762 resultados para change management
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Editorial remarks.-- Open discussion: Conceptual change in regulation in a model of public service provision ; Policies and institutional frameworks for drinking water supply and sanitation ; Strategies for low-carbon development in megacities in Latin America ; Adapting to climate change in water management in the irrigation sector.-- Meetings: Towards a vision on natural resource governance for equality ; Water resources faced with uncertainty and the risk of climate change ; Regulation challenges in the water sector.-- News of the Network: Lessons to be drawn from the interprovincial Colorado River flow distribution agreement ; Rural drinking water programme in Chile ; Ecuador’s Act on Water Resources and Water Use and Exploitation.-- Internet and WWW News
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This report analyses the agriculture, energy, and health sectors in Trinidad and Tobago to assess the potential economic impacts of climate change on the sectors. The fundamental aim of this report is to assist with the development of strategies to deal with the potential impact of climate change on Trinidad and Tobago. It also has the potential to provide essential input for identifying and preparing policies and strategies to help advance the Caribbean subregion closer to solving problems associated with climate change and attaining individual and regional sustainable development goals. Some of the key anticipated impacts of climate change for the Caribbean include elevated air and sea-surface temperatures, sea-level rise, possible changes in extreme events and a reduction in freshwater resources. The economic impact of climate change on the three sectors was estimated for the A2 and B2 IPCC scenarios until 2050. An exploration of various adaptation strategies was also undertaken for each sector using standard evaluation techniques. The study of the impact of climate change on the agriculture sector focused on root crops, green vegetables and fisheries. For these sectors combined, the cumulative loss under the A2 scenario is calculated as approximately B$2.24 and approximately B$1.72 under the B2 scenario by 2050. This is equivalent to 1.37% and 1.05% of the 2008 GDP under the A2 and B2 scenarios, respectively. Given the potential for significant damage to the agriculture sector a large number of potential adaptation measures were considered. Out of these a short-list of 10 potential options were selected by applying 10 evaluation criteria. All of the adaptation strategies showed positive benefits. The analysis indicate that the options with the highest net benefits are: (1) Building on-farm water storage, (2) Mainstreaming climate change issues into agricultural management and (3) Using drip irrigation. Other attractive options include water harvesting. The policy decisions by governments should include these assessments, the omitted intangible benefits, as well as the provision of other social goals such as employment. The analysis of the energy sector has shown that the economic impact of climate change during 2011-2050 is similar under the A2 (US$142.88 million) and B2 (US$134.83 million) scenarios with A2 scenario having a slightly higher cost (0.737% of 2009 GDP) than the B2 scenario (0.695% of 2009 GDP) for the period. On the supply side, analyses indicate that Trinidad and Tobago’s energy sector will be susceptible to the climate change policies of major energy-importing countries (the United States of America and China), and especially to their renewable energy strategies. Implementation of foreign oil substitution policy by the United States of America will result in a decline in Trinidad and Tobago’s Liquefied Natural Gas (LNG) export (equivalent to 2.2% reduction in 2009 GDP) unless an alternative market is secured for the lost United States of America market. China, with its rapid economic growth and the highest population in the world, offers a potential replacement market for Trinidad and Tobago’s LNG export. In this context the A2 scenario will offer the best option for Trinidad and Tobago’s energy sector. The cost-benefit analysis undertaken on selected adaptation strategies reveal that the