Effect on hospital incentive payments and quality performance of a hospital pay for performance (P4P) programme in Belgium.

BACKGROUND: Belgium initiated a hospital pay for performance (P4P) programme after a decade of fixed bonus budgets for "quality and safety contracts". This study examined the effect of P4P on hospital incentive payments, performance on quality measures, and the association between changes in quality performance and incentive payments over time. METHODS: The Belgian government provided information on fixed bonus budgets in 2013-2017 and hospital incentive payments as well as hospital performance on quality measures for the P4P programmes in 2018-2020. Descriptive analyses were conducted to map the financial repercussion between the two systems. A difference-in-difference analysis evaluated the association between quality indicator performance and received incentive payments over time. RESULTS: Data from 87 acute-care hospitals were analyzed. In the transition to a P4P programme, 29% of hospitals received lower incentive payments per bed. During the P4P years, quality performance scores increased yearly for 55% of hospitals and decreased yearly for 5% of hospitals. There was a significant larger drop in incentive payments for hospitals that scored above median with the start of the P4P programme. CONCLUSIONS: The transition from fixed bonus budgets for quality efforts to a new incentive payment in a P4P programme has led to more hospitals being financially impacted, although the effect is marginal given the small P4P budget. Quality indicators seem to improve over the years, but this does not correlate with an increase in reward per bed for all hospitals due to the closed nature of the budget.

A long look at short prokaryotic Argonautes.

Argonaute proteins (Agos) use small 15-30 nucleotide-long guides to bind and/or cleave complementary target nucleic acids. Eukaryotic Agos mediate RNA-guided RNA silencing, while 'long' prokaryotic Agos (pAgos) use RNA or DNA guides to interfere with invading plasmid and viral DNA. Here, we review the function and mechanisms of truncated and highly divergent 'short' pAgos, which, until recently, remained functionally uncharacterized. Short pAgos have retained the Middle (MID) and P-element-Induced Wimpy Testis (PIWI) domains important for guide-mediated target binding, but lack the ability to cleave their targets. Instead, emerging insights reveal that various short pAgos interact with distinct accessory 'effector' enzymes. Upon guide-mediated detection of invading DNA by short pAgos, their associated effector enzymes kill the host cell and, consequentially, prevent spread of the invader.

Short prokaryotic Argonaute systems trigger cell death upon detection of invading DNA.

Argonaute proteins use single-stranded RNA or DNA guides to target complementary nucleic acids. This allows eukaryotic Argonaute proteins to mediate RNA interference and long prokaryotic Argonaute proteins to interfere with invading nucleic acids. The function and mechanisms of the phylogenetically distinct short prokaryotic Argonaute proteins remain poorly understood. We demonstrate that short prokaryotic Argonaute and the associated TIR-APAZ (SPARTA) proteins form heterodimeric complexes. Upon guide RNA-mediated target DNA binding, four SPARTA heterodimers form oligomers in which TIR domain-mediated NAD(P)ase activity is unleashed. When expressed in Escherichia coli, SPARTA is activated in the presence of highly transcribed multicopy plasmid DNA, which causes cell death through NAD(P)+ depletion. This results in the removal of plasmid-invaded cells from bacterial cultures. Furthermore, we show that SPARTA can be repurposed for the programmable detection of DNA sequences. In conclusion, our work identifies SPARTA as a prokaryotic immune system that reduces cell viability upon RNA-guided detection of invading DNA.

High-throughput biochemical profiling reveals functional adaptation of a bacterial Argonaute.

Argonautes are nucleic acid-guided proteins that perform numerous cellular functions across all domains of life. Little is known about how distinct evolutionary pressures have shaped each Argonaute's biophysical properties. We applied high-throughput biochemistry to characterize how Thermus thermophilus Argonaute (TtAgo), a DNA-guided DNA endonuclease, finds, binds, and cleaves its targets. We found that TtAgo uses biophysical adaptations similar to those of eukaryotic Argonautes for rapid association but requires more extensive complementarity to achieve high-affinity target binding. Using these data, we constructed models for TtAgo association rates and equilibrium binding affinities that estimate the nucleic acid- and protein-mediated components of the target interaction energies. Finally, we showed that TtAgo cleavage rates vary widely based on the DNA guide, suggesting that only a subset of guides cleaves targets on physiologically relevant timescales.

