of the LTC costs of the individual. This partial contribution seems to ensure some intergenerational fairness because the younger generation does not assume the complete burden of LTC costs of an older generation.
The third proposal is the pensioner tax which is a specific tax on pension incomes. This is a premium rate levied on pension income and it provides an increasing source of LTC funding as the group of pensioners is increasing. This works like tax broadening strategy for an intra-generational pooling of funds.
Finally, the idea supporting the cohort-specific savings is that each birth cohort funds its own additional LTC expenditures. This is like tying pre-funding to specific age-related costs as suggested by OECD [19].
Pooling funds are a key factor in well-functioning healthcare systems aiming to UHC. Accumulating and managing financial resources from a large pool of individuals ensures that the individual risk of paying for healthcare expenditures is in fact dispersed by all the individuals in the pool. The channel through which such dispersion happens is called cross-subsidization. This takes place by having higher income people paying for lower income people, lower risk people paying for higher illness-risk people, and active people paying for inactive people, such as children and elderly. The second advantage of large pools is the potential to obtain economies of scale and market power. Large funding pools work more efficiently with less administrative costs and with lower negotiated prices.
\nCountries with fragmented insurance system do not have pools of individuals large enough to ensure that an individual unpredictable financial risk becomes predicted and distributed among all the individuals contributing to the insurance funding pool. This is the case in several LMIC where there may coexist different health insurance. These multiple insurance pools result in increasing administrative costs, individual’s selection risk, and individual’s segmentation according to income and wealth.
\nHowever, the fragmentation of the funding pools is not bad per se. Countries may choose to have one pool organized under a single organization or allow the co-existence of several insurances (or pools), which may (or not) compete among themselves. The government decision about the organization and the structure of the pool of individuals has to guarantee that it is equitable and there is no risk selection. So the two necessary conditions to finance a UHC are “compulsion” of a contributions and “subsidization” across individuals, as explained by Fuchs [20]. How these conditions are met depends on the government choice. Pooling against LTC risk is a basic social concern since potentially all citizens are in risk of needing LTC and the poorer ones are at risk of financial hardship.
\nIn aging societies such as in Europe, the group of elderly who are at risk of becoming frail and developing multi-morbidity conditions is large and increasing. So, the risk of being in need of LTC is rising and it requires large pool of funding in order to disperse this risk by all contributors.
\nPurchasing healthcare services comprises three areas of concern. The first one addresses the decision of which services are included in the package of UHC and which services are to be bought; the second concern is the choice of providers; and the third concern relates on the form to purchasing and provision the healthcare services.
\nThe decision on which services are included is not identical across countries. High-income countries may include services which in LMIC may not be in the UHC package because of strong funding restrictions. These countries may be more interested in including services more suitable for their reality such as malaria-related services, HIV antiretroviral therapy, diphtheria-tetanus-pertussis vaccine, or they may be more interested in improving the quality of the services already provided [21].
\nConsidering that the provided care must be fair and efficient, the decision on the services included in a LTC package may be difficult to decide. OECD [14] has proposed the idea of targeted universalism of LTC, that is, the target of care covered is where the need is highest. This idea grounded on the fact that universal LTC may not be attainable for all, but it should be for those in greatest need [22].
\nThe choice of providers may be passive by just assigning a predetermined budget or paying bills or it may be done strategically, meaning that it is a process that aims to maximize performance [15]. Concerning this choice of providers in LTC care, it is diverse, including health or social sector and from institutional/formal care or home/informal care. Informal care may be funded by public subsidization since this form of care has been accepted as cost-effectiveness [23].
\nThe decision concerning the form of purchasing is highly dominated by the choice of the provider payment mechanisms (PPM) and contractual arrangements (discussed in more detail in Chapter 3 of this book). This choice is fundamental to ensure efficiency and transparency of the system. Provider payment mechanisms have a particular role in providing the correct incentives to providers to guarantee access, quality, and efficiency. The PPM comprises several possible arrangements such as global budget, fee for service, capitation, per diem, case based, and pay-for-performance [24].
