Who collaborating centers in iran meeting with who colleagues june 4 2014
This presentation is the property of its rightful owner.
Sponsored Links
1 / 97

WHO Collaborating Centers In Iran meeting with WHO Colleagues June 4,2014 PowerPoint PPT Presentation


  • 110 Views
  • Uploaded on
  • Presentation posted in: General

WHO Collaborating Centers In Iran meeting with WHO Colleagues June 4,2014 . Reza Malekzadeh M.D Professor of Medicine Deputy for Research and Technology MOHE IR Iran. WHO Collaborating Centres. Digestive Disease Research Institute, TUMS

Download Presentation

WHO Collaborating Centers In Iran meeting with WHO Colleagues June 4,2014

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Who collaborating centers in iran meeting with who colleagues june 4 2014

WHO Collaborating Centers In Iranmeeting with WHO ColleaguesJune 4,2014

Reza Malekzadeh M.D

Professor of Medicine

Deputy for Research and Technology

MOHE IR Iran


Who collaborating centres

WHO Collaborating Centres

  • Digestive Disease Research Institute, TUMS

  • Endocrinology & Metabolism Research Institute, TUMS

  • Research Centre for Diseases of Ear, Nose Throat, IUMS

  • Mental Health Research Centre, IUMS

  • Centre for Nursing Care Research, IUMS

  • National Research Institute of Tuberculosis and Lung Disease, SBMU

  • Community Oral Health Department, School of Dentistry, SBMU

  • Ophthalmic Research Centre, SBMU

  • Tobacco Prevention and Control Research Centre, SBMU

  • Educational Development Centre, SBMU

  • Isfahan Cardiovascular Research Centre, MUI

  • Regional Knowledge Hub for HIV/AIDS Surveillance, KMU

  • National Public Health Management Centre, TBZMED

  • Rabies Research Department, Pasteur Institute of Iran, MOHME

  • Reference Health Laboratories, MOHME

  • Iranian Blood Transfusion Organization (IBTO)


Who collaborating centres p ending status

WHO Collaborating CentresPending Status

  • National Nutrition and Food Technology Research Institute, SBMU

  • Research Institute for Endocrine Sciences, SBMU

  • Scientific Publication and Information Development Center, MOHME


Proposal for designation as whocc

Proposal for designation as WHOCC

  • National Institute of Health Research, TUMS

  • Institute for Environmental Research, TUMS

  • Safety Promotion and Injury Prevention Research Centre, SBMU

  • Toxicological research Centre, SBMU

  • Health Policy Research Centre, SUMS

  • Occupational Health Research Centre,IUMS

  • Institute for Futures Studies in Health, KMU

  • Malarial and Vector Research Group, Biotechnology Research Centre, Pasteur Institute of Iran

  • Reference Food and Drug Laboratories, FDO

  • Noor Ophthalmology Research Centre


Who collaborating centres potential centres candidates

WHO Collaborating CentresPotential Centres Candidates

  • Centre for Research and Training in Skin Disease and Leprosy, TUMS

  • Sina Trauma and Surgery Research Centre, TUMS

  • Growth and Development Research Centre, TUMS

  • Psychiatry and Psychology Research Centre, TUMS

  • Food Security Research Center, MUI

  • ZahedanHealth Promotion Research Centre, ZAUMS

  • Liver and Gastrointestinal Diseases Research Centre, TBZMED


Health in the islamic republic of iran

Health in the Islamic Republic of Iran

May 2014


Global burden of disease gbd study iran 2010

Global Burden of Disease (GBD) Study Iran, 2010

Archives of Iranian Medicine May 2014

special ISSUE


History of gbd

History of GBD

  • GBD is the largest study on health at global, regional, and national levels

  • GBD has been started since 1990 with collaboration of 486 researchers from 302 research center in 50 countries

  • Methodologically, GBD is a systematic review of all published and unpublished data at national levels in 188 countries from 1990 to 2010

  • In GBD, novel statistical methods have been used to estimate prevalence of diseases and risk factors in places and times where no data is available


Main features of gbd

Main Features of GBD

  • Innovation of indicators that make possible the comparison of burden of diseases between different countries, in different regions, and different time frames