Cobertura de plano de saúde no Brasil: análise dos dados da Pesquisa Nacional de Saúde 2013 e 2019 / Health insurance coverage in Brazil: analyzing data from the National Health Survey, 2013 and 2019

Resumo Este artigo objetivou descrever a cobertura de plano de saúde no Brasil. Foram analisados dados das edições de 2013 e 2019 da Pesquisa Nacional de Saúde. A cobertura de plano de saúde médico ou odontológico foi analisada segundo características sociodemográficas, econômicas, de trabalho, situação censitária e Unidade da Federação. A cobertura de plano de saúde médico ou odontológico foi 27,9% (IC95%: 27,1-28,8) para 2013 e 28,5% (IC95%: 27,8-29,2) para 2019. Os resultados mostram que a cobertura continua concentrada nos grandes centros urbanos, nas regiões Sudeste e Sul, entre aqueles com melhor nível socioeconômico e aqueles que possuem algum vínculo de trabalho formal. Em 2019, dentre os trabalhadores formalizados, somente 30,7% relatou que o pagamento da mensalidade é feito diretamente a operadora, sendo 72,7% dentre os trabalhadores informais. Cerca de 92% dos planos de saúde médico cobrem internação e dentre as mulheres com plano de saúde, quase 20% delas não possuem cobertura para o parto. Apenas 11,7% das mulheres com idade entre 15 e 44 anos possuem cobertura para o parto através do plano de saúde. Os resultados mostram que a cobertura por plano de saúde mantém-se bastante desigual, reforçando a importância do Sistema Único de Saúde para a população brasileira.

Abstract This paper aimed to describe health insurance coverage in Brazil. Data from the 2013 and 2019 editions of the National Health Survey (PNS) were analyzed. The medical or dental health insurance coverage was analyzed according to demographic and socioeconomic characteristics, work status, urban/rural area, and Federation Unit. Coverage of medical or dental health insurance was 27.9% (95% CI: 27.1-28.8) for 2013 and 28.5% (95% CI: 27.8-29.2) for 2019. The results show coverage is still concentrated in large urban centers, in the Southeast and South, among those with better socioeconomic status and some formal employment. In 2019, only 30.7% of formal workers reported the monthly payment is made directly to the providers, while 72.7% of informal workers reported this information. About 92% of medical health insurance covers hospitalization, and almost 20% of women with health insurance are not covered for labor. Only 11.7% of women aged between 15 and 44 are covered for childbirth by health insurance. The results show the health insurance coverage is still quite unequal, reinforcing the Unified Health System (SUS) importance for the Brazilian population.

Recognition of double-stranded DNA by the Rhodobacter sphaeroides Argonaute protein.

In contrast to eukaryotic Argonaute proteins that act on RNA targets, prokaryotic Argonautes (pAgos) can target DNA, using either small RNA or small DNA guides for its recognition. Since pAgos can recognize only a single strand of DNA and lack a helicase activity, it remains unknown how double-stranded DNA can be bound both in vitro and in vivo. Here, using in vitro reconstitution and footprinting assays we analyze formation of specific complexes with target DNA by a catalytically inactive pAgo, RsAgo from Rhodobacter sphaeroides programmed with small guide RNAs. We showed that RsAgo can recognize a specific site in double-stranded DNA after stepwise reconstitution of the complex from individual oligonucleotides or after prior melting of the DNA target. When bound, RsAgo stabilizes an open DNA bubble corresponding to the length of the guide molecule and protects the target DNA from nuclease cleavage. The results suggest that RsAgo and, possibly, other RNA-guided pAgos cannot directly attack double-stranded DNA and likely require DNA opening by other cellular processes for their action.

Thermus thermophilus Argonaute Functions in the Completion of DNA Replication.

In many eukaryotes, Argonaute proteins, guided by short RNA sequences, defend cells against transposons and viruses. In the eubacterium Thermus thermophilus, the DNA-guided Argonaute TtAgo defends against transformation by DNA plasmids. Here, we report that TtAgo also participates in DNA replication. In vivo, TtAgo binds 15- to 18-nt DNA guides derived from the chromosomal region where replication terminates and associates with proteins known to act in DNA replication. When gyrase, the sole T. thermophilus type II topoisomerase, is inhibited, TtAgo allows the bacterium to finish replicating its circular genome. In contrast, loss of gyrase and TtAgo activity slows growth and produces long sausage-like filaments in which the individual bacteria are linked by DNA. Finally, wild-type T. thermophilus outcompetes an otherwise isogenic strain lacking TtAgo. We propose that the primary role of TtAgo is to help T. thermophilus disentangle the catenated circular chromosomes generated by DNA replication.

Argonaute system of Kordia jejudonensis is a heterodimeric nucleic acid-guided nuclease.

