Distance education institutions, students and staff have often had to overcome negative perceptions about the overall quality of their programmes and qualifications. In this paper, we identify four of the major challenges cited as undermining the credibility and effectiveness of open, distance and e-learning (ODeL): the quality of teaching, learning and quality assurance processes; outcomes; access; and the perceptions of students, staff and employers. We conclude with reflections on current and future developments in ODeL, including the impact of massive open online courses (MOOCs): how far do they have the potential to address the challenges identified? We argue that some of these have been, or can be, resolved in many contexts, and are now the same as those faced by all teaching and learning programmes. We should shift the main focus of distance teaching and learning programmes from inputs such as media adopted, to outcomes, in terms of students successfully achieving their intended goals in education, employment and future livelihoods. This will impact on employers' and others' perceptions of ODeL. Examples are drawn from all sectors and are, therefore, necessarily selective, and, unless specified, are relevant to all modes of ODeL. IntroductionDistance education students in all sectors have had a difficult time. Not only are they often studying part-time with all the pressures of additional family responsibilities or work, but also, for many years, their qualifications were not considered of any real value by their peers and potential employers. Results gained by distance education were considered secondrate; at University level, for example, learners might be thought to be inherently inferior because they were not 'good enough' to get into a 'proper' university, as evidenced by their lack of, or low, previous educational qualifications. The Open University UK (OU UK), for example, accepts undergraduate students with no qualifications at all; other Universities, such as the University of South Africa (Unisa) and Indira Gandhi National Open University accept students with lower entry qualifications than those required for conventional universities. In addition, results obtained were regarded as extremely dubious by many people who were suspicious about the quality of teaching and overall quality assurance processes (especially in assessment practices).

It is no longer enough for a company in today's business climate to focus on profits and growth. Environmental and social issues also need to be considered as a priority. Perhaps surprisingly, working on sustainability can make sound entrepreneurial sense – it is not just an ethical issue. Nevertheless, the demands of the challenges sustainability issues raise should not be underestimated.

BackgroundThe primary objective of this study was to make the first step in the modelling of pharmaceutical demand in Italy, by deriving a weighted capitation model to account for demographic differences among general practices. The experimental model was called ASSET (Age/Sex Standardised Estimates of Treatment).Methods and Major FindingsIndividual prescription costs and demographic data referred to 3,175,691 Italian subjects and were collected directly from three Regional Health Authorities over the 12-month period between October 2004 and September 2005. The mean annual prescription cost per individual was similar for males (196.13 euro) and females (195.12 euro). After 65 years of age, the mean prescribing costs for males were significantly higher than females. On average, costs for a 75-year-old subject would be 12 times the costs for a 25–34 year-old subject if male, 8 times if female. Subjects over 65 years of age (22% of total population) accounted for 56% of total prescribing costs. The weightings explained approximately 90% of the evolution of total prescribing costs, in spite of the pricing and reimbursement turbulences affecting Italy in the 2000–2005 period. The ASSET weightings were able to explain only about 25% of the variation in prescribing costs among individuals.ConclusionsIf mainly idiosyncratic prescribing by general practitioners causes the unexplained variations, the introduction of capitation-based budgets would gradually move practices with high prescribing costs towards the national average. It is also possible, though, that the unexplained individual variation in prescribing costs is the result of differences in the clinical characteristics or socio-economic conditions of practice populations. If this is the case, capitation-based budgets may lead to unfair distribution of resources. The ASSET age/sex weightings should be used as a guide, not as the ultimate determinant, for an equitable allocation of prescribing resources to regional authorities and general practices.

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