Transparency interventions to improve health system outcomes in low and middle-income countries: a narrative systematic review.

OBJECTIVES: This study aimed to identify the types of transparency interventions in the health systems of the low-income and middle-income countries and the outcomes of such interventions in those systems. METHOD: We searched major medical databases including PubMed, Embase and Scopus, for any kind of interventional study on transparency in health systems. We also looked for additional sources of information in organisational websites, grey literature and reference checking. Using the PRISMA algorithm for identifying related studies, we included 24 articles. RESULTS: Our initial search, from 1980 to August 2021, retrieved 407 articles, 24 of which were narratively analysed. Response to a problem (mostly corruption) was the main reason for the initiation of a transparency intervention. Transparency interventions differed in terms of types, performance methods, collaboration partners and outcomes. They help improve the health system mostly in the short term and in some cases, long term. CONCLUSION: Although our findings revealed that transparency initiatives could reduce some problems such as counterfeit drugs and corruption, and improve health indicators in a short term, still their sustainability remains a concern. Health systems need robust interventions with clearly defined and measured outcomes, especially sustainable outcomes to tackle corruption fundamentally.

Economic instability, income, and unemployment effects on mortality: using SUR panel data in Iran.

This study aims to investigate the effects of socioeconomic factors on mortality in Iran. To this end, this research examines how economic instability, income, and unemployment affect mortality using a seemingly unrelated regression (SUR) with panel data for 30 provinces in Iran from 2004 to 2019. The results indicate that unemployment and mortality have a countercyclical relationship among the working age-groups 20-59 but a procyclical pattern among old-age (60+), except for rural mortality. This result is harmonious between employment and age-group mortality. This finding implies that unemployment increases mortality in working age-groups due to psychological stress and poverty risk. In addition, the income level decreases mortality in all ages over 40 years due to the provision of higher access to health and medical services and social welfare. However, it increases mortality in rural areas and age-group 20-39 because of their hazardous, unsafe, and stressful work conditions. Therefore, policymakers should plan for an inclusive economic growth to reduce poverty and out-of-pocket payments and increase the quality and accessibility of public health services, especially for beneficiaries of lower social groups. Moreover, they should adopt strategies to alleviate the burden of premature, preventable, and treatable deaths.

Strategies for improving the financing of family medicine program: Evidence from Iran.

Background and Aims: The impact of health financing on the performance of the entire health system, including access, quality, and efficiency of healthcare, has been emphasized in the Astana Declaration, and the need to strengthen primary healthcare (PHC) and policy integration has been emphasized. After about two decades, the family medicine (FM) program in Iran is still facing great challenges. The aim of this study is to explore strategies for strengthening financing of the FM program in Iran, a vital component of PHC. Methods: A qualitative study was conducted in 2021. Purposeful sampling was used to select 34 policymakers, managers, and experts from various levels of the Ministry of Health, Iran universities of medical sciences, plan and budget organization of Iran, and health insurance organization in Iran. Thirty-four semistructured interviews were conducted to collect data, which were analyzed by content analysis. Results: Through the analysis of interviews, our study has identified five strategies (identification and management of sustainable resources, pooling of sustainable resources, modeling of service provision, payment system model and its implementation process, and FM management structure), and 13 actions for strengthening financing of the FM program in Iran. Conclusion: Our study has identified five strategies and 13 actions for strengthening the financing of the FM program in Iran. These strategies and actions should be considered by policymakers during the review of the FM program in Iran. Without implementation of the suggested strategies and action, allocated resources may be wasted.

Challenges of Budgeting and Public Financial Management in Iran's Health System: A Qualitative Study.

