What are the relative pros and cons of different pathways of agricultural commercialisation in Africa? This paper examines aspects of three commercial farming cases, each of which represents one of the three most dominant models of commercial agriculture-small-scale outgrowers, medium-size commercial farms and a large estate-in the high-potential area of Meru County in Kenya. The paper provides a comparative perspective across the cases, examining their outcomes in terms of land relations, labour, livelihoods and local economic linkages. The study used a mixed-methods approach, including a household survey and a range of qualitative methods including detailed life histories. We find diverse dynamics across our cases: increasing land consolidation spurred by the rising class of commercial coffee farmers, but also land fragmentation as a result of population pressure and prevalence of inheritance as a pathway to land acquisition in the case of horticultural outgrowers. The plantation generates relatively better paid employment for permanent skilled workers, while the commercial farms create employment for casualised, insecure and poorly paid seasonal labour. These labour regimes are highly gendered. The outgrowers combine family and hired labour. Across the three cases, farmers diversify income between on-farm and off-farm sources. The commercial and outgrower farms are dynamically integrated into the local economy, while the estate is less so. These features of the three models generate processes of social differentiation, which are reshaping the agrarian structure and rural economy in Meru County. 1 We use the term 'estate' in this paper to refer to a large-scale mixed farming operation with on-farm processing, as this is the term widely used in East Africa. In the other countries in this study, we use the term 'plantation', which is the term more widely used in relation to tree crops and more generally in West Africa.

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Two major trends that have been affecting the provision of oncology care in the United States are a shift from volume-based to value-based care and a push toward patient-centered healthcare. However, these two trends are not always completely aligned with each other. Value-based payment models, including clinical pathways, are one strategy being implemented by oncology stakeholders to help encourage the uptake of value-based oncology care. If structured with the patient in mind, they can improve quality of care for patients with cancer, decrease inappropriate care while enabling appropriate personalization of care, and constrain rising prices by demanding a stronger link between cost and value. If not structured appropriately, they can limit patient choice, impede access to innovative treatments, and encourage one-size-fits-all oncology care. .

The quality of patient care often varies based on numerous factors, including health care setting, geographic location, access to medications, insurance coverage, and treatment protocols. Variations in health care are well established, and often lead to different services having varied outcomes depending on location. 1-3 Recently, the issue of whether the use of clinical pathways-evidence-based treatment protocols designed to assist with the management of patient care-can decrease costs without reducing quality has been the subject of much discussion. The ability of pathways to reduce inappropriate variability in care is also at issue. Increasingly, payers are considering pathways in oncology when contracting with providers as a mechanism to improve quality, reduce variability, and decrease costs. This raises questions regarding what data are used to determine treatment options included in a pathway, the consistency with which they are monitored, how they affect reimbursement and insurance, and ultimately how they affect patient outcomes. As clinical treatment guidelines and pathways are increasingly deployed in oncology practice, they have a growing impact on the quality of treatment and how it is delivered. NCCN, The US Oncology Network, and McKesson Specialty Health are collaborating to develop enhanced oncology pathways delivered through innovative technology, which will strengthen standards in evidence-based, high-quality cancer care and enable new forms of transparent provider and payer relationships. Called "Value Pathways powered by NCCN," they are the next step in a collaboration to deliver a first-of-its-kind clinical quality and regimen support system, building on a solution initially developed by Proventys, Inc. as CDS Oncology. This workflow-integrated software will allow physicians to assess treatment options consistent with evidence-based standards at the point of care. Value Pathways powered by NCCN, delivered through the clinical quality and regimen support system, is an important step forward in ensuring that patients receive the highest quality treatment while offering options to address the costs of cancer care. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)the most comprehensive and most frequently updated clinical practice guidelines available in any area of medicine-will serve as the foundational evidence source within the clinical quality and regimen support system and will be supplemented by the collaboratively developed Value Pathways. Anchored in clinical quality and evidence-based medicine, Value Pathways powered by NCCN will build on The US Oncology Network's Level I Pathways (discussed in more detail on page 121) and help patients receive the highest-quality care with the best opportunity for positive outcomes, while also recognizing the importance of value in determining appropriate treatment. These pathways will provide payers and employers with a quality-based program, developed by trusted oncologist-led sources through a transparent process, suitable to drive val...

There are many accepted methods to ascertain the integrity of a geomembrane (GM) by subjecting it to a battery of physical, mechanical and chemical tests. However, there is no single comprehensive performance testing programme that simulates the stresses to which a GM might be subjected in a service environment. This paper first discusses the development and testing of a new test system based on multi-axial deformation; observations concerning system design criteria and relevance to field conditions are made. The paper also presents the results of a physical testing programme, wherein standard materials tests were implemented using the new system; stress/strain, strain rate, creep and relaxation data are presented. Where comparisons were possible, these results reinforced fluid-based multi-axial testing data in the literature. New data and conclusions are discussed. Finally, a new test, cyclic testing, is suggested, demonstrated and discussed. © 1996 ISWA