  • Innovation of indicators that measure not only diseases (289 diseases) and risk factors (67 risk factors), but also health, quality of life, and disability


Epidemiological transition

Epidemiological Transition

  • In developing countries, a trend from communicable diseases to non-communicable chronic diseases has been observed

  • The epidemiological transition is an evident sign of development in a developing country


Gbd 2010 iran

GBD 2010 Iran

  • Burden of 67 risk factors and 291 diseases for three time points (1990, 2005, and 2010) during the last 20 years in Iran*

  • The obvious finding is a shift away from premature death to years lived with disability and from infectious and communicable etiologies to chronic non-communicable diseases (NCDs)

*AIM 2014 May


Two decades increase in life expectancy

Two Decades increase in Life expectancy

  • Despite post revolution conflicts, an 8-year war, tight economic sanctions by Western countries, and multiple earthquakes over the last three decades:

  • Life expectancy increased by 22 years for women and 21 years for men


Results 2010 gbd

Results 2010GBD

  • Total number of deaths in 2010 in Iran: 351,814

  • Deaths in men in 2010: 223,768

  • Deaths in women in 2010: 128,045

  • Transport accidents have been the main causes of YLL


Ncds in global scale

NCDs in global scale

Causes of death, 1990

Causes of death, 2010

GBD 2010


Ncds in iran

NCDs in Iran

Causes of death, 1990

Causes of death, 2010

GBD 2010


Main ncds in iran

Main NCDs in Iran

Fatal Diseases

Ischemic Heart Disease

Stroke

Hypertension

Diabetes

Transport accidents

Cancers

Non-fatal disabling Diseases

Mental Diseases

Musculoskeletal Diseases

Diabetes

Transport accidents

Chronic Respiratory Diseases

Unintentional Injuries

GBD 2010


Main causes of death in men in iran 2010

Main causes of death in men in Iran, 2010

GBD 2010


Main causes of death in women in iran 2010

Main causes of death in women in Iran, 2010

GBD 2010


Main causes of disability in men in iran 2010

Main causes of disability in men in Iran, 2010

GBD 2010


Main causes of disability in women in iran 2010

Main causes of disability in women in Iran, 2010

GBD 2010


Factors influencing the epidemiological transition

Factors Influencing the Epidemiological Transition

  • Increased Literacy Rate

  • Modernization

  • Increased Urbanization

  • Increased Socio-Economical Status

  • Change in life style towards Western Style

    AND

  • The efficiency of the health system in prevention and control of communicable, maternal, and neonatal diseases and nutritional disorders


Achievements of health system in iran

Achievements of Health System in Iran

  • Increased life expectancy at birth by 22 years despite war, earthquakes, and economical sacntions

  • Decrease in mortality rates in all ages

  • Decrease in mortality rates among children under 5 years old

  • Decrease in maternal mortality rates

  • Decrease in fertility rates

Ministry of Health and Medical Education


Achievements of health system in iran1

Achievements of Health System in Iran

  • The percentage of iodinated salt surpasses 95%

  • The vaccination coverage of BCG, DPT, Polio, MMR, and hepatitis B surpassed 99%

  • Polio is eradicated

  • The prevalence and incidence of main communicable diseases including malaria, typhoid, and tuberculosis has decreased

Ministry of Health and Medical Education


Decreased inequality in under 5 mortality rate from 1981 to 2011

Decreased Inequality in Under 5 Mortality Rate from 1981 to 2011

Farzadfar et al unpublished


The trend in control of malaria from 1994 to 2012

The Trend in Control of Malaria from 1994 to 2012

Ministry of Health and Medical Education


Trend in control of typhoid from 1962 to 2010

Trend in Control of Typhoid from 1962 to 2010

Ministry of Health and Medical Education


The trend in incidence of tuberculosis

The Trend in Incidence of Tuberculosis

Ministry of Health and Medical Education


Trend in detection and control of hiv

Trend in Detection and Control of HIV

  • Prevalence of HIV/AIDS in patients suffering from tuberculosis:

    in 2010: 3.8%

    in 2012: 2.5%

Ministry of Health and Medical Education


Improvement of infrastructure

Improvement of Infrastructure

  • The achievement of campaigns for construction and literacy, increased GDP per capita, and the establishment of primary health care system in Iran:

