International Journal of
Radiation Oncology biology
physics
www.redjournal.org
Around the Globe Anthony Zietman MD, Editor-in Chief Introduction The style and structure of a nation’s health care system is not an accident; it evolves organically from the character, the politics, and the culture of its people. While generalizations are always risky, a comparison of the Canadian health care system (government-managed and equitable) with that of the United States (market-driven, exuberant, pioneering) seems to support that statement. There are important historical and social reasons why the United Kingdom has the health system it does, whereas Japan, for example, has one very different. Every system brings its own unique challenges as a working environment for physicians but each brings unique opportunities. This journal wishes to live up to its international title by recognizing and sharing the differences that exist between nations to help increase our mutual understanding. I have charged many of the members of our diverse editorial board to write articles on health care in their own countries and what it is like to practice there in the field of radiation oncology. How, for example, are Turkish radiation oncologists coping with health care reform in their country? How do British radiation oncologists manage working within a guidelineconstrained national health service while delivering chemotherapy as well? What challenges does the incorporation of Hong Kong back into a rapidly developing China bring to its physicians? These questions, and others, will be answered by this series, which we have entitled “Around the Globe”. These essays, which will be published periodically, reflect the opinions of their author and will give us a snapshot, a flavor, of radiation oncology in their nation. We hope that you will be as fascinated by this concept as we on the editorial board are, and we launch this month with an article on practice in Singapore. This densely-populated, island nation is fast becoming a regional hub in advanced technology health care. How did it happen? Read on to find out.
Inside the Singapore Medical System Francis Chin, MD, FRCR, Division of Radiation Oncology, National Cancer Centre Singapore, Singapore As anyone who has ever bought an air ticket knows, the choices offered to a buyer are the following: good, cheap, and fast. Sadly, only 1 or 2 are usually available at a time, but rarely are all 3. What is good and cheap usually is not fast, cheap and fast will not be good, and so on. Three similar options are available in health care systems, also in the form of good care, affordable care, and accessible care. Good care is self-explanatory. Affordable care and accessible care are similar but still different. Affordable care may be cheap or free, but if only an elite group in society can access it, either because of their position in society or because that group happens to live near a good hospital, it will not be fair. It will also not be sustainable for the long term if good, cheap care eventually bankrupts the whole health care system and then no one can enjoy it. A good health system needs to balance all these competing forces. Singapore is a small city state in South East Asia with a population of 5.3 million people. It gained its independence from the British about 48 years ago and back then, the medical education Int J Radiation Oncol Biol Phys, Vol. 87, No. 5, pp. 864e866, 2013 0360-3016/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2013.09.032
system closely followed the UK training system; thus, it would not be surprising to find that the ideals of the National Health System (NHS) have strongly influenced the direction and development of Singapore’s health care model. Indeed that may have happened if not for the insights and experiences of a particular young law student studying in the United Kingdom in 1948 shortly after the NHS was developed. While at the optician’s office for a pair of glasses, he was told that the glasses were free under the then-new NHS. Although pleasantly surprised, he was reputed to have said without hesitation “Then I will have two pairs” (1). That young lawyer was Lee Kuan Yew, who later became the first Prime Minister in the newly independent Singapore. His practical insight into human behavior was that when presented with a buffet of freebies, no Singaporean can resist overconsumption and no society can indefinitely pay for every need, however wealthy. After a few initial years, even the NHS stopped paying for eyeglasses.
