The Future for Health in Portugal Everyone Has a Role to Play

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1 Health Systems & Reform ISSN: (Print) (Online) Journal homepage: The Future for Health in Portugal Everyone Has a Role to Play Nigel Crisp To cite this article: Nigel Crisp (2015) The Future for Health in Portugal Everyone Has a Role to Play, Health Systems & Reform, 1:2, , DOI: / To link to this article: Accepted author version posted online: 18 Apr Published online: 18 Apr Submit your article to this journal Article views: 724 View related articles View Crossmark data Citing articles: 3 View citing articles Full Terms & Conditions of access and use can be found at

2 Health Systems & Reform, 1(2):98 106, 2015 Copyright Ó Taylor & Francis Group, LLC ISSN: print / online DOI: / Commentary The Future for Health in Portugal Everyone Has a Role to Play Nigel Crisp* Independent member of the UK House of Lords; London, UK CONTENTS Introduction Methods Discussion Relevance for Other Countries Conclusions The Future References Abstract Portugal s Gulbenkian Foundation set up an independent commission to look forward 25 years to create a new vision for health and health care and make recommendations how that vision could be achieved and sustained. The Commission recognized the wide public support for the health system and the good clinical skills of its health professionals. It noted that Portugal had an aging population, high levels of chronic diseases (particularly diabetes, obesity, and mental health problems), low fertility rates, and high levels of migration. The Commission also noted that Portugal s health system had wide variability in performance and outcomes, did not use evidence systematically, and duplicated many specialist services. The Commission s final report proposed a two-part approach of tackling the social determinants of health and seeking to improve health care delivery. It did not treat finance as a separate strategy or variable but as an integral part of both of these approaches. Thus, for example, on sustainability the report concluded that whilst incentives and financial mechanisms could help, the sustainability of the system would be dependent on politicians being willing to introduce health into all policies and action by citizens, wider society and health professionals. This Commission s report is relevant to other countries that need to address both improving the health of their population and improving health care. In Portugal, a program of activities is underway after publication of the Commission s report. The Gulbenkian Foundation is promoting these activities by supporting three Gulbenkian Challenges: reducing hospital infections, preventing 50,000 people from getting diabetes in the next five years, and improving child health. Keywords: determinants, health reform, morbidity, Portugal health system, quality, sustainability Received 26 January 2015; revised 8 March 2015; accepted 12 March *Correspondence to: Nigel Crisp, House of Lords, London SW1A 0PW. Color versions of one or more of the figures in the article can be found online at INTRODUCTION Portugal has been very badly affected by the financial crisis which started in 2008 and alongside Greece, Ireland, and Cyprus had to agree to tough austerity measures in order to secure financial support from the so-called Troika of the European Commission, the European Central Bank, and the 98

3 Crisp: Health in Portugal Everyone Has a Role to Play 99 International Monetary Fund. These measures were designed to tackle the major macroeconomic problems affecting the country and allow the country to return to normal international trading conditions. Portugal exited from the program as planned after three years in May Though the program has been judged as fairly successful, many of Portugal s problems were long-standing. As a Committee Report for the European Parliament observed, The macroeconomic problems of the country were deeply rooted before the crisis and only exacerbated by financial market jitters. 1 The financial crisis and the subsequent economic measures led, among other things, to reduced public expenditure and wages, high unemployment, and increased poverty levels. All of these factors have influenced health. Moreover, there were more than 50 measures in the Troika agreement for Portugal that dealt directly with health, covering such areas as costs of pharmaceuticals, employment-based insurance schemes, and health worker pay and pensions. As with the economy, many of the issues to be dealt with in health such as the overlap between insurance and state systems and the weakness of primary care mentioned below were also long-standing and predated the crisis. Portugal s health system needed attention and had experienced many reforms in recent years. Against this background, the Gulbenkian Foundation, an international charitable foundation with cultural, educational, social, and scientific interests, decided in 2012 to establish a commission to review the future for health in Portugal. The Foundation, the largest in Portugal, is highly respected and influential and thus well placed to offer an independent space to convene and lead discussions on the future. 2 The Foundation turned to the present author, a former Chief Executive of the English National Health Service who had subsequently worked in a number of other countries, to lead the Commission and bring an independent perspective to the review. The Commission s brief, starting in early 2013, was to look forward 25 years to create a new vision for health and health care in Portugal, describe what this would mean in practice and set out how it might be achieved and sustained. 