The professional path of postgraduates of a professional master's degree in primary health care in the municipality of Rio de Janeiro, Brazil: an evaluative study. / Trajetória profissional de egressos de Curso de Mestrado Profissional em Atenção Primária à Saúde no Município de Rio de Janeiro, Brasil: estudo avaliativo.

A four-block exploratory study was conducted with an electronic online, anonymous questionnaire to study the path of postgraduates  from two professional master's degree classes, as follows: personal, current professional activity, course-professional situation relationship, and open-ended questions for positive/negative points. Results: Most of them remained in the primary care area and public services; in health care and as tutors; developed a course-related work activity, and 75% reported a high impact of the course. A lower effect was perceived in the remuneration. A higher effect was noted in the professional training, the networks of relationships, personal growth, and work. The active pedagogical strategies were well evaluated. Conclusion: This is a feasible and applicable evaluation method for graduate monitoring systems, and it allows knowing the relationship between training and work.

Visando estudar a trajetória de egressos de duas turmas de Mestrado Profissional realizou-se estudo exploratório, com questionário eletrônico on line, anônimo, com quatro blocos: pessoal; atividade profissional atual; relação do curso-situação profissional e ainda perguntas abertas para pontos positivos/negativos. Resultados: a maioria mantinha-se na área da atenção primária e em serviços públicos; na assistência à saúde e muitos como preceptores; desenvolviam atividade no trabalho relacionada ao curso e 75% relatam alto o impacto do curso. Menor efeito foi percebido na remuneração e maiores na formação profissional, nas redes de relações; no crescimento pessoal e no trabalho. As estratégias pedagógicas ativas foram bem avaliadas. Conclusão: metodologia de avaliação factível e aplicável para sistemas de acompanhamento de egressos; permite conhecer a relação formação e trabalho.

[Similarities and diferences between Academic and Professional Master Programs as Educational Public Policy in the field of Public Health]. / Similaridades e diferenças entre o Mestrado Acadêmico e o Mestrado Profissional enquanto política pública de formação no campo da Saúde Pública.

In the attempt to find a specificity for the Professional Master Program in Public Health (PM), we asked, what is, from the point of view of its means and purposes, kept or broke from the training models of the Academic (traditional) Masters Program (AM). In the public health field, this discussion possess an extra "flavor", as both program aim, in Brazil, to prepare health professionals to the Brazilian Unified Health System (SUS). Therefore, this research sought to investigate the heuristic and innovative vocation of the PM vis-à-vis the AM as an education public policy. From a comparative approach, we analyzed the main characteristics and differences among AM and PM, face the flexibilization process of graduate programs in Brazil, and discussed if these features would characterize the PM into an educational public policy. Data was analyzed by the Content Analysis method. We conclude that educational institutions tend to reproduce the AM training model in the PM and the expectation of making the health service matter and reason for training is not sufficient to distinguish both modes.

Ao buscar uma especificidade para o Mestrado Profissional (MP) em Saúde Pública, interrogamos, o que ele, ao se instituir, procurou do ponto de vista de seus meios e finalidades, conservar ou romper com os modelos de formação dos Mestrados Acadêmicos (MA). No campo da Saúde Pública, o tema ganha outros temperos se considerarmos que tanto o MP quanto o MA preservam na finalidade a formação para o Sistema Único de Saúde. Nesse sentido, a pesquisa buscou investigar a vocação heurística e inovadora do MP face ao MA como uma política pública de formação. Em uma perspectiva comparada, analisamos as principais características dos cursos de MP em saúde pública, frente ao processo de flexibilização da pós-graduação brasileira que o diferencia do MA, e discutimos se essas características tornam o MP uma política pública de formação. Na análise dos dados utilizamos o método da Análise de Conteúdo. Concluímos que as instituições de ensino tendem a reproduzir o modelo de formação do MA no MP e a expectativa de tornar o serviço de saúde matéria e motivo para a formação não é suficiente para distinguir ambas modalidades.

Traditional Complementary and Integrative Medicine: challenges in constructing an evaluation model of care. / Medicina Tradicional Complementar e Integrativa: desafios para construir um modelo de avaliação do cuidado.

The complexity and diversity of what is proposed in Traditional and Complementary Medicine constitute a challenge for those seeking evidence of its effectiveness. Its growth, offer and, use justify the need to build more complex and more appropriate methodological frameworks to explicit the uniqueness of this approach to healthcare and the diversity of its techniques. Based on a narrative review of the recent literature, this article aims to contribute to the construction of an evaluation model, focused on understanding the uniqueness and diverse dimensions of this specific care, seeking to reflect on the challenges and evidences of successful therapy. The proposed model is based on qualitative healthcare approaches, in which the experiences of the involved agents (professionals and users) in the therapeutic process become central. Assessing their effectiveness means recognizing the interconnected processes and their multiple dimensions: host practices, dialogue, diagnosis, action, and outcomes achieved.

A complexidade e a diversidade do que se propõe sob a lógica da Medicina Tradicional Complementar e Integrativa (MTCI) constituem um desafio para os interessados em evidências de sua efetividade. Seu crescimento, oferta e uso justificam a necessidade de construir referenciais metodológicos mais complexos e mais adequados para explicitar a singularidade do cuidado e a diversidade de suas técnicas. Este artigo, partindo de uma revisão narrativa da literatura, visa contribuir para a construção de um modelo de avaliação que, centrado na compreensão da singularidade e nas diversas dimensões do cuidado, busca refletir sobre os desafios de se buscar evidências do êxito terapêutico. O modelo proposto tem como base as abordagens qualitativas em saúde em que experiências dos agentes envolvidos (profissionais e usuários) no processo terapêutico ganham centralidade. Avaliar a efetividade do cuidado significa reconhecer a cadeia de processos interligados e suas diversas dimensões: acolhimento, diálogo, diagnóstico, ação e resultados alcançados.

[The Integrar Project: an evaluation of comprehensive health care services in Vitória, Espírito Santo, Brazil]. / Projeto Integrar: avaliação da implantação de serviços integrados de saúde no Município de Vitória, Espírito Santo, Brasil.

This article describes an experience with the integration of various healthcare services, called the Integrar Project, in Vitória, capital of the State of Espírito Santo, Brazil, and analyzes the project's contribution to the development of comprehensive healthcare practices. The case study used a qualitative approach and covered the period from 2000 to 2003, identifying the project's potential in the areas of maternal and child health, continuing health education, and the family health strategy, but also identified difficulties in establishing integrated treatment projects involving both the Family Health Program teams and the various medical specialties. To a major extent the work proposal failed to materialize, highlighting the need to review the strategy to include new forms of communications and developing greater formal cooperation, beyond the existing informal coordination between individuals, teams, or services, based on a contractual logic in public healthcare services. Standards and norms that are negotiated through dialogue and a management contract would allow the involvement of professionals in sharing common goals and changing work processes. Such changes would involve management tools and new values to ensure accountability.

[Palliative care in cancer: elements for debating the guidelines]. / Cuidados paliativos oncológicos: elementos para o debate de diretrizes nesta área.

The aim of this study was to present elements for debating guidelines on palliative care programs for cancer. A literature survey searched various databases (MEDLINE, LILACS, and Cochrane Library), homepages of palliative care organizations, publications by renowned authors in this area, reference textbooks on the subject, relevant articles cited by these books, and the thesis/dissertation database of CAPES (the Brazilian Coordinating Body for Training University Level Personnel). The data were grouped into four thematic categories: symptomatic palliation, organization of services, psychosocial characteristics, and spiritual characteristics. The article then proceeds to discuss cancer as a public health problem and its impact on individuals, the concept of palliative care and its context in health care, program models and their guidelines, death and dying, and care and caregivers. The study concludes by discussing the challenges for the Brazilian National Health System in structuring end-of-life programs as a consequence of the population's aging and increasing cancer incidence.

Partnerships in Health Systems: Social Organization as limits and possibilities in the Family Health Strategy Management. / Parcerias na saúde: as Organizações Sociais como limites e possibilidades na gerência da Estratégia Saúde da Família.

This is a case study in the municipality of Rio de Janeiro about management in the Family Health Strategy based on the Social Organizations model. The aims were to characterize and analyze aspects of the governance system adopted by the Rio de Janeiro Municipal Health Department and identify limits and possibilities of this model as a management option in Brazil's Unified Health System. A qualitative study was performed based on a literature review, document analysisand interviews with key informants. This management model facilitated the expansion of access to primary healthcare through the Family Health Strategy in Rio - where the population covered increased from 7.2% of the population in 2008 to 45.5% in 2015. The results showthat some practices in the contractual logic need to be improved, including negotiation and accountability with autonomywith the service suppliers. Evaluation and control has focus on processes, not results, and there has not been an increase in transparency and social control. The system of performance incentives has been reported as inducing improvements in the work process of the health teams. It is concluded that the regulatory capacity of the municipal management would need to be improved. On the other hand, there is an important and significant process of learning in progress.

[Managerial performance in public health services: a case study in Mato Grosso do Sul, Brazil]. / Desempenho gerencial em serviços públicos de saúde: estudo de caso em Mato Grosso do Sul, Brasil.

This paper presents part of a doctoral dissertation that developed a theoretical model capable of identifying managerial performance in various administrative levels of a Municipal Health Secretariat. The methodology was a case study of the Municipal Health Secretariat in Campo Grande, capital of the State of Mato Grosso do Sul, Brazil. The theoretical model was based on recent debates emphasizing the need to modernize public administration, with an emphasis on efficacy and efficiency in the organizations as a whole. Some 31 interviews were conducted with the objective of identifying the managers' performance, through questions based on their daily practices in planning, organization, direction, and control. Managers from higher hierarchical levels obtained better results, while those in basic health units generally developed activities and complied with decisions passed down by imposition, with limited capacity to plan, organize, or control activities pertaining to their management sphere. These results stem partially from the charismatic leadership and centralizing administration of the current management in the municipal health system.

Trajetória profissional de egressos de Curso de Mestrado Profissional em Atenção Primária à Saúde no Município de Rio de Janeiro, Brasil: estudo avaliativo / The professional path of postgraduates of a professional master's degree in primary health care in the municipality of Rio de Janeiro, Brazil: an evaluative study

Resumo Visando estudar a trajetória de egressos de duas turmas de Mestrado Profissional realizou-se estudo exploratório, com questionário eletrônico on line, anônimo, com quatro blocos: pessoal; atividade profissional atual; relação do curso-situação profissional e ainda perguntas abertas para pontos positivos/negativos. Resultados: a maioria mantinha-se na área da atenção primária e em serviços públicos; na assistência à saúde e muitos como preceptores; desenvolviam atividade no trabalho relacionada ao curso e 75% relatam alto o impacto do curso. Menor efeito foi percebido na remuneração e maiores na formação profissional, nas redes de relações; no crescimento pessoal e no trabalho. As estratégias pedagógicas ativas foram bem avaliadas. Conclusão: metodologia de avaliação factível e aplicável para sistemas de acompanhamento de egressos; permite conhecer a relação formação e trabalho.

Abstract A four-block exploratory study was conducted with an electronic online, anonymous questionnaire to study the path of postgraduates from two professional master's degree classes, as follows: personal, current professional activity, course-professional situation relationship, and open-ended questions for positive/negative points. Results: Most of them remained in the primary care area and public services; in health care and as tutors; developed a course-related work activity, and 75% reported a high impact of the course. A lower effect was perceived in the remuneration. A higher effect was noted in the professional training, the networks of relationships, personal growth, and work. The active pedagogical strategies were well evaluated. Conclusion: This is a feasible and applicable evaluation method for graduate monitoring systems, and it allows knowing the relationship between training and work.

Social inequality, health policies and the training of physicians, nurses and dentists in Brazil and in Portugal.

This study analyzes the production of scientific knowledge on Health Inequalities (HI) and its use in policies of education of dentists, nurses and physicians in Brazil and Portugal. Documents published between January 2000 and December 2001, in Portuguese, French, English and Spanish, were identified by means of a combination of a manual and intentional electronic database survey of the grey literature. Fifty-three documents were selected from a total of 1,652. The findings revealed that there is still little knowledge available to enable an assessment of policies for human resource training in healthcare in general and for those related to physicians, nurses and dentists in particular. In Brazil, few studies have thus far been made to understand how such training can contribute towards reducing these inequalities and, in the case of Portugal, no studies were found that established a direct relationship between human resource training and the future role that these could play in combating inequality. Despite a vast increase in scientific production, many lacunae still exist in this field. Knowledge production and its relationship with decision-making still seem to be separate processes in these two countries.

Activators of processes of change: a proposal oriented to the transformation of educational practices and the training of health professionals.