We purified and characterized a prokaryotic argonaute (pAgo) (KjMP) and its associated protein (KjAA) from a bacterium Kordia jejudonensis. The two proteins present as a complex were revealed by the copurification of KjAA with His-tagged KjMP by Ni-NTA affinity column. The KjAA/KjMP complex was a heterodimer evaluated from the molecular weight estimated using size exclusion chromatography. The pAgo complex presented a guide-dependent target DNA cleavage. RNA was the preferred guide; however, DNA also functioned, albeit weakly. Additionally, 5'-phosphorylate or non-phosphorylated guide was equally effective. The purified complex exhibited nonspecific nuclease activity on dsDNA and ssDNA. This is the first study to report that short pAgo and its associated protein form a complex, which has a nucleic acid-guided target recognition and cleavage.

Trends in biodiversity and habitat quantification tools used for market-based conservation in the United States.

Market-based conservation mechanisms are designed to facilitate the mitigation of harm to and conservation of habitats and biodiversity. Their potential is partly hindered, however, by the quantification tools used to assess habitat quality and functionality. Of specific concern are the lack of transparency and standardization in tool development and gaps in tool availability. To address these issues, we collected information via internet and literature searchers and through conversations with tool developers and users on tools used in U.S. conservation mechanisms, such as payments for ecosystem services (PES) and ecolabel programs, conservation banking, and habitat exchanges. We summarized information about tools and explored trends among and within mechanisms based on criteria detailing geographic, ecological, and technical features of tools. We identified 69 tools that assessed at least 34 species and 39 habitat types. Where tools reported pricing, 98% were freely available. More tools were applied to states along the U.S. West Coast than elsewhere, and the level of tool transferability varied markedly among mechanisms. Tools most often incorporated conditions at numerous spatial scales, frequently addressed multiple risks to site viability, and required 1-83 data inputs. Most tools required a moderate or greater level of user skill. Average tool-complexity estimates were similar among all mechanisms except PES programs. Our results illustrate the diversity among tools in their ecological features, data needs, and geographic application, supporting concerns about a lack of standardization. However, consistency among tools in user skill requirements, incorporation of multiple spatial scales, and complexity highlight important commonalities that could serve as a starting point for establishing more standardized tool development and feature-incorporation processes. Greater standardization in tool design may expand market participation and facilitate a needed assessment of the effectiveness of market-based conservation.

Tendencias en la Biodiversidad y en las Herramientas de Cuantificación de Hábitat Usadas para la Conservación Basada en el Mercado en los Estados Unidos Resumen Los mecanismos de conservación basada en el mercado están diseñados para facilitar la mitigación del daño y la conservación de los hábitats y la biodiversidad. Sin embargo, el potencial de estos mecanismos está parcialmente reducido por las herramientas de cuantificación usadas para evaluar la calidad y funcionalidad del hábitat. Son de preocupación específica la falta de transparencia y la estandarización del desarrollo de herramientas y los vacíos en la disponibilidad de las herramientas. Para tratar estos temas recolectamos información por medio del internet y los buscadores de literatura y a través de conversaciones con los desarrolladores y usuarios de las herramientas utilizadas en los mecanismos de conservación en los Estados Unidos, como la eco-etiqueta y los programas de pago por servicios ambientales (PES, en inglés), el banco de conservación y el intercambio de hábitats. Resumimos la información sobre las herramientas y exploramos tendencias entre y dentro de los mecanismos basados en criterios que detallan las características geográficas, ecológicas y técnicas de las herramientas. Identificamos 69 herramientas que evaluaron al menos a 34 especies y 39 tipos de hábitat. En donde las herramientas reportaron tarificación, el 98% estaban disponibles gratuitamente. Más herramientas estaban aplicadas a estados ubicados a lo largo de la costa oeste de los Estados Unidos que en cualquier otro sitio y el nivel de transferibilidad de las herramientas varió notablemente entre los mecanismos. Las herramientas comúnmente incorporaron las condiciones a numerosas escalas espaciales, trataron con frecuencia los múltiples riesgos para la viabilidad de sitio y requirieron 1 - 83 entradas de datos. La mayoría de las herramientas requirió un nivel moderado o mayor de habilidad para el usuario. Los estimados medios de la complejidad de las herramientas fueron similares entre todos los mecanismos, a excepción de los programas PES. Nuestros resultados ilustran la diversidad de características ecológicas, necesidades de datos y aplicación geográfica que existe entre las herramientas, lo que respalda las preocupaciones sobre la falta de estandarización. Sin embargo, la consistencia entre las herramientas en cuanto a los requerimientos de habilidades para el usuario, la incorporación de múltiples escalas espaciales y la complejidad resaltan las similitudes importantes que podrían servir como punto inicial para el establecimiento de un desarrollo más estandarizado de herramientas y procesos que incorporen las características del sitio. Una mayor estandarización del diseño de herramientas podría expandir la participación del mercado y facilitar una urgente evaluación de la efectividad de la conservación basada en el mercado.