\nThe organization of the purchasers in the health system depends on the competition established among them. There are different forms of organization of the providers purchasing market as described by Kutzin [16]. The simplest form is the single payer system, where there is only one national institution which is responsible for the payments to providers (e.g., in Japan). When there are multiple payers, meaning multiples insurers, there is a distinction between the case when the population covered is in one area, or in different geographical areas. When it covers different geographical areas, more than one regional body is responsible for purchasing and it is a subset of the simple payer system (e.g., in Canada). If the population covered is in the same geographical area, then there may be, or not, competition for the people covered by the insurers. In this way, there are multiple noncompeting insurers (e.g., in France) or there are multiple competing insurers (e.g., in Germany) [16].
\nUniversal long-term healthcare is a difficult concept to achieve and to compare internationally. Several difficulties arise related to the decisions over the three dimensions of UHC: (i) eligibility, (ii) package of services, and (iii) cost sharing.
\nEligibility is defined by the high-care needs felt among the oldest cohort. This group of people not only has severe functional limitations but also has run-down most of their savings and assets. The package of services included in LTC needs to balance the cost and effectiveness of different modes of providing services. This may not be easy to assess. Some questions may then be raised, e.g., “how to decide what support is given to IADL?” or “how to decide to support in cash or in services?” Cost sharing is supposed to be based on the ability to pay; however, it may not be easy to define the fair share between public and individual responsibilities of pay. On the other hand, using saving and assets may be unfair as those individuals did not spend their money in past while others did.
\nThe EU Commission [25] has suggested a typology of LTC provision for the EU members, enabling some international comparisons. This typology is built based on three criteria concerning the features of formal care. The first criterion is the organization of LTC which can be public, private, or non-for-profit. The second criterion corresponds to funding classified in general taxation, compulsory social insurance, voluntary private insurance, or out-of-pocket. Finally, the third criterion is provision which may take place at home or in an institution. Applying these criteria, it is possible to group the EU countries into five clusters, also presented in Figure 5.
Cluster A (in yellow) includes countries with public provision of LTC financed by general taxes, low informal care, high informal care support, and modest cash-for-care benefits (Denmark, Netherlands, and Sweden).
Cluster B (in orange) includes countries with medium public (mainly financed by compulsory social insurance) and low private formal care, high informal care and high informal care support, and modest cash-for-care benefits (Belgium, Czech Republic, Germany, Slovakia, and Luxembourg).
Cluster C (in green) accounts for countries with medium public and private formal care (financed social insurance and general revenue), high informal care use and high informal care support, and high cash-for-care benefits (Austria, England, Finland, France, Spain, and Ireland).
Cluster D (in blue) includes countries with modest social insurance against LTC risks; low public and high private LTC funding, high use of informal care but low informal care support, and low cash-for-care benefits (Hungary, Italy, Greece, Poland, Portugal, and Slovenia).
Cluster E (in pink) group includes countries with little social insurance against LTC risks; very low public spending, very high informal care use but no support of it, and no or very low cash-for-care benefits (Bulgaria, Cyprus, Estonia, Lithuania, Latvia, Malta, and Romania).
Classification of LTC provision in EU. Legend: Yellow—Cluster A; Orange—Cluster B; Green—Cluster C; Blue—Cluster D; Pink—Cluster E.
Despite the funding criterion, clusters of countries include different mechanisms of funding LTC, both tax and social contribution based. So, clustering of LTC provision across countries in Europe may contribute to meaningful international comparisons of LTC policies, as well as the efficiency and fairness of funding strategies.
\nAging is expected to double public spending in LTC in the period 2010–2060. The current scenario of aging population and increasing of the LTC costs raises several challenges, including the question, “how to finance equitable and high quality LTC in fair manner?”
\nTo assess this question, two overall challenges appear related to the sustainability of LTC under the UHC umbrella: first the financial sustainability and second the political and social sustainability.
\nThe financial sustainability implies that there is some resource collection mechanism allowing a balance between the decreasing number of active people and the increasing number of elderly. Some countries have an underdeveloped LTC provision which makes financial sustainability a major concern given the increasing demand for LTC.
\nOn the other hand, funding needs to be economic sustainable so that the share of GDP resources is collected and applied on LTC do not risk the country in a debt crisis. The funding mechanisms of health systems adapting to an aging society need to be carefully thought, in particular in countries where public debt is already a problem [18].