3 The following sections of this brief report describe the methods used by the Commission, its findings and recommendations, the relevance to other countries, and, finally, the prospects for the future in Portugal. METHODS The Commission was set up to be open and inclusive and to involve as many Portuguese people as possible. It recognized at the outset that, whatever outside help might be available just as with the country s economic situation in the end it was only Portuguese people who could make lasting improvements in Portugal s health and health system. The Foundation described this process at the outset as follows: The process adopted by the Commission will itself be important in establishing a future consensus and in building the motivation for change and the energy and momentum to carry it through the inevitable challenges. The process will be open and engaging, seeking ideas from and consulting with all sectors of the population, and drawing on experience and expertise from around the world. While the Commission will build on the successful history of the last 40 years, it will ensure that as wide a range of ideas as possible are considered from Portugal and around the world no matter how radical that they are submitted to rigorous analysis and tested out with stakeholders. Although the Chairman and 3 of the 6 other members of the Commission are from abroad, the study itself will involve a large majority of Portuguese citizens and be firmly based in Portuguese culture. In essence it will be a national study with global implications; facilitated externally but firmly rooted in Portugal. 3 The Commission was structured to achieve this openness and inclusivity through establishing four working groups focusing on the key areas of concern, an advisory board, and a young professionals advisory board and holding many stakeholder and consultation meetings. More than 50 people were directly involved, many more were consulted, and the media provided good external coverage. The Commission began work in January 2013 and its report was published in September 2014 in Portuguese and English. Its working group reports will be published in I was joined on the Commission by three other foreigners: Professor Don Berwick, formerly Administrator of the Centers for Medicare and Medicaid in the United States; Wouter Bos, formerly Deputy Prime Minister and Finance Minister of The Netherlands; and Dr. Ilona Kickbusch, Director of the Global Health Program at the Graduate Institute of International and Development Studies in Geneva. We had three similarly distinguished Portuguese commissioners: Professor Joao Lobo Antunes, Chairman of the Department of Neurosurgery at the University of Lisbon and Founder and President of the Institute of Molecular Medicine at Lisbon Academic Medical Center; Professor Pedro Pitta Barros, Professor of Economics and Vice-Rector at Universidade Nova de Lisboa; and Professor Jorge Soares, Director of the Innovation in Health program at the Gulbenkian Foundation and Professor of Pathology in the University of Lisbon.

4 100 Health Systems & Reform, Vol. 1 (2015), No. 2 The Foundation also made clear that it wanted a report that could and would be implemented: In addition, thinking and activity on improving health in Portugal will not stop when the Report is published and the Commissioners will therefore also consider how best some of the work might be carried on further and/or how demonstration projects could be developed to take forward its proposals. 3 This requirement resulted in the creation of the three Gulbenkian Challenges follow-on activities in three important areas of health which are described below. Findings The Health of the Population Portugal became a democracy in 1974 and its population has experienced enormous improvements in health as well as prosperity over the subsequent years in both cases from a very low baseline. Life expectancy is approaching the European average and there have been particular improvements in child health, where Portugal now has one of the best perinatal mortality rates in Europe. These improvements are attributed by the European Observatory to a combination of factors: improved access to an expanding health network, continued political commitment, and economic growth, which led to improved living standards and increasing investment in healthcare. 4 Forty years on, Portugal today is experiencing many of the same health risks and problems as other Western countries. It has an aging population, increasing levels of long-term chronic conditions or noncommunicable diseases, and high levels of obesity. 5 The best estimate is that about 54% of the population or 5.4 million Portuguese people suffer from at least one chronic disease (L. Campos, University of Lisbon Medical School, unpublished data, 22 May 2014). It is also facing the same financial crisis about how to sustain its health system as every other industrialized country. Figure 1 shows the breakdown in causes of death in Portugal in 2008, 86% of which were attributed to noncommunicable diseases. There are, however, some distinctive features about health in Portugal. There are high levels of diabetes, stroke, and HIV/AIDS compared to other Western European countries. Portugal has the highest prevalence of diabetes in Europe (at 12.7% in 2011), and it is continuing to grow rapidly with about 70,000 new diagnoses a year. 6 Diabetes and the complications of diabetes are costing the country about 10% of its health budget or around 1% of GDP. 6 There is also evidence of lower levels of mental well-being than in other OECD countries and very high use of antidepressants. 