  • Increased access to healthy drinking water

  • Increased access to healthy waste

  • Increased access to electricity and gas

  • Improved roads between cities


The age structure in iran 2013

The age structure in Iran 2013

Statistical Center of Iran


Population of iran from 1956 to 2011

Population of Iran from 1956 to 2011

Statistical Center of Iran


Urbanization in iran from 1956 to 2011

Urbanization in Iran from 1956 to 2011

Statistical Center of Iran


The literacy rate among people older than 5 from 1956 to 2011

The literacy rate among people older than 5 from 1956 to 2011

Statistical Center of Iran


Access to drinking water and healthy waste in rural areas from 2006 to 2010

Access to Drinking Water and Healthy Waste in Rural Areas from 2006 to 2010

Statistical Center of Iran


The number of hiv aids deaths

The Number of HIV/AIDS Deaths

Ministry of Health and Medical Education


The necessity of change in the health system

The Necessity of Change in the Health System

  • The necessity of changing policies based on new needs and priorities of the health system

  • The necessity of integrating service packages into the current health system to control NCDs and accidents

  • The necessity of inter-sectoral collaboration

  • The necessity of cost effective planning for optimal allocation of limited financial resources


Non communicable diseases

Non-Communicable Diseases

  • NCDs are main threats to economy

  • NCDs lead to inequality in income, decrease in household wealth, increase in health care cost, and decease in productivity

    Prevention is crucial


The trend of the fraction of ylls caused by main ncds 1990 to 2010

The Trend of the fraction of YLLs caused by main NCDs, 1990 to 2010

GBD 2010


Mental diseases

Mental Diseases

  • Prevalence in different regions in Iran: 29%

  • Prevalence in Tehran:

    • In 1998: 21.5%

    • In 2007: 34.2%

  • Lifetime risk of incidence: 14.3%

  • Prevalence in women: 14.3%

  • Prevalence in men: 7.3%


The trend in prevalence and burden of main ncds

The Trend in Prevalence and Burden of Main NCDs

  • Necessity of national surveys to measure and monitor those diseases that impose most burden on Iranians

  • Necessity of improving the quality of routine data

  • The Golestan Cohort Study is the largest prospective study in Middle East has released comprehensive results


Who collaborating centers in iran meeting with who colleagues june 4 2014

*

*Gastro-Esophageal Malignancies In Northern Iran

Arch Iran Med. 2013 Jan;16(1):46-53. doi: 013161/AIM.0014.

T


Golestan cohort study gcs

Golestan Cohort Study (GCS)

  • This is a prospective study on 50,045 subjects 40 to 75 years old

  • Recruitment of subjects in 326 villages and Gonbad city, from 2004 to 2008

  • Subjects consisted of 57% women, 8% rural dwellers, and 74% Turkmens

  • Data collected:

    • Demographic

    • Life style

    • Anthropometric

    • Biochemical samples

    • 10 year follow up


Prevalence of hypertension

Prevalence of Hypertension

GCS 2007


Treatment coverage of hypertension

Treatment Coverage of Hypertension

GCS 2007


Prevalence of diabetes

Prevalence of Diabetes

GCS 2007


Treatment coverage of diabetes

Treatment Coverage of Diabetes

GCS 2007


Prevalence of overweight and obesity

Prevalence of Overweight and Obesity

  • Prevalence of overweight: 62.2%

  • Prevalence of obesity: 28%

  • Comparing to United States:

    • Iranian women are more obese than American women

    • Iranian men or thinner than American men

GCS 2007


Who collaborating centers in iran meeting with who colleagues june 4 2014

The Prevalence of Overweight and Obesity in Iranian and American men and women in GCS

Baharmih,Malekzadeh R BMC public health 2006

GCS 2007


Epidemic of overweight obesity and lack of physical activity

Epidemic of Overweight, Obesity, and Lack of Physical Activity

  • Prevalence of Overweight: 38%

  • Prevalence of Obesity: 22%

  • Significant decrease in physical activity especially among women

  • Prevalence of Diabetes: 10%

  • Prevalence of fatty liver: 30%

GCS 2007


Who collaborating centers in iran meeting with who colleagues june 4 2014

Diet

  • Prevalence of excess consumption: 40%

  • Iranian diet: 40% excess carbohydrate, 30% excess oil

  • High consumption of white rice: Iran is the 13th country in the world in terms of excess consumption of rice (46 kg per person per year)

Non-Communicable Diseases Surveillance Survey 2009


The main risk factors of ncds

The Main Risk Factors of NCDs

Non-Communicable Diseases Surveillance Survey 2009


The most prevalent of ncds risk factors among adolescents and youth

The Most Prevalent of NCDs Risk Factors among Adolescents and Youth

CASPIAN Kelishadi et al 2008, 2007


Risk factors in adolescents and youth

Risk Factors in Adolescents and Youth

  • 10 to 18 years

    • Second hand smoking: 50.6%

    • Low physical activity: 36%

    • Smoking: 12%

  • 15 to 24 years

    - Low physical Activity: 34.5%

    - Overweight: 28%

    - Smoking cigarettes and Hookah: 8%

CASPIAN Kelishadi et al 2008, 2007


Drug abuse

Drug Abuse

  • Iranians consumes 42% of all opium in the world (?)

  • Transit from Afghanistan to Iran

  • Drug abuse as a leisure or due to beliefs on its therapeutic effects


Drug abuse1

Drug Abuse

  • Prevalence of drug abuse in subjects 40 years old and older in GCS: 17%

  • The mean proportion of adolescents who abuse drugs (Kerman, Zanjan, Shiraz, Tabriz):

    • Boys: 12.7% - 26.5%

    • Girls: 7.7% - 11.5%


Sequelae of drug abuse

Sequelae of Drug Abuse

  • Increased all-cause mortality rate

  • Increased mortality rate due to cardiovascular diseases and cancers

  • Increased mortality rate due to asthma, tuberculosis, and chronic respiratory diseases

GCS 2012


Alcohol consumption

Alcohol Consumption

  • High School Adolescents:

    • Boys: 18%

    • Girls: 8%

CASPIAN Kelishadi et al 2008, 2007


Environmental risk factors

Environmental Risk Factors

  • Expansion of slum areas without access to health care and low sanitation

  • Air and noise pollution in cities

  • Exposure to poisons in work places

  • Limited water sources and the risk of drought

  • Use of fossil fuels

  • Inequity in access to fuels

  • Destruction of jungles and green spaces


Who collaborating centers in iran meeting with who colleagues june 4 2014

Management and Quality of Health Care for NCDs at National Level

Non-Communicable Diseases Surveillance Survey, 2005


Management of ncds

Management of NCDs

  • Necessity of research on prevalence of Diseases, communicable and non-communicable at provincial level for cost-efficient policy making

  • Necessity of detecting risk factors for prevention


Who collaborating centers in iran meeting with who colleagues june 4 2014

The Coverage of Diabetes and Hypertension Diagnosis and Treatment in Urban and Rural Areas of Iran, 2005

Non-Communicable Diseases Surveillance Survey 2005


The association of risk factors with ncds

The Association of Risk Factors with NCDs


Who collaborating centers in iran meeting with who colleagues june 4 2014

GBD 2010


Who collaborating centers in iran meeting with who colleagues june 4 2014

GBD 2010


The pathway from risk factors to ncds

The Pathway from Risk Factors to NCDS

Direct Health Care Costs

NCDs

NCDs

Raised Blood Pressure, Obesity, High Blood Glucose, High Lipids

Indirect Costs due to Income and Productivity Losses

Unhealthy Diet, Smoking, Physical Inactivity, Substance abuse

Social Determinants of Health

Globalization, Urbanization, Population Ageing


Impact on socio economic development a vicious circle 2

Impact on Socio-Economic Development: A Vicious Circle (2)

High costs due to chronic nature of diseases

Needs to access drugs and health services

Treatments not part of core services

Probable needs to seek services and drugs in private sector

Increased Out-of-Pocket

Catastrophic Expenditure


Financial turnover in health system in iran

Financial Turnover in Health System in Iran

  • Total Health Expenditure

  • The proportion of health expenditure out of GDP

  • Out of Pocket

  • The share of public and private insurance organizations

  • Insurance coverage

  • Catastrophic expenditure

  • Payment Mechanism


Gdp billion dollars from 1999 to 2013

GDP (Billion Dollars) from 1999 to 2013

Statistical Center of Iran


Trend of health expenditure by financial sources billion rials

Trend of Health Expenditure by Financial Sources (Billion Rials)

Ministry of Health and Medical Education, National Health Accounts


Trend of health expenditure by health care functions billion rials

Trend of Health Expenditure by Health Care Functions (Billion Rials)

Ministry of Health and Medical Education, National Health Accounts


Trend of health expenditure by providers billion rials

Trend of Health Expenditure by Providers (Billion Rials)

Ministry of Health and Medical Education, National Health Accounts


The proportion of total health expenditure out of gdp in iran

The Proportion of Total Health Expenditure out of GDP in Iran

Data: WHO (Global Health Expenditure Database)


Total health expenditure per capita

Total Health Expenditure Per Capita

Data: WHO (Global Health Expenditure Database)


Out of pocket expenditure as of total health expenditure

Out of Pocket Expenditure as % of Total Health Expenditure

Data: WHO (Global Health Expenditure Database)


Percentage of catastrophic expenditure

Percentage of Catastrophic Expenditure

Data: Household Expenditure Survey


Challenges in health system 1

Challenges in Health System (1)

  • Limited Financial Resources

  • Lack of accordance between the capacity of health system and the need for prevention, control, and treatment of NCDs

  • Incomplete insurance coverage and high percentage of out of pocket and catastrophic expenditure

  • Increase in induced demands

  • No implementation of referral system in urban areas


Challenges in health system 2

Challenges in Health System (2)

  • No insurance coverage in slums areas

  • Inequity in access to health care

  • Low quality of health care

  • Low satisfaction of health care

  • Lack of an appropriate approach towards Health Technology Assessment

  • Focus on treatment instead of prevention

  • Lack of evidence-based policy making

  • Low quality of health data infrastructure


What should we do

What should we do?

  • Reconfigure the current primary care system to be responsive to the new burden estimates.

  • Fast and cost-effective move toward a system that focuses on preventing NCDs and road injuries


The alternative no action scenario

The alternative no-actionscenario :

  • Is secondary and tertiary prevention of these conditions that will impose enormous financial costs on the system and, indirectly, on the population.


Ir phc is not well prepared for ncd challenges

IR PHC is not well prepared for NCD challenges

  • The PHC in Iran, similar to several other health systems in LMIC, is not well prepared for confronting the challenges caused by the epidemics of NCDs because of its typical policy direction toward preventing maternal-child conditions and infectious diseases


The policy message

The policy message

  • Nationwide, low-cost, early, and sustainable interventions are needed to mitigate NCDs’ increasing burden


Ncd challenge

NCD Challenge

  • Prevention, early diagnosis and care of NCDs need a different and well prepared health infrastructure to avert huge co-morbidities which contribute greatly to rising health care costs and compromise of economic productivity


Ministry of health and medical education mohme undersecretary of research and technology

Ministry of Health and Medical Education (MoHME)Undersecretary of Research and Technology

Strategic Plan (2014-2019)

June 2014


Strategic plan 2014 2019 strategic aim one

Strategic Plan (2014-2019)Strategic Aim One

Strategic Aim One:

Strengthening Health Research Infrastructure

1-1- Reestablish of the National Research Center for Medical Sciences

1-2- Disease Registries Program

1-3- Cohort Studies

  • in adult (min. 100,000 population per study)

  • in neonates and children (min. 2,000 population per study)


Why cohort studies

Why Cohort Studies?

  • UK Medical Research Council (MRC)has a 50-year history of supporting population cohort studies, including:

  • British 1946 Birth Cohort: the world’s longest continuously running birth cohort

  • UK Biobank: which tracks half a million participants.

  • Million Women Study: the largest longitudinal study of women’s health

  • 2·2 million people in the UK are currently taking part in these large population cohort studies—one in 30 of the general population


Who collaborating centers in iran meeting with who colleagues june 4 2014

Why Cohort Studies?

34 largest UK population cohort studies:

  • Almost £30 million is spent per year on the 34 largest UK population cohort studies

  • 50% of these cohort have been followed for more than 20 years

  • 92% of cohort participants are aged 45 years or older

  • 62% are female


Who collaborating centers in iran meeting with who colleagues june 4 2014

Why Cohort Studies?