This paper investigates an educational proposal articulated through a policy of the Ministry of Health, which aims to promote changes in the training of health professionals. An inter-institutional partnership promoted the training of specialists as Activators of Processes of Change. This study analyzes the characteristics of a post-graduate semi-distance-learning course, examining the transformation potential of health praxis. It involves the analysis of documents and interviews published in official reports of the course addressing competency profile construction, the political-pedagogical project and management and evaluation of the proposal. The analysis of data and information used the principles of the meaning interpretation method as a reference. The educational praxis of the tutors was transformed, since students became professionals in change activation. 698 activators were qualified, with a loss of 12.9%. The characteristics of the proposal enhanced participants' involvement in the construction of new capacities, highlighting the broadening of analysis and intervention in reality. Eliciting the potential of individuals and the group, and the spaces for reflection proved to be the main achievement in the construction of educational projects, in the context of the Unified Health System.

[CAPES evaluation model: desirable and necessary, but incomplete]. / Modelo de avaliação CAPES: desejável e necessário, porém, incompleto.

Seeking to contribute to the improvement of evaluation criteria in the public health graduate studies program, this article presents the main characteristics identified by foreign observers during the 2001 program evaluation of the Brazilian government research support agency CAPES (Coordinating Body for Training University-Level Personnel) and presents some critical observations on the criteria used to evaluate the quality of teaching in graduate studies programs. These comments were based on recent trends in other countries.

[Avoidable perinatal deaths and the environment outside the health care system: a case study in a city in Greater Metropolitan Rio de Janeiro]. / Obitos perinatais evitáveis e ambiente externo ao sistema de assistência: estudo de caso em município da Região Metropolitana do Rio de Janeiro.

This paper focuses on the role of environmental factors external to the health care system in the occurrence of perinatal deaths in maternity hospitals belonging to the local health system in a city in Greater Metropolitan Rio de Janeiro in 1994. Elements from the political and administrative context that contribute to an understanding of the relationship between failures in health care and structural deficiencies in these maternity hospitals were divided into four groups of variables: distribution of resources, spatial and temporal factors, organizational and managerial features, and action by interest groups. Semi-structured interviews were conducted. The study concluded that poor performance in four groups of variables may have contributed to perinatal mortality: distribution of resources was insufficient to provide quality in health care, especially in private maternity hospitals; there was no formal or informal regional or hierarchical organization of obstetric care in the city; Ministry of Health guidelines were ignored in all four maternity hospitals, while in three of the hospitals there were no admissions procedures and delivery and fetal follow-up listed in their own rules; and the level of actual participation was low.

[The Family Health Program: supervision or "shared vision"? A case study in a medium-sized Brazilian city]. / Programa Saúde da Família: supervisão ou "convisão"? Estudo de caso em município de médio porte.

This study discusses supervision of the Family Health Program (FHP) in Teresópolis Rio de Janeiro State, Brazil, based on a qualitative case study approach. Considering that supervision is an important tool in health programs management, five main objectives were achieved: analysis of supervisory activities, description of characteristics and working patterns, outlining of FHP supervisor profiles, and identification of subjective factors that could interfere in the supervision process. Finally, supervision was considered as an essential step in program organization and implementation. Information sources were interviews with program supervisors and staff members, observation, and document search. The aim was to identify perceptions, attitudes, values, and tendencies concerning supervision. Thanks to this study, it was possible to discuss participatory supervision in the health area, by providing a more level relationship between participants and their effect on health practices, fostering the autonomy of various players in the supervisory process and fostering program support, both suitable for changes in the Brazilian health care model.

[Accreditation and its implementation in graduate studies in Public Health]. / A acreditação e sua implementação na área de ensino pós-graduado em Saúde Pública.

This article aims to contribute to a better understanding of the establishment and implementation of accreditation in graduate courses in public health and to encourage discussions to improve quality in this area. The term accreditation is defined, and two of its main thrusts are discussed: quality and competence. The basis for establishing and implementing an accreditation system is described, and some of the key characteristics of the Brazilian experience are presented.

[Experience with games in operative groups as part of health education for diabetics]. / A experiência de jogos em grupos operativos na educação em saúde para diabéticos.