\nSecond, political and social sustainability means that people in a country have decided and support how much they are willing to pay to finance LTC within UHC, in particular, to finance healthcare to those who are in need and cannot afford to pay for it [26]. Since complete universalism of LTC may not be feasible and trade-offs must be done, target universalism may be the most fair and efficient path to be chosen. The fairness of funding has to be not only intra-generational but also inter-generational. For target universalism to be successful, it has to be socially accepted and supported. This implies that the relative importance of social values is not dominated by economic values.
\nInformal care is a cornerstone of sustainable LTC provision, and it contributes to the financial sustainability. But informal care itself faces challenges related to care and attendance allowances, as well as opportunity costs for predominantly female informal care workers. These women need to be carefully considered in the system in order to make informal care possible to families [27]. On the other hand, informal care contributes to the closing gap between the fast increasing demand of LTC and the slow increase of its supply. The political support and the social sustainability of informal care are steps toward the implementation of the (target) universal LTC.
\nThe aim of this chapter was to present the concept of universal health coverage and of long-term care and to discuss how it may be financed under the current scenario of demographic aging and increasing demand for long-term care.
\nUniversal health coverage is the main aim of health systems all over the world. The achieved universalism is measured along three dimensions—breath, depth, and height of a UHC cube. Long-term care is one of the services provided by UHC, which needs rules of eligibility, of services provided, and of cost- sharing.
\nIn a fast aging society, the importance of LTC is increasing. This means that funding should register a corresponding increasing funds collection. The difficult of LTC funding emerges because there are less and less people active contributing to the collective funds and more and more older people in need of LTC. This implies, first, the use of alternative forms of funding, which should be based on a large pool of individuals, and, second, the use of strategic purchasing and provider payment mechanisms.
\nThe variety of LTC systems across countries makes comparisons difficult, so a possible classification proposed by the EU Commission is described in the chapter. Funding criterion does not dominate the clustering of countries. There are equally important features (organization and provision), which contribute to the characteristics of the LTC system.
\nUHC and LTC are expected to be sustainable and fair, and target universalism is a possible answer. The implementation of the desired health system needs to respond to sustainability challenges, either financial or socio-political. The response to these challenges will guarantee people access to LTC when needed in an equitable way, without suffering hardship late in their life years. So, not only a more active and socially focused leadership is needed across countries but also better governance is expected so that social values are considered with comparable weight as economic values.
\nHealth systems being very complex in terms of demographic, economic, legal and regulatory, epidemiological, socio-cultural and political, and technological aspects, an improvement in one of these areas necessarily has an impact on a global improvement of the universality of coverage. Therefore, it is expected that governments strengthen these components of the health system to make it possible to achieve its goals and provide a high-quality healthcare. In economic terms, not to defend the universality of access, more than an ideological act, would be a serious economic error.
\nThe authors declare no conflict of interest.
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I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. 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After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:null},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). 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I received a B.Eng. degree in Computer Engineering with First Class Honors in 2008 from Prince of Songkla University, Songkhla, Thailand, where I received a Ph.D. degree in Electrical Engineering. My research interests are primarily in the area of biomedical signal processing and classification notably EMG (electromyography signal), EOG (electrooculography signal), and EEG (electroencephalography signal), image analysis notably breast cancer analysis and optical coherence tomography, and rehabilitation engineering. I became a student member of IEEE in 2008. During October 2011-March 2012, I had worked at School of Computer Science and Electronic Engineering, University of Essex, Colchester, Essex, United Kingdom. In addition, during a B.Eng. I had been a visiting research student at Faculty of Computer Science, University of Murcia, Murcia, Spain for three months.\n\nI have published over 40 papers during 5 years in refereed journals, books, and conference proceedings in the areas of electro-physiological signals processing and classification, notably EMG and EOG signals, fractal analysis, wavelet analysis, texture analysis, feature extraction and machine learning algorithms, and assistive and rehabilitative devices. I have several computer programming language certificates, i.e. Sun Certified Programmer for the Java 2 Platform 1.4 (SCJP), Microsoft Certified Professional Developer, Web Developer (MCPD), Microsoft Certified Technology Specialist, .NET Framework 2.0 Web (MCTS). 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