UNASSIGNED: To develop a framework and index for measuring universal health coverage (UHC) at the district level in India and to assess progress towards UHC in the districts.
UNASSIGNED: We adapted the framework of the World Health Organization and World Bank to develop a district-level UHC index (UHC d ). We used routinely collected health survey and programme data in India to calculate UHC d for 687 districts from geometric means of 24 tracer indicators in five tracer domains: reproductive, maternal, newborn and child health; infectious diseases; noncommunicable diseases; service capacity and access; and financial risk protection. UHC d is on a scale of 0% to 100%, with higher scores indicating better performance. We also assessed the degree of inequality within districts using a subset of 14 tracer indicators. The disadvantaged subgroups were based on four inequality dimensions: wealth quintile, urban-rural location, religion and social group.
UNASSIGNED: The median UHC d was 43.9% (range: 26.4 to 69.4). Substantial geographical differences existed, with districts in southern states having higher UHC d than elsewhere in India. Service coverage indicator levels were greater than 60%, except for noncommunicable diseases and for service capacity and access. Health insurance coverage was limited, with about 10% of the population facing catastrophic and impoverishing health expenditure. Substantial wealth-based disparities in UHC were seen within districts.
UNASSIGNED: Our study shows that UHC can be measured at the local level and can help national and subnational government develop prioritization frameworks by identifying health-care delivery and geographic hotspots where limited progress towards UHC is being made.
UNASSIGNED: Élaborer un cadre et un indice servant à mesurer la couverture sanitaire universelle (CSU) à l\'échelle des districts en Inde, et évaluer les progrès effectués dans ce domaine.
UNASSIGNED: Nous avons adapté le cadre de l\'Organisation mondiale de la Santé et de la Banque mondiale pour mettre au point un indice de CSU par district (CSU d ). Nous avons utilisé des données recueillies systématiquement dans le cadre d\'un programme et d\'une enquête sur la santé en Inde pour calculer le CSU d de 687 districts, en partant des moyennes géométriques de 24 indicateurs traçants relevant de cinq catégories: santé reproductive, maternelle, néonatale et infantile; maladies infectieuses; maladies non transmissibles; capacité et accès aux services; et enfin, protection contre les risques financiers. Le CSU d est compris entre 0 et 100%, les scores les plus élevés indiquant de meilleures performances. Nous avons également évalué le degré d\'inégalité au sein des districts à l\'aide d\'un sous-ensemble de 14 indicateurs traçants. Les sous-groupes défavorisés reposaient sur quatre formes d\'inégalité: quintiles de richesse, implantation urbaine ou rurale, groupe religieux et groupe social.
UNASSIGNED: Le CSU d médian était de 43,9% (écart: 26,4 à 69,4). Nous avons observé des variations géographiques considérables, les districts des États du sud affichant un meilleur CSU d que partout ailleurs en Inde. L\'indicateur relatif à la couverture des services dépassait les 60%, sauf pour les maladies non transmissibles ou encore la capacité et l\'accès aux services. De son côté, la couverture d\'assurance-maladie était limitée, environ 10% de la population étant confrontée à des dépenses de santé catastrophiques entraînant un appauvrissement. Enfin, d\'importantes disparités dans la CSU ont été constatées à l\'intérieur des districts.
UNASSIGNED: Notre étude montre que la CSU peut être mesurée à l\'échelle locale, ce qui peut aider les autorités locales et nationales à hiérarchiser les priorités en identifiant les prestations de soins de santé et les zones géographiques à risque où l\'évolution vers une CSU se fait attendre.
UNASSIGNED: Desarrollar un marco y un índice para medir la cobertura sanitaria universal (CSU) a nivel de distrito en India y evaluar los avances hacia la CSU en los distritos.