This paper presents and discusses an educational strategy implemented in a specialized hospital clinic. The goal was to stimulate individuals to reflect on their everyday lifestyles as related to their disease, specifically diabetes mellitus. The strategy can be characterized as an educational tool from the perspective of health promotion and disease prevention and control. The experience was implemented on an interactive basis (health professionals and individual patients) with educational games in operative groups. Pedagogical techniques were used: orientation concerning diabetes mellitus, individual consultation, the operative group, and educational games (communications and learning). The techniques enabled participants to improve knowledge and exchange experiences. In addition, the health professionals gained a better understanding of the participants' experience with their illness.

[Professional Master's in Public Health: from legal precepts to experience in a research and education institution]. / Mestrado Profissional em Saúde Pública: do marco legal à experiência em uma instituição de pesquisa e ensino.

This study is about the discourses that prevailed over the course of time in Brazilian legislation for the Master's Course in Public Health, and how a Brazilian research and education institution in the area of Public Health appropriated these discourses in the creation of its course proposals. Discourse analysis techniques were applied to legal documents and to sixteen master's programs developed in the institution under scrutiny. The results revealed that with respect to legislation, analysis of the historical timeline makes it possible to say that the initial lack of definition progressively gave rise to the understanding that the identity of such post-graduate education presupposes pedagogical practices that promote the strengthening of ties between academia and the workplace. And, in relation to the master's course proposals for public health in the institutions under scrutiny, they still operate with traditionally consolidated training schemes and tend to standardize their proposals with those of the academic model. It was assumed in this study that the series of proposals would clearly mirror the intentions and, above all, the vision of the training institutions in the area of public health on this stricto sensu model, the identity of which also appears poorly defined.

[Contractual arrangements in primary health care: the experience of Portugal and Brazil]. / Contratualização na Atenção Primária à Saúde: a experiência de Portugal e Brasil.

The contractual arrangements adopted in the Family Health Strategy are a topic as yet scantly addressed in studies. It is introduced in Brazil in different models in accordance with the contracting entity and the legal status of the contracted service provider; and in Portugal, it is based on a model of inter-governmental contractual arrangements with the Family Health Units. In this paper, the current status of contractual arrangements in both countries is presented and their attributes of joint planning, accountability with autonomy and performance-based incentive programs are discussed. The main contributions are: better coordination of the health organizations; substitution of the hierarchical command-control logic with greater participation; and accountability of professionals with enhanced performance of their activities. The conclusion reached is that one of the facilitating elements is gradual construction, in an environment of ongoing learning, with health professionals playing the leading role. However, the major challenges include transparency in the implementation of processes, the enforcement of sound auditing mechanisms and information systems, as well as the continuous review of indicators and their suitability for the health needs of the population.

[Professional paths of alumni from doctorate programs in health and biological sciences]. / Trajetória profissional de egressos de cursos de doutorado nas áreas da saúde e biociências.

OBJECTIVE: To analyze the career path and professional satisfaction of alumni from the doctorate degree programs in health sector. METHODS: Exploratory study with 827 alumni of doctoral programs in public health, biological and health sciences at the Fundação Oswaldo Cruz , RJ, Southeastern Brazil, from 1984 to 2007. The subjects were grouped in three cross-temporal cohorts according to year. The profiles of the alumni were analyzed, their career paths mapped and information on the perceptions of the education they received and the reasons that led them to choose the institute for their doctoral courses gathered, as well as their evaluations of the courses. The data were collected by means of an online questionnaire. RESULTS: There are differences between cohorts of alumni related to the periods they followed the courses, their distinct educational backgrounds and labor processes between those from the biological and health sciences areas, and to the specificities of the different areas where the institution offers doctoral courses: public health, biological and health sciences. CONCLUSIONS: The results allow the academic management of the educational processes to expand its knowledge, thus establishing a baseline for tracking the trajectory of alumni, and may contribute to upgrading the follow up process of Brazilian graduate programs.