Background: Efficient and effective management of budgets and financial resources is critical for health systems to achieve their goals; in this regard, countries may face budgetary and financial challenges owing to the weak prediction of resources and consumptions, and lack of prioritization for their budget. This study aims to identify the most critical policies and events that have affected public financial management and health budgeting and existing challenges in Iran. Methods: We conducted the present study in 2022 using a 2-stage qualitative method. First, by reviewing upstream documents and laws, we identified evidence related to health budgeting. Then, we conducted 13 semi-structured interviews with informed people in the health budgeting field that led us toward the main challenges through thematic content analysis. Results: After reviewing 48 upstream documents related to health budgeting, we identified 85 policies. After reviewing the articles, we achieved 11 themes and 71 subthemes. The most critical challenges of the budgeting cycle were as follows: (I) budget formulation, including inappropriate budget structure, conflicts of interest and infringement, lack of financial sustainability, and transparency; (II) budget execution, including a nonexecutable approved budget, complicated allocation process, and ineffective allocations; and (III) monitoring, reporting, and evaluation (MR&E), including fragmentation of MR&E processes, ineffective monitoring and evaluation, weak evaluation of platforms, and inadequate transparency. Conclusion: Most challenges in the health budgeting system are related to the budget formulation and approval stage that have their roots in implementation, monitoring, and reporting. In addition, Iran's macroeconomic and financial issues have also damaged the budgeting of the health sector. Budget problems affect the goals and outcomes of this sector, especially the health system.

Challenges in the implementation of an electronic referral system: A qualitative study in the Iranian context.

Referral chain reduces patient costs and results in more efficient use of workforce and equipment. Despite the implementation of the Family Physician Programme in Iran, the referral system does not function as intended. Therefore, this study was conducted to explain the challenges in the implementation of an electronic referral system in Iran. This qualitative study was performed in Golestan province in northern Iran. The participants were 46 family physicians, specialist physicians, healthcare managers, experts, and patients who were selected through purposive sampling. Data were collected using in-depth individual interviews and were analysed using content analysis. Implementation of the electronic referral system faces management challenges (planning, organisation, motivation, control), administrative challenges (scheduling, patient load and waiting time, visit and diagnosis, feedback), and educational, policy, sociocultural, technological, and economic challenges. Policymakers can adopt appropriate strategies to improve the quantity and quality of their electronic referral system according to the challenges identified herein.

A Systematic Review on the Economic Evaluations Evidence of Enhanced External Counter-Pulsation (EECP) for Managing Chronic Stable Angina.

Background: Chronic Stable Angina (CSA) does not respond to clinical interventions always. Therefore, enhanced external counter pulsation (EECP) has been approved by the Food and Administration Drug (FDA) as an effective technology. This study aimed to synthesize evidence on the economic evaluation of EECP in managing CSA through a systematic approach. Methods: In this systematic review study, PubMed/Medline, Cochrane Library, Web of Sciences, Scopus, National Institute for Health Research Journals Library, and the University of York Centre for Review and Dissemination (CRD) were searched. The targeted population was people who suffered from CSA, and the main therapeutic intervention was EECP. The comparators were not limited to any particular ones. Outcomes were changes in the Canadian Cardiovascular Society grading of angina pectoris, quality of life, and any other investigated relevant outcomes in the retrieved studies. The quality of studies was assessed through Philips et al and Joanna Briggs Institute Critical Appraisal tools. We synthesized data through a narrative approach. Results: We retrieved 7821 studies; among which 3 studies were included in the final phase. Two studies were systematic reviews and the Markov model economic evaluation. Another study was a partial economic evaluation. Conclusion: All studies only considered direct costs. EECP is a cost-effective technology in managing CSA, however, the sensitivity analysis of the studies showed the cost-effectiveness ratio is varied considerably and further studies are needed to extrapolate its economic value.

Patients' satisfaction with healthcare services providers and its determinants in the urban family physician program in Iran: A cross-sectional study.

Introduction: The quality of healthcare services can be determined by patient satisfaction as it affects the performance, sustainability, and durability of health services. This study aims to determine patients' satisfaction with healthcare service providers and its determinants in the urban family physician program in Fars and Mazandaran provinces, Iran. Methods: A cross-sectional study was conducted on the populations covered by the urban family physician program in Fars and Mazandaran provinces in 2016. In total, 864 households were selected in each province using random cluster sampling. Socio-demographic variables and underlying factors were gathered. Patient satisfaction levels were evaluated using a validated questionnaire. Results: Of the 1,480 participants with a mean age of 46.9 ± 14.2 years, 53.3% lived in Fars province and 74.2% were female. Furthermore, 67.9% of the patients were satisfied with their healthcare service providers. A higher satisfaction level was observed among the patients who resided in Fars province, lived in cities with <100,000 residents, walked <10 minutes to the family physician's office, had a family physician they previously knew, accepted the family physician, had a positive attitude towards the importance of having a family physician and a referral system, and had adequate knowledge of the family physician program. Conclusion: The results indicated that two-thirds of the patients were satisfied with healthcare service providers. Several socio-demographic variables were associated with the patients' satisfaction levels. Improving the family physician program by providing adequate medical equipment and monitoring physicians' performance could increase patient satisfaction and improve the sustainability of the program.

Primary care physician payment mechanisms toward universal health coverage: A study of Iran and selected countries.

BACKGROUND AND AIM: Primary care physician (PCP) payment mechanisms can be important tools for addressing issues of access, quality, and equity in health care. The purpose of the present study is to compare the PCP payment mechanisms of Iran, Canada, Australia, New Zealand, England, Sweden, Norway, Denmark, the Netherlands, Turkey, and Thailand. METHODS: This is a descriptive-comparative study comparing the PCP payment mechanisms of Iran and selected countries in 2020. Data for each country are collected from reliable databases and are tabulated to compare their payment models. Framework analysis is used for data analysis. RESULTS: The results are provided in terms of PCP payment mechanisms, adjusting factor for capitation, reasons for fee-for-service payment, the role of pay-for-performance (PFP) programme, domain and indicators, and reasons for developing PFP in each country. CONCLUSION: The majority of the countries with high UHC service coverage index have applied a mix of PCP payment mechanisms, most of which include capitation and PFP. Moreover, adjusting capitation by factors such as age, sex, and health status will lead to provision of better services to high-risk populations. In recent years, PFP has been paid to Iranian PCPs in addition to salary. Given the various existing models for primary health care in Iran and the increasing burden of chronic diseases, a more appropriate combination of payment mechanisms that create more incentives to provide active and high-quality care should be developed. Also, when developing payment mechanisms, the required infrastructure such as electronic health record should be considered.

Deductibles in Health Insurance, Beneficial or Detrimental: A Review Article.

BACKGROUND: One of the ways for cost-sharing in health system that has been taken into consideration in recent years in some developed countries is paying deductibles. In case of using deductibles, the insured people more carefully and accurately will use health care services, and potentially many unnecessary costs will be avoided. METHODS: To investigate the evidence of deductibles in health systems across the world, a literature review was conducted by searching the materials published in databases including ISI web of science, PubMed, Scopus and also Google scholar search engine from 2000 to 2017. Besides the related websites including WHO and the World Bank were searched. Inclusion criteria were studies carried out only in health insurance, English language, and the year of the study. RESULTS: The most important positive impacts of deductibles were decrease in utilization of different services, high profitability for the young and healthy people, lower health benefit claims by the insured people, and increase in financial profitability of health insurance organization. Besides, the most negative impacts increase in out of pocket burdens and also higher hospitalization over time. CONCLUSION: Deductible plans have their own advantages and disadvantages for the insured and insurance organizations in terms of financial dimensions as well as utilization of health services, and explicitly none of these plans can be flawless. Given the increasing costs of health systems and the potential moral hazard of insured persons, it seems these systems sooner or later should inevitably move towards new cost-sharing plans, including deductibles.

Legal and policy requirements of basic health insurance package to achieve universal health coverage in a developing country.

OBJECTIVES: This study has analyzed the policy-making requirements related to basic health insurance package at the national level with a systematic view. RESULTS: All the documents presented since the enactment of universal health insurance in Iran from 1994 to 2017 were included applying Scott method for assuring meaningfulness, authenticity, credibility and representativeness. Then, content analysis was conducted applying MAXQDA10. The legal and policy requirements related to basic health insurance package were summarized into three main themes and 11 subthemes. The main themes include three kinds of requirements at three level of third party insurer, health care provider and citizen/population that contains 5 (financing insurance package, organizational structure, tariffing and purchasing the benefit packages and integration of policies and precedents), 4 (determining the necessities, provision of services, rules relating to implementation and covered services) and 2 (expanded coverage of population and insurance premiums) sub themes respectively. According to the results, Iranian policy makers should notice three axes of third party insurers, health providers and population of the country to prepare an appropriate basic benefit package based on local needs for all the people that can access with no financial barriers in order to be sure of achieving UHC.

Detecting medical prescriptions suspected of fraud using an unsupervised data mining algorithm.

