Improving health worker performance: the patient-perspective from a PBF program in Rwanda

The effect of performance-based financing (PBF) on patients' perception of primary health care services in developing countries in not well documented. Data from a randomized impact evaluation in Rwanda conducted between 2006 and 2008 in 157 primary level facilities is used to explore patients' satisfaction with clinical and non-clinical services and quantify the contribution of individual and facility characteristics to satisfaction including PBF. Improvements in productivity, availability and competences of the health workforce following the implementation of PBF have a positive effect on patients' satisfaction with clinical services even if patients' satisfaction is not tied to a reward. The positive effect of PBF on non-clinical dimensions of satisfaction also suggests that PBF incentivizes providers to raise patients' satisfaction with non-clinical services if it is associated with future financial gains. It is recommended that low and middle income countries build on the experience from high income countries to better listen to patients' voice in general and include an assessment of patients' satisfaction in incentive mechanisms as a way to increase the benefits of the strateg

An analysis of health service delivery performance in Rwanda

Health systems worldwide fail to produce optimal health outcomes, and successive reforms have sought to make them more efficient, more equitable and more responsive. The overarching objective of this thesis is to explore how to motivate healthcare providers in improving performance in service delivery in low income countries. The thesis explores whether financial incentives for healthcare providers raise productivity and how they may affect equity in utilization of healthcare services and responsiveness to patients’ needs. The thesis argues that, as performance-based financing (PBF) focuses on supply side barriers, it may lead to efficiency gains rather than equity improvements. It uses data from a randomized controlled impact evaluation in Rwanda to generate robust evidence on performance-based financing and address a gap in the knowledge on its unintended consequences. Statistical methods are used to analyze four aspects: the impact on health workforce productivity; the impact on health workforce responsiveness; the impact on equity in utilization of basic health services; and, the impact on spatial disparities in the utilization of health services. Findings indicate that performancebased financing has a positive impact on efficiency: it raises health workforce productivity through higher workload and lower absenteeism; and, it encourages healthcare providers to be more responsive which positively impacts the quality of care perceived by patients. Findings also indicate that the impact on equity is uncertain as PBF can deter equity in access for the poorest in the absence of a compensating mechanism; however, PBF is a powerful reform catalyzer and can reduce inequalities between regions and households when combined with appropriate reforms that control for its potential perverse effects. This thesis advocates that strategies aiming to raise healthcare providers’ motivation should be used to raise performance in service delivery in low-income countries with particular attention to their effect on end users

Skills and technology for pharmaceuticals

International audienc

Le diabète de type 2 à La Réunion (le poids de la tradition)

SAINT DENIS/REUNION-Droit Lettre (974112101) / SudocPARIS-BIUP (751062107) / SudocSudocFranceF

Energy Consumption and Health Outcomes in Africa

International audienceWe examine causal links between energy consumption and health indicators (Mortality rate under-5, life expectancy, greenhouse effect, and government expenditure per capita) for a sample of 16 African countries over the period 1971-2010 (according to availability of countries' data). We use the panel-data approach of Kónya (2006), which is based on SUR systems and Wald tests with country specific bootstrap critical values. Our results show that health and energy consumption are strongly linked in Africa. Unilateral causality is found from energy consumption to life expectancy and child under-5 mortality for Senegal, Morocco, Benin, DRC, Algeria, Egypt, and South Africa. At the same time, we found a bilateral causality between energy consumption and health indicators in Nigeria. In particular, our findings suggest that electricity consumption Granger causes health outcomes for several African countries

Transcriptional Coactivator and Chromatin Protein PC4 Is Involved in Hippocampal Neurogenesis and Spatial Memory Extinction

International audienceAlthough the elaborate combination of histone and non-histone protein complexes defines chromatin organization and hence regulates numerous nuclear processes, the role of chromatin organizing proteins remains unexplored at the organismal level. The highly abundant, multifunctional, chromatin-associated protein and transcriptional coactivator positive coactivator 4 (PC4/Sub1) is absolutely critical for life, because its absence leads to embryonic lethality. Here, we report results obtained with conditional PC4 knock-out (PC4(f/f) Nestin-Cre) mice where PC4 is knocked out specifically in the brain. Compared with the control (PC4(+/+) Nestin-Cre) mice, PC4(f/f) Nestin-Cre mice are smaller with decreased nocturnal activity but are fertile and show no motor dysfunction. Neurons in different areas of the brains of these mice show sensitivity to hypoxia/anoxia, and decreased adult neurogenesis was observed in the dentate gyrus. Interestingly, PC4(f/f) Nestin-Cre mice exhibit a severe deficit in spatial memory extinction, whereas acquisition and long term retention were unaffected. Gene expression analysis of the dorsal hippocampus of PC4(f/f) Nestin-Cre mice revealed dysregulated expression of several neural function-associated genes, and PC4 was consistently found to localize on the promoters of these genes, indicating that PC4 regulates their expression. These observations indicate that non-histone chromatin-associated proteins like PC4 play a significant role in neuronal plasticity

New sequential combinations of non-invasive fibrosis tests provide an accurate diagnosis of advanced fibrosis in NAFLD

International audienc

Del17p without TP53 mutation confers poor prognosis in intensively treated newly diagnosed multiple myeloma patients

International audienceDespite tremendous improvements in the outcome of patients with multiple myeloma (MM) in the past decade, high-risk patients have not benefited from the approval of novel drugs. The most important prognostic factor is the loss of parts of the short arm of chromosome 17, known as deletion 17p (del(17p)). A recent publication (on a small number of patients) suggested that these patients are at very high-risk only if del(17p) is associated with TP53 mutations, the so-called "double-hit" population. To validate this finding, we designed a much larger study on 121 patients presenting del(17p) in >55% of their plasma cells, and homogeneously treated by an intensive approach. For these 121 patients, we performed deep next generation sequencing targeted on TP53. The outcome was then compared to a large control population (2505 patients lacking del(17p)). Our results confirmed that the "double hit" situation is the worst (median survival = 36 months), but that del(17p) alone also confers a poor outcome compared with the control cohort (median survival = 52.8 months vs 152.2 months, respectively). In conclusion, our study clearly confirms the extremely poor outcome of patients displaying "double hit", but also that del(17p) alone is still a very high-risk feature, confirming its value as a prognostic indicator for poor outcome

Primary plasma cell leukemias displaying t(11;14) have specific genomic, transcriptional, and clinical features

International audiencePrimary plasma cell leukemia (pPCL) is an aggressive form of multiple myeloma (MM) that has not benefited from recent therapeutic advances in the field. Because it is very rare and heterogeneous, it remains poorly understood at the molecular level. To address this issue, we performed DNA and RNA sequencing of sorted plasma cells from a large cohort of 90 newly diagnosed pPCL and compared with MM. We observed that pPCL presents a specific genomic landscape with a high prevalence of t(11;14) (about half) and high-risk genomic features such as del(17p), gain 1q, and del(1p32). In addition, pPCL displays a specific transcriptome when compared with MM. We then wanted to characterize specifically pPCL with t(11;14). We observed that this subentity displayed significantly fewer adverse cytogenetic abnormalities. This translated into better overall survival when compared with pPCL without t(11;14) (39.2 months vs 17.9 months, P 5 .002). Finally, pPCL with t(11;14) displayed a specific transcriptome, including differential expression of BCL2 family members. This study is the largest series of patients with pPCL reported so far