UNASSIGNED: Se adaptó el marco de la Organización Mundial de la Salud y del Banco Mundial para desarrollar un índice de cobertura sanitaria universal a nivel de distrito (CSU d ).Se utilizaron datos de encuestas y programas de salud recopilados sistemáticamente en India para calcular el CSU d de 687 distritos a partir de medias geométricas de 24 indicadores de seguimiento en cinco ámbitos de seguimiento: salud reproductiva, materna, neonatal e infantil; enfermedades infecciosas; enfermedades no transmisibles; capacidad y acceso a los servicios; y protección contra riesgos financieros. El CSU d está en una escala de 0 a 100%, y los puntajes más altos indican un mejor desempeño. También se evaluó el grado de desigualdad dentro de los distritos utilizando un subconjunto de 14 indicadores de seguimiento. Los subgrupos desfavorecidos se basaron en cuatro dimensiones de desigualdad: quintil de riqueza, ubicación urbano-rural, religión y grupo social.
UNASSIGNED: El promedio de CSU d fue del 43,9% (rango: 26,4 a 69,4). Existían diferencias geográficas significativas: los distritos de los estados del sur tenían un CSU d más alto que los del resto de India. Los niveles de los indicadores de cobertura de servicios eran superiores al 60%, excepto para las enfermedades no transmisibles y para la capacidad y el acceso a los servicios. La cobertura del seguro sanitario era limitada, y alrededor del 10% de la población se enfrentaba a gastos sanitarios catastróficos y empobrecedores. Se observaron disparidades significativas en la CSU según el nivel de riqueza dentro de los distritos.
UNASSIGNED: Este estudio demuestra que la CSU puede medirse a escala local y puede ayudar a los gobiernos nacionales y subnacionales a desarrollar marcos de priorización mediante la identificación de los puntos críticos geográficos y de prestación de asistencia sanitaria en los que los avances hacia la CSU son limitados.
UNASSIGNED: تطوير إطار عمل مؤشر لقياس التغطية الصحية الشاملة (UHC) على مستوى المناطق في الهند، وتقييم التقدم المحرز نحو التغطية الصحية الشاملة في المناطق.
UNASSIGNED: قمنا بضبط إطار عمل كل من منظمة الصحة العالمية والبنك الدولي، لتطوير مؤشر التغطية الصحية الشاملة
(UHC d على مستوى المناطق). قمنا باستخدام بيانات وبرنامج المسح الصحي، والتي تم جمعها بشكل روتيني في الهند لحساب مؤشر التغطية الصحية الشاملة لعدد 687 منطقة من المتوسط الهندسي لعدد 24 مؤشر تتبع في خمسة نطاقات للتتبع: الصحة الإنجابية، وصحة الأم، وصحة حديثي الولادة، وصحة الطفل؛ والأمراض المعدية؛ الأمراض غير المعدية؛ القدرة على تقديم الخدمة والحصول إليها؛ والحماية من المخاطر المالية. يتم تقييم مؤشر التغطية الصحية الشاملة على مقياس من 0 إلى %100، وتشير الدرجات الأعلى إلى أداء أفضل. كما قمنا أيضًا بتقييم درجة عدم المساواة داخل المناطق باستخدام مجموعة فرعية مكونة من 14 مؤشرًا للتتبع. واستندت المجموعات الفرعية المهمشة إلى أربعة أبعاد لعدم المساواة: فئة الثروة، والموقع الحضري والريفي، والدين، والطبقة الاجتماعية.
UNASSIGNED: كان مؤشر التغطية الصحية الشاملة (النطاق: 26.4 إلى 69.4). تواجدت اختلافات جغرافية أساسية، حيث تتمتع المناطق في الولايات الجنوبية بمؤشر للتغطية الصحية الشاملة أعلى من الأماكن الأخرى في الهند. وكانت مستويات مؤشر تغطية الخدمة أكبر من %60، فيما عدا الأمراض غير المعدية، والقدرة على تقديم الخدمة وإمكانية الحصول إليها. كانت تغطية التأمين الصحي محدودة، إذ يواجه نحو %10 من السكان نفقات صحية باهظة ومكلفة. ولوحظت فوارق كبيرة على أساس الثروة في التغطية الصحية الشاملة داخل المناطق.
UNASSIGNED: تظهر دراستنا أنه يمكن قياس التغطية الصحية الشاملة على المستوى المحلي، ويمكن أن تساعد الحكومة الوطنية والإقليمية على تطوير أطر عمل للأولويات من خلال تحديد النقاط الساخنة الجغرافية لتقديم الرعاية الصحية، حيث يتم إحراز تقدم محدود نحو التغطية الصحية الشاملة.
UNASSIGNED: 旨在制定一个用于衡量印度县级全民健康覆盖 (UHC) 情况的框架和指数，并评估各个县在实现 UHC 方面的进展情况。.
UNASSIGNED: 通过借鉴世界卫生组织和世界银行的框架，我们制定了一个县级 UHC 指数 (UHCd)。我们使用在印度收集的常规健康调查和规划数据，根据以下五大示踪领域的 24 个示踪指标的几何平均值计算出了 687 个县的 UHCd：生殖、孕产妇、新生儿和儿童健康；传染病；非传染性疾病；服务能力与其可及性；以及金融风险保护。UHCd 的评分范围为 0 到 100%，分数越高表明表现越好。我们还使用其中 14 个示踪指标评估了各个县的不平等程度。对弱势亚群体的评估基于四个不平等维度：财富五分位数、城乡位置、宗教信仰和社会群体。.
UNASSIGNED: UHCd 中位数为 43.9%（范围：26.4 - 69.4）。存在巨大的地理差异，印度南部各邦下属县的 UHCd 明显高于其他县。除非传染性疾病和服务能力与其可及性领域外，服务覆盖率指标水平均高于 60%。健康保险覆盖范围有限，约 10% 的人口面临着灾难性和致贫性卫生支出。在推行 UHC 的过程中，我们发现各县存在巨大的财富差异。.
UNASSIGNED: 研究表明，我们可以在地方层面对 UHC 情况进行衡量，并且可以通过锁定在实现 UHC 方面进展有限的卫生保健服务和地理集中区域，帮助国家和地方政府制定确定优先次序的框架。.
UNASSIGNED: Разработать систему и индекс для измерения всеобщего охвата населения услугами здравоохранения (ВОУЗ) на уровне округа в Индии и оценить прогресс в достижении ВОУЗ в округах.
UNASSIGNED: Для разработки индекса ВОУЗ на уровне округов (UHC d ) использовалась система Всемирной организации здравоохранения и Всемирного банка. Для расчета показателя UHC d для 687 округов Индии использовались данные регулярных обследований и программ в области здравоохранения, полученные на основе геометрических средних значений 24 показателей в пяти областях: репродуктивное здоровье, здоровье матери, новорожденного и ребенка; инфекционные заболевания; неинфекционные заболевания; возможность предоставления услуг и доступ к ним; защита от финансовых рисков. Показатель UHC d оценивается по шкале от 0 до 100%, при этом более высокие баллы свидетельствуют о лучшей результативности. Кроме того, проведена оценка степени неравенства внутри округов с использованием подмножества из 14 отслеживаемых показателей. Неблагополучные подгруппы были определены по четырем параметрам неравенства: квинтиль благосостояния, городская и сельская местность, религия и социальная группа.
UNASSIGNED: Медиана UHC d составила 43,9% (диапазон: от 26,4 до 69,4). Существовали значительные географические различия: в округах южных штатов показатель UHC d был выше по сравнению с другими регионами Индии. Уровни показателей охвата услугами превышали 60%, за исключением неинфекционных заболеваний, а также возможностей предоставления услуг и доступа к ним. Охват услугами медицинского страхования был ограничен, и около 10% населения сталкивались с катастрофическими и приводящими к обнищанию расходами на здравоохранение. Внутри округов наблюдалось значительное неравенство по уровню благосостояния в отношении всеобщего охвата услугами здравоохранения.
UNASSIGNED: Результаты исследования свидетельствуют о том, что всеобщий охват населения услугами здравоохранения может быть измерен на местном уровне и может помочь национальным и субнациональным органам власти разработать систему приоритетов, определив систему оказания медицинских услуг и географические точки, в которых прогресс на пути к всеобщему охвату населения услугами здравоохранения является ограниченным.

BACKGROUND: Over the years, low-and middle-income countries have adopted several policy initiatives to strengthen community health systems as means to attain Universal Health Coverage (UHC). In this regard, Zambia passed a Community Health Strategy in 2017 that was later halted in 2019. This paper explores the processes that led to the halting and re-issuing of this strategy with the view of drawing lessons to inform the development of such strategies in Zambia and other similar settings.
METHODS: We employed a qualitative case study comprising 20 semi-structured interviews with key stakeholders who had participated in either the development, halting, or re-issuing of the two strategies, respectively. These stakeholders represented the Ministry of Health, cooperating partners and other non-government organizations. Inductive thematic analysis approach was used for analysis.
RESULTS: The major reasons for halting and re-issuing the community health strategy included the need to realign it with the national development framework such as the 7th National Development Plan, lack of policy ownership, political influence, and the need to streamline the coordination of community health interventions. The policy process inadequately addressed the key tenets of community health systems such as complexity, adaptation, resilience and engagement of community actors resulting in shortcomings in the policy content. Furthermore, the short implementation period, lack of dedicated staff, and inadequate engagement of stakeholders from other sectors threatened the sustainability of the re-issued strategy.
CONCLUSIONS: This study underscores the complexity of community health systems and highlights the challenges these complexities pose to health policymaking efforts. Countries that embark on health policymaking for community health systems must reflect on issues such as persistent fragmentation, which threaten the policy development process. It is crucial to ensure that these complexities are considered within similar policy engagement processes.

BACKGROUND: Universal health coverage (UHC) ensures affordability of a variety of essential health services for the general population. Although UHC could mitigate the harmful effects of coronavirus disease 2019 (COVID-19) on patients and their socioeconomic position, the debate on UHC\'s scope and ability to improve health outcomes is ongoing. This study aimed to identify the impact of UHC policy withdrawal on the health outcomes of South Korea\'s severely ill COVID-19 patients.
METHODS: We used a propensity score matching (PSM) and difference-in-differences combined model. This study\'s subjects were 44,552 hospitalized COVID-19 patients contributing towards health insurance claims data, COVID-19 notifications and vaccination data extracted from the National Health Information Database and the Korea Disease Control and Prevention Agency from 1 December 2020 to 30 April 2022. After PSM, 2460 patients were included. This study\'s exposures were severity of illness and UHC policy change. The primary outcome was the case fatality rate (CFR) for COVID-19, which was defined as death within 30 days of a COVID-19 diagnosis. There were four secondary outcomes, including time interval between diagnosis and hospitalization (days), length of stay (days), total medical expenses (USD) and the time interval between diagnosis and death (days).
RESULTS: After the UHC policy\'s withdrawal, the severely ill patients\' CFR increased to 284 per 1000 patients [95% confidence interval (CI) 229.1-338.4], hospitalization days decreased to 9.61 days (95% CI -11.20 to -8.03) and total medical expenses decreased to 5702.73 USD (95% CI -7128.41 to -4202.01) compared with those who were not severely ill.
CONCLUSIONS: During the pandemic, UHC may have saved the lives of severely ill COVID-19 patients; therefore, expanding services and financial coverage could be a crucial strategy during public health crises.

BACKGROUND: Universal Health Coverage (UHC) is a common health policy objective outlined in the Sustainable Development Goals. With provincial governments taking the initiative, Pakistan has implemented and extended UHC program amid a complex public health landscape. In this context, we assess Pakistan\'s progress toward achieving UHC at the national and subnational level.
METHODS: We use data from the Demographic and Health Surveys and the Household Integrated Economic Survey to construct a UHC index at the national and subnational level for 2007, 2013, and 2018. Furthermore, we use Concentration Index (CI) and CI decomposition methodologies to assess the primary drivers of inequality in accessing medical services. Logistic regression and Sartori\'s two-step model are applied to examine the key determinants of catastrophic health expenditure (CHE).
RESULTS: Our analysis underscores Pakistan\'s steady progress toward UHC, while revealing significant provincial disparities in UHC progress. Provinces with lower poverty rate achieve higher UHC index, which highlights the synergy of poverty alleviation and UHC expansion. Among the examined indicators, child immunization remains a key weakness that one third of the children are not fully vaccinated and one sixth of these not-fully-vaccinated children have never received any vaccination. Socioeconomic status emerges as a main contributor to disparities in accessing medical services, albeit with a declining trend over time. Household socioeconomic status is negatively correlated with CHE incidence, indicating that wealthier households are less susceptible to CHE. For individuals experiencing CHE, medicine expenditure takes the highest share of their health spending, registering a staggering 70% in 2018.
CONCLUSIONS: Pakistan\'s progress toward UHC aligns closely with its economic development trajectory and policy efforts in expanding UHC program. However, economic underdevelopment and provincial disparities persist as significant hurdles on Pakistan\'s journey toward UHC. We suggest continued efforts in UHC program expansion with a focus on policy consistency and fiscal support, combined with targeted interventions to alleviate poverty in the underdeveloped provinces.

BACKGROUND: India launched a national health insurance scheme named Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018 as a key policy for universal health coverage. The ambitious scheme covers 100 million poor households. None of the studies have examined its impact on the quality of care. The existing studies on the impact of AB-PMJAY on financial protection have been limited to early experiences of its implementation. Since then, the government has improved the scheme\'s design. The current study was aimed at evaluating the impact of AB-PMJAY on improving utilisation, quality, and financial protection for inpatient care after four years of its implementation.
METHODS: Two annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state\'s population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem.
RESULTS: Enrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure.
CONCLUSIONS: AB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries.

暂无摘要。

BACKGROUND: Kerala has initiated many Universal Health Coverage (UHC) reforms in the last decade. The Aardram Mission launched in 2017 stands out owing to its scope, objectives, and commitments for strengthening Primary Health Care (PHC) in the State. The current study proposes to explore access and financial protection through the lens of equity in Kerala especially in the context of major UHC reforms carried out during the last decade. This paper will also highlight the key lessons from Kerala\'s approach towards UHC and health systems strengthening through a political economy approach.
METHODS: Data from the Kerala state sample of 75th Round (2017-18) National Sample Survey is used for this study. Comparison is also drawn from the 71st Round Sample Survey, 2014, to measure the state\'s progress in terms of access and financial protection. Logistic regression was used for the calculation. The findings were further explored through a political economy approach.
RESULTS: The share of public facilities for outpatient care is 47.5%, which is a significant increase from 34.0% (in 2014) in the state. The share of public sector for out-patient care has increased for the lower socio-economic population in the state. The share of public sector for in-patient care has also increased to 37.3% in 2017-18 from 33.9% in 2014, but not to the extent as the increase shown in outpatient care. The average out-of-pocket-expenditure during hospitalization has increased more in private facilities as compared to public for both outpatient care and hospitalization.
CONCLUSIONS: Overall increase in the share of public facilities for both outpatient care and hospitalization is indicative of the enhanced trust among the people at large of the public healthcare delivery system in Kerala, post the launch of UHC reforms in the State. The insurance linked UHC reforms would be insufficient for the State to progress further towards UHC. Kerala with a long and successful history in \'public provisioning\' should focus more on strengthening PHC through Aardram Mission in its journey towards pursuit of UHC.

BACKGROUND: The Disease Control Priorities 3 (DCP3) project provides long-term support to Pakistan in the development and implementation of its universal health coverage essential package of health services (UHC-EPHS). This paper reports on the priority setting process used in the design of the EPHS during the period 2019-2020, employing the framework of evidence-informed deliberative processes (EDPs), a tool for priority setting with the explicit aim of optimising the legitimacy of decision-making in the development of health benefit packages.
METHODS: We planned the six steps of the framework during two workshops in the Netherlands with participants from all DCP3 Pakistan partners (October 2019 and February 2020), who implemented these at the country level in Pakistan in 2019 and 2020. Following implementation, we conducted a semi-structured online survey to collect the views of participants in the UHC benefit package design about the prioritisation process.
RESULTS: The key steps in the EDP framework were the installation of advisory committees (involving more than 150 members in several Technical Working Groups [TWGs] and a National Advisory Committee [NAC]), definition of decision criteria (effectiveness, cost-effectiveness, avoidable burden of disease, equity, financial risk protection, budget impact, socio-economic impact and feasibility), selection of interventions for evaluation (a total of 170), and assessment and appraisal (across the three dimensions of the UHC cube) of these interventions. Survey respondents were generally positive across several aspects of the priority setting process.
CONCLUSIONS: Despite several challenges, including a partial disruption because of the COVID-19 pandemic, implementation of the priority setting process may have improved the legitimacy of decision-making by involving stakeholders through participation with deliberation, and being evidence-informed and transparent. Important lessons were learned that can be beneficial for other countries designing their own health benefit package such as on the options and limitations of broad stakeholder involvement.

BACKGROUND: In 2018, Kenya\'s Ministry of Health (MoH) gazetted the Health Benefits Package Advisory Panel (HBPAP) to develop a benefits package for its universal health coverage (UHC) programme. In this study, we examine the political process that led to the gazettement of the HBPAP.
METHODS: We conducted a case study based on semi-structured interviews with 20 national-level participants and, reviews of documents such as organizational and media reports. We analyzed data from the interviews and documents thematically using the Braun and Clarke\'s six step approach. We identified codes and themes deductively using Kingdon\'s Multiple Streams Theory which postulates that the successful emergence of a policy follows coupling of three streams: the problem, policy, and politics streams.
RESULTS: We found that the problem stream was characterized by fragmented and implicit healthcare priority-setting processes that led to unaffordable, unsustainable, and wasteful benefits packages. A potential policy solution for these problems was the creation of an independent expert panel that would use an explicit and evidence-based healthcare priority-setting process to develop an affordable and sustainable benefits package. The political stream was characterized by the re-election of the government and the appointment of a new Cabinet Secretary for Health. Coupling of the problem, policy, and political streams occurred during a policy window that was created by the political prioritization of UHC by the newly re-elected government. Policy entrepreneurs who included health economists, health financing experts, health policy analysts, and health systems experts leveraged this policy window to push for the establishment of an independent expert panel as a solution for the issues identified in the problem stream. They employed strategies such as forming networks, framing, marshalling evidence, and utilizing political connections.
CONCLUSIONS: Applying Kingdon\'s theory in this study was valuable in explaining why the HBPAP policy idea was gazetted. It demonstrated the crucial role of policy entrepreneurs and the strategies they employed to couple the three streams during a favourable policy window. This study contributes to the body of literature on healthcare priority-setting processes with an unusual analysis focused on a key procedural policy for such processes.

BACKGROUND: To achieve Universal Health Coverage (UHC), China have implemented health system reform to expend health coverage and improve health equity. Scholars have explored the implementing effect of this health reform, but gaps remained in health care received by elderly. This study aims to assess the effect of implementing health insurance payment reform on health care received by elderly, as well as to evaluate its effect on cost sharing to identify whether improve financial protection of elderly under this reform.
METHODS: We identified hospitalization of 46,714 elderly with cerebral infarction from 2013 to 2023. To examine the determinant role played by DRGs payment reform in healthcare for elderly and their financial protection, this study employs the OLS linear regression model for analysis. In the robustness checks, we validated the baseline results through several methods, including excluding the data from the initial implementation of the reform (2021), reducing the impact of the pandemic, and exploring the group effects of different demographic characteristics.
RESULTS: The findings proposed that implementing DRGs payment reduces drug expenses but increases treatment expense of chronic disease for elderly in China. This exacerbates healthcare costs for elderly patients and seems to be contrary to the original purpose of health care reform. Additionally, the implementation of DRGs payment reduced the spending of medical insurance fund, while increased the out-of-pocket of patients, revealing a shift in health care expenses from health insurance fund to out-of-pocket.
CONCLUSIONS: This study shares the lessons from China\'s health reform and provides enlightenment on how to effective implement health reform to improve health equity and achieve UHC in such low- and middle-income countries facing challenges in health financing.