Nowadays, health insurance companies face various types of fraud, like phantom billing, up-coding, and identity theft. Detecting such frauds is thus of vital importance to reduce and eliminate corresponding financial losses. We used an unsupervised data mining algorithm and implemented an outlier detection model to assist the experts in detecting medical prescriptions suspected of fraud. The implementation ran medicine code, patients' sex, and patients' age variables through three successive screening steps. The proposed model is capable of detecting 25% to 100% of cases violating the standards for some medicines that are not supposed to be prescribed at the same time in one single prescription. This model can also detect medical prescriptions suspected of fraud with a sensitivity of 62.16%, specificity of 55.11%, and accuracy of 57.2%. This paper shows that data mining can help detecting potential fraud cases in medical prescriptions more quickly and accurately than by the manual inspection as well as reducing the number of medical prescriptions to be checked which will result in reducing investigators heavy workload. The results of the proposed model can also help policymakers to plan for fighting against fraudulent activities. Graphical Abstract Detecting Medical Prescriptions Suspected of Fraud Using an Unsupervised Data Mining Algorithm.

Scoping literature review on the basic health benefit package and its determinant criteria.

BACKGROUND: There are various criteria and methods to develop Basic Health Benefit Package (BHBP) in world health systems. The present study aimed to extract criteria used in health systems in different countries around the world using scoping review method. METHODS: A systematic search was carried out in Cochrane Library, PubMed, Scopus, Science Direct, Web of Science, ProQuest, World Bank, World Health Organization, and Google databases between January and April 2016. Papers and reports were gathered according to selected keywords and were examined by two authors. Finally, the criteria were extracted from the selected papers. RESULTS: The primary search included 8876 papers. After studying the articles' titles, abstracts, and full texts, 9 articles and 14 reports were selected for final analysis. After the final analysis, 19 criteria were extracted. Due to diversity of criteria in terms of number and nature, they were divided into three categories. The categories included intervention-related criteria, disease-related criteria, and community-related criteria. The largest number of criteria belonged to the first category. Indeed, the most widely applied criteria included cost-effectiveness (20), effectiveness (19), budget impact (12), equity (12), and burden of disease (10). CONCLUSION: According to the results, different criteria were identified in terms of number and nature in developing BHBP in world health systems. It seems that certain criteria, such as cost-effectiveness, effectiveness, budget impact, burden of disease, equity, and necessity, that were most widely utilized in countries under study could be for designing BHBP with regard to social, cultural, and economic considerations.

Interaction between stewardship and social health insurances: A comparative and document analysis.

Background: Social health insurances provide protection to access affordable coverage of services and stewardships of health system need to intervene to fulfill these objectives. This study conducted to assess interaction between stewardship and social health insurances. Methods: This qualitative study conducted in two phases as comparative study and document analysis in 2018. Comparative study employed to identify the dimensions and requirements of interaction between stewardship of health systems and social health insurances in countries around the world. In document analysis, all evidence about Iran health financing reviewed. Data extraction forms were used to gather data. Results: There were less interaction between stewardship and social health insurances in revenue collection and risk pooling. Advisory role of stewardship and proposals to coverage of uninsured people and performing risk analysis were some examples of such interaction. In Iran's health system, where stewardship plays a magnificent role in service provision, the basis of interactions are contracts, payment systems and timeline of payments. Conclusion: Mechanisms of interaction in Iran is not clear or does not work properly. Thus, nonstructural merging of social health insurances needs to redefine these mechanisms.

Effect of Motivational Interviewing on Weight Efficacy Lifestyle among Women with Overweight and Obesity: A Randomized Controlled Trial.

Obesity and overweight have become increasingly a major public health problem across the world. This study aimed at exploring the effects of motivational interviewing on weight efficacy lifestyle among women with obesity and overweight. A single-blind randomized clinical trial study was conducted on 100 overweight and obese women who attended a nutrition clinic. The samples were selected based on the clinical records and assigned into two groups, namely motivational interviewing arm (50 samples) and nutrition education arm (50 samples). Data were collected using a standard validated questionnaire entitled "weight efficacy lifestyle". The intervention was designed according to five motivation sessions and four nutrition education programs, such that the participants of the nutrition education arm were also provided with the nutrition pamphlets related to weight control. Data were finally analyzed using the SPSS statistical software by performing the independent t-test, chi-square, LSD and repeated measures ANOVA tests. P<0.05 were considered statistically significant. The mean age of women was 39.9±9.1 and 36.3±8.9 years in the control and motivational interviewing arms, respectively. Compared with the control group, the score of the motivational interviewing group was statistically significant in terms of weight efficacy lifestyle P=0.0001) and all subscales including social pressure (P=0.0001), physical discomfort (P=0.005), food accessibility (P=0.0001), positive and entertainment activities (P=0.0001), as well as negative emotions (P=0.003). Motivational interviewing appeared to be effective in increasing weight efficacy lifestyle among women with overweight and obesity. TRIAL REGISTRATION NUMBER: IRCT2014051817736N1.

Challenges of Implementation of the National Phenylketonuria Screening Program in Iran: A Qualitative Study.

INTRODUCTION: Newborn screening (NBS) is a public health measure aimed at identification of early cases, management of afflicted infants, and making efforts to reduce the morbidity and mortality among newborns. All countries may face challenges in implementation of screening programs. The present study aimed to determine the challenges of implementation of the National Phenylketonuria (PKU) Screening Program in Iran. METHODS: In this qualitative study, 38 health policymakers, managers, and PKU experts in Iran were purposively selected as the respondents in 2015. The semi-structured interview was used for collecting the required data and information. After transcription of interviews, their content was analyzed using framework analysis. RESULTS: The results were categorized into five main themes and 22 subthemes. The main themes extracted from data were management challenges, diagnosis challenges, treatment challenges, care challenges, and patients' family problems. Each category consisted of several subthemes. CONCLUSION: Considering the challenges of implementing this program, some measures such as increased stability of managers in the health system, greater interaction of the Ministry of Health and Medical Education with the heath stakeholders, improving the level of parents' awareness, the use of efficient information systems, support and legal backing for requiring parents who refuse newborn screening for various reasons, and appropriate insurance coverage seem necessary to be taken.

Job Burnout, Job Satisfaction, and Related Factors among Health Care Workers in Golestan Province, Iran.

INTRODUCTION: Burnout causes physical and emotional tireness, job dissatisfaction, resulting in reduced efficiency and a feeling of alienation from colleagues. Also, job satisfaction has a major impact on job-related behaviors, such as turnover intention, absenteeism, and job performance. The aim of this study was to determine job burnout, job satisfaction rate, and related factors among health care workers in Golestan Province in Iran. METHODS: This cross-sectional study was conducted with 1,141 health workers in Golestan Province in northern Iran. Data were collected using a questionnaire that was comprised of four sections. It consisted of socio-economic characteristics, physical environment and facilities of health house (rural health clinic), Maslach burnout inventory, and a satisfaction questionnaire. Multi-nomial Logistic Regression was conducted to analyze the data using SPSS software, version 22. RESULTS: There were significant relationships between the intensity of job burnout and age (p < 0.001), years of experience (p < 0.001), low education level (p = 0.027), number of children (p = 0.002), dissatisfaction with income (p < 0.001), physical environment of health houses (p = 0.003), facilities of health houses (p = 0.025). There were significant relationships between the frequency of job burnout and age (p < 0.001), years of experience (p < 0.001), low education level (p = 0.016), number of children (p = 0.003), dissatisfaction with income (p < 0.001), and the physical environment of health houses (p = 0.008). There were significant relationships between job satisfaction and the satisfaction from income (p = 0.001), the physical environment of health houses (p = 0.001), and the facilities of health houses (p = 0.001). CONCLUSION: Burnout was average among health workers, and health workers job satisfaction rate was lower than the average level in health workers. Effective interventions are recommended with regards to the unfavorable condition of job satisfaction and its relationship with job burnout.

Inequality in Utilization of In-patients Health Services in Iran.

BACKGROUND: Health services for those in need. Inpatient care shows a more serious side of individual care and patients and their family members perceive a high level of stress and urge. We conducted this study to determine inequalities of in-patient health care utilization in Iranian people and to assess factors that influence utilization. METHODS: In each province, the sample was comprised of 380 urban and 380 rural households that were recruited by a systematic random sampling method. A total of 23,560 households, which included around 102,000 individuals were recruited. We used the questionnaire for data collection. Met admission need (MAN) was the main variable and was considered household assets for determining the economic status. We did all analyses using the STATA version 9.1. RESULTS: The rates of MAN for urban and rural areas were 83% and 81.3% respectively. The rate of MAN was significantly higher in patients with higher educational level. Patients with primary health insurance coverage had significantly higher rate of MAN. CONCLUSIONS: Meeting admission needs was estimated around 84% and it seems that modifying insurance coverage is the most feasible intervention for increasing utilization of health services.