Evaluación del mecanismo de pago capitado en el seguro integral de salud del Perú / Assessment of the mechanism of payment capitated in the peruvian seguro integral de salud.

Objetivo: Evaluar el impacto del mecanismo de pago capitado, implementado por el Seguro Integral de Salud (SIS), en la ejecución de los recursos provenientes de la fuente de financiamiento donaciones y transferencias, durante los años 2012 al 2016, Perú. Métodos: Se evaluó los porcentajes de ejecución de las regiones, el número de prestaciones preventivas versus el número de prestaciones recuperativas y se midió el impacto en el incremento de las atenciones preventivas en las regiones piloto versus las regiones del contrafactual. Se realizó un estudio descriptivo retrospectivo pre post y diferencia de diferencias entre las regiones piloto Apurímac, Amazonas, Ayacucho, Callao y Huancavelica comparados con un contrafactual apareado por Índice de Desarrollo Humano; además, se consideró a las regiones de Moquegua, Loreto, Puno, Cajamarca y Huánuco. Resultados: Se observó un incremento del porcentaje promedio de ejecución, previo al mecanismo capitado, de 68,5% en el 2012 al 92,3% el 2016; asimismo, el incremento a nivel nacional de las prestaciones preventivas versus las prestaciones recuperativas, llegando invertirse el peso específico de las prestaciones preventivas a favor de las mismas y mediante el método de diferencias en diferencias se evidenció que las regiones piloto tuvieron una diferencia positiva de 1551 prestaciones preventivas por cada 10 000 asegurados sobre las regiones del contrafactual.

Objective:To Assess the impact of the capitated payment mechanism, implemented by the Comprehensive Health Insurance (SIS), in the execution of resources from the source of financing, donations and transfers, during the years 2012 to 2016, Peru. Methods: Assessment of the execution percentages of the regions, the number of preventive benefits versus the number of recuperative benefits and the impact on the increase of preventive care in the pilot regions versus the counterfactual regions was measured. A retrospective descriptive study was carried out pre post and difference of differences between the pilot regions Apurímac, Amazonas, Ayacucho, Callao and Huancavelica compared with a counterfactual paired by the Human Development Index; In addition, the regions of Moquegua, Loreto, Puno, Cajamarca and Huánuco were considered. Results: An increase in the average percentage of execution was observed, prior to the capitated mechanism, from 68,5% in 2012 to 92,3% in 2016; likewise, the increase at the national level of preventive benefits versus recuperative benefits, with the specific weight of preventive benefits being invested in favor of them and, using the difference in differences method, it was evident that the pilot regions had a positive difference of 1551 preventive benefits for every 10,000 insured persons versus the counterfactual regions.

Atención en salud basada en el valor: retos y oportunidades / Value-based health care: challenges and opportunities / Assistência médica baseada em valor: desafios e oportunidades

La atención en Salud Basada en el Valor es un modelo de atención re-ciente, innovador, dirigido a garantizar mejores resultados en salud para la población atendida, paralelo a un uso óptimo de los recursos. Para su implementación, dicho modelo propone una serie de principios, los cua-les son analizados dentro del presente documento. Para esto, se tiene en cuenta no sólo sus características fundamentales, sino también, su facti-bilidad, posibles barreras y oportunidades. Los principios revisados son: unidades integradas de atención, medición de resultados en salud y cos-tos, plataformas tecnológicas, modelos de pago centrados en la atención, sistemas integrados de atención y expansión geográfica. Adicionalmente, se incluyen la atención centrado en el paciente y el trabajo en equipo co-mo componentes fundamentales de este modelo también

Value-based Health Care is a recent, innovative delivering healthcare model which has emerged as a cost-effective alter-native to provide superior health outcomes for patients while decreasing inefficiencies in the system. For its successful im-plementation this model provides a set of principles which are revised in the present article, providing insights on their feasibility, challenges and opportunities. The principles revised here are: Integrated Practice Units, Health Outcomes and Cost Measurement, Value-based Payments, enabling health systems platforms, and efficient allocation of resources. Along with the-se, a person-centered approach and stakeholders' participation and engagement have been also revised as key components of the model.

A assistência médica baseada em valor é um modelo de assis-tência inovador que visa garantir melhores resultados de saúde para a população atendida e o uso ideal dos recursos. Para sua implementação, propõe-se uma série de princípios anali-sados neste documento, uma análise na qual são levadas em consideração as características fundamentais, viabilidade, pos-síveis barreiras e oportunidades que esse modelo pode gerar. Os princípios revisados são: unidades de atendimento integra-das, mensuração de resultados de saúde e custo, plataformas tecnológicas, modelos de pagamento focados na geração de valor, sistemas / redes de atendimento integrados e expansão geográfica. Além disso, o atendimento centrado no paciente e o trabalho em equipe são incluídos como componentes funda-mentais deste modelo.

