Using measures of quality of care to assess equity in health care funding for primary care: analysis of Indonesian household data.

BACKGROUND: Many countries implementing pro-poor reforms to expand subsidized health care, especially for the poor, recognize that high-quality healthcare, and not just access alone, is necessary to meet the Sustainable Development Goals. As the poor are more likely to use low quality health services, measures to improve access to health care need to emphasise quality as the cornerstone to achieving equity goals. Current methods to evaluate health systems financing equity fail to take into account measures of quality. This paper aims to provide a worked example of how to adapt a popular quantitative approach, Benefit Incidence Analysis (BIA), to incorporate a quality weighting into the computation of public subsidies for health care. METHODS: We used a dataset consisting of a sample of households surveyed in 10 provinces of Indonesia in early-2018. In parallel, a survey of public health facilities was conducted in the same geographical areas, and information about health facility infrastructure and basic equipment was collected. In each facility, an index of service readiness was computed as a measure of quality. Individuals who reported visiting a primary health care facility in the month before the interview were matched to their chosen facility. Standard BIA and an extended BIA that adjusts for service quality were conducted. RESULTS: Quality scores were relatively high across all facilities, with an average of 82%. Scores for basic equipment were highest, with an average score of 99% compared to essential medicines with an average score of 60%. Our findings from the quality-weighted BIA show that the distribution of subsidies for public primary health care facilities became less 'pro-poor' while private clinics became more 'pro-rich' after accounting for quality of care. Overall the distribution of subsidies became significantly pro-rich (CI = 0.037). CONCLUSIONS: Routine collection of quality indicators that can be linked to individuals is needed to enable a comprehensive understanding of individuals' pathways of care. From a policy perspective, accounting for quality of care in health financing assessment is crucial in a context where quality of care is a nationwide issue. In such a context, any health financing performance assessment is likely to be biased if quality is not accounted for

Equity of health financing in Indonesia: A 5-year financing incidence analysis (2015-2019).

BACKGROUND: In 2014, Indonesia launched a single payer national health insurance scheme with the aim of covering the entire population by 2024. The objective of this paper is to assess the equity with which contributions to the health financing system were distributed in Indonesia over 2015 - 2019. METHODS: This study is a secondary analysis of nationally representative data from the National Socioeconomic Survey of Indonesia (2015 - 2019). The relative progressivity of each health financing source and overall health financing was determined using a summary score, the Kakwani index. FINDINGS: Around a third of health financing was sourced from out-of-pocket (OOP) payments each year, with direct taxes, indirect taxes and social health insurance (SHI) each taking up 15 - 20%. Direct taxes and OOP payments were progressive sources of health financing, and indirect tax payments regressive, for all of 2015 - 2019. SHI contributions were regressive except in 2017 and 2018. The overall health financing system was progressive from 2015 to 2018, but this declined year by year and became mildly regressive in 2019. INTERPRETATION: The declining progressivity of the overall health financing system between 2015 - 2019 suggests that Indonesia still has a way to go in developing a fair and equitable health financing system that ensures the poor are financially protected. FUNDING: This study is supported through the Health Systems Research Initiative in the UK, and is jointly funded by the Department of International Development, the Economic and Social Research Council, the Medical Research Council and the Wellcome Trust

Régulation de la télomérase par l'hélicase Pif1 chez la levure Saccharomyces cerevisiae (implication dans la stabilité du génome)

