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Population health in business: Employers and their employees

PPP’s Population Health in Business series examines the impact of businesses on health outcomes. The first roundtable examined the impact of the employee-employer relationship on health equity within a given region.

– By Mary Brown and Eliot Gillings –

Key insights

  • Employment can greatly impact an individual’s health, though this impact varies depending on the nature of work and the workplace environment. Variations in these health implications are major contributors to health inequalities in the UK. 
  • Given that the majority of employees work in the private sector, health and wellbeing strategies of private businesses significantly impact health outcomes across ICSs. 
  • Good employee health and wellbeing strategies and positive workplace culture are associated with increased productivity and better staff retention – meaning the quality of a business’s approach to employee health directly impacts their strength and as an organisation. A positive workplace culture is one that fosters clear and open communication and strong co-working bonds. 
  • Businesses can influence the health and wellbeing of their employees through pay, flexibility in location and working hours, and increased control over tasks and responsibilities.  
  • Health inequalities have been found to exist within individual businesses, with poorer health outcomes experienced by those at lower occupational grades.  
  • Businesses that incorporate health into every level of their corporate decision-making, and seek to prioritise those in greatest need, are more easily able to impact health equity than businesses that do not.  
  • ‘Business progression frameworks’ developed by ICS and council leaders can provide private businesses with clear guidance regarding how their employee health and wellbeing strategy can impact local health, thereby driving accountability.  

Introduction: Businesses and employee health outcomes

An individual’s health is predominantly impacted by the conditions in which they are born, live, work and age. Impacting mortality, quality of life and playing a significant role in determining the health conditions an individual may experience or develop throughout their life, these wider determinants of health play a major role in determining health and care need and healthy life expectancy.  

Integrated care systems attempt to positively influence these social determinants through population health management (PHM) strategies, which utilise data to plan proactive care and improve health and wellbeing using their collective resources. PHM strategies therefore examine the impacts of determinants of health that fall outside the remit of care providers, but nonetheless influence the health of those they care for.  

Employment can significantly impact a person’s health outcomes. Good working conditions, adequate pay, a supportive and flexible working environment, and low work stress can all contribute to good health for employees. However, as 82.4 per cent of individuals in employment work within the private sector, the PHM strategies devised by public bodies are most likely to be maximally effective where they support and compliment the employee health and wellbeing strategies of private companies. 

On the 25th of January 2023, PPP brought together senior sector stakeholders for a roundtable entitled Business and their employees: Improving employee health outcomes, chaired by Professor Donna Hall CBE, Chair of the Bolton NHS Foundation Trust and The New Local Government Network. The aim of the roundtable was to establish the impact of employment on health, understand how this can be influenced from a PHM perspective and clarify how delivery can be monitored going forwards.  

While discussion focused on developing healthy patterns of work within larger corporate settings, the recommendations put forward in this summary remain pertinent for smaller businesses seeking to contribute to improved community health outcomes via their employee health and wellbeing strategies.

The relationship between health and productivity

“The cost of poor employee mental health to employers in the UK is presently estimated to be £56 billion”

While there is a moral obligation for employers to carefully consider approaches to employee health and wellbeing, there is also a strong economic case for investing in such programmes as there exist clear relationships between good employee health and productivity, staff retention, and access to investment.  

The cost of poor employee mental health to employers in the UK is presently estimated to be £56 billion – as employees experiences poor mental health are less likely to attend work, and more likely to experience difficulty completing work-related tasks. Globally, the impacts of depression and anxiety alone are estimated to cost businesses £1 trillion. In fact, mental health accounts for just over half of productivity loss due to ill health, with the other 45 per cent of health issues leading to people being off work being predominantly physical (most notably musculoskeletal injury).

Findings from the Health Foundation in 2022 suggest that poor health could be a key factor driving economic inactivity post-pandemic. The article notes economic inactivity (the number of individuals out of work) has increased by close to 700,000 since before the pandemic, including 300,000 individuals between 50-69 years old who are likely to never return to the workplace. Among the 50-69-year-olds who were not attending work, the majority reported ill-health as the main reason for their absence.

“Health and wellbeing strategies deliver clear value to employers by reducing economic inactivity, boosting productivity and improving staff retention”

Poor health can also impact productivity within the workplace. Research from the University of Oxford shows that happy workers are 13 per cent more productive, and the recently published Shaping a brighter world of work: The employer outlook report noted that the strength of an employer’s health and wellbeing policy had a direct impact on an employee’s overall feelings about their work – thereby impacting productivity and staff retention. As the report noted, “having healthy and satisfied employees is a necessary element of a competitive strategy.” This is especially true in the context of recruiting and retaining younger employees. According to a 2018 Gallup survey, an organisation’s interest in employee wellbeing is seen as more important than the financial stability of the organisation by millennial and Gen Z employees.

Health and wellbeing strategies deliver clear value to employers by reducing economic inactivity, boosting productivity and improving staff retention. However, these metrics are difficult to quantify without conducting staff surveys, and outcomes are often influenced by external factors – such as the ethnic or cultural background of an employee, or their home address.  

The impact of employment on health

Businesses impact the health of their employees in a variety of ways. While job quality, pay, in-work benefits, job security, working hours, employee representation, training and progression, as well as mental and physical health support can create the most evident impacts, there are a variety of broader cultural issues that also play a role in influencing the health and wellbeing of employees.

“Businesses can support better health through the development of employee health and wellbeing schemes that aim to reduce employee exposure to risk factors”

Professor Sir Michael Marmot has found that health inequalities exist within businesses and has shown that health differs according to occupational hierarchy within an organisation, outlined in Health inequalities among British civil servants: the Whitehall II study. At the top of the occupational pyramid, employees tended to have far better health than those at lower occupational grades, who had less control and higher stress associated with their job roles.  

For example, specific health inequalities can be observed in rates of cardiovascular disease among civil servants, incidence of which is higher among lower grades than higher. Risk factors that precipitate this include obesity, smoking, reduced leisure time, lower levels of physical activity, higher prevalence of underlying illness and higher blood pressure. 

Businesses can support better health through the development of employee health and wellbeing schemes that aim to reduce employee exposure to risk factors. These programmes should promote healthy lifestyles and provide resources for healthy eating, physical activity, and stress reduction. These may include: 

  • Providing access to healthy food options, such as fresh fruits and vegetables, whole grains, and lean proteins. 
  • Encouraging physical activity through on-site fitness facilities, gym memberships, or incentives for participating in physical activity programs. 
  • Offering health screenings and education on preventing and managing chronic diseases such as high blood pressure, diabetes, and heart disease. 
  • Providing flexibility in work schedules and encouraging breaks to promote work-life balance and reduce stress. 
  • Providing ergonomic workstations and equipment to reduce musculoskeletal injuries. 
  • Providing access to Employee Assistance Programmes (EAPs) which offer free and confidential assessments, counselling and other support services. 

Health inequity within businesses can also be ameliorated through the development of effective health creation frameworks, as outlined by the Health Creation Alliance. Health creation is the process through which individuals and communities gain a sense of purpose, hope, mastery and control over their own lives and immediate environment. When this happens, health and wellbeing is enhanced. For health creation to occur, people need control, contact, and confidence. As such, to reduce health inequalities and create healthy environments, businesses must ensure that employees at all occupational levels have meaningful contact between their colleagues and community, confidence in their abilities and purpose, and a sense of control over their lives and work.

Recommendation: Businesses should identify the key health conditions and inequities within their business and should share findings with their local ICS.

Developing a positive workplace culture

The culture of a workplace is defined by its traditions, interactions, attitudes, values and behaviours. An employee’s health and wellbeing are often connected to the strength of their workplace’s culture and their ability to communicate with fellow employees of differing seniority levels. As a result of the popularisation of online working during the Covid-19 pandemic, many organisations have altered their working patterns – which has, in turn, affected both culture and communication. 

Online working offers a number of benefits. Opportunities for increased flexibility in terms of working hours and environment, improved accessibility and reduced commute times can be beneficial for employees – including facilitating their participation in extracurricular activities and thereby supporting a healthy work-life balance.  

“The more technology we use, the higher the value of human contact” Roundtable contributor

However, as some contributors to the roundtable noted, these benefits are counterbalanced by the separation created by online working environments. Without access to shared physical space, there is a danger of reduced employee control over the quality and style of communication within a workplace. In some businesses this has reduced supportiveness and familiarity – leading to employee dissatisfaction, difficulty recruiting, and poor staff retention rates. For employees themselves, these environments can also contribute to increased loneliness and isolation. 

A number of contributors suggested that while hybrid, or online, working environments were beneficial to a number of businesses, there was nonetheless a need for these environments to offer opportunities for their employees to interact face-to-face. As one contributor suggested “the more technology we use, the higher the value of human contact.” 

There is, accordingly, a need for businesses to provide their employees with opportunities to form positive relationships – both online and in-person. This should include social gatherings and extracurricular events, as well as the encouragement of open communication in the workplace. As one contributor noted, “it is true that pubs are not particularly healthy for physical health, but they are healthy for relationships”. Positive employee communication can be fostered by supporting greater openness within the workplace – such as by having senior members of staff initiate employee health and wellbeing sessions and speaking readily about their own mental or physical struggles. Some contributors noted that they had observed a correlation between how engaged senior members of staff were with an organisation’s health and wellbeing offerings, and the overall uptake of services.  

“Positive workplace cultures are often ones where individuals at lower occupational ranks report feeling empowered to innovate by their line managers”

This is particularly true for junior roles, which many private businesses are currently experiencing difficulty recruiting for, as an employee’s relationship with their line manager is extremely important. There is, for instance, a strong correlation between an employee’s reported satisfaction with their line manager and the number of health-related work absences, and, as Michael Marmot’s Whitehall Study suggests, positive workplace cultures are often ones where individuals at lower occupational ranks report feeling empowered to innovate by their line managers. A sense of control at work among employees, which is important for employee wellbeing and productivity, can be fostered by maintaining positive relationships with their line managers.  

A 2021 report by Capita and YouGov found that 62 per cent of employees perceived productivity to be improved by line managers that were “outcomes focused”, whereas only 29 per cent saw line managers that were “completion focused” as beneficial. It also reported that other methods of maintaining control, including the ability to influence working locations and patterns, were all perceived to increase productivity. 

The development of positive communication and a healthy workplace culture can also be supported by the institutions of workplace rituals. Workplace rituals can be shared habits or behaviours which connect employees and define the culture of an organisation, such as ringing a bell when something has been achieved, celebrating employee birthdays, or scheduling weekly or monthly team events. According to research by Harvard Business School Professor Michael Norton, regular workplace rituals led to a 16 per cent increase in how meaningful employees reported their work to be and better overall. Rituals, therefore, may be particularly important for Millennial and Gen Z employees, who tend to view ‘meaningful’ work as particularly important. Businesses, in turn, stand to benefit from employees perceiving their work as more ‘meaningful’, as research indicates this is correlated with increased happiness, motivation and productivity.

Recommendation: An employee health and wellbeing strategy should include objectives for improving communication between employees, particularly between different seniority levels. Strategies should also view socialisation and the development of workplace ‘rituals’ as key to developing a healthy culture.

Contributors also noted that while many businesses offer EAPs, there is little employee appetite for this sort of intervention – with businesses reporting average uptake numbers of five and a half per cent. These figures, taken in context with the reportedly beneficial impact of programmes that embed themselves within an employee’s normal workday, would suggest that programmes which require significant additional input from employees perform comparatively poorly – however greater evidence is needed. 

In 2016, the UK’s EAP Association (EAPA) funded a review into the usage of EAP’s, concluding that while the majority of EAP’s covered their costs in terms of economic savings for organisations, more research was needed to identify the cost and benefits at an employer level. While the EAPA have subsequently developed an EAP ROI calculator, there remains a great deal of uncertainty regarding how the costs of EAPs translate into improvements to the business – and what sorts of interventions from EAPs are most effective. 

Recommendation: ICSs should encourage employers to re-evaluate their Employee Assistance Programmes (EAPs) to ensure support programmes are easy to use and deliver a clear benefit to employees.

Targeting those in greatest need

The health and wellbeing strategy of a private business should play a key role in an ICSs health equity strategy and should seek to reduce inequality in outcomes within the workplace and community. Key areas where businesses can effectively impact employee and community health and wellbeing are within their recruitment strategies, and their level of support for non-work elements of an employee’s life.  

“Employers who generally utilise their employee health and wellbeing strategies to break down barriers to access, or improve social determinants of health, tend to report positive employee feedback”

Since the passing of the ‘dubbeldagar’ (or ‘double days’) reform in 2012, both parents of newborn children in Sweden have been able to take 30 days of paid, full-time leave simultaneously over the course of the child’s first year of life. This reform has enabled parents to spend greater time with one another and their children, offering a myriad health and wellbeing benefits. For instance, there is a consistent correlation between workplace flexibility and maternal postpartum health, and parents with greater workplace flexibility consistently report improved mental wellbeing. Moreover, the implementation of ‘family friendly’ workplace policies support the presence of women within the workplace – meaning such policies could be key to supporting the health equity ambitions of local systems.

Employers who generally utilise their employee health and wellbeing strategies to break down barriers to access, or improve social determinants of health, tend to report positive employee feedback. The East London NHS Foundation Trust, for instance, has committed to working with its own workforce, giving them advice about housing, access to financial services, advice about debt and other useful guidance that could impact the social determinants of health.  

“Businesses should also take care to ensure their employee health and wellbeing strategies are available to all members of staff regardless of seniority”

Employers should also adopt a workforce agenda that seeks to support the health equity goals of their local system, and should seek to develop a recruitment strategy that improves employment opportunity within their local area. For instance, the Chaplain Housing Trust (CHT) in Vermont USA set themselves the human resource objective for 2020-2022 of attracting a broad range of talent from a variety of backgrounds and ethnicities, in order to better reflect the community they served. Through placing job advertisements at its rental housing sites, online and on local job boards to attract members of more disadvantaged communities, CHT has been able to begin recruiting more effectively from the community they serve. A similar model has been adopted by the Hiyos Practice in West London (who are presently running workshops to provide local community members with work experience opportunities), and other health care providers in the UK. This model, however, has yet to be implemented at scale by non-healthcare businesses. 

Businesses should also take care to ensure their employee health and wellbeing strategies are available to all members of staff regardless of seniority and should also seek to partner with the firms they contract to offer similar support. This is because, as identified within the Marmot Review, those at greatest risk of poor health within a business are those of lowest occupational rank, including in the firms that business might contract our work for.

Recommendation: Employee health and wellbeing strategies should target those at higher risk of health inequalities, particularly those at lower occupational grades. Strategies should prioritise interventions that help employees easily access support linked to improved social determinants of health and should be extended to contracted employees where possible.

Embedding health into corporate decision making

Given that employment can have a multifaceted impact on an individual’s health, it can be difficult to accurately express the impact of suboptimal health outcomes. As such, while businesses should aim to incorporate health and wellbeing considerations more fully into their corporate agendas, there is the question of how they can most effectively measure and balance their impacts on employee health and wellbeing against other metrics. For example, while New Zealand’s Living Standards Framework measures a range of indicators across four assets – natural capital, human capital, social capital, and financial and physical capital – quantifying the costs and benefits of policies can be difficult when prioritising between the four capitals. 

It is therefore necessary that a clear vision for how businesses should incorporate health and wellbeing into their decision making is established by an independent body – both to clarify the balance of priorities and to establish a level playing field.  

In order to ensure health and wellbeing is built into the framework of corporate social responsibility, integrated care boards (ICBs) should consider accountability frameworks for businesses within their remit. On the basis of this framework, rewards and sanctions should be put in place to incentivise the prioritisation of employee health. Business success should not be defined simply on an economic basis but should be defined too by their social contribution to their community and employees, with health at the centre of these goals. 

“It is therefore necessary that a clear vision for how businesses should incorporate health and wellbeing into their decision making is established by an independent body”

The Plymouth Plan 2014-2034 offers a pertinent example of the sort of framework that should become commonplace. A vision devised by individuals from the NHS, manufacturing, education, the city council, retail and technology, the plan offers additional support for local businesses and organisations who make a commitment to supporting health and wellbeing outcomes. Plymouth council, since the implementation of the Plymouth Plan, has also pledged to double the size of the local cooperative economy – as there is strong evidence to suggest that cooperatives may promote the health of employees by providing greater control over their employment and better job retention during economic recession. 

Leeds City Council has also aligned its health and inclusive growth agendas. The Council’s strategy for health and wellbeing includes an ambition to support Leeds in its development into a “strong economy with quality local jobs”, and their growth strategy aims for Leeds to be “the best city for health and well-being.” This agenda has been supported by the development of a ‘business progression framework,’ intended to support private businesses in integrating themselves into anchor networks and to help get them working towards the goals of the local system – thereby encouraging businesses to integrate their health and wellbeing strategies with their ESG and broader corporate social responsibility (CSR) goals. 

