Performance-based incentives and community health workers' outputs, a systematic review.

ObjectiveTo review the evidence on the impact on measurable outcomes of performance-based incentives for community health workers (CHWs) in low- and middle-income countries.MethodsWe conducted a systematic review of intervention studies published before November 2020 that evaluated the impact of financial and non-financial performance-based incentives for CHWs. Outcomes included patient health indicators; quality, utilization or delivery of health-care services; and CHW motivation or satisfaction. We assessed risk of bias for all included studies using the Cochrane tool. We based our narrative synthesis on a framework for measuring the performance of CHW programmes, comprising inputs, processes, performance outputs and health outcomes.FindingsTwo reviewers screened 2811 records; we included 12 studies, 11 of which were randomized controlled trials and one a non-randomized trial. We found that non-financial, publicly displayed recognition of CHWs' efforts was effective in improved service delivery outcomes. While large financial incentives were more effective than small ones in bringing about improved performance, they often resulted in the reallocation of effort away from other, non-incentivized tasks. We found no studies that tested a combined package of financial and non-financial incentives. The rationale for the design of performance-based incentives or explanation of how incentives interacted with contextual factors were rarely reported.ConclusionFinancial performance-based incentives alone can improve CHW service delivery outcomes, but at the risk of unincentivized tasks being neglected. As calls to professionalize CHW programmes gain momentum, research that explores the interactions among different forms of incentives, context and sustainability is needed

Performance-based incentives and community health workers’ outputs, a systematic review

Objective To review the evidence on the impact on measurable outcomes of performance-based incentives for community health workers (CHWs) in low-and middle-income countries. Methods We conducted a systematic review of intervention studies published before November 2020 that evaluated the impact of financial and non-financial performance-based incentives for CHWs. Outcomes included patient health indicators; quality, utilization or delivery of health-care services; and CHW motivation or satisfaction. We assessed risk of bias for all included studies using the Cochrane tool. We based our narrative synthesis on a framework for measuring the performance of CHW programmes, comprising inputs, processes, performance outputs and health outcomes. Findings Two reviewers screened 2811 records; we included 12 studies, 11 of which were randomized controlled trials and one a non-randomized trial. We found that non-financial, publicly displayed recognition of CHWs’ efforts was effective in improved service delivery outcomes. While large financial incentives were more effective than small ones in bringing about improved performance, they often resulted in the reallocation of effort away from other, non-incentivized tasks. We found no studies that tested a combined package of financial and non-financial incentives. The rationale for the design of performance-based incentives or explanation of how incentives interacted with contextual factors were rarely reported. Conclusion Financial performance-based incentives alone can improve CHW service delivery outcomes, but at the risk of unincentivized tasks being neglected. As calls to professionalize CHW programmes gain momentum, research that explores the interactions among different forms of incentives, context and sustainability is needed

Understanding community health worker employment preferences in Malang district, Indonesia, using a discrete choice experiment

Background Community health workers (CHWs) play a critical role in supporting health systems, and in improving accessibility to primary healthcare. In many settings CHW programmes do not have formalised employment models and face issues of high attrition and poor performance. This study aims to determine the employment preferences of CHWs in Malang district, Indonesia, to inform policy interventions. Methods A discrete choice experiment was conducted with 471 CHWs across 28 villages. Attributes relevant to CHW employment were identified through a multistage process including literature review, focus group discussions and expert consultation. Respondents' choices were analysed with a mixed multinomial logit model and latent class analyses. Results Five attributes were identified: (1) supervision; (2) training; (3) monthly financial benefit; (4) recognition; and (5) employment structure. The most important influence on choice of job was a low monthly financial benefit (US∼2) (β=0.53, 95% CI=0.43 to 0.63), followed by recognition in the form of a performance feedback report (β=0.13, 95% CI=0.07 to 0.20). A large monthly financial benefit (US∼20) was most unappealing to respondents (β=-0.13, 95% CI=-0.23 to -0.03). Latent class analysis identified two groups of CHWs who differed in their willingness to accept either job presented and preferences over specific attributes. Preferences diverged based on respondent characteristics including experience, hours' worked per week and income. Conclusion CHWs in Malang district, Indonesia, favour a small monthly financial benefit which likely reflects the unique cultural values underpinning the programme and a desire for remuneration that is commensurate with the limited number of hours worked. CHWs also desire enhanced methods of performance feedback and greater structure around training and their rights and responsibilities. Fulfilling these conditions may become increasingly important should CHWs work longer hours

