Beyond reducing direct medical cost: examining health outcomes in tuberculosis through a difference-in-differences analysis of South Korea's out-of-pocket payment exception policy.

Background: Universal health coverage and social protection are major global goals for tuberculosis. This study aimed to investigate the effects of an expanded policy to guarantee out-of-pocket costs on the treatment outcomes of patients with tuberculosis. Methods: By linking the national tuberculosis report and health insurance data and performing covariate-adjusted propensity-score matching, we constructed data on health insurance beneficiaries (treatment group) who benefited from the out-of-pocket payment exemption policy and medical aid beneficiaries as the control group. Using difference-in-differences analysis, we analyzed tuberculosis treatment completion rates and mortality in the treatment and control groups. Results: A total of 41,219 persons (10,305 and 30,914 medical aid and health insurance beneficiaries, respectively) were included in the final analysis (men 59.6%, women 40.4%). Following the implementation of out-of-pocket payment exemption policy, treatment completion rates increased in both the treatment and control groups; however, there was no significant difference between the groups (coefficient, -0.01; standard error, 0.01). After the policy change, the difference in mortality between the groups increased, with mortality decreasing by approximately 3% more in the treatment group compared with in the control group (coefficient: -0.03, standard error, 0.01). Conclusion: There are limitations to improving treatment outcomes for tuberculosis with an out-of-pocket payment exemption policy alone. To improve treatment outcomes for tuberculosis and protect patients from financial distress due to the loss of income during treatment, it is essential to proactively implement complementary social protection policies.

Unequal burdens of COVID-19 infection: a nationwide cohort study of COVID-19-related health inequalities in Korea.

OBJECTIVES: While the Korean government's response to the coronavirus disease 2019 (COVID-19) pandemic is considered effective given the relatively low mortality rate, issues of inequality have been insufficiently addressed. This study explored COVID-19-related health inequalities in Korea. METHODS: Age standardization for various health inequality indices was derived using data from the Korean National Health Insurance Service, the Korea Disease Control and Prevention Agency, and the Microdata Integrated Service of Statistics Korea. The slope index of inequality (SII) and relative index of inequality (RII) were calculated for socioeconomic variables, while absolute difference (AD) and relative difference (RD) were used for gender and disability inequalities. RESULTS: We observed a number of COVID-19-related health outcome inequalities. Gender inequality was particularly noticeable in infection rates, with the rate of women 1.16 times higher than that of men. In contrast, socioeconomic inequality was evident in vaccination rates, with a 4.5-fold (SII, -4.519; 95% confidence interval, -7.403 to -1.634) difference between the highest and lowest household income groups. Regarding clinical progression post-infection, consistent findings indicated higher risk for men (RD for hospitalization, 0.90; severe cases, 0.54; and fatality, 0.65), individuals with disabilities (RD for hospitalization, 2.27; severe cases, 2.29; and fatality, 2.37), and those from lower socioeconomic groups (SII for hospitalization, 1.778; severe cases, 0.089; and fatality, 0.451). CONCLUSIONS: While the infection risk was nearly ubiquitous, not everyone faced the same level of risk post-infection. To prevent further health inequalities, it is crucial to develop a thoughtful policy acknowledging individual health conditions and resources.

Mainstreaming of Health Equity in Infectious Disease Control Policy During the COVID-19 Pandemic Era.

The Korean government's strategy to combat coronavirus disease 2019 (COVID-19) has focused on non-pharmaceutical interventions, such as social distancing and wearing masks, along with testing, tracing, and treatment; overall, its performance has been relatively good compared to that of many other countries heavily affected by COVID-19. However, little attention has been paid to health equity in measures to control the COVID-19 pandemic. The study aimed to examine the unequal impacts of COVID-19 across socioeconomic groups and to suggest potential solutions to tackle these inequalities. The pathways linking social determinants and health could be entry points to tackle the unequal consequences of this public health emergency. It is crucial for infectious disease policy to consider social determinants of health including poor housing, precarious working conditions, disrupted healthcare services, and suspension of social services. Moreover, the high levels of uncertainty and complexity inherent in this public health emergency, as well as the health and socioeconomic inequalities caused by the pandemic, underscore the need for good governance other than top-down measures by the government. We emphasize that a people-centered perspective is a key approach during the pandemic era. Mutual trust between the state and civil society, strong accountability of the government, and civic participation are essential components of cooperative disaster governance.

Social selection in historical time: The case of tuberculosis in South Korea after the East Asian financial crisis.

The perspectives of social selection and causation have long been debated. Social selection theory is as "social" as social causation theory, since all diseases are social and no biological process occurs outside society. To identify the social selection pathway and historical juncture affected by socioeconomic and political changes, we investigated the reciprocal impact of suffering from tuberculosis (TB) on the current socioeconomic position (SEP), stratified by childhood SEP. We also examined the extent to which the social consequences of ill health changed since the East Asian economic downturn. Data were collected for 2007-2012 from the Korea National Health and Nutritional Examination Survey. To identify associations between TB history and current household income (HHI), we constructed an ordinal logistic regression model adjusted for covariates, including age, gender, educational attainment, and job status. We adopted a recursive regression model to examine trend changes in this association from 1980-2012 to 2003-2012. Of 28,136 participants, 936 had experienced TB. In the first ordinal logistic regression, the TB group was more likely to have lower HHI than the non-TB group. The odds ratios (ORs) increased from 1.30 (1980-2012) to 1.86 (2003-2012) for the TB group, increasing their probability of having low HHI. Among the low childhood SEP group, the TB group's probability of having low HHI was 1.35 (95% confidence interval [CI]: 1.16-1.57) during 1980-2012, which increased to 2.01 (95% CI: 1.37-2.95) during 2003-2012. For the high childhood SEP group, the TB group's OR range fluctuated, similar to that for the non-TB group. The results support the social selection pathway from TB history to adverse impact on current SEP. Our study identified downward social mobility due to TB history among the low childhood SEP group. Moreover, negative social consequences deteriorated since the East Asian economic crisis.

Fitness costs of rifampicin resistance in Mycobacterium tuberculosis are amplified under conditions of nutrient starvation and compensated by mutation in the ß' subunit of RNA polymerase.

Rifampicin resistance, a defining attribute of multidrug-resistant tuberculosis, is conferred by mutations in the ß subunit of RNA polymerase. Sequencing of rifampicin-resistant (RIF-R) clinical isolates of Mycobacterium tuberculosis revealed, in addition to RIF-R mutations, enrichment of potential compensatory mutations around the double-psi ß-barrel domain of the ß' subunit comprising the catalytic site and the exit tunnel for newly synthesized RNA. Sequential introduction of the resistance allele followed by the compensatory allele in isogenic Mycobacterium smegmatis showed that these mutations respectively caused and compensated a starvation enhanced growth defect by altering RNA polymerase activity. While specific combinations of resistance and compensatory alleles converged in divergent lineages, other combinations recurred among related isolates suggesting transmission of compensated RIF-R strains. These findings suggest nutrient poor growth conditions impose larger selective pressure on RIF-R organisms that results in the selection of compensatory mutations in a domain involved in catalysis and starvation control of RNA polymerase transcription.