7,8 As in other Latin countries, there is a large difference in life expectancy between men and women: 77.3 years as opposed to 83.6 years in Men have higher mortality from cerebrovascular disease, cancers, and traffic accidents. More generally, there are high levels of deaths of both men and women from conditions amenable to health care. A study of 19 high-income countries found that Portugal had the third highest rate of such deaths in and the second highest in One of the most telling comparisons with other countries is that Portuguese men and women can only expect 6.6 and 6 years of healthy life, respectively, after the age of 65, whereas the best in Europe, Norwegian men and women, can look forward to 15.4 and 15.9 years. 11 The difference in total life expectancy between the countries is not that great, but the Norwegians will be healthier for longer. Figure 2 shows that Portugal is near the bottom of a table of comparisons of healthy years of life in Europe and markedly below its near neighbors of Spain and France. There are also distinctive social issues. Portugal s population is not only aging but many of its young people, particularly graduates, are emigrating permanently or temporarily in search of employment. This has long been a trend in Portugal, but the trend is accelerating due to the recent economic pressures, and the population has begun to fall. Emigration is thus aggravating a situation where the Portuguese fertility rate currently stands at 1.32 among the lowest in the world and the proportion of people of working age in the population is falling. FIGURE 1. Deaths in Portugal 2011

5 Crisp: Health in Portugal Everyone Has a Role to Play 101 FIGURE 2. Healthy Years of Life After Age 65 Obesity levels are high, with children s levels among the worst in the world. According to the World Health Organization reference system, the prevalence of overweight and obesity were 37.9% and 15.3%, respectively, among six- to eight-year-olds in Portugal also has the highest level of reported overweight among 15-year-olds among the EU24 countries. 13 Recent national data suggest that rates may be even higher than reported in these international studies. 14 Though the improvements in children s physical health over recent years are rightly a source of pride for Portuguese people, the UNICEF assessment of children s health and well-being, which uses indicators across health, education, material well-being, and other factors, shows that Portugal is 15th in a comparison of 29 OECD countries. 15 The Commission heard some concern about the mental wellbeing of younger people. These findings, together with the increasing migration of younger people and growing levels of obesity, are major concerns in an aging population that will become increasingly dependent on the health and capabilities of its young people. The health of the population is also affected by the fact that Portugal has the highest proportion of people living in absolute poverty among the EU15 countries 16 and a high proportion of people (including 25% of the elderly population) living in rural areas with poorer access to services. There is also evidence that immigrants fare less well in health terms than the majority population, despite Portugal s open policy of offering them equal access to health care. 17 It is too early to quantify the impacts of the financial crisis on health. However, we can expect that reducing standards of living with all public sector employees having a 15% drop in earnings rising unemployment, and cuts in public services will all have a detrimental effect. The Commission heard reports of growing mental health problems, increased addictions, and schools staying open during the holidays to ensure that their pupils were fed properly. Young people have been particularly affected by unemployment, which stood at 35% in February 2014, more than double the OECD average. 18 Suicide rates across Europe have risen since the crisis, particularly among young men. 19 Some of the key features both of the health status of the population and of the social issues that affect health are summarized in Table 1, based on the sources indicated earlier. This brief summary shows that improving Portugal s health in the future will depend on tackling the social determinants as well as improving the health system itself. Recognition of the need for this dual approach was a key part of the Commission s analysis and, as will be seen, shaped many of its recommendations. Findings The Health System The Portuguese health system is complex and, like other long-standing systems, has become more complex over the years as one generation of reforms has overlaid earlier versions. The Serviço Nacional de Saude or SNS is at the core Aging population living with ill health Diabetes and other chronic diseases Children and young people Financial crisis Only six years of healthy life after 65, nine years less than Norway. Many older people live in rural areas Chronic diseases affect 5.4 million people. Highest prevalence of diabetes in Europe, costing almost 1% of GDP High levels of obesity, low fertility rates, and high emigration among young Lower standard of living, unemployment, stress. Cuts in public services TABLE 1. Health and Social Issues