Estado burocrático e a formação em gestão em saúde em perspectiva histórica: semelhanças e diferenças entre Brasil e Espanha / Bureaucratic state and health management training from a historical perspective: similarities and differences between Brazil and Spain

Resumo Este artigo descreveu o contexto histórico da formação em gestão em saúde oferecida no Brasil e buscou identificar suas semelhanças e diferenças com aquela oferecida na Espanha. Adotou-se uma abordagem qualitativa da realidade e o método comparado foi empregado. Como fonte de dados, utilizaram-se a bibliografia científica, os documentos oficiais, que orientam as intervenções no campo da formação em gestão em saúde nos dois países, e a entrevista semiestruturada. As entrevistas foram realizadas com gestores selecionados pelo fato de estarem ocupando ou de terem ocupado cargos de gestão e que tenham participado da conformação da política de saúde, totalizando quatro gestores brasileiros e seis espanhóis. Apoiados na análise de conteúdo temática, os resultados se relacionaram com a categoria "institucionalidade" a partir dos seguintes temas: política de saúde e educação; política de formação de gestores; e profissionalização. Identificou-se como elemento comum o fato de tanto o Brasil quanto a Espanha adotarem a proteção à saúde como direito de cidadania por meio de sistemas públicos e universais de saúde. A diferença mais significativa diz respeito à cobertura populacional, alcançada na quase totalidade na Espanha no final dos anos 1990. Evidenciou-se a inexistência de uma política nacional de formação de gestores nos dois países, considerada central para a profissionalização da gestão em saúde. Ainda que o tema da profissionalização esteja presente no Brasil, na Espanha assumiu contornos institucionais distintos com avanços significativos em período recente.

Abstract The article described the historical context of health management training in Brazil and aimed at identifying similarities and differences between this training in Brazil and Spain, using qualitative approach and comparative method. Data sources included the scientific literature, official documents orienting interventions in health management training, and semi-structured interviews. Interviews were conducted with managers selected on the basis of currently occupying or having occupied management positions, besides experience and participation in shaping policies in health, totaling four managers in Brazil and six in Spain. Based on thematic content analysis, the results were related to the category of "institutionality" according to the following themes: health and education policy, management training policy, and professionalization. A common element was that Brazil and Spain both adopt health protection as a civic right through universal public health systems. The most significant difference relates to population coverage, nearly complete in Spain in the late 1990s. The study showed the lack of a national training policy for managers in both countries and that such a policy is essential for professionalization in health management. Although the theme of professionalization exists in Brazil, in Spain it has distinct institutional characteristics, having achieved important recent progress.

Similaridades e diferenças entre o Mestrado Acadêmico e o Mestrado Profissional enquanto política pública de formação no campo da Saúde Pública / Similarities and diferences between Academic and Professional Master Programs as Educational Public Policy in the field of Public Health

Resumo Ao buscar uma especificidade para o Mestrado Profissional (MP) em Saúde Pública, interrogamos, o que ele, ao se instituir, procurou do ponto de vista de seus meios e finalidades, conservar ou romper com os modelos de formação dos Mestrados Acadêmicos (MA). No campo da Saúde Pública, o tema ganha outros temperos se considerarmos que tanto o MP quanto o MA preservam na finalidade a formação para o Sistema Único de Saúde. Nesse sentido, a pesquisa buscou investigar a vocação heurística e inovadora do MP face ao MA como uma política pública de formação. Em uma perspectiva comparada, analisamos as principais características dos cursos de MP em saúde pública, frente ao processo de flexibilização da pós-graduação brasileira que o diferencia do MA, e discutimos se essas características tornam o MP uma política pública de formação. Na análise dos dados utilizamos o método da Análise de Conteúdo. Concluímos que as instituições de ensino tendem a reproduzir o modelo de formação do MA no MP e a expectativa de tornar o serviço de saúde matéria e motivo para a formação não é suficiente para distinguir ambas modalidades.

Abstract In the attempt to find a specificity for the Professional Master Program in Public Health (PM), we asked, what is, from the point of view of its means and purposes, kept or broke from the training models of the Academic (traditional) Masters Program (AM). In the public health field, this discussion possess an extra "flavor", as both program aim, in Brazil, to prepare health professionals to the Brazilian Unified Health System (SUS). Therefore, this research sought to investigate the heuristic and innovative vocation of the PM vis-à-vis the AM as an education public policy. From a comparative approach, we analyzed the main characteristics and differences among AM and PM, face the flexibilization process of graduate programs in Brazil, and discussed if these features would characterize the PM into an educational public policy. Data was analyzed by the Content Analysis method. We conclude that educational institutions tend to reproduce the AM training model in the PM and the expectation of making the health service matter and reason for training is not sufficient to distinguish both modes.