Limits of monetization in protecting ecosystem services.

The monetary valuation of ecosystem services is gaining traction in policy and business communities. Several tools and decision-making processes have been proposed, including criteria to assess the appropriateness of using monetary valuation for biodiversity conservation outcomes. These criteria include measures such as scale, uniqueness, and threat. We used case studies of monetization projects for which the outcomes were measured to explore the limitations and application of these criteria. There was limited evidence of the effectiveness of such schemes. The majority of the schemes were established in areas where the criteria specifically excluded their use in isolation. Thus, although some aspects of monetization may be beneficial for biodiversity conservation, these schemes were not being used appropriately and require some quantitative minimum (or maximum) measurements to be applied through additional policy or governance measures to ensure biodiversity conservation outcomes.

Pagamento por serviços ambientais (psa) e práticas de agricultura sustentável: contribuições da análise do comportamento / Payments for environmental services (pes) and practices of sustainable agriculture: contributions from behavior analysis

O Pagamento por Serviços Ambientais (PSA) é uma estratégia utilizada desde o final da década de 1990 para recompensar os serviços ambientais prestados por agricultores, financiando ações de recomposição da vegetação em áreas desmatadas, práticas agrícolas de baixo impacto já desempenhadas, e incentivando para que estes passem a adotar práticas sustentáveis de agricultura. O objetivo deste artigo é conhecer os princípios contidos nas estratégias de PSA para a solução de problemas ambientais, bem como discutir como são implantados na prática, a partir da interpretação analítico-comportamental de uma experiência de PSA na região de Ribeirão Preto, Estado de São Paulo. Reconhece-se os argumentos que validam os ganhos ambientais obtidos, e considera-se a necessidade de problematizar a suficiência dos incentivos financeiros na promoção de mudanças comportamentais e sua manutenção ao longo do tempo (AU).

This paper aims to know the Payment for Environmental Services (PES) principles and its implementation in practice, based on a behavior-analytic interpretation of a PES experience in the State of São Paulo, region of Ribeirão Preto. PES program is a strategy used since the 1990s to give financial incentives for farmers to provide environmental services. PES is a tool to fund actions of restoration at deforested areas, recognize low-impact practices already performed, and promote the adoption of sustainable practices. The arguments that support environmental gains provided by PES are recognized, but the effectiveness of financial incentives to promote behavior change and its maintenance for long term is questionable (AU).

El Pago por Servicios Ambientales (PSA) es una estrategia que se viene utilizando desde finales de la década de 1990 para recompensar los servicios ambientales prestados por agricultores, mediante la financiación de acciones de recomposición vegetal en áreas deforestadas, prácticas agrícolas de bajo impacto que ya vienen siendo implementadas, e incentivando la adopción de prácticas de agricultura sustentable. El objetivo de este artículo es reconocer los principios de las estrategias de PSA para la solución de problemas ambientales, y debatir la forma en la que éstas se dan en la práctica, a partir de la interpretación analítico-comportamental de una experiencia de PSA en la región de Ribeirão Preto, Estado de São Paulo, Brasil. Se reconocen los argumentos que certifican los beneficios ambientales alcanzados, pero se considera necesario evaluar la capacidad que tienen los incentivos financieros en la promoción de cambios comportamentales y el mantenimiento de estos en el tiempo (AU).

Envelhecimento, saúde do idoso e o setor de planos de saúde no Brasil / Aging, elder ́s health and health insurance sector in Brazil / Envejecimiento, salud del anciano y el sector de planes de salud en Brasil

O artigo, após uma breve reflexão sobre a saúde do idoso, explana sobre como o sistema de saúde suplementar no Brasil vem assistindo este segmento etário, dando ênfase às normatizações realizadas pela agência reguladora do setor. Estas normas legais buscam a implantação de uma rede de atenção à saúde pautada na promoção desta última e não apenas curadora, mas com enfoque mais cuidador. Para tanto, destaca a estratificação de riscos e a capacidade funcional como sendo balizadores desta.

The article, after a brief reflection concerning the health status of aging individuals, elucidates on how the supplementary health system assists the aging population in Brazil, emphasizing the regulations implemented by the responsible agency related to the sector. These legal norms aim for the proper stabilization of a healthcare network based on prevention instead of only ailments treatments, alongside with an ample focus on the caregiver. For such, risk stratification and functional capacity are highlighted as an indispensable foundation.