Les télomères sont les structures nucléoprotéiques qui constituent l'extrémité des chromosomes eucaryotes. L'ADN télomérique est formé par la répétition de courtes séquences, qui ne sont pas répliquées intégralement. A chaque division cellulaire, la taille des télomères diminue donc, jusqu'à atteindre un seuil critique au-delà de laquelle la cellule ne peut plus se diviser. Dans les cellules germinales ou chez les organismes unicellulaires, la taille des télomères reste constante grâce à la présence d'une enzyme, la télomérase. Il s'agit d'une transcriptase inverse, formée d'une sous-unité portant l'activité catalytique (Est2 chez S. cerevisiae), et d'un ARN (TLC1 chez S. cerevisiae) qui sert de matrice pour l'ajout des répétitions. La réactivation de la télomérase dans des cellules somatiques peut conduire à leur transformation cancéreuse, car elles acquièrent la capacité de proliférer indéfiniment. A l'inverse, un déficit de l'expression ou de l'activité de la télomérase peut conduire à une autre maladie, la dyskératose congénitale. La compréhension de la régulation de la télomérase est donc importante, notamment dans la recherche sur ces deux pathologies. Chez Saccharomyces cerevisiae, la régulation négative de la télomérase implique notamment Pif1, une hélicase conservée chez l'Homme. Elle inhibe la télomérase en la dissociant de l'ADN télomérique. Nous avons montré que Pif1 et un sous domaine de la télomérase, le domaine des doigts, appartiennent à une même voie de régulation. En utilisant de la télomérase, qui la rend résistante à Pif1 au télomère, et qui permet de détecter une interaction entre Pif1 et le complexe télomérase, nous avons caractérisé cette voie. Ainsi, nous avons montré, d'une part, que le domaine des doigts de la télomérase est impliqué dans le maintien global de la stabilité du génome. En effet, de même que Pif1, il limite l'ajout de télomères sur des cassures double-brin de l'ADN, favorisant ainsi leur réparation par des voies conventionnelles. D'autre part, nous avons décrit l'interaction existant entre Pif1 et le domaine des doigts. par microscopie, nous avons identifié un complexe au moins partiellement cytoplasmique. Des analyses biochimiques in vivo nous ont permis de conclure que ce complexe est indépendant de l'ADN. Il n'est perdu que lors de mutations de la sous-unité catalytique de la télomérase. Nous pensons que les protéines Pif1 et Est2 interagissent directement l'une avec l'autre. Ces résultats permettent de mieux comprendre la régulation de la télomérase chez S. cerevisiae, et mettent au jour une implication directe, jusqu'alors inconnue, de la télomérase dans le maintien de l'intégrité du génome.Most of eukaryotic organisms posses telomeres at the extremity of their linear chromosomes. Telomeres are formed by G-rich repetitive sequences, TG1-3 in Saccharomyces cerevisiae, and of associated proteins. At each stage of replication, telomere length decreases. Telomerase is the reverse transcriptase that is involved in the re-synthesis of telomeres. In S. cerevisiae, the enzyme is composed of the Est2 protein and of the TLC1 RNA. A few years ago, we described the est2-up34 mutation of the finger domain of Est2, which leads to elongated telomeres. This mutation also makes telomerase resistant to Pif1, a negative regulator of telomerase, which dissociates it from telomeric DNA. Here, we studied more precisely the relationship between Pif1 and telomerase, using the est2-up34 mutation as a tool. First, we analyzed the phenotypes of this mutation at a DSB site. We found that est2-up34 cells are deficient in repair, as GCR rate and sensitivity to genotoxic agents were both increased. The mutated telomerase was more recruited to a lesion, and seems to be insensitive to Rad52 competition. Moreover, est2-up34 mutation is epistatic to RAD24 deletion. We propose that the finger domain is involved in the inhibition of telomerase binding to a DSB, which demonstrate an uncharacterized role in the maintenance of genome stability. Second, we focused on the interaction between Pif1 and telomerase. We found that it exists outside of the nucleus, and is DNA independent. However, the complex formed by Pif1 and telomerase is addressed to DNA after DSB induction, which then could be involved in the regulation of telomerase at a break. Using several gene deletions, we faileds to detect any element required for this interaction. In fact, the complex only depends upon the presence of Est2, suggesting a direct interaction between both proteins. We proposed that Pif1 and the finger domain of telomerase interact to maintain genome stability.LYON-ENS Sciences (693872304) / SudocSudocFranceF

The finger subdomain of yeast telomerase cooperates with Pif1 p to limit telomere elongation

