How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations.

Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.

Contemporary women's secure psychiatric services in the United Kingdom: A qualitative analysis of staff views.

WHAT IS KNOWN ON THE SUBJECT?: Three pilot UK-only Women's Enhanced Medium Secure Services (WEMSS) was opened in 2007 to support women's movement from high secure care and provide a bespoke, women-only service. Evidence suggests that women's secure services are particularly challenging environments to work in and staffing issues (e.g., high turnover) can cause difficulties in establishing a therapeutic environment. Research in this area has focused on the experiences of service users. Studies which have examined staff views have focused on their feelings towards women in their care and the emotional burden of working in women's secure services. No papers have made a direct comparison between staff working in different services. WHAT DOES THIS STUDY ADD TO EXISTING KNOWLEDGE?: This is the first study to explore the views and experiences of staff in the three UK WEMSS pilot services and contrast them with staff from women's medium secure services. Drawing upon data from eighteen semi-structured interviews (nine WEMSS, nine non-WEMSS), key themes cover staff perceptions of factors important for women's recovery and their views on operational aspects of services. This study extends our understanding of the experiences of staff working with women in secure care and bears relevance for staff working internationally, as well as in UK services. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The study reveals the importance of induction and training for bank and agency staff working in women's secure services. Further, regular clinical supervision should be mandatory for all staff so they are adequately supported. ABSTRACT: Introduction Women's Enhanced Medium Secure Services (WEMSS) is bespoke, gender-sensitive services which opened in the UK in 2007 at three pilot sites. This study is the first of its kind to explore the experiences of WEMSS staff, directly comparing them to staff in a standard medium secure service for women. The literature to date has focused on the experiences of service users or staff views on working with women in secure care. Aim This qualitative study, embedded in a multimethod evaluation of WEMSS, aimed to explore the views and experiences of staff in WEMSS and comparator medium secure services. Methods Qualitative interviews took place with nine WEMSS staff and nine comparator medium secure staff. Interviews focused on factors important for recovery, barriers to facilitating recovery and operational aspects of the service. Discussion This study provides a rare insight into the perspectives of staff working in UK women's secure services, an under-researched area in the UK and internationally. Findings suggest that the success of services, including WEMSS, is compromised by operational factors such as the use of bank staff. Implications for practice Comprehensive training and supervision should be mandatory for all staff, so best practice is met and staff adequately supported.

Early changes in the sulfation of chondroitin in guinea-pig articular cartilage, a possible predictor of osteoarthritis.

Male Dunkin Hartley guinea-pigs have been shown to develop spontaneous osteoarthritis, in the knee joint, which is histologically apparent from the age of 3 months onwards. We have used capillary electrophoresis (CE) to examine subtle changes in the sulfation of chondroitin in guinea-pig articular and xiphisternal cartilage. An age-related increase in the 6:4 sulfation ratio of chondroitin was observed, with the medial tibial plateau developing more rapidly than the other joint surfaces. The observed sulfation patterns may be related to the onset of spontaneous osteoarthritis which, in the guinea-pig, develops initially on the medial tibial plateau. Chondroitin from patellar groove cartilage of animals between 3 and 12 months of age always had a significantly lower 6:4 sulfate ratio than the other joint surfaces.