Unified National Health System Research Articles

Financial toxicity among patients with breast cancer in a publically funded health care system in Brazil.

e18818 Background: The concept of financial toxicity (FT) has been used to describe the unanticipated economic damage potentially caused by cancer treatment. Currently, it has been associated with decreased health-related quality of life (QoL), treatment nonadherence and increased risk of mortality. Even in publicly funded environments as Brazilian Unified National Health System, factor such as income loss or out-of-pocket costs could become an issue for cancer care. The aim of this study was to examine the FT related to the breast cancer diagnosis and treatments in a public Brazilian tertiary hospital through Comprehensive Score for Financial Toxicity (COST) instrument. The COST is a 12-item survey scored from 0 to 44, with lower scores reflecting worse financial well-being. Methods: This cross-sectional study was conducted among breast cancer patients in active treatment for at least 6 months attending medical oncology out-patient department. Socio-demographic, clinical characteristics and a simplified assessment of QoL were collected as well as responses to COST questionnaire. Descriptive statistic and analysis of correlations between quantitative variables and scores of QoL and COST were performed. Results: A total of 100 female patients were included with median age of 53 years old. The mean time from initial diagnosis was of 49.6 months and clinical stage IV represented 46% of all cases. Prior to the cancer treatment, 48 (48%) of the patients had their own job as a main source of income. However, after the cancer diagnosis, only 9 (9%) patients keep working, 36 (36%) needed to use savings and 29 (29%) applied for a bank loan. To adjust their finances, 66 (66%) patients reduced spending on leisure. The median COST score was 18.5 (ranged from 4 to 41). According to the age, patients with ≤ 45 years old were at higher risk of suffering FT (p = 0.01). There was also an association between the COST score and QoL since the higher the FT, the lower the QoL (p < 0.001). Conclusions: Patients with breast cancer are at risk of losing their work capacity, become financially dependent of other, and suffering a reduction in QoL as a result of FT. Mostly younger patients are at greater risk of FT. Despite a universal health-model, this study highlights a substantial proportion of patients who experienced FT. Therefore, further studies confirming these findings in larger groups are warranted to develop better strategies and policies to mitigate this form of toxicity.

Following the money: an analysis of financial transfers from the municipality of Rio de Janeiro, Brazil to social health organizations

This article analyzed the activity of Social Health Organizations (OSS) in the Brazilian Unified National Health System (SUS) and the use of management contracts and contract addenda as instruments of privatization. The article aimed to understand the processes that legitimize privatization, based on quantification of the amounts transferred through management contracts and contract addenda to organizations that signed contracts with the Rio de Janeiro Municipal Health Department, Rio de Janeiro, Brazil, from 2009 to 2018. A descriptive, exploratory, mixed-methods study was developed to analyze the amounts transferred to the OSS. The study used secondary public data available on the Health Department's websites and other official documents. A total of 268 documents were identified, 61 of which were contracts and 207 addenda, related to 15 institutions. The funds transferred to these organizations totaled BRL 15.94 billion (USD 2.9 billion). The OSS that received the most public funds was IABAS (Institute of Primary and Advanced Health Care), with a total of BRL 4.021 billion (USD 731 million). In 2014, Rio de Janeiro's total health budget was approximately BRL 4 billion (USD 727 million), of which BRL 2.5 billion (USD 455 million) was transferred to OSS, representing 62% of the municipal health budget. The data show that management contracts and contract addenda serve as instruments for privatization of the SUS. This privatization does not employ the conventional model but a functional and fluctuating one.

Evaluation of cervical cancer control actions within Brazil and its regions based on data recorded in the Brazilian Unified National Health System

This study analyzes the performance of screening and diagnosis tests for cervical cancer among women aged 25 to 64 years, as well as the delay for the initiation of treatment within Brazil and in its geographic regions, from 2013 to 2020. Information on populational procedures and estimates was obtained from the information systems of the Brazilian Unified National Health System and the Brazilian National Supplementary Health Agency. We calculated the coverage indicators of the Pap smear, the percentages of altered cytopathological and histopathological tests, and the percentage of women diagnosed with cervical cancer with over 60 days of treatment. There was great variation in the coverage of the Pap smear test among the Brazilian regions with a downward trend from 2013, which was aggravated from 2019 to 2020. The number of altered cytopathological tests was 40% lower than estimated, and the difference between the recorded number of cancer diagnoses and the estimated number of patients was below 50%. The percentage of women diagnosed with invasive cervical cancer, who started treatment after 60 days, ranged from 50% in the South to 70% in the North Region with a decrease from 2018. In 2020, there was a decrease in the number of screening and follow-up tests, reducing the proportion of women delayed in starting treatment in the North, Southeast, and South regions. The decline in screening coverage and inadequate follow-up of women with altered results indicate the need to improve early detection strategies for the disease and establish mechanisms for constant evaluation and monitoring of actions.

Palliative care in emergency care: invoking Kairos and rethinking health care systems.

Acute crises of decompensation of a chronic disease are, in most cases, handled in an Emergency Room setting. In these services, emergency care professionals face several challenges, such as incomplete information on the patient's disease, scarce resources, and the pressure of having to make decisions in a short time. In this context, what can be done to provide patient-centered care that is at the same time technically appropriate and aligned with their values? Understanding the patient's situation in relation to their disease; talking to the patient about their clinical condition, comprehending their values and feelings; and understanding time as Kairos - that is, the time of the consultation as an opportunity to understand the patient's needs and build a shared therapeutic plan - are possible solutions to this challenge. Proper handling of patients with severe diseases requires that all links of health care systems are functional and coordinated from primary health care to hospital and home care, starting with the education of health care professionals and the strengthening of work settings that foster the expression of Kairos. This is a long and fundamental path for health care systems such as the Brazilian Unified National Health System (SUS) and that health managers and professionals should not afford to ignore.

Interfederative consortium and hospital management in the Brazilian Unified National Health System in Bahia State, Brazil: the decision-making process in the light of neo-institutionalism

This article analyzes the decision for the Interfederative Health Consortium (CIS) model as an alternative for the management of a hospital of the Brazilian Unified National Health System (SUS) in Bahia, Brazil. Agreements were reviewed and semi-structured interviews were conducted with key actors at the central level of the Bahia State Health Department (Sesab) and the CIS Northeast II. The findings were analyzed considering the theoretical framework of neo-institutionalism, emphasizing the characterization of the historical and political-institutional context within the SUS, the actors involved in decision making, and the rules and guidelines of both institutions, Sesab and the CIS. The results showed the decision was predominantly guided by political motivations of state and municipal executives, based on the purpose of decentralizing the management of health actions and services and regionalization, with predominant actions of actors linked with the government and incipient participation of the technical area of the Sesab. Also, in convergence with the theoretical framework adopted, there were rules and guidelines inherent to both institutions, Sesab and CIS, which contributed to the adoption of the model and other elements of the historical context that also affected the decision-making process. This study contributed to a better understanding of the operationalization logic of hospital care management in SUS Bahia, with its multiple factors, stimulating the development of new investigations about management models in SUS. reduction of the burden and costs of hospital admission due to neglected tropical diseases in the state.

Brazilian Unified National Health System poor for the poor, COVID-19, and financialized capitalism

Brazilian Unified National Health System poor for the poor, COVID-19, and financialized capitalism

Interfederative Health Consortium in the State of Bahia, Brazil: implementation, management mechanism, and sustainability of the organizational arrangement in the Brazilian Unified National Health System

Analysis of the implementation, management, operation and sustainability of the Interfederative Health Consortia and the Regional Specialty Polyclinics, in the State of Bahia, Brazil. This is a single case study of a qualitative nature, with interviews with managers, social control, regulation, legislative, and mayors of municipalities in the member. The results indicate that capital expenditures and permanent cofinancing by the state manager are factors that encourage the participation of vertical consortia. The support of small municipalities, social participation bodies, and municipal councils stood out. We observed the strengthening of the cooperative relationship among public administrators from formal decision-making spaces and by the need for daily management of specialized care (SC). The offer of SC via consortia mitigated the dependence on buying SC from private services. The fear of losing autonomy, centralizing care in state equipment, and ignoring municipal financing were challenges in the process of restructuring regional specialty services. The support and sustainability of the initiative was based on the evaluation of a situation in which the accessibility to SC was more favorable after implementation of the Polyclinic and of user satisfaction with the quality of services. Strategies to communicate with the population and to bring together instances of social control need to be undertaken. We consider that the case represents a format, within public management, for the provision of more viable and timelier SC, gaining in dimension and quality, especially in territories with a significant number of small municipalities.

The entry of foreign capital into the health system in Brazil

The study describes the history of legislation, analyzes the trajectory and the amount of foreign capital in the Brazilian health system. The Organic Health Law restricted the participation of foreign capital; sectoral legislation, however, allowed its subsequent entry into supplementary medical care and, in 2015, a new law promoted unrestricted openness, including in hospitals and healthcare services. Our study analyzes documents, legislation, and data obtained from secondary public bases or via the Law on Access to Information. Direct investments and merger and acquisition acts in the private health sector were considered. Five phases were identified: inaugural planning, regulated expansion, legal restriction, sectorized release, and expanded opening. From 2016 to 2020, the amount of foreign resources entering the country's healthcare services was almost ten times more than the previous five-year period. Thirteen companies or funds were identified, most of them from the United States. Regulation allowing for the opening of foreign capital were preceded by business lobbies and public-private interactions that can affect the quality of public policies and the integrity of the legislative process. The invested capital seeks established and profitable companies in various segments of activity. Admission occurs in non-universal private care networks, which serve specific, geographically concentrated clientele. We conclude that foreign capital, an element of health financialization process, is expressed as a possible vector of the expansion of inequalities in the population's access to health services and as an additional obstacle to the consolidation of the Brazilian Unified National Health System.

The resilience of Brazilian Unified National Health System in the context of the COVID-19 pandemic: how to strengthen?

The resilience of Brazilian Unified National Health System in the context of the COVID-19 pandemic: how to strengthen?

Epidemiological and clinical profile and trend analysis of hospitalizations for fall-related injuries among older adults, Alagoas (Brazil), 2008–2019

Objective: To analyze the epidemiological and clinical profile and the time trend of hospitalizations for fall-related injuries among older people (aged 60 years or older) in Alagoas between 2008 and 2019. Methods: This is a time series study with data collected from the Hospital Information System of the Unified National Health System (SIHSUS) referring to hospitalizations for fall-related injuries among older adults in Alagoas between 2008 and 2019. Hospitalization and lethality rates, average annual percent change (AAPC), and annual percent change (APC) were calculated; time trends were analyzed using a Joinpoint Regression Model according to sex, skin color, age range, and causes. A 95% confidence interval (95%CI) was adopted. A p-value<0.01 was adopted for defining statistical significance. Results: In Alagoas, 14 817 cases of hospitalizations due to fall-related injuries were reported among older people in the analyzed period. The highest incidence rate was observed in 2016 (48.39/10 000 inhabitants). There were 517 deaths, and the mean lethality rate was 3.4%. A higher proportion of cases was seen in men (66.36%; n=9832), those aged 80 years or older(34.59%; n=5125), and with Brown skin (54.70%; n=8106). The incidence coefficient varied, showing an upward trend with time (APC: 4.1; 95%CI 0.2–8.2; p<0.01). Conclusion: During the analyzed period, the study showed a higher incidence in individuals aged 80 years or older, men, and found an upward trend in hospitalizations. We suggest the optimization of hospital care and promotion of fall prevention programs among older adults.

Spatial reorganization of the Brazilian Unified National Health System's inpatient care supply.

The joint provision of efficient and equitable healthcare service delivery is a critical factor in improving social welfare. However, healthcare services pose a particular challenge when balancing healthcare provider efficiency and equity. Typically characterized by economies of scale and scope, inpatient care involves a wide variety of medical care that usually demands a broad range of health professional expertise and technological complexity to ensure health care quality. This study analyzes the current spatial organization of the Brazilian general hospitals and their respective flow of patients to identify the possible benefits of closing inefficient hospitals. We studied how inpatient care referrals may be reallocated without increasing access inequities following the potential closure of inefficient public hospitals. We used data from the Brazilian Hospital Information System of the Brazilian Unified National Health System (SIH/SUS) and the Brazilian National Register of Health Establishments (CNES). The smallest and least efficient hospitals were selected as units for potential closure, conditioned on an optimization criterion that minimizes patient travel distances to the nearest efficient hospital. Our results show that there is room for hospital resource reorganization in Brazil without compromising health care access equity.

Cuidados paliativos: percurso na atenção básica no Brasil

In 2022, an important international report was published on the “value of death” not only in the field of health, but in relation to human societies in general. This report proposed to reimagine systems related to end of life in which death is understood not only as a physiological event but also as a relational and spiritual phenomenon with a value of its own and inseparable from life. It identifies the low priority given by most governments worldwide to the issue of alleviating suffering and supporting bereavement, evidenced by the low investment in palliative care. At the same time, we are witnessing in Brazil changes that threaten the feasibility of palliative care policies in primary health care. The denial of finitude within health systems is reflected in global indicators such as the quality of death index of The Economist magazine, in which Brazil ranks 42nd, the global atlas of palliative care of the World Hospice and Palliative Care Alliance, where Brazil is in level 3b, and the global trends in opioid consumption of International Narcotics Control Board of the World Health Organization, in which opioid consumption in Brazil is in the hundreds of doses per million inhabitants per day. Despite notable advances in the legislative and executive fields with regard to palliative care, the Brazilian Unified National Health System (SUS) and primary health care have suffered important structural setbacks that will impact the design of public policy for palliative care. The goal of this article is to undertake an initial analysis of the impacts of current policies within this context and their repercussions in the construction of a solid policy for palliative care.

Timely outpatient treatment of cervical cancer: the influence of region of residence for women in the state of Minas Gerais, Brazil

This study aimed to investigate whether there is an association between the Extended Health Regions (EHR) of residence in the state of Minas Gerais, Brazil, and the interval between diagnosis and start of treatment for women who underwent outpatient treatment (chemotherapy or radiotherapy) for cervical cancer by the Brazilian Unified National Health System (SUS), between 2001 and 2015. This is a cross-sectional study, part of a cohort with 8,857 women. Negative binomial regression models were used to evaluate the association of EHR of residence and the interval between diagnosis and start of treatment (in days), considering a significance level of 5%. The models were constructed using blocks of sociodemographic, clinical, and treatment-related covariates. It was found that the EHR of residence of women is associated with the interval between diagnosis and start of treatment. The northern EHR was the region of the state where the average time to start treatment was lower, and not residing in this EHR increases the average time to start treatment between 24% and 93% compared to other EHRs in the state. The disparity in the interval between diagnosis and start of treatment between the regions of Minas Gerais is evident. The availability of services enabled for the treatment of cancer in the EHRs does not necessarily results in a greater agility for the start of treatment. Understanding the flows of Oncology Care Networks and their regional differences is essential to improve public policies that ensure compliance with current laws, such as Law n. 12,732/2012, which recommends the start of treatment for cancer patients within 60 days after diagnosis.

Does the pharmaceutical industry interfere in the sustainability of the public health system in Brazil? A reflection on the pressure for the incorporation of medicines

The objective is to analyze the contribution of the pharmaceutical industry to the sustainability of the Brazilian Unified National Health System (SUS), based on the pressure for the incorporation of medicines. For this purpose, a descriptive study was conducted on requests for the incorporation of medicines sent to Commission for Incorporation of Technologies in the SUS (CONITEC) from 2012 to 2020. Characteristics such as technology indication, economic evaluation, financing component, public consultation, and CONITEC decision were analyzed. The results were compared according to the type of solicitor using statistical tests. 514 requests were analyzed, of which 438 related to incorporation. The pharmaceutical industry accounted for 37% of the requests and 33.5% of the incorporations. Differences were observed between the solicitors regarding the type of economic evaluation and incremental cost-utility ratio value, with half of the industry's demands above the threshold of 3 PIB per capita/QALY. The pharmaceutical industry obtained more contributions in public consultations of its requests and presented concentration of requests for antineoplastic and immunomodulatory agents and for anti-infectious, especially for hepatitis C and HIV. There was also a lower number of demands from the pharmaceutical industry in the Basic and Strategic Components of Pharmaceutical Assistance. Our findings point to the tension between the significant participation of the industry as an applicant, the high mobilization of public consultations, the emphasis on Specialized Component drugs, and CONITEC's resistance to this pressure, with a tendency of greater refusal and greater participation of other solicitors in requests for expansion of use, exclusion, and incorporation of drugs that are less requested by the pharmaceutical industry.

Hospital admissions due to neglected tropical diseases in Piauí, in the Northeast region of Brazil: costs, time trends, and spatial patterns, 2001-2018

To characterize the magnitude of hospital admissions and costs of patients with neglected tropical diseases, their time trends, and spatial patterns in Piauí, in the Northeast Region of Brazil, in 2001-2018. Ecological study of mixed designs, with calculation of relative risk (RR), time-trend analysis by Poisson regression, and inflection points, using data from neglected tropical diseases Hospital Admission Authorizations available in the Hospital Information System of the Brazilian Unified National Health System (SIH/SUS). Data showed 49,832 hospital admissions due to neglected tropical diseases in the period (rate: 86.70/100,000 inhabitants; 95%CI: 83.47; 89.93); of these, dengue (78.2%), leishmaniasis (8.6%), and leprosy (6.4%). The total cost was BRL 34,481,815.43, 42.8% of which referred to medium complexity cases. Higher risks of hospitalization occurred among people ≥ 60 years (RR = 1.8; 95%CI: 1.5; 2.2), mixed race/color (RR = 1.7; 95%CI: 1.1; 2.4), residents of municipalities presenting medium social vulnerability (RR = 1.5; 95% CI: 1.3; 1.6), and population size (RR = 1.6; 95%CI: 1.4; 1.9). The time trend showed a reduction in hospital admissions due to neglected tropical diseases, 2003-2018 (annual percent change - APC: -10.3; 95%CI: -14.7; -5.6). The spatial pattern showed clusters with higher rates of hospital admission in border municipalities located south of the Mid-north macroregion, north of the Semiarid macroregion, and south of the Cerrados macroregion. Piauí remains with high hospital admission rates and costs for neglected tropical diseases. Despite the reduction in time trends, knowledge burden, population groups, and municipalities at greater risk and vulnerability reinforce the importance of monitoring and strengthening control actions to maintain the reduction of the burden and costs of hospital admission due to neglected tropical diseases in the state.

Hip arthroplasty in the Brazilian Unified National Health System: analysis of hospital deaths in the State of Rio de Janeiro, Brazil

Population aging brings challenges to the health system. Increased degenerative joint diseases and occurrence of falls may require hip arthroplasties. The objective of this study was to evaluate factors associated with hospital deaths due to hip arthroplasties in the Brazilian Unified National Health System (SUS), in the State of Rio de Janeiro, Brazil. A cross-sectional study was carried out using the Brazilian Hospital Information System of the SUS, considering hospitalizations and deaths from hip arthroplasties that occurred between 2016 to 2018. The analyses considered hospitalizations by type of care (elective, urgency and accidents or injury and poisoning). Binary logistic regression was performed to obtain a ratio for the chance of death. Mortality increased according to the severity of hospitalization. Most of the hospitalizations with death were due to femoral fracture, demanded intensive care, had mean length of stay of 21.5 days, and involved women aged 80 years and over, of the white race/color, who had their procedure performed in municipal units qualified in orthopedics and traumatology of high complexity and classified as general II, located in the patients' region of residence. The chance of death was significant for the age of the patient, use of intensive care unit (ICU), and length of hospital stay. We expect an increase in the demand for hip arthroplasties and physical rehabilitation due to population aging. Health teams must be prepared to deal with an ageing population. Knowing the factors that increase the risk of death favors care planning and management by hospital staff, including in the reduction of hospital stay, which is so impactful on the functional condition of the elderly.

Rare diseases in the Brazilian National Congress: analysis of parliamentary action

Public policies that serve the Brazilian population with rare diseases are increasingly discussed, either regarding access to medicines, multidisciplinary care, therapeutic alternatives, or representativeness. Although the Brazilian Ministry of Health published in 2014 the Ordinance n. 199, which instituted the Brazilian National Policy of Integral Care for People with Rare Diseases and approving the Guidelines for Integral Care to People with Rare Diseases under the Brazilian Unified National Health System (SUS), this population remains unaided regarding the peculiarities of their treatments. In this scenario, patient associations began to seek spaces for political representation, increasingly provoking legislative initiatives in the Brazilian National Congress, seeking for alternatives for the millions of Brazilians living with rare diseases. By using a qualitative documentary research, the study considers all projects presented until August 2020 on this topic, identifying the main parliamentarians involved, their biographical characteristics, and at which stage of the public policy cycle this topic is in the Brazilian National Congress; thus, identifying a possible path for the consolidation of a policy. We observed that the actions regarding rare diseases are independent of any political party alignment, being an agenda shared by antagonistic groups. This agenda, however, faces the challenge of having only 18 parliamentarians responsible for 50% of all the legislative matters already presented. Furthermore, we also observed that parliamentarians prefer to boost the debate and give visibility to the subject than to invest in new attempts at legal and regulatory changes.

Participatory modeling of educational activities in the Healthcare Planning strategy: backing for assessment of effectiveness

The Healthcare Planning strategy is a powerful device for reorganization of work processes in healthcare networks and has been implemented by the Brazilian National Council of State Health Secretaries since 2013 in 25 health regions in 11 states, offering a set of educational activities for healthcare workers in the Brazilian Unified National Health System. This study aims to describe the process of participatory and consensual modeling of educational activities to back the assessment of the strategy's effectiveness. Development of the modeling used consultation with 18 key informants, selected intentionally according to their proximity to the educational activities' planning and execution. The key informants analyzed the initially proposed modeling, stating their degree of agreement with the content and providing suggestions and commentary, analyzed by the researchers. Minimum total agreement, predetermined at 75%, was obtained after three rounds of consultation. Important suggestions were provided throughout the rounds, evidencing priority elements for backing assessment of the strategy's effectiveness. Final total agreement in the modeling varied from 76.5% to 100%, according to the component, demonstrating that participatorily modeling can be considered satisfactory. This construction can encourage studies on strategies that seek to improve the health system's effectiveness through development of health workers' competencies, skills, and attitudes.

Public-private partnerships in hospital administration in the Brazilian Unified National Health System in Bahia State, Brazil

The process of building Brazil´s Unified Health System has always been a space of dispute between the political forces that defend greater private sector participation in patient care and administration of services and those who defend strengthening public administration. In the context of underfinancing of the Brazilian Unified National Health System (SUS), associated with the restrictions imposed by the so-called Fiscal Responsibility Law, new management models have been adopted in hospital administration, including public-private partnerships (PPPs). Considering the relevance of investigating decision-making processes pertaining to the adoption of these models by State Health Departments, this study aims to analyze the decision-making processes and incorporation of this hospital administration model in the State of Bahia, Brazil, the first administrative concession in Brazil´s health sector. This is a case study in which the theoretical reference was Social Game Theory elaborated by Carlos Matus, linked to the Public Policy Cycle analytical model. The data were produced with document research and semi-structured interviews with key informants who participated in the pre-decision and decision-making stages of the PPP model. The article presents the political game involved in the choice of this alternative among other hospital administration models, besides debating the models´ advantages and disadvantages according to the key actors and concludes that determinants (not only financial, but also political and ideological) marked the decision-making process for the PPP model in Bahia, in which the driving factor and source of consultancy was the International Finance Corporation, an arm of the World Bank.

Impacts of the 2017 Brazilian National Primary Care Policy on public primary health care in Rio de Janeiro, Brazil.

In 2017, in a scenario of financial restrictions caused by an economic crisis in Brazil, a new primary health care policy promoted changes in the way different primary health care models were prioritized and implemented, with possible negative effects on the access to primary health care. This study aims to investigate if the 2017 Brazilian National Primary Care Policy (PNAB) negatively affected the primary care organization based on the Family Health Strategy (FHS) model and on the access to public primary care services in the city of Rio de Janeiro. The annual averages and the pre- and post-2017 averages of 15 variables were analyzed to identify possible trend breaks in 2017. A Bayesian structural time series model was used to determine the differences between actual and predicted post-2017 averages of each variable. The data were obtained via the Brazilian Health Informatics Department (DATASUS), the Department of Informatics of the Brazilian Unified National Health System. The annual average of family health teams was 1,179.9 teams, in 2017, and 788.8 teams in 2020, while the annual average of equivalent family health teams was 163.6, in 2017, and 125.4, in 2020. The actual post-2017 average of 989.3 family health teams (p = 0.004) was 16.7% lower than the predicted post-2017 average of 1,187.4 teams. In total, 62.6% and 40.5% of the population in Rio de Janeiro were covered by the FHS in 2017, and 2020, respectively. The provision of public primary care services decreased after 2017. Results show a deterioration of the FHS in Rio de Janeiro after 2017 and no increase in the traditional primary care model. Access to public primary care services reduced in the same period.