Volume 87 Number 5 2013
During Singapore’s early years, the focus was on public health and prevention by vaccination. Tremendous gains were made in improving public housing, basic sanitation, and public works. The incidence of tuberculosis and other infectious diseases collapsed when the population was moved from cramped, unhygienic conditions into modern public housing. The engineering corps in the public works and sanitation department probably contributed more to overall national health gains than all the professors of surgery and medicine combined. It was cost effective, rapid, and a visible improvement. That was the first low-lying fruit. Next came improvements in infant mortality, leading Singapore to maintain one of the lowest infant mortality rates in the world for the past 2 decades (2). As the nation advanced and the economy grew, the disease pattern gradually turned to lifestyle diseases such as hypertension, diabetes, stroke, and cancer. In the year of Singapore’s independence, 1965, the gross domestic product (GDP) per capita was $511 USD. Today, Singapore’s per capita GDP is $60,410 USD, the third highest in the world by International Monetary Fund estimates (3). Singapore has a much admired and much studied health care system. The World Health Organization ranks Singapore’s health care system as sixth overall in its World Health Report. In the early years, health care spending was merely 3% to 4% of the GDP and remained so for many years (4). How does this small nation manage to spend so little and maintain such high standards of modern medicine? First, 3% of a rapidly increasing GDP is an increasing absolute amount which paid for rising health care costs. This statistical achievement was possible as long as GDP growth kept apace in a rapidly developing nation. It is ultimately unsustainable because 10% to 15% of GDP growth is no longer possible in a developed nation, and health care costs in Singapore are expected to rise first to 7%, then to 11% of GDP, eventually consistent with other developed nations. Singapore’s emphasis is on preventive health, personal responsibility, and mandatory savings. The health care system is designed to ensure that every citizen has access to health care in a timely, cost-effective, and seamless manner. No citizen will be denied health care because of an affordability problem. The government provides subsidies of up to 80% of the total bill in acute public hospital wards. Other sources of funds are available to top up the difference for those having difficulties with their bills.
Around the Globe
865
The government’s health care system is based on the “3M” framework. There is a mandatory personal health savings plan called MediSave, in which 7% to 9% of one’s salary is deducted monthly to a personal MediSave account. It covers about 85% of the population. There is also a government sanctioned health insurance plan called MediShield that covers for catastrophic medical bills. Premiums are kept affordable to encourage participation. A person aged 45 years pays an annual premium of $220 SGD, increasing yearly to reach $865 SGD at age 80. It is universal coverage with an annual limit of $100,000 SGD per year and no lifetime limits (5). A new version called MediShield Life will cover all citizens irrespective of pre-existing illness and age. There are safeguards, deductibles, and copayments to prevent excessive abuse of the medical system. The patient pays a 10% copayment but out-of-pocket expenses are kept low because MediSave can be used for most inpatient hospital treatments. For the unemployed or poor Singaporean citizens without adequate MediSave savings who are unable to pay for MediShield premiums, there is a last resort safety net called MediFund. The interest from an original capital amount from government surpluses pays for MediFund payments. There is strict means testing and usually only poor families already on other public assistance welfare programs qualify for MediFund. The government-run hospitals apply means testing to determine the level of subsidy for the patient. For example, for a breast lump removal operation, a subsidized patient’s median bill is $832 SDG, whereas for a full-paying patient in the private sector hospital, the cost is $5393 SGD (6). All of these figures are published online because it is believed that transparency of costs and market forces will compel the various hospitals to find ways to trim their costs and to make themselves more attractive to patients. Private patients can choose their personal doctors, whereas subsided patients are given an allocated doctor. The analogy of an airline was once used by Singaporean political leaders to describe this situation. Private patients are business class passengers; they pay more for the privacy of a wellequipped single room. Subsidized patients in a 4- or 6-bed common wards are like economy class passengers. The promise is, regardless of business or economy class, every passenger arrives at the same time and each patient will have the same medical outcome under the same doctor. When flying Singapore (medical) Airlines, besides being good, cheap, and fast, there is also choice.