Homologous Recombination Is Stimulated by a Decrease in dUTPase in Arabidopsis

Deoxyuridine triphosphatase (dUTPase) enzyme is an essential enzyme that protects DNA against uracil incorporation. No organism can tolerate the absence of this activity. In this article, we show that dUTPase function is conserved between E. coli (Escherichia coli), yeast (Saccharomyces cerevisiae) and Arabidopsis (Arabidopsis thaliana) and that it is essential in Arabidopsis as in both micro-organisms. Using a RNA interference strategy, plant lines were generated with a diminished dUTPase activity as compared to the wild-type. These plants are sensitive to 5-fluoro-uracil. As an indication of DNA damage, inactivation of dUTPase results in the induction of AtRAD51 and AtPARP2, which are involved in DNA repair. Nevertheless, RNAi/DUT1 constructs are compatible with a rad51 mutation. Using a TUNEL assay, DNA damage was observed in the RNAi/DUT1 plants. Finally, plants carrying a homologous recombination (HR) exclusive substrate transformed with the RNAi/DUT1 construct exhibit a seven times increase in homologous recombination events. Increased HR was only detected in the plants that were the most sensitive to 5-fluoro-uracils, thus establishing a link between uracil incorporation in the genomic DNA and HR. Our results show for the first time that genetic instability provoked by the presence of uracils in the DNA is poorly tolerated and that this base misincorporation globally stimulates HR in plants

The dUTPase Enzyme Is Essential in Mycobacterium smegmatis

Thymidine biosynthesis is essential in all cells. Inhibitors of the enzymes involved in this pathway (e.g. methotrexate) are thus frequently used as cytostatics. Due to its pivotal role in mycobacterial thymidylate synthesis dUTPase, which hydrolyzes dUTP into the dTTP precursor dUMP, has been suggested as a target for new antitubercular agents. All mycobacterial genomes encode dUTPase with a mycobacteria-specific surface loop absent in the human dUTPase. Using Mycobacterium smegmatis as a fast growing model for Mycobacterium tuberculosis, we demonstrate that dUTPase knock-out results in lethality that can be reverted by complementation with wild-type dUTPase. Interestingly, a mutant dUTPase gene lacking the genus-specific loop was unable to complement the knock-out phenotype. We also show that deletion of the mycobacteria-specific loop has no major effect on dUTPase enzymatic properties in vitro and thus a yet to be identified loop-specific function seems to be essential within the bacterial cell context. In addition, here we demonstrated that Mycobacterium tuberculosis dUTPase is fully functional in Mycobacterium smegmatis as it rescues the lethal knock-out phenotype. Our results indicate the potential of dUTPase as a target for antitubercular drugs and identify a genus-specific surface loop on the enzyme as a selective target

Geopolymer/PEG Hybrid Materials Synthesis and Investigation of the Polymer Influence on Microstructure and Mechanical Behavior

Geopolymers are aluminosilicate inorganic polymers, obtained from the alkali activation of powders containing SiO2+Al2O3>80wt%, mainly proposed as environmentally friendly building materials. In this work, metakaolin-based geopolymers have been prepared and a water-soluble polymer, polyethylene glycol (PEG), has been added in different percentages to obtain organic-inorganic hybrid geopolymers. The influence of both the polymer amount and aging time on the structure and the mechanical behavior of the materials were investigated. FTIR spectroscopy allowed us to follow the evolution of the aluminosilicate framework during the geopolymerization process. This analysis revealed that PEG leads to a network which is rich in Al-O-Si bonds and forms H-bonds with the inorganic phase. SEM microscope showed that the two phases are interpenetrated on micrometric scales. Traction and bending tests have been carried out on appropriate samples to investigate the mechanical behavior of the obtained hybrids, showing that both PEG content and aging time affect the material behavior

Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project

Background and objectives: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. Methods: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. Results: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. Conclusion: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia