CHAPTER – VII

OVERVIEW AND CONCLUSION

7.1 Introduction

Health care financing by the government is recognized as an important area of policy

intervention especially in the context of a developing country like India with enormous
mismatch between its health care needs and levels of health spending. Health care
financing involves the basic functions of collecting revenue, pooling resources and
purchasing goods and services (WHO, 2000). While it is important to have adequate
level of health care spending by the government to match the health care needs, it is
also equally important to have the resources directed towards priority areas of
intervention 15 , utilized in an efficient manner and ensure that resource allocations
address the right priorities to take care of the health needs of the vulnerable groups in
the population.

In India, the constitutional division of responsibilities assigns health care provision

chiefly to be undertaken by the state government supplemented by services from the
central government. Hence, states account for about 75 per cent of the total
expenditure incurred by the government on health. In due course of time, especially at
the beginning of the nineties, the central and state governments were pushed into a
worst financial crisis that compelled them to initiate the stabilization measures as part of
the fiscal reforms that seek to contain the expenditures and augment revenues to
restore fiscal equilibrium. In the context of changes in macroeconomic policies, there
has also been a considerable change in thinking over the role of state in the provision of
health care services wherein it is emphasised that the state intervention should be
‘minimal’ and the market forces were expected to act predominantly in the provision of
all services.

15
It is expected that priorities for intervention would change under the liberalized regime as
government will have to play a different role.

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Against this backdrop, the study has made an attempt to examine the implications of
fiscal reform measures on health sector spending by the governments and track the
changes in the composition of expenditures on different health care services, its
repercussions on the service outcomes as well as health outcomes. The study also
attempted to identify the role of state in the provision of health care services under a
scenario wherein the state is shrinking its responsibilities in the provision of essential
public health care services.

Objectives and Methodology

Against the above backdrop, the following objectives have been formulated for the
present study.

• To critically evaluate the various government health policies and examine their
adequacy and relevance in the light of prevailing health needs.
• To study the fiscal deficit reduction measures and analyse their implications on
health care spending by the government.
• To analyse the growth and behaviour of government expenditure on health care
across the selected Indian states before and during reforms.
• To assess the health system performance in Indian states.
• To study the allocative efficiency of expenditure on health care services by
government and examine its adequacy against the health care needs of the
people and identify the role of state in provision of health care services under the
changed scenario.
• To draw policy inferences to suggest strengthening the health sector in the
country.

To accomplish the above mentioned objectives, the study has employed both descriptive
statistics and econometric estimation techniques. Statistical tools such as coefficient of
variation and simple correlation have been used to examine the inter-state variations for
different variables and the linkages between variables. The study examines the research
issues across fourteen major states in India from 1985-86 to 2004-05. The trends in

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health care expenditures of the government, the regional disparities in health care
inputs, the coverage of health care services and the health outcomes have been
measured. The kinked exponential model has been used to find the trend rate of growth
of health expenditure of the Centre, States and the combined rate of growth of health
expenditure of these two entities. The panel data method has been used to identify the
impact of fiscal reforms on health spending by the governments and the determinants of
health sector spending in the states. The health system performance – the impact of
health inputs on the health outcomes has been examined by adopting the stochastic
production frontier approach using the panel data method and the technical efficiency of
the states in attaining their health outcomes have been estimated using the state-
specific coefficients obtained from the Fixed Effect Model. A detailed analysis of the
allocative efficiency of health expenditures vis-à-vis the health care needs has been
attempted by examining the distribution of item wise expenditures incurred by the
government by different types of health care services in case of Karnataka.

7.2 Findings of the study

The thesis consists of seven chapters. The first chapter is an introductory chapter that
deals with the statement of the problem, research issues to be addressed, review of
literature, research gaps, objectives, methodology and data source, scope and
limitations of the study.

In the second chapter, a comprehensive review of the various Committee

recommendations and health care policies in the country over the years has been made
and a critical review of the various interventions for health sector development during
the plans right from the First Five Year Plan to the Tenth Five Year Plan has been
discussed. Review of health care policy recommendations emerging from a number of
committees and health policies reveal that there is no dearth for policy inputs in the
country. The plan interventions have also envisioned realization of numerous policy
objectives and accordingly initiatives were prioritized to attain the desirable outcomes.

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Analysis of the pattern of investment in the health sector during the Five Year Plans
reveals that the outlays have gradually declined over the years except for an increase in
the outlays during the Tenth Plan period. The outlays for health department in the total
plan investments have gradually declined over the plan era. Quite contrary to this, the
family welfare outlays have increased over the plan period. In the Tenth plan, these
outlays have exceeded the health department’s outlays and this can be attributed to the
launch of the National Rural Health Mission in 2005 with a long term goal of improving
the rural health system in eighteen states. The outlays on major components of health
care like control of communicable diseases and medical education, training and research
have shown wide fluctuations during the entire plan period and outlays on hospitals and
dispensaries have declined substantially since the Sixth Plan period. Evaluation of the
plan strategies reveal that there exist a vast gap between the priorities set,
implementation of the programs and actual goals stressed by the policies.

The third chapter has attempted to develop a framework to understand the mechanisms
through which the fiscal deficit reduction measures are bound to affect the health
outcomes. The analysis of fiscal situation in the states reveals that fiscal imbalances
have been a persistent phenomenon in the states since the mid-eighties. The states
were in a critical situation throughout the decade of the nineties as evident from an
increasing trend in the growth of their fiscal deficit, revenue deficit and primary deficit.
After experiencing revenue surpluses until 1986-87, the states witnessed deficit in their
revenues until 1999-00 after which these have declined. These developments have
occurred on account of the fact that revenue receipts both own tax revenues as well as
own non-tax revenues have shown a sluggish growth rate. The revenue expenditures
have grown at a higher pace when compared to the rate of growth in revenue receipts
leading to a huge gap between them. The devolution of resources from the Centre to
the states, re given to finance some of their development expenditures have declined
during the reforms which clearly indicates that the central government to a certain
extent has passed on its fiscal burden on the states further depriving the states of
adequate resources. The capital receipts have grown sharply during the reform phase
due to the increasing share of both public borrowing as well as small savings. However,
these increased capital receipts have not got translated into capital expenditures
required to create the necessary infrastructure. Analysis of the growth of capital

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expenditure in the states reveals that these expenditures have received a setback since
the later years of the eighties and through out the nineties and it was only since 2000-
01 that there was an increase in the expenditures. Such a trend explains the fact that
the capital expenditures which are met mostly from capital receipts have been used to
finance the revenue deficits during the reform phase which has further accentuated the
revenue deficit by means of increased interest payments which are paid from the
revenue expenditure. These findings bring to light the fact that the rise in the revenue
expenditure has been at the cost of sacrificing capital expenditure and the capital
receipts emerging a major source to meet the increasing revenue expenditures.

A comparative analysis of the proportion of expenditure directed for physical resources

and human resources by the states from their total expenditure reveals a declining share
of allocations towards both social and economic infrastructure alike during the reform
phase. Analysis of trends in fiscal deficits, public expenditure and health expenditures by
the states shows that the share of fiscal deficits of all states in the GDP has increased
from 3.4 per cent during 1985-86 to 1990-91 to 3.8 per cent during 1991-92 to 2004-
05, while the share of public expenditure has increased from 15.8 per cent in the former
period to 16.0 per cent of GDP during the later phase which explains that the fiscal
contraction measures have not affected the growth of public expenditure whereas the
share of health expenditure in the GDP has declined from 1.6 per cent to 1.4 per cent
during the reform phase. While this seems to be the situation at the all India level,
similar analysis of the relation between fiscal deficits, public expenditure and health
expenditures to the NSDP in the fourteen major states during the pre-reform and reform
phase shows interesting results. Four scenarios emerge wherein (i) fiscal deficit, public
expenditure and health expenditure have increased. This has occurred in states like
Haryana, Bihar and Orissa indicating that even though the deficits persisted, due
emphasis was placed to protect productive expenditures like health expenditure and also
public expenditures. Nevertheless, the increase in their deficits indicate that they were
not able to contain the deficits (ii) In the second scenario, fiscal deficit and public
expenditure have increased while health expenditure has declined. This scenario is
observed in most low income states like Madhya Pradesh, Rajasthan and Uttar Pradesh
and few middle income states like Tamil Nadu and West Bengal. The results clearly
indicate that the health expenditures have received less priority in these states even

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when the public expenditures increased (iii) A conventional case of increase in fiscal
deficit contributing to decline in public expenditure as well as health expenditure has
occurred in Karnataka, Kerala Maharashtra and Andhra Pradesh (iv) fiscal deficit has
declined, public expenditure has increased and health expenditure has declined in high
income states like Gujarat and Punjab which again confirms that the priorities for
government spending have shifted elsewhere especially when the states are expanding
their horizons exploring new ventures. The decline in central transfers is more severe in
all the high income states, middle income states like Kerala and Tamil Nadu and even in
low income states like Uttar Pradesh and Rajasthan. These reduced levels in transfers
are a matter of concern for the low income states because their revenue mobilisation
tends to be less and reductions in transfers will still place them far away from their
counterparts and restrict their spending behaviour towards key development sectors like
health.

The panel data method was used to examine whether the fiscal reforms have had any
impact on the health sector spending in the major states, the factors that have
determined the health sector spending in these states and whether there prevails any
significant influence of the reforms on the factors that determine the health sector. The
results reveal that fiscal reforms per se have not made any impact on the health sector
spending in the states with the dummy introduced to capture the impact of reforms
becoming insignificant. The results also indicate that the states’ income levels (NSDP)
and resource transfers from the Centre positively influence the health sector spending in
the major states. The interactive dummies introduced to capture the combined effect of
reforms with the NSDP and resource transfers from the Centre is not significant in case
of both these variables which shows that the reforms have not had any effect on these
variables.

In chapter four, the status of health care spending by the central and state governments
have been examined along with inter-state disparities in health care expenditures across
the fourteen major states. The chapter also includes an analysis of the distribution of
health care infrastructure and its status, the state of health manpower and the
underlying problems on account of these variations and the outcome of different health

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care interventions – both service outcomes and health outcomes have also been
discussed. Analysis of the trends in health spending by the central and state
governments reveals that the real expenditure on health unadjusted for the population
has been on the increase over the years. The distribution of the health expenditures by
the Centre and States reveals that about 75 per cent of the total expenditure on health
is incurred by the states.

To examine the effect of policy changes on the behaviour of health expenditure by the
government, the growth rate of health expenditure is estimated for the Centre, States
and combined expenditures of both Centre and states separately using the ‘kinked
exponential model’. The growth pattern of health care spending was analysed under
three phases – the first phase 1974-75 to 1983-84 has been considered as the one
before the first National Health Policy was formulated; the second phase 1984-85 to
1991-92 after the health policy was initiated and the third phase 1992-93 to 2004-05
characterising the fiscal reform period. The estimated growth rates for the states show a
significant but negative growth in the first phase and positive growth in the health
expenditure during the second and third phase, which are insignificant indicating that
the policy changes in the states do not have a significant bearing on the health
expenditure. The growth rate of the health expenditure by Centre shows a gradual
increase from the first phase until the third phase and is positive and significant for all
the three phases. These findings imply that the Centre’s health spending has been in
accordance with the policy prescriptions that have stressed for an increased health
spending by the government. The growth rate of health expenditure both by states and
Centre taken together is positive during the second and third phases; however it is
significant only in the third phase.

Though the expenditure incurred by the government has grown over the years in
absolute terms, the share of health expenditure in the total expenditure and income of
the states has declined during the reforms. The per capita real expenditure on health
has increased steadily for the country with considerable inter-state variations and these
disparities have increased more specifically in the low and middle income states. This
expenditure has declined in West Bengal, Punjab and Uttar Pradesh during the mid-

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nineties and has declined even in Gujarat, Maharashtra, Punjab, Karnataka, West Bengal
and Madhya Pradesh in 2004-05. It is also observed that the per capita real expenditure
on health has been increasing at a relatively lower rate in the poorer states. The decline
in per capita real expenditure on health will reduce the availability of per head benefits
which will have an impact on the health status of the population. These reduced
expenditures in the especially in the poorer states will be insufficient to address the
health needs of the population especially when population increases at a much higher
rate in these states when compared with their counterparts. The reductions in capital
expenditures on health in few low income states during the nineties have got reflected
in terms of increasing shortfalls in health infrastructure mostly Primary Health Centres,
Sub-centres and Community Health Centres in these states. The capital expenditure
level however is enhanced during the end of the nineties. Considerable shortfall prevail
in all major states in case of specialists in the government facilities and also in case of
both male and female multi-purpose workers in the less developed states. There is a
bias in the distribution of hospitals as well as beds in the urban areas thereby depriving
the rural areas of these facilities.

The levels of attainment in maternal health care indicators like the levels of ante-natal
care, the institutional deliveries and the deliveries conducted by health professionals
although shows improvement over the years varies extensively across the states with
the attainment levels being unsatisfactory in the poorer states. The immunisation
coverage for children shows marginal increase during the later period in most low
income states with reduced levels of coverage in Karnataka, Andhra Pradesh,
Maharashtra, Punjab and Tamil Nadu and the percentage of underweight children have
increased in Bihar, Madhya Pradesh and even in Haryana, Gujarat and Kerala. In
essence, these findings reveal that the overall effectiveness of child health related
programs have been on the decline.

Overall there has been an improvement in health outcomes like the Infant Mortality Rate
and Life Expectancy at Birth however, with considerable inter-state differences and
unsatisfactory levels in the poorer states. Child Mortality has increased in some of the
low income states like Madhya Pradesh, Orissa and Rajasthan and also in Punjab. The

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Maternal Mortality Rate is higher in all the states. The disease burden has increased and
deaths due to communicable diseases like tuberculosis, acute respiratory infection and
water borne diseases like acute diarrhoeal diseases have risen in the country. The
middle income states have witnessed the brunt in the reductions in expenditure for
control of communicable diseases and the outcome of these reductions are reflected in
the form of higher morbidity and mortality occurring due to communicable diseases in
these states.

In order to understand the performance of the health system in terms of utilizing their
resources to attain the desired level of outcomes, the extent of efficiency of the states in
allocating existing resources has been captured in chapter five using the Stochastic
Production Frontier approach. The health input variables chosen are the physical capital
stock (hospitals, primary health centres, hospitals and beds) and the human capital
stock (doctors and nurses). All the input variables are standardized for a population of
one lakh. The outcome variables are measured in terms of the Infant Mortality Rate
(IMR) and Life Expectancy at Birth (LEB). The input variables and the outcome variables
have been transformed into the logarithmic form. The relative efficiency for all 14 major
States was computed using the state - specific coefficients derived from the Stochastic
Production Frontier estimates of the Fixed Effect Model. Considering the state having
lowest value of Infant Mortality Rate as the most efficient state (MES) the efficiency for
each state was derived and the state having the highest value of Life Expectancy at
Birth has been considered as the most efficient state. The potential IMR or LEB explains
the level of IMR or LEB that the states could have achieved on utilizing the available
resources as efficiently as the MES and was computed considering the average of the
actual IMR for the study period and the relative efficiency.

The assessment of health system performance shows that the states are not utilizing the
available resources as efficiently as that of the Most Efficient State. Most low income
states show inefficient utilization of resources available for health care. Kerala, due to its
lowest Infant Mortality Rate is assumed to be the Most Efficient State operating at 100
per cent. There are vast differences among the major states in their performance levels
compared with the Most Efficient State. Orissa’s health system performance is observed

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to be the lowest as it operates at a mere 73.1 per cent followed by Madhya Pradesh
which operates at 75.6 per cent, while Haryana operates at 86.9 per cent. Orissa,
Madhya Pradesh, Uttar Pradesh and Rajasthan show a marked difference between the
actual and potential IMR, thereby indicating that the available resources need to be
efficiently utilized by these states. The results further indicate that even if the available
resources are utilized efficiently, more resources are required in these states to attain
fairly decent levels of health outcomes. Among the middle income states, Karnataka
needs to utilize its resources more efficiently, while the same is applicable to Gujarat
among the high income states.

As the variation in Life Expectancy at Birth over the years is small, the efficiency of the
states does not show significant deviation from that of Kerala which tends to be the
Most Efficient State (MES). The efficiency in resource utilization is 97 per cent in
Maharashtra and 91 per cent in Madhya Pradesh. The low income states - Orissa,
Madhya Pradesh, Uttar Pradesh and Rajasthan show a marked difference between the
actual and potential Life Expectancy at Birth as seen in the case of IMR. However in the
case of middle and high income states, the pattern varies, with moderate and very small
differences, respectively between their actual and potential Life Expectancy at Birth.

A comparison of the performance levels in the pre-reform and the reform phase reveals
that the efficiency in the reform phase is lesser than the previous period. This indicates
that the efficiency of utilization of resources has declined during the reform phase in all
the major states. The decline in efficiency between the two phases is more prominent in
Madhya Pradesh, Punjab, Andhra Pradesh and Karnataka. The difference between the
potential and actual Life Expectancy at Birth has also increased in all the states during
the reforms. The results of the panel estimation show that the exogenous factors like
the non-health system variables namely the per capita income, literacy rate and
availability of adequate water supply along with health system variables significantly
influence the Infant Mortality Rate and Life Expectancy at Birth.

In chapter six, an attempt is made to build a framework for the identification of

institutional responsibilities in the delivery of health care services by the state. Taking
note of the reforms and fiscal capacities of the states, an attempt is also made to

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explore possibilities for defining the role of the state in the provision of different health
care services. The nature of different health care services is examined and a criterion
has been evolved for the allocation of resources for these services drawing insights from
the public expenditure theories. The characteristics and impact of various diseases on
the society has been examined in detail and the interventions for the treatment of these
diseases with varied characteristics have been identified in order to prioritise the
resources such that the disease burden in the state can be tackled effectively. The
framework thus developed has been used to analyse the pattern of expenditure
allocation by the government on different health care services vis-à-vis the expenditure
allocation for important diseases have been examined. A detailed examination of the
above issues has been attempted in case of Karnataka.

The allocation of health expenditure by the Government of Karnataka reveals interesting

results. The real expenditure on all components of health care – medical and public
health, family welfare, water supply and nutrition has declined towards the late nineties
until 2004-05. The health spending in the total expenditure of the state, the NSDP and
the total social sector expenditure has also declined since 2000-01. The per capita real
expenditure on health has also declined since 2000-01 which is reflected in the poor
quality of services at the government health care facilities as observed by the surveys at
the national and district level. Curative care services have received increased allocations
when compared to preventive health care services. Though, the expenditure on rural
health services are the lowest, a considerable amount from general services is allocated
to rural local bodies in the form of assistance from state. However as observed from the
general expenditure pattern, a substantial proportion of this is expected to be on
salaries. The declining trend in expenditure towards training under family welfare
services shows a direct impact on the outcomes in terms of more number of child births
performed by untrained hands.

The existing pattern of diseases in the state shows that most morbidity and mortality are
due to conditions that can be contained through effective involvement of the state
through preventive and promotive measures. Health education is an important
component under public health as the focus lies on prevention and control of diseases.

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However the expenditure under the same has been on the decline and its impact is felt
in the increasing morbidity on account of infectious and parasitic diseases. More than 60
per cent of the expenditures for prevention and control of diseases is spent on
administration, while the expenditure on program interventions is relatively less and
shows an irregular pattern of allocation over the years.

Though the state has an important role in the provision of preventive and promotive
care services, these expenditures have shown a declining trend during the later years of
the study. The declining expenditures under Maternal and Child Health have coincided
with a steady increase in both the morbidity and mortality rates related to women and
children. However the change in the program strategy by the government under
Maternal and Child Health when renamed as ‘Reproductive and Child Health,’ has
influenced the expenditure pattern by showing an increase from 2000-01. This has also
corresponded with increase in immunization, women seeking ante-natal care and post
natal care from government providers and increased number of institutional deliveries.

The out-of-pocket spending shows a huge expenditure on private facilities for in-patient,
out-patient care and maternal and child health services. While the average expenditure
on government provided services is much lesser than that charged in the private
facilities, the preference is more towards private care due to lack of satisfaction, low
accessibility and long waiting period faced in the government facilities.

Policy prescriptions

The stabilization measures adopted in the form of fiscal reforms have affected the per
capita real expenditure in the major states and the results vary across states. Even
when the fiscal deficits have increased, the overall expenditure and the revenue receipts
of the government have increased considerably but at a much slower pace. The growth
in revenue receipts were not complemented from the Centre in the form of resource
transfers to the states which have affected the distributive pattern of their expenditures.
The sharp increase in capital receipts have not got reflected in the capital expenditures
that have remained low throughout the period of study. As a result of such allocations,
the social and economic infrastructures have had reduced share from the total

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expenditures. The relative share of health expenditure in the total expenditure and total
income of the states has also declined. Nevertheless, the results show that the income
of states (NSDP) and the resource transfers from Centre are important determinants of
health spending in the states. Therefore, from the above observations, it becomes
evident that in the short-run, the states are not in a position to augment their revenues
to meet their financial requirements. The resource transfers from Centre will be critical
for the states to reduce inequalities especially in case of the poorer states to finance
their development activities of which health sector investment is a crucial one. The
states will also have to realize more income from various activities in the economy so
that they will be able to cater to their increasing needs.

The difference between the actual outcomes attained and the potential outcomes that
could have been achieved by the states reveals the utilization of available resources at
sub-optimal levels. Even if these resources would have been utilized to their optimum
capacities, these are not sufficient to meet the health care requirements. The analysis of
health system performance as well as the recent National Family Health Survey – III has
clearly highlighted the inefficient utilization of resources in recent years. All these reveal
a clear indication of the misallocation of resources and changing composition in resource
allocation although the health expenditures have grown in absolute and real terms. This
necessitates an urgent need for the states to identify priority areas for intervention
assessing the actual health needs of its people such that satisfactory levels of outcomes
are achieved.

The direction of expenditure towards different health care services in Karnataka reveals
that higher proportions of the expenditures are committed in nature and the remaining
share is not sufficient to purchase drugs and consumables that are required for service
provision. Shortage of these items has actually shifted the burden on the households to
purchase essential health care goods and services. Therefore, in the present context,
the resources are getting utilized to pay for the services rendered by health
professionals with no incentives for adequate service provision. Curative care services
are getting prioritized when the felt need for government participation is for
interventions in preventive and promotive care. The infectious and parasitic diseases

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contribute the greatest share to the morbidity and mortality rates in the state followed
by maternal and child health related diseases. Considering the magnitude of infectious
and parasitic diseases and maternal and child health related diseases that tend to affect
the morbidity as well as mortality rates, the state needs to increase its participation in
the provision of preventive health care services rather than focusing on curative care
services. More resources need to be allocated towards this type of care.

On the basis of the existing resource allocation by the state on different health care
services and the criterion on which resources needs to be allocated as discussed in
chapter six, the immediate issue that needs to be examined is how best the government
should intervene in the provision of these services – whether it should inform, finance,
deliver, facilitate, monitor or regulate. The government has no other alternative but to
finance and deliver essential public health care services like ensuring adequate
sanitation and control of communicable diseases through its tax revenue considering the
ill-effects arising from inadequate provision of these services. It has to educate the
public to maintaining good health and hygiene through appropriate information. It has
to act as a monitor and set standards in order to ensure safety of food and drugs.

In the quasi-public health care services, the government can assume any one of these
roles – either finance or facilitate. The government needs to subsidise the cost of
provision of certain health care services under this head like immunisation against
communicable diseases, providing nutritional supplements for the vulnerable sections,
providing adequate water supply, maternal and child health and family welfare services.
Hence its role here is to finance the production of these services. However, in the case
of drug dispensation, the government can buy the essential life saving drugs and
provide it free of cost to those who cannot afford to pay and partially recover the cost of
provision through user charges from those who have the ability to pay. Nevertheless,
the government should set appropriate guidelines in the production of drugs to ensure
adequate standards. The government should finance and facilitate medical research with
a special emphasis on developing new effective drugs and vaccines that would address
the health problems i.e. the diseases that concern a large section of the population. The

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government should act as a facilitator in providing insurance for the vulnerable sections
who cannot afford to buy them from the open market.

Private health care services can be permitted with some amount of government
regulation. For example, in the case of medical education, the government can set
minimum standards required for medical profession and in the case of super-specialty
hospitals, the government can regulate them by giving accreditation status and also set
Standard Treatment Guidelines specifying the costs of treatment for various diseases.
Thus, in this case, the government can function through its quasi-fiscal policies even
though these services are undertaken by the private sector.

In a developing country context like India, the state still has a crucial role in the
provision of health care services, lest the health and well-being of a substantial
proportion of the population shall remain unaddressed. Bearing in mind the role that the
state is required to play in the provision of essential health care services based on their
characteristics, a close coordination between the government and the private sector can
be effective in addressing the larger health needs of the people in an effective manner.
Therefore, a major responsibility rests with the government in channelising the available
resources to important items of care and ensures that the resources do not become
unproductive and ineffective in addressing the health problems that concern the society
at large.

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