866
Around the Globe
Public hospitals in Singapore have autonomy in their management decisions and compete for patients. There are 4 clusters of public hospitals in Singapore akin to the foundation hospitals of the UK NHS system to compete with each other. Market forces provide the best motivations and incentives to eliminate wastage. Hospitals are subject to competitive market forces and have scale for bulk group purchases of medicine and equipment but also have flexibility to manage their own doctors and patients. Patient choice exerts a strong incentive for the hospitals to maintain standards. Singapore is a small country barely 49 km, or 30 miles, from tip to tip, and patients can choose to go to any hospital because it is not difficult to seek a second opinion. Choice and accessibility is important for patient satisfaction. Over the past 25 years, various national centers of excellence such as The National Eye Centre, National Neurological Institute, National Heart Centre, and National Cancer Centre were set up to build expertise in managing conditions that are of particular importance in Singapore. Within these centers of excellence, there is an integration of research with academic learning as well as a strong focus on treating patients. Singapore is a small country and it makes sense to offer tertiary care only in a few national centers. Almost every hospital is also accredited by Joint Commission International to benchmark itself globally for quality and safety. Singapore has a good reputation for providing high-quality medical care. Patients from Indonesia, Malaysia, and even as far as United Arab Emirates and China come for medical treatment. Within a 6-hour flight from Singapore is a potential population catchment of about 2 billion people. A typical 6-week course of intensity modulated radiation therapy in a public hospital in Singapore for a full-paying patient is about $14,000 SGD ($11,000 USD) and waiting times are about 2-4 weeks from consultation to start of treatment. Cheap, good, and fast compared with some other developed countries. Because of inbound medical tourism, the medical sector grows and Singaporean doctors are able to keep their skills sharp and treat complicated medical conditions. These foreign patients come to private hospitals but also to public hospitals where they pay full private rates. In doing so, these public hospitals earn additional revenue and profit and are able to cross-subsidize some of the other treatments for their subsidized patients. Singapore has a vibrant private hospital sector and public hospitals, although offering competitive salaries cannot hope to match the lucrative pay packages in the private sector. Public hospitals need to offer an academic environment and so that they retain talent with the lure of working with the latest technology in medicine and surgery. There is a worldwide trend of increasingly expensive tertiary level care, which is partly driven by technology as well as the increasing expectations of the population. In the National Cancer Centre, for radiation oncology, we have gone from cobalt machines to linacs offering intensity modulated radiation therapy and image guided radiation therapy, with plans to build a proton center in the future. The engineers, computer programmers, and physicists can take much credit for advancing radiation oncolgy by developing better dosimetric calculation algorithms and
International Journal of Radiation Oncology Biology Physics building better machines, but it costs far more than it did in the past. This capital investment is well spent because we can have more accurate targeting of tumors and better sparing of normal organ tissues. Better oncology treatment for patients is not just about better cure rates, but also about living normally thereafter without long-term side effects. The proton center being built in Singapore is an example of a strategic capital investment to attract patients who require this specialized cancer treatment modality. Half the cost of the proton center is the building and the land it sits on. We hope to build cheaply by integrating the proton center into our future new cancer center design. It is hoped that if we get our sums right, we can offer proton treatment in a cost-effective and competitive manner compared with other proton centers in Asia. The proton center is a win-win-win situation for the hospital, doctors, and patients. The hospital retains essential radiationexpertise staff and has better utilization of the equipment while attracting more patients for their other services. Doctors supplement their income while still retaining their academic ties with the public hospitals. Patients pay less to see senior doctors of their choice in public hospitals and can access a state of the art facility. There will always be challenges and strains on the health care system as people get older and medical conditions require more complicated treatments. An increasing population resulting from immigration also adds to the shortage of hospital beds and doctors. Over the next few years, Singapore will be increasing the intake of new medical students, starting new medical schools, and aggressively building new hospitals. In the past, there was only 1 medical school adopting the UK medical curriculum. Currently, 2 more medical schools have established collaborations with Duke University in the United States and Imperial College in the United Kingdom. Postgraduate training in the past was predominately UK-based, but in the future, the Accreditation Council for Graduate Medical Education-accredited courses are being rolled out. With all these future plans in place, we hope that the Singapore (medical) Airlines will always continue to be a great way to fly.
References 1. Lee KY. The Singapore Story: Memoirs of Lee Kuan Yew. Singapore: Times; 1998. 2. Singapore Department of Statistics. Key annual indicators. Singapore, 2011. 3. International Monetary Fund. World Economic Outlook Database (April 2013). Available at: http://www.imf.org/external/pubs/ft/weo/ 2013/01/weodata/index.aspx. Accessed September 26, 2013. 4. World Health Organization. The World Health Report 2000 e Health systems: Improving performance. Geneva, Switzerland: 2013. 5. Ministry of Health, Singapore. Costs and Financing. MediShield premiums. Available at: http://www.moh.gov.sg/content/moh_web/ home/costs_and_financing/schemes_subsidies/Medishield/Premiums. html. Accessed September 26, 2013. 6. Ministry of Health, Singapore. Costs and financing. Hospital bill sizes. Breast lump removal/biopsy. Available at: http://www.moh.gov.sg/ content/moh_web/home/costs_and_financing/HospitalBillSize/breast_ lump_removal.html. Accessed September 26, 2013.
Radiation Oncology biology
physics
www.redjournal.org
Around the Globe Anthony Zietman MD, Editor-in Chief Introduction The style and structure of a nation’s health care system is not an accident; it evolves organically from the character, the politics, and the culture of its people. While generalizations are always risky, a comparison of the Canadian health care system (government-managed and equitable) with that of the United States (market-driven, exuberant, pioneering) seems to support that statement. There are important historical and social reasons why the United Kingdom has the health system it does, whereas Japan, for example, has one very different. Every system brings its own unique challenges as a working environment for physicians but each brings unique opportunities. This journal wishes to live up to its international title by recognizing and sharing the differences that exist between nations to help increase our mutual understanding. I have charged many of the members of our diverse editorial board to write articles on health care in their own countries and what it is like to practice there in the field of radiation oncology. How, for example, are Turkish radiation oncologists coping with health care reform in their country? How do British radiation oncologists manage working within a guidelineconstrained national health service while delivering chemotherapy as well? What challenges does the incorporation of Hong Kong back into a rapidly developing China bring to its physicians? These questions, and others, will be answered by this series, which we have entitled “Around the Globe”. These essays, which will be published periodically, reflect the opinions of their author and will give us a snapshot, a flavor, of radiation oncology in their nation. We hope that you will be as fascinated by this concept as we on the editorial board are, and we launch this month with an article on practice in Singapore. This densely-populated, island nation is fast becoming a regional hub in advanced technology health care. How did it happen? Read on to find out.
Inside the Singapore Medical System Francis Chin, MD, FRCR, Division of Radiation Oncology, National Cancer Centre Singapore, Singapore As anyone who has ever bought an air ticket knows, the choices offered to a buyer are the following: good, cheap, and fast. Sadly, only 1 or 2 are usually available at a time, but rarely are all 3. What is good and cheap usually is not fast, cheap and fast will not be good, and so on. Three similar options are available in health care systems, also in the form of good care, affordable care, and accessible care. Good care is self-explanatory. Affordable care and accessible care are similar but still different. Affordable care may be cheap or free, but if only an elite group in society can access it, either because of their position in society or because that group happens to live near a good hospital, it will not be fair. It will also not be sustainable for the long term if good, cheap care eventually bankrupts the whole health care system and then no one can enjoy it. A good health system needs to balance all these competing forces. Singapore is a small city state in South East Asia with a population of 5.3 million people. It gained its independence from the British about 48 years ago and back then, the medical education Int J Radiation Oncol Biol Phys, Vol. 87, No. 5, pp. 864e866, 2013 0360-3016/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2013.09.032
system closely followed the UK training system; thus, it would not be surprising to find that the ideals of the National Health System (NHS) have strongly influenced the direction and development of Singapore’s health care model. Indeed that may have happened if not for the insights and experiences of a particular young law student studying in the United Kingdom in 1948 shortly after the NHS was developed. While at the optician’s office for a pair of glasses, he was told that the glasses were free under the then-new NHS. Although pleasantly surprised, he was reputed to have said without hesitation “Then I will have two pairs” (1). That young lawyer was Lee Kuan Yew, who later became the first Prime Minister in the newly independent Singapore. His practical insight into human behavior was that when presented with a buffet of freebies, no Singaporean can resist overconsumption and no society can indefinitely pay for every need, however wealthy. After a few initial years, even the NHS stopped paying for eyeglasses.