International audienc

The global downregulation of protein synthesis observed during hepatogenic maturation is associated with a decrease in TOP mRNA translation

Translational regulation is of paramount importance for proteome remodeling during stem cell differentiation at both the global and the transcript-specific levels. In this study, we characterized translational remodeling during hepatogenic differentiation of induced pluripotent stem cells (iPSCs) by polysome profiling. We demonstrate that protein synthesis increases during exit from pluripotency and is then globally repressed during later steps of hepatogenic maturation. This global downregulation of translation is accompanied by a decrease in the abundance of protein components of the translation machinery, which involves a global reduction in translational efficiency of terminal oligopyrimidine tract (TOP) mRNA encoding translation-related factors. Despite global translational repression during hepatogenic differentiation, key hepatogenic genes remain efficiently translated, and the translation of several transcripts involved in hepatospecific functions and metabolic maturation is even induced. We conclude that, during hepatogenic differentiation, a global decrease in protein synthesis is accompanied by a specific translational rewiring of hepatospecific transcripts

Incidence of catastrophic health spending in Indonesia: insights from a Household Panel Study 2018–2019

Abstract Background Indonesia implemented one of the world’s largest single-payer national health insurance schemes (the Jaminan Kesehatan Nasional or JKN) in 2014. This study aims to assess the incidence of catastrophic health spending (CHS) and its determinants and trends between 2018 and 2019 by which time JKN enrolment coverage exceeded 80%. Methods This study analysed data collected from a two-round cross-sectional household survey conducted in ten provinces of Indonesia in February–April 2018 and August–October 2019. The incidence of CHS was defined as the proportion of households with out-of-pocket (OOP) health spending exceeding 10% of household consumption expenditure. Chi-squared tests were used to compare the incidences of CHS across subgroups for each household characteristic. Logistic regression models were used to investigate factors associated with incurring CHS and the trend over time. Sensitivity analyses assessing the incidence of CHS based on a higher threshold of 25% of total household expenditure were conducted. Results The overall incidence of CHS at the 10% threshold fell from 7.9% to 2018 to 4.4% in 2019. The logistic regression models showed that households with JKN membership experienced significantly lower incidence of CHS compared to households without insurance coverage in both years. The poorest households were more likely to incur CHS compared to households in other wealth quintiles. Other predictors of incurring CHS included living in rural areas and visiting private health facilities. Conclusions This study demonstrated that the overall incidence of CHS decreased in Indonesia between 2018 and 2019. OOP payments for health care and the risk of CHS still loom high among JKN members and among the lowest income households. More needs to be done to further contain OOP payments and further research is needed to investigate whether CHS pushes households below the poverty line

Low incidence of SARS-CoV-2, risk factors of mortality and the course of illness in the French national cohort of dialysis patients

International audienceThe aim of this study was to estimate the incidence of COVID-19 disease in the French national population of dialysis patients, their course of illness and to identify the risk factors associated with mortality. Our study included all patients on dialysis recorded in the French REIN Registry in April 2020. Clinical characteristics at last follow-up and the evolution of COVID-19 illness severity over time were recorded for diagnosed cases (either suspicious clinical symptoms, characteristic signs on the chest scan or a positive reverse transcription polymerase chain reaction) for SARS-CoV-2. A total of 1,621 infected patients were reported on the REIN registry from March 16th, 2020 to May 4th, 2020. Of these, 344 died. The prevalence of COVID-19 patients varied from less than 1% to 10% between regions. The probability of being a case was higher in males, patients with diabetes, those in need of assistance for transfer or treated at a self-care unit. Dialysis at home was associated with a lower probability of being infected as was being a smoker, a former smoker, having an active malignancy, or peripheral vascular disease. Mortality in diagnosed cases (21%) was associated with the same causes as in the general population. Higher age, hypoalbuminemia and the presence of an ischemic heart disease were statistically independently associated with a higher risk of death. Being treated at a selfcare unit was associated with a lower risk. Thus, our study showed a relatively low frequency of COVID-19 among dialysis patients contrary to what might have been assumed