Male skin cancer incidence in Golestan province, Iran.

OBJECTIVE: To evaluate province-specific estimates of incidence in males by age groups for skin cancer in the Golestan province, Iran. METHODS: Data was collected from a cancer registry that was conducted by Health Deputy of Golestan province for a period of one year (2004). Age-specific rate and age-standardized incidence rate (ASR) were determined. Age-specific rate and age-standardized incidence rate (ASR) of skin cancer was compared with Mazanderan province and Iran. The age distribution was collected according to the following age strata: 0-4, 5-9, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 80-84 and 85 above. Skin cancer data was identified and collected through 18 Pathology Laboratory centers, where the cases had been referred in the Golestan province. RESULTS: A total of 409 primary cancer cases were captured. From these 64 cases were skin cancer. ASR skin cancer incidence among males in Golestan province was: 13.23/100000. But skin cancer with the highest ASR (ASR: 161.90/100,000) among males were in the age group 80-84 years. The lowest incidence was in age 30-34 years. (ASR: 1.88/100,000). CONCLUSION: The incidence of skin cancer in Golestan Province is rising especially in the age group 80-84 years. It is the highest incidence reported in the world.

Prevalence of hepatitis D virus infection in hepatitis B surface antigen-positive subjects in Golestan province, northeast Iran.

BACKGROUND AND PURPOSE: Hepatitis D virus (HDV) is a defective RNA virus dependent on hepatitis B virus (HBV) infection for its replication and expression. It is known that coexistent infection with HDV tends to aggravate the course of HBV-associated liver disease. This study was carried out to determine the seroprevalence of HDV among hepatitis B surface antigen (HBsAg)-positive individuals in the northeast part of Iran. METHODS: 139 HBsAg-positive subjects detected from a population-based single stage cluster sampling in Golestan province of Iran were enrolled. All cases were evaluated for the presence of anti-HDV antibodies using commercially available enzyme-linked immunoabsorbent assay kits. Logistic regression was used to determine the relationship between independent variables and HDV seropositivity. RESULTS: Of 139 cases, 68 were males (48.9%) and 71 were females (51.1%). The mean age was 41.9 +/- 11.3 years (range, 25-64 years). Anti-HDV antibody was positive in 8 subjects (5.8%), with a female predominance (9.9% vs 1.5%, p=0.06; odds ratio, 7.32; 95% confidence interval, 0.87-61.23). No significant relationship was seen between anti-HDV seropositivity and demographic factors such as age, place of residence and marital status. CONCLUSIONS: These findings show that HDV infection is endemic in Golestan province (northeast) of Iran. Seroprevalence of anti-HDV in the present study was higher than in some previous studies from other parts of Iran. Our results suggest that the prevalence of HBV/HDV coinfection in Golestan province of Iran has increased during the last decade. Therefore, practitioners and health care managers should be made aware of the risk of dual infection with HBV and HDV.

Hepatitis B/C virus co-infection in Iran: a seroepidemiological study.

BACKGROUND/AIMS: As hepatitis B and C virus have the same transmission routes, dual infection may occur. The aim of this study was to determine the seroprevalence of HCV in HBsAg-positive subjects. METHODS: 139 HBsAg-positive subjects were enrolled in the study. Serum samples were tested using ELISA method for anti-HCV antibodies. Chi-square and Fisher's exact tests were used to compare the proportions. RESULTS: There were 68 (48.9%) males and 71 (51.1%) females. The mean age was 41.89+/-11.30 years. One case was excluded because of inadequate blood sampling. Anti-HCV antibody was positive in 17 (12.3%) of the 138 remaining subjects. Seropositivity of HCV was similar between female and male patients (p=0.69). CONCLUSION: The seroprevalence of co-infection with hepatitis B virus and hepatitis C virus in our study was higher than such reports from some countries (Italy), but was in line with worldwide prevalence (>10%).