El artículo, tras una breve reflexión sobre la salud del anciano, explora sobre cómo el sistema de salud suplementario en Brasil viene viendo este segmento de edad, dando énfasis a las normatizaciones realizadas por la agencia reguladora del sector. Estas normas legales buscan la implantación de una red de atención a la salud pautada en la promoción de esta última y no sólo curadora, sino con enfoque más cuidador. Para ello, destaca la estratificación de riesgos y la capacidad funcional como balizadores de ésta.

Percepción de los agentes compradores y personas muestreadoras sobre el sistema de liquidación para pago de leche cruda en Antioquia / Perception of purchasing agents and sampling staff on the raw milk payment calculation system in Antioquia / Percepção dos agentes compradores e pessoas coletoras sobre o sistema de liquidação para pagamento do leite cru em Antioquia

Resumen Introducción. El sistema de pago por calidad promueve cambios que impactarán de manera positiva las formas actuales de producción y comercialización de leche. Objetivo. Analizar la percepción de los agentes compradores (AC) y tomadores de muestra (TM) sobre el sistema de liquidación de la leche cruda a los proveedores en Antioquia. Materiales y métodos. Se realizaron entrevistas a 14 funcionarios de los AC y se aplicaron 84 encuestas a TM. Para analizar la percepción de las personas se realizaron análisis de factor para datos mixtos y análisis de cluster jerárquico en componentes principales. Resultados. Se identificó que los AC no tenían mucho conocimiento de las resoluciones 17 del 2012 y 77 del 2015 del Ministerio de Agricultura y Desarrollo Rural; solo las empresas grandes y tecnificadas tenían mayor conocimiento. Los AC, en su mayoría, tenían una percepción positiva frente a la aplicación de estas; según ellos incentivarían al mejoramiento de la calidad de leche y el pago equitativo a los proveedores, y generarían mayor transparencia y confianza en la relación comercial con el proveedor. Los TM, en términos generales, no conocían las resoluciones, y manifestaron que tenían una buena relación con los AC y con los proveedores. Conclusión. Para los AC y los TM, el sistema de pago por calidad genera bienestar en la relación comercial con el proveedor y en sector lácteo en general, aunque puede ocasionar incertidumbre por los cambios en las formas de producción y comercialización.

Abstract Introduction. Payment per quality system generates changes that will positively impact current milk production and commercialization procedures. Objective. Analyze the perception of purchasing agents (PA) and sample testing staff (ST) on the raw milk payment calculation for suppliers in Antioquia. Materials and methods. 14 interviews were conducted with PA staff and 84 surveys were applied to ST. To analyze their perception, we used mixed data factor analysis and hierarchical cluster analysis of main components. Results. It was identified that with the exception of large highly technical companies, PA had little knowledge of Resolutions 17 of 2012 and 77 of 2015 from the Colombian Ministry of Agriculture and Rural Development. Most PA have a positive perception on the application of these resolutions; according to them, it would incentivize improvements in milk quality and a fair payment to suppliers, and would create more transparency and trust in the commercial relationship with the supplier. In general, ST did not know the resolutions and expressed that they have a good relationship with PA and suppliers. Conclusion. For PA and ST, the payment per quality system generates benefits in their commercial relationship with the supplier and the dairy sector in general, although it can cause uncertainties due to changes in production and commercialization procedures.

Resumo Introdução. O sistema de pagamento por qualidade promove mudanças que impactarão de maneira positiva as formas atuais de produção e comercialização do leite. Objetivo. Analisar a percepção dos agentes compradores (AC) e tomadores de amostra (TM) sobre o sistema de liquidação do leite cru aos fornecedores em Antioquia. Materiais e métodos. Se realizaram entrevistas a 14 funcionários dos AC e se aplicaram 84 enquetes a TM. Para analisar a percepção das pessoas se realizaram análise de fator para dados mistos e análise de cluster hierárquico em componentes principais. Resultados. Se identificou que os AC não tinham muito conhecimento das resoluções 17 de 2012 e 77 de 2015 do Ministério de Agricultura e Desenvolvimento Rural; só as empresas grandes e tecnificadas tinham melhor conhecimento. Os AC, na sua maioria, tinham uma percepção positiva frente à aplicação destas; segundo eles incentivariam ao melhoramento da qualidade do leite e o pagamento equitativo aos fornecedores, e gerariam maior transparência e confiança na relação comercial com o fornecedor. Os TM, em termos gerais, não conheciam as resoluções, e manifestaram que tinham uma boa relação com os AC e com os fornecedores. Conclusão. Para os AC e os TM, o sistema de pagamento por qualidade gera bem-estar na relação comercial com o fornecedor e no sector lácteo em geral, embora pode ocasionar incerteza pelas mudanças nas formas de produção e comercialização.

Remuneración a los proveedores de servicios de salud en Bogotá / Payment to providers of health services in Bogotá

RESUMEN Objetivo Revisar los conceptos, desarrollos y efectos de los mecanismos de pago utilizados en diversos países, con el fin de proponer una metodología de pago aplicable para los hospitales de Bogotá. Método Se efectuó una revisión bibliográfica de tres aspectos de interés: conceptos esenciales, desarrollos alcanzados y efectos derivados de los mecanismos de pago utilizados en diversos países. Luego se efectuaron sesiones de trabajo entre los autores y con diversos grupos y equipos de la secretaria de salud de Bogotá, los hospitales, la academia y las autoridades nacionales en salud, para el diseño metodológico de un esquema de pago aplicable a los hospitales de la red adscrita de salud en Bogotá. Resultados La revisión bibliográfica permitió establecer los ejes de trabajo para un esquema de pago prospectivo por red con incentivos de desempeño, basado en optimización de la eficiencia técnica (provisión de servicios de salud a menor costo) y locativa (optimización de la mezcla de los servicios de salud) y en mejores resultados de atención. Discusión El esquema de reconocimiento planteado debe ser un factor integrador del proceso de atención al paciente y redundar en una mejor operación del aseguramiento, la prestación de servicios y la gobernanza de la atención en salud, al tiempo que optimiza el flujo de recursos y la sostenibilidad local del sistema.(AU)

ABSTRACT Objective To review the concepts, developments and effects of the payment mechanisms used in different countries to propose a payment methodology applicable to hospitals in Bogotá. Method Literature review in which essential concepts, developments and effects derived from payment mechanisms used in different countries were analyzed. The authors and various groups and teams of the Bogotá Health Department participated, hospitals, academia and national health authorities held work sessions with the intention of creating a methodological design for a payment scheme that could be applied to the hospitals attached to the health network in Bogotá. Results The literature review allowed establishing work axes for a prospective payment scheme per network that included performance bonuses based on the optimization of technical efficiency (provision of health services at lower cost, locative efficiency (optimization of the mix of health services), and on better care outcomes. Discussion The proposed payment scheme should be an integrating factor in the patient care process, and should also result in a better operation, service delivery and health care governance, while optimizing the flow of resources and local sustainability.(AU)

Autonomous Generation and Loading of DNA Guides by Bacterial Argonaute.

Several prokaryotic Argonaute proteins (pAgos) utilize small DNA guides to mediate host defense by targeting invading DNA complementary to the DNA guide. It is unknown how these DNA guides are being generated and loaded onto pAgo. Here, we demonstrate that guide-free Argonaute from Thermus thermophilus (TtAgo) can degrade double-stranded DNA (dsDNA), thereby generating small dsDNA fragments that subsequently are loaded onto TtAgo. Combining single-molecule fluorescence, molecular dynamic simulations, and structural studies, we show that TtAgo loads dsDNA molecules with a preference toward a deoxyguanosine on the passenger strand at the position opposite to the 5' end of the guide strand. This explains why in vivo TtAgo is preferentially loaded with guides with a 5' end deoxycytidine. Our data demonstrate that TtAgo can independently generate and selectively load functional DNA guides.

Improving quality of care through payment for performance: examining effects on the availability and stock-out of essential medical commodities in Tanzania.

OBJECTIVE: To evaluate the effects of payment for performance (P4P) on the availability and stock-out rate of reproductive, maternal, newborn and child health (RMNCH) medical commodities in Tanzania and assess the distributional effects. METHODS: The availability of RMNCH commodities (medicines, supplies and equipment) on the day of the survey, and stock-outs for at least one day in the 90 days prior to the survey, was measured in 75 intervention and 75 comparison facilities in January 2012 and 13 months later. Composite scores for each subgroup of commodities were generated. A difference-in-differences linear regression was used to estimate the effect of P4P on outcomes and differential effects by facility location, level of care, ownership and socio-economic status of the catchment population. RESULTS: We estimated a significant increase in the availability of medicines by 8.4 percentage points (P = 0.002) and an 8.3 percentage point increase (P = 0.050) in the availability of medical supplies. P4P had no effect on the availability of functioning equipment. Most items with a significant increase in availability also showed a significant reduction in stock-outs. Effects were generally equally distributed across facilities, with effects on stock-outs of many medicines being pro-poor, and greater effects in facilities in rural compared to urban districts. CONCLUSION: P4P can improve the availability of medicines and medical supplies, especially in poor, rural areas, when these commodities are incentivised at both facility and district levels, making services more acceptable, effective and affordable, enhancing progress towards universal health coverage.

Generating spatially optimized habitat in a trade-off between social optimality and budget efficiency.

Auctions have been proposed as alternatives to payments for environmental services when spatial interactions and costs are better known to landowners than to the conservation agency (asymmetric information). Recently, an auction scheme was proposed that delivers optimal conservation in the sense that social welfare is maximized. I examined the social welfare and the budget efficiency delivered by this scheme, where social welfare represents the difference between the monetized ecological benefit and the conservation cost incurred to the landowners and budget efficiency is defined as maximizing the ecological benefit for a given conservation budget. For the analysis, I considered a stylized landscape with land patches that can be used for agriculture or conservation. The ecological benefit was measured by an objective function that increases with increasing number and spatial aggregation of conserved land patches. I compared the social welfare and the budget efficiency of the auction scheme with an agglomeration payment, a policy scheme that considers spatial interactions and that was proposed recently. The auction delivered a higher level of social welfare than the agglomeration payment. However, the agglomeration payment was more efficient budgetarily than the auction, so the comparative performances of the 2 schemes depended on the chosen policy criterion-social welfare or budget efficiency. Both policy criteria are relevant for conservation. Which one should be chosen depends on the problem at hand, for example, whether social preferences should be taken into account in the decision of how much money to invest in conservation or whether the available conservation budget is strictly limited.

Modelo cuantitativo para mejorar el financiamiento de la atención primaria en Chile / Quantitative model to improve primary health care financing in Chile / Modelo quantitativo para melhorar o financiamento da atenção primária no Chile

RESUMEN Objetivo Proponer y aplicar una metodología para estimar el gasto esperado ajustado de cada localidad en el sistema chileno de atención primaria de la salud (APS) en el año 2016. Métodos En primer lugar, se formalizó el cálculo del gasto esperado per cápita a nivel nacional, en base a un detallado plan de salud, y luego se introdujo en este gasto un ajuste de suma cero para cada localidad a través del perfil local de sexo y edad y el promedio local del nivel socioeconómico, años de vida perdidos y ruralidad, por su incidencia estadísticamente significativa en las epidemiologías y en las estructuras de gasto. Resultados El modelo logra un vínculo conceptual y empírico entre los gastos esperados y las variables de ajuste, es flexible a mejoras sucesivas, y la propiedad de suma cero facilita la discusión del presupuesto global. En la aplicación a datos reales de Chile para el año 2016 se encuentra que la distancia absoluta entre los montos del modelo y los montos usados en dicho año es de 7,6% en promedio. Conclusiones Existen alternativas sencillas para sustentar empíricamente el cálculo de los gastos esperados a través de las localidades, para lo cual es de gran ayuda contar con una buena estimación del gasto esperado a nivel nacional.

ABSTRACT Objective Propose and apply a methodology to estimate adjusted expected expenditure in each locality in the Chilean primary health care (PHC) system in 2016. Methods First of all, expected per capita expenditure at the national level was calculated on the basis of a detailed health plan, and then a zero-sum adjustment was made to the expenditure in each locality, using the local age/sex profile and the local average socioeconomic level, years of life lost, and rurality, given their statistically significant impact on epidemiology and spending structures. Results The model establishes a conceptual and empirical link between expected expenditure and adjustment variables; it is flexible in terms of successive improvements; and its zero-sum property facilitates discussion of the global budget. When real data for the year 2016 in Chile were used, it was found that the absolute distance between the amounts in the model and the amounts actually used that year was 7.6%, on average. Conclusions There are simple empirical options for calculating expected expenditure across localities, for which it is very helpful to have a good estimate of expected expenditure at the national level.

RESUMO Objetivo Propor e implementar uma metodologia para o cálculo do gasto com saúde projetado ajustado para cada municipalidade no sistema chileno de atenção primária à saúde para o ano de 2016. Métodos Primeiro padronizou-se o cálculo do gasto per capita projetado em nível nacional, baseado em um detalhado plano de saúde. Em seguida foi feito um ajuste de soma zero no gasto com saúde para cada municipalidade segundo o perfil local de sexo e idade da população e o valor médio para nível socioeconômico, anos de vida perdidos e ruralidade de acordo com a associação de significância estatística em estudos epidemiológicos e estruturas do gasto. Resultados O modelo consegue estabelecer um vínculo conceitual e empírico entre os gastos projetados e as variáveis de ajuste, ele se adapta a melhorias sucessivas e a propriedade de soma zero facilita a discussão do orçamento global. Ao serem aplicados dados reais do Chile para 2016, observou-se uma distância absoluta entre os valores do modelo e os valores do ano considerado de, em média, 7,6%. Conclusões Existem alternativas simples para fundamentar empiricamente o cálculo do gasto com saúde projetado para as municipalidades, sendo bastante útil poder dispor de uma boa estimativa do gasto com saúde projetado em nível nacional.