Recommendation: ICSs should craft ‘business progression’ strategies to chart the progress of private businesses within their local system. These frameworks should share some universal objectives and metrics but must also be tailored to the specific needs of the system in question.

Recommendation: Health equity considerations should be incorporated into corporate decision making at every level.

Driving accountability

“Businesses can help to drive accountability by embedding health and wellbeing support into the day-to-day elements of their business”

Businesses are becoming increasingly aware of the impacts of health and wellbeing strategies on business activity within local communities. Many organisations are developing workforce strategies that support the preventative health strategies of their local systems accordingly. However, there remains little recourse for local systems should businesses fail to carry out their health and wellbeing commitments. In fact, within organisations themselves, unless specific complaints are made and pursued by management, there is typically little accountability for delivery. 

Businesses can help to drive accountability by embedding health and wellbeing support into the day-to-day elements of their business. This may include making wellbeing check-ins a part of regular one-to-ones and team meetings or encouraging employees to set health and wellbeing goals as part of performance reviews. However, there is a strong case for local systems to provide businesses with what may be termed a ‘business progression framework’. There is also an appetite from private businesses for this sort of intervention. As one contributor noted, “a number of businesses have reported that they actually want more regulation around their employment, goods and services and investment. Because otherwise it’s a race to the bottom. They want everybody on a level playing field, but they want that level playing field to be raised.” 

“Anchor institutions can be defined as large organisations whose sustainability is connected to the populations they serve and who seek to utilise their assets and resources to support improvements in health equity and the overall quality of life within their local area”

These ‘progression frameworks’ would provide businesses with a clear set of criteria by which they could evaluate the impact and development of their employee health and wellbeing. Leeds City Council’s ‘Business Anchor Progression Framework’ provides an example of what such a framework could look like. Broken down into four sections (employment, procurement, environment and assets and corporate and community) the framework is “designed for businesses with a large or influential local presence who want to play a full anchor role locally and is a wide-ranging tool that considers the breadth of a company’s activities.”

Anchor institutions can be defined as large organisations whose sustainability is connected to the populations they serve and who seek to utilise their assets and resources to support improvements in health equity and the overall quality of life within their local area. The framework used in Leeds poses questions to businesses such as “to what extent do you encourage the mental and physical health and wellbeing of staff through facilities, policy, culture and support?” The framework is primarily aimed at private sector businesses, that have generally yet to be incorporated into UK anchor networks. The framework also asks businesses to grade their present status and their organisation’s ambitions on a scale of one to four and is intended to provide businesses with clarity on their responsibilities as community anchors and support them in identifying key areas of improvement.  

The effectiveness of such frameworks is, however, limited by the fact that they are self-evaluated and reliant on imprecise metrics. While businesses who engage with the framework in good faith and embrace the idea of being an ‘anchor’ institution are likely to benefit from such guidance, it is difficult to judge the extent to which certain changes in a business’s employee health and wellbeing strategy may impact those employees, or the communities to which they belong.  

A variety of data could be utilised to gain a clearer understanding of a business’s impact on their local system. Procurement data, resource allocation for employee support programmes, and accessibility budgets could all provide a clearer view of how organisations are prioritising their role within ICS PHM strategy – however, much of this data remains inaccessible to the public. Businesses should, accordingly, seek to make this data available to local ICS leadership.  

“There is a pressing need for ICPs and businesses alike to support case studies from private businesses looking into the broader impacts of their health and wellbeing strategies”

Simply sharing more information, however, will not suffice should businesses and local systems alike hope to gain a more complete understanding of the role of business in the delivery of a health equity strategy. The multifaceted nature of a business’s relationship with the community it serves make understanding the broader, population health level effects of an employer’s health and wellbeing strategy more complex.  

Integrated care partnerships (ICPs) could play a central role in ensuring businesses contribute to population health in a locality. The Health and Social Care Board defines the ICP as a collaborative network of service providers, which includes healthcare professionals, the voluntary and community sectors, local council representatives, and service users and carers – and could incorporate private businesses. ICPs aim to improve the way local services are designed for the benefit of individuals in local communities. However, the ICP is poorly defined, and the makeup of an ICP differs between systems, some of which may already be incorporating businesses leaders. 

There is a pressing need for ICPs and businesses alike to support case studies from private businesses looking into the broader impacts of their health and wellbeing strategies. ICS leadership have routinely called for these new systems to come to act as a convener of broader public service provision outside of NHS settings, and local businesses could play a crucial role in realising this goal. The Department for Work and Pensions (DWP) should also be called upon to support the development of ‘progression frameworks’ for private business via their Voluntary Reporting Framework. The framework, which collects information on health and wellbeing strategies and support for employees with disabilities, envisages the former as comprised of 4 pillars: ‘my body’, ‘my mind’, ‘my finances’ and ‘my community.’

Delineating how each of these four elements can be impacted by corporate behaviour, ideally referencing case studies businesses have shared with local ICSs, would help to support ICSs in developing effective frameworks that do not approach employee health and wellbeing proscriptively, but instead understand the interplay of different determinants and actions and respond accordingly with the specific needs of their system in mind.  

Recommendation: Businesses should be further encouraged to submit case studies documenting their approaches to employee health and wellbeing, and their perceived success, to the DWP and their local ICBs.

Recommendation: The DWP should support ICSs in developing ‘business progression’ frameworks by developing a more robust Voluntary Reporting Framework.

Conclusions

As one of the key determinants of health, the type and conditions of one’s employment impact an individual’s health outcomes. For businesses, there is both a moral imperative and economic incentive to take steps to ensure good health for their employees. For longer healthy life expectancy, and reduced health inequalities in the UK, businesses must incorporate health into all corporate decision-making processes. 

The goal of an integrated care strategy is to utilise the combined power and authority of an ICB, partner local authorities, and NHS England (when commissioning in that area) to deliver a joined-up, preventative and person-centred strategy that can improve health equity within the ICBs commissioning area. Given that the majority of employed individuals work within the private sector, there is a clear role for private businesses to play in the formation and delivery of integrated care strategies.  

However, the interests of private businesses may not always align with those of an ICS – even in instances where businesses are actively seeking to support better health equity through their own corporate strategy. This report has highlighted opportunities for collaboration, discussed the value of collaboration and posited how this collaboration can be structured and monitored. The recommendations set out in this document are not intended to be proscriptive, as businesses and ICSs should adjust their strategies to respond to the specific needs of their local system, however they are intended to signpost areas of priority for both parties as they seek to close the gap on health inequity through joined-up action.  

Recommendations

  1. ICSs should craft ‘business progression’ strategies to chart the progress of private businesses within their local system. These frameworks should share some universal objectives and metrics but must also be tailored to the specific needs of the system in question.  
  2. Businesses should identify the key health conditions and inequities within their business and should share findings with their local ICS. 
  3. Businesses should be further encouraged to submit case studies documenting their approaches to employee health and wellbeing, and their perceived success, to the DWP and their local ICBs. 
  4. The DWP should support ICSs in developing ‘business progression’ frameworks by developing a more robust Voluntary Reporting Framework.   
  5. Health equity considerations should be incorporated into corporate decision making at every level.  
  6. An employee health and wellbeing strategy should include objectives for improving communication between employees, particularly between different seniority levels. Strategies should also view socialisation and the development of workplace ‘rituals’ as key to developing a healthy culture.  
  7. Employee health and wellbeing strategies should target those at higher risk of health inequalities, particularly those at lower occupational grades. Strategies should prioritise interventions that help employees easily access support linked to improved social determinants of health and should be extended to contracted employees where possible. 
  8. ICSs should encourage employers to re-evaluate their Employee Assistance Programmes (EAPs) to ensure support programmes are easy to use and deliver a clear benefit to employees.   

The Population Health in Business series is a series of roundtables hosted by Public Policy Projects (PPP) and chaired by Professor Donna Hall CBE of the Bolton NHS Foundation Trust and New Local. Each roundtable explores a different aspect of the relationship between private businesses and local leaders, and hosts senior leaders from the health and care sectors, the charitable sector, local councils and private businesses.  

To be involved in the project, or to find out more, please email policy analysts Eliot Gillings (eliot.gillings@publicpolicyprojects.com) or Mary Brown (mary.brown@publicpolicyprojects.com).

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