What are the strength of Cohort study?

  • Ability to identify multiple risk factors over time

  • Assessment of exposures that cannot be randomized (smoking, alcohol,…)

  • Collection of serial measurements and samples that enables measurement of changes in exposure and their effect on health outcomes over time

  • Identifying the effect of one risk factor on multiple outcomes

  • Cohorts are generally more inclusive than RCTs which are usually highly selective

  • Findings from cohort studies can, therefore, be more generalizable to the population as a whole

  • Feasibility of further research through linkage to routine data and further laboratory and genetic study


Who collaborating centers in iran meeting with who colleagues june 4 2014

Why Cohort Studies?

Cross-cohort collaborations

  • An effective way to increase statistical power

  • The Healthy Ageing Across the Life Course (HALCyon) collaboration merged data from nine cohorts to undertake studies of ageing that would not have been feasible using any single cohort

  • Cohort and Longitudinal Studies Enhancement Resources (CLOSER) initiative, funded by the MRC and Economic and Social Research Council, brings together nine cohorts with the aim of combining variables across these studies

  • Cohorts should use standardized and validated approaches, where possible, to facilitate cross-cohort comparisons


Who collaborating centers in iran meeting with who colleagues june 4 2014

Strategic Plan (2014-2019)Strategic Aim One

1-4- To Build Core Laboratories in 10 Medical Universities

1-5- Development of Cutting-Edge Science

  • Iran National Brain Mapping Center

  • Regenerative Medicine Centre

  • Iranian Genomes Project

    1-6- Application of Electronic Health Records in Clinical, Epidemiologic and Health Management Research


Strategic plan 2014 2019 strategic aim two

Strategic Plan (2014-2019)Strategic Aim Two

Strategic Aim Two:

Capacity building for academic and research staff

2-1- Clinician Scientist Training Program

2-2- Postdoctoral Research Program

2-3- Improving the Quality of PhD by Research Program

2-4- Research Grant for Top Scientists (with high ranked h-index)

2-5- International Collaboration with Health and Biomedical Research Centers


Who collaborating centers in iran meeting with who colleagues june 4 2014

International Collaboration of Medicine Documents in Iran

SCImago Journal & Country Rank


Strategic plan 2014 2019 strategic aim three

Strategic Plan (2014-2019)Strategic Aim Three

Strategic Aim Three:

Health Technology Development

3-1- Clinician Scientist Training Program

3-2- Development of Incubators in Medical Universities

3-3- Supporting Knowledge-Based Companies in Health and Biomedical Field


Strategic plan 2014 2019 strategic aim four

Strategic Plan (2014-2019)Strategic Aim Four

Strategic Aim Four:

Development of Sources of Health Research Funding

4-1- Allocation of at least one percent of a medical university’s budgets for research

4-2- Supporting establishment of non-governmental health and biomedical research centers

4-3- Development of health and biomedical research charities

4-4- Absorption of funds for health research from other governmental sources


Who collaborating centers in iran meeting with who colleagues june 4 2014

“Development of Research and Technology” Budget Chapterin Ministry of Health Compared to Ministry of Science (1393)


Research budget in iranian medical universities research centers and ministry 1393 compared to 1392

Research Budget in Iranian Medical Universities, Research Centers and Ministry (1393 compared to 1392)


Charitable spending on research in the uk 2008 2012

Charitable spending on research in the UK 2008-2012

Medical research charities have consistently spent more than £1bn on research in each of the past five years

See more at: http://www.amrc.org.uk/our-members/sector-data/research-spend#sthash.U2ZGARpv.dpuf


Strategic plan 2014 2019 strategic aim five

Strategic Plan (2014-2019)Strategic Aim Five

Strategic Aim Five:

Enhancing the Quality of Health Research

5-1- Improving assessment of health research and researchers

5-2- Quantitative and Qualitative Development of “Health System Research”

5-3- Supporting Iranian Medical Journals for Indexing in MEDLINE, ISI Web of Science and Scopus as well as Enhancing Their Quality

5-4- Improving Peer-Review System in Health Research and Technology Assessment

5-5- Shifting Authority of Medical Journals from Public Universities to Scientific Medical Associations and NGOs


  • Login