6 102 Health Systems & Reform, Vol. 1 (2015), No. 2 of provision. It was established in September 1979 as a tax-funded and universal system and was a key element in the country s 1979 Constitution. It is widely supported within the country. However, sub-sistemas essentially insurance schemes for occupational groups that preexisted the SNS were allowed to continue to provide for some of the more affluent people in society. In addition, Portugal has a small number of private insurance schemes. Services are provided by a mix of the public and private sectors. Most hospital services are provided by the public sector, whereas many community and diagnostic services are provided by the private sector. Many of these private sector services are paid for directly by the user with, for example, many children being taken for regular checkups with private pediatricians. The level of out-of-pocket expenditure, not paid for by insurance schemes or the SNS, is very high in Portugal. Figure 3 shows that these payments amount to about 27% of total health care expenditure (right-hand scale) and that Portuguese people spend much more out of pocket than people in France, Germany, and the UK, even though it is a much poorer country. This finding led the Commission to recognize that there was little scope to expect the population to pay more for its health care. This meant that, given the limited scope to raise taxes or increase state subsidies, the Commission s financial focus needed to be firmly on reducing costs and improving value for money. Both the Troika and the current government of Portugal have attempted to improve and simplify the current financial arrangements by removing subsidies for sub-sistemas; reducing costs, particularly in staff salaries and pharmaceuticals; and removing conflicts of interests between the public and private sectors. This has led to falls in the overall expenditure on health and in the percentage of GDP spent on health in the last three years. It is not yet clear how far these reductions are sustainable or whether they will lead to longer term benefits. Portugal has experienced many different reforms in its health system over the years. These have been characterized as introducing market mechanisms from 1985 to 1995; return to the foundational principles of the SNS from then to 2000; return to the privatization trend up to 2005; followed once more by return to the foundational principles and bottom up organizational change in primary health care in the last few years. 3 These reform trends have mirrored and to some extent been influenced by reforms in other national health systems, especially England s National Health Service. The way these reforms have or in many cases have not been implemented reflects the lack of central executive authority in the SNS and the decentralization of decision making. Some reforms were only partially implemented, and new reforms were then introduced on top of them, leading to considerable variation around the country. Thus, for example, the primary health care reforms of the last few years only cover part of the country even though there appears to FIGURE 3. Out-of-Pocket Payments for Selected OECD Countries

7 Crisp: Health in Portugal Everyone Has a Role to Play 103 be considerable support for them and some evidence of their success. This national variation is reflected in many policies. There are three competing systems for accreditation, for example, and considerable duplication of services. Moreover, the country has only recently introduced guidelines and protocols that seek to improve the quality of care and, in doing so, begin to hold clinicians accountable for their practice. The Commission found a lack of data compared to other Western European countries, poor quality in what was available, and lack of transparency. Some claimed that this variation and lack of accountability were in significant part due to the resistance to central authority that built up during the dictatorship and the relative weakness of civil society that was only developing in the last 40 years (witness statements during Commission consultation, March 2014). Whatever the historical reasons for these features, the Commission decided to emphasize the importance of evidence, systematic quality improvement, and good data in its final recommendations. As many observers noted, implementing these recommendations would take time and effort and require considerable cultural change (witness statements during Commission consultation, March 2014). Despite these system weaknesses, the Commission observed many examples of good clinical skills, professional education, and, in general, high standards of clinical practice. It also noted the strong support for the SNS from the public and from most medical professionals, who were often clearly motivated by public benefit and public service. These features in Portugal provide a good basis from which to make improvements in health services and the health of the people. The population and its health services are, however, under a great deal of pressure currently with reduced spending, service reductions, and increases in many social factors, such as unemployment and poverty, which will inevitably affect health. There is need for determined and radical change, which the Commission sought to indicate. The Commission s Conclusions and Recommendations The Commission concluded that two distinct but linked focuses of action are needed in order to improve health in Portugal. The first would address the social determinants of health directly dealing with areas that directly affect health outcomes, from education and housing to employment and the environment and the second would make improvements in the health system itself. Both approaches have their champions in Portugal. Many clinicians are working to improve their services. There is also strong interest in taking action on the social determinants of health but relatively little systematic progress with, for example, strengthening the underdeveloped public health infrastructure or, with some exceptions, creating links across municipalities and between them and the SNS. The Commission s summary of its findings emphasized the interconnectedness of these twin approaches and stressed the importance of moving forward decisively while constantly learning from experience: Health is influenced by many different factors from education, the environment and the economy to the quality of health services and the skills of health professionals. Looking forward 25 years we can expect enormous change as these factors interact in multiple ways to shape the future. This change and complexity means there is a need to learn constantly and adapt as the future unfolds in order to take advantage of new opportunities and avoid new threats and risks. It also means that everyone must contribute to improving health and that every sector of society needs policies which help maintain and improve health. Health cannot be left purely to health professionals or politicians nor can it be treated simply as a business or a government service. Everyone has a role to play. 3 The Commission set out a new approach and a new vision that built on the existing policies and direction of the Portuguese system: This report offers a new approach to improving health. It places the focus firmly on action by citizens and wider society. It aims to reduce the incidence of chronic diseases such as diabetes and the length of time that people suffer from them both of which are higher in Portugal than in most Western European countries and it shows how quality improvement methodologies and better access to evidence improve health services and reduce expenditure. The report envisages a transition from today s hospitalcentered and illness-based system where things are done to or for a patient to a person-centered and health-based one where citizens are partners in health promotion and health care. It will use the latest knowledge and technology and offer access to advice and high-quality services in homes and communities as well as in clinics and specialist centers. This vision maintains the founding values of the SNS and builds on the strengths of the current system, the skills of health professionals, and the achievements of the past but it demands new approaches, different infrastructure, and a lower and more sustainable cost base. 3 The Commission went on to identify 20 recommendations that fell into seven groups. Each of these high-level recommendations has specific measures to achieve them with progress being monitored after one year, three years, and so on:

8 104 Health Systems & Reform, Vol. 1 (2015), No A new compact for health. The Commission argued that there needed to be a new settlement or compact to bring all sectors of the population together around a common vision and a plan. This needs to be led by an alliance drawn from the whole of society and supported with new systems for continually learning, assessing the evidence, and implementing improvement. 2. Action by citizens. The Commission recognized that health starts at home and in the actions and behaviors of family, friends, neighbors, employers, and local communities. New emphasis is needed to mobilize, educate, and engage all of these parties. 3. Action across society. In the words of a recent World Health Organization report: Modern societies actively market unhealthy lifestyles 21 and modern environments make it difficult to make healthy choices. Action is needed from all sectors of Portuguese society to improve health as well as from citizens and national and local governments. 4. The continuous pursuit of improved quality. The Commission s recommendations included the development of an agency to collect and disseminate evidence and the need to introduce processes for continuous quality improvement. 5. A person-centered and team-based health system. The prevalence of chronic diseases in the population means that Portugal, in common with many other countries, needs to introduce new service models that provide integrated care, offer more services in the home and local community, and support them with the creation of specialist networks. 6. New roles and strengthened leadership at all levels. The Commission noted the high quality of Portuguese health professionals but argued that greater flexibility in roles (for example, further development of nursing) was needed for the future. It also noted that health and other leaders needed to work together across organizational and societal boundaries. 7. Financial sustainability. The Commission noted the efforts that were being made to improve financial planning and management and to improve contracting for services, including some experimentation with valuebased approaches. However, it concluded that though these changes might have some benefit in the longer term, the greatest gains would come from addressing directly the health issues and in particular the high incidence of people with chronic conditions. It concluded that financial sustainability would only be achieved by reducing the incidence of these diseases and the associated morbidity, developing new models of care for them, and making sure that evidence is applied systematically everywhere and waste reduced to a minimum. The Gulbenkian Challenges The Calouste Gulbenkian Foundation was committed from the outset to supporting the implementation of the Commission s key findings. It therefore decided to initiate three ambitious Gulbenkian Challenges. These Challenges are demonstration projects that will lead the way for full implementation of the report. Each exemplifies the approach described in the report showing what can be achieved while tackling some of the most important challenges in Portugal. They are as follows: 1. Reducing hospital-acquired infections: halving rates in ten hospitals in three years. 2. Slowing the growth in diabetes: preventing 50,000 people getting the disease in five years. 3. Helping the country become a leader in early childhood health and development with measurable improvements in the health and well-being of children in the longer term. Each challenge engages a different part of the health system and wider society. The infection challenge requires action by hospitals, government, and academia. The diabetes challenge will be led by the Portuguese Diabetic Association and municipalities, and the children s challenge will be led by the health and education sectors working together. Each will provide measurable health and financial benefits for the population and the health system. DISCUSSION RELEVANCE FOR OTHER COUNTRIES Many of the features that affect the Portuguese health system apply to other Western and industrialized countries. An aging population, increasing levels of chronic diseases, financial constraints, and raised public expectations now confront many countries. How they appear in Portugal is unique, but their occurrence in society is more universal. Moreover, many of these issues now affect low- and middle-income countries that are moving toward universal health coverage for their populations. The key question for them all richer and poorer is how to ensure that health care is available to everyone in a high-quality and sustainable way. The Commission s approach to these issues is based on the understanding that improving health services by itself cannot improve health. It is possible to create a wonderful

9 Crisp: Health in Portugal Everyone Has a Role to Play 105 service for diabetes, but that will not be sustainable if the number of people getting diabetes is constantly increasing. A twin track approach is needed: addressing the social determinants of health and improving the quality of health services. Moreover, the Commission argues that there is too often an overemphasis on economic and financial measures in health system reform. It argues that the best way to control costs and waste is through service redesign and health promotion and not through trying to tackle them with new incentives and other financial measures. At its core this approach requires four components: 1. A clear vison for and understanding of the transition described earlier from today s hospital-centered and illness-based system where things are done to or for a patient to a person-centered and health-based one where citizens are partners in health promotion and health care that needs to be made in the health system over the longer term and a plan to start making that transition. 2. Everyone having a role to play citizens as well as clinicians, teachers, and businesspeople as well as municipalities and national government. Health cannot be left to health professionals or politicians, nor can it be treated simply as a business or a government service. Health needs to be part of all policies. 3. A systematic approach to quality and evidence supported by good measurement and data, openness, and effective processes for improvement and implementation. 4. An approach to sustainability that recognizes that new financial mechanisms and outcome-based incentives can help if managed well; but the financial salvation of the system will depend on political willingness to introduce health into all policies, effective health promotion and concerted action by citizens, wider society and health professionals. 3 This approach implicitly challenges many recent approaches to reform that rely heavily on economic and financial measures to deliver change. They have had very mixed results. This set of reforms is focused much more directly on the nature and dynamics of health and health care. CONCLUSIONS THE FUTURE Though most Western countries have been faced with some level of austerity as a result of the financial crisis, Portugal has suffered more than most and had to make cuts not just freeze growth in its health expenditure. This dire situation contributed to a willingness to consider more radical solutions. The Commission benefited greatly from the high standing and neutrality of the Gulbenkian Foundation and held discussions with all of the main political parties and presented its findings to the President of the Republic, the Parliamentary Health Committee, and party leaders. In all cases its findings have been well received. The review also benefited from having so many leading Portuguese people involved in and supporting the process. There are Portuguese champions for most of the recommendations. Early signs suggest that many of the recommendations will be implemented. The government has, for example, appointed for the first time a Chief Nursing Officer, who will help lead the development of the profession. The Foundation is starting to implement the three challenges and the report is being widely discussed at conferences and other meetings. Further action will depend on the outcomes of the national election scheduled for the autumn of 2015 and the views of the new government. Whatever happens politically, implementation will be difficult because all of the recommendations explicitly or implicitly challenge the status quo and there will be interests opposed to all of them from the creation of specialized networks to giving patients and nurses more power, to sharing responsibility and accountability across organizations and sectors. The Commission has proposed that it should review progress in January 2016 to see how much has changed and, crucially, what has been learned from attempting to implement these recommendations. DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST No potential conflicts of interest were disclosed. REFERENCES [1] The European Parliament. The Troika and financial assistance in the Euro area: successes and failures; report for Economic and Monetary Affairs Committee. Strasbourg: The European Parliament; 2014, 44. [2] A Fundaç~ao Calouste Gulbenkian. n.d. Available at (accessed 14 May 2015) [3] Gulbenkian Foundation. The future for health everyone has a role to play. Lisbon, Portugal: Calouste Gulbenkian Foundation; [4] Barros PP, Machado SR, Sim~oes J. Portugal: health system review. Health Systems in Transition 2011; 13(4): [5] World Health Organization. Non-communicable diseases: country risk profiles. Geneva, Switzerland: World Health Organization; 2011.

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