Volume 87 Number 5 2013
During Singapore’s early years, the focus was on public health and prevention by vaccination. Tremendous gains were made in improving public housing, basic sanitation, and public works. The incidence of tuberculosis and other infectious diseases collapsed when the population was moved from cramped, unhygienic conditions into modern public housing. The engineering corps in the public works and sanitation department probably contributed more to overall national health gains than all the professors of surgery and medicine combined. It was cost effective, rapid, and a visible improvement. That was the first low-lying fruit. Next came improvements in infant mortality, leading Singapore to maintain one of the lowest infant mortality rates in the world for the past 2 decades (2). As the nation advanced and the economy grew, the disease pattern gradually turned to lifestyle diseases such as hypertension, diabetes, stroke, and cancer. In the year of Singapore’s independence, 1965, the gross domestic product (GDP) per capita was $511 USD. Today, Singapore’s per capita GDP is $60,410 USD, the third highest in the world by International Monetary Fund estimates (3). Singapore has a much admired and much studied health care system. The World Health Organization ranks Singapore’s health care system as sixth overall in its World Health Report. In the early years, health care spending was merely 3% to 4% of the GDP and remained so for many years (4). How does this small nation manage to spend so little and maintain such high standards of modern medicine? First, 3% of a rapidly increasing GDP is an increasing absolute amount which paid for rising health care costs. This statistical achievement was possible as long as GDP growth kept apace in a rapidly developing nation. It is ultimately unsustainable because 10% to 15% of GDP growth is no longer possible in a developed nation, and health care costs in Singapore are expected to rise first to 7%, then to 11% of GDP, eventually consistent with other developed nations. Singapore’s emphasis is on preventive health, personal responsibility, and mandatory savings. The health care system is designed to ensure that every citizen has access to health care in a timely, cost-effective, and seamless manner. No citizen will be denied health care because of an affordability problem. The government provides subsidies of up to 80% of the total bill in acute public hospital wards. Other sources of funds are available to top up the difference for those having difficulties with their bills.
Around the Globe
865
The government’s health care system is based on the “3M” framework. There is a mandatory personal health savings plan called MediSave, in which 7% to 9% of one’s salary is deducted monthly to a personal MediSave account. It covers about 85% of the population. There is also a government sanctioned health insurance plan called MediShield that covers for catastrophic medical bills. Premiums are kept affordable to encourage participation. A person aged 45 years pays an annual premium of $220 SGD, increasing yearly to reach $865 SGD at age 80. It is universal coverage with an annual limit of $100,000 SGD per year and no lifetime limits (5). A new version called MediShield Life will cover all citizens irrespective of pre-existing illness and age. There are safeguards, deductibles, and copayments to prevent excessive abuse of the medical system. The patient pays a 10% copayment but out-of-pocket expenses are kept low because MediSave can be used for most inpatient hospital treatments. For the unemployed or poor Singaporean citizens without adequate MediSave savings who are unable to pay for MediShield premiums, there is a last resort safety net called MediFund. The interest from an original capital amount from government surpluses pays for MediFund payments. There is strict means testing and usually only poor families already on other public assistance welfare programs qualify for MediFund. The government-run hospitals apply means testing to determine the level of subsidy for the patient. For example, for a breast lump removal operation, a subsidized patient’s median bill is $832 SDG, whereas for a full-paying patient in the private sector hospital, the cost is $5393 SGD (6). All of these figures are published online because it is believed that transparency of costs and market forces will compel the various hospitals to find ways to trim their costs and to make themselves more attractive to patients. Private patients can choose their personal doctors, whereas subsided patients are given an allocated doctor. The analogy of an airline was once used by Singaporean political leaders to describe this situation. Private patients are business class passengers; they pay more for the privacy of a wellequipped single room. Subsidized patients in a 4- or 6-bed common wards are like economy class passengers. The promise is, regardless of business or economy class, every passenger arrives at the same time and each patient will have the same medical outcome under the same doctor. When flying Singapore (medical) Airlines, besides being good, cheap, and fast, there is also choice.
866
Around the Globe
Public hospitals in Singapore have autonomy in their management decisions and compete for patients. There are 4 clusters of public hospitals in Singapore akin to the foundation hospitals of the UK NHS system to compete with each other. Market forces provide the best motivations and incentives to eliminate wastage. Hospitals are subject to competitive market forces and have scale for bulk group purchases of medicine and equipment but also have flexibility to manage their own doctors and patients. Patient choice exerts a strong incentive for the hospitals to maintain standards. Singapore is a small country barely 49 km, or 30 miles, from tip to tip, and patients can choose to go to any hospital because it is not difficult to seek a second opinion. Choice and accessibility is important for patient satisfaction. Over the past 25 years, various national centers of excellence such as The National Eye Centre, National Neurological Institute, National Heart Centre, and National Cancer Centre were set up to build expertise in managing conditions that are of particular importance in Singapore. Within these centers of excellence, there is an integration of research with academic learning as well as a strong focus on treating patients. Singapore is a small country and it makes sense to offer tertiary care only in a few national centers. Almost every hospital is also accredited by Joint Commission International to benchmark itself globally for quality and safety. Singapore has a good reputation for providing high-quality medical care. Patients from Indonesia, Malaysia, and even as far as United Arab Emirates and China come for medical treatment. Within a 6-hour flight from Singapore is a potential population catchment of about 2 billion people. A typical 6-week course of intensity modulated radiation therapy in a public hospital in Singapore for a full-paying patient is about $14,000 SGD ($11,000 USD) and waiting times are about 2-4 weeks from consultation to start of treatment. Cheap, good, and fast compared with some other developed countries. Because of inbound medical tourism, the medical sector grows and Singaporean doctors are able to keep their skills sharp and treat complicated medical conditions. These foreign patients come to private hospitals but also to public hospitals where they pay full private rates. In doing so, these public hospitals earn additional revenue and profit and are able to cross-subsidize some of the other treatments for their subsidized patients. Singapore has a vibrant private hospital sector and public hospitals, although offering competitive salaries cannot hope to match the lucrative pay packages in the private sector. Public hospitals need to offer an academic environment and so that they retain talent with the lure of working with the latest technology in medicine and surgery. There is a worldwide trend of increasingly expensive tertiary level care, which is partly driven by technology as well as the increasing expectations of the population. In the National Cancer Centre, for radiation oncology, we have gone from cobalt machines to linacs offering intensity modulated radiation therapy and image guided radiation therapy, with plans to build a proton center in the future. The engineers, computer programmers, and physicists can take much credit for advancing radiation oncolgy by developing better dosimetric calculation algorithms and
International Journal of Radiation Oncology Biology Physics building better machines, but it costs far more than it did in the past. This capital investment is well spent because we can have more accurate targeting of tumors and better sparing of normal organ tissues. Better oncology treatment for patients is not just about better cure rates, but also about living normally thereafter without long-term side effects. The proton center being built in Singapore is an example of a strategic capital investment to attract patients who require this specialized cancer treatment modality. Half the cost of the proton center is the building and the land it sits on. We hope to build cheaply by integrating the proton center into our future new cancer center design. It is hoped that if we get our sums right, we can offer proton treatment in a cost-effective and competitive manner compared with other proton centers in Asia. The proton center is a win-win-win situation for the hospital, doctors, and patients. The hospital retains essential radiationexpertise staff and has better utilization of the equipment while attracting more patients for their other services. Doctors supplement their income while still retaining their academic ties with the public hospitals. Patients pay less to see senior doctors of their choice in public hospitals and can access a state of the art facility. There will always be challenges and strains on the health care system as people get older and medical conditions require more complicated treatments. An increasing population resulting from immigration also adds to the shortage of hospital beds and doctors. Over the next few years, Singapore will be increasing the intake of new medical students, starting new medical schools, and aggressively building new hospitals. In the past, there was only 1 medical school adopting the UK medical curriculum. Currently, 2 more medical schools have established collaborations with Duke University in the United States and Imperial College in the United Kingdom. Postgraduate training in the past was predominately UK-based, but in the future, the Accreditation Council for Graduate Medical Education-accredited courses are being rolled out. With all these future plans in place, we hope that the Singapore (medical) Airlines will always continue to be a great way to fly.
References 1. Lee KY. The Singapore Story: Memoirs of Lee Kuan Yew. Singapore: Times; 1998. 2. Singapore Department of Statistics. Key annual indicators. Singapore, 2011. 3. International Monetary Fund. World Economic Outlook Database (April 2013). Available at: http://www.imf.org/external/pubs/ft/weo/ 2013/01/weodata/index.aspx. Accessed September 26, 2013. 4. World Health Organization. The World Health Report 2000 e Health systems: Improving performance. Geneva, Switzerland: 2013. 5. Ministry of Health, Singapore. Costs and Financing. MediShield premiums. Available at: http://www.moh.gov.sg/content/moh_web/ home/costs_and_financing/schemes_subsidies/Medishield/Premiums. html. Accessed September 26, 2013. 6. Ministry of Health, Singapore. Costs and financing. Hospital bill sizes. Breast lump removal/biopsy. Available at: http://www.moh.gov.sg/ content/moh_web/home/costs_and_financing/HospitalBillSize/breast_ lump_removal.html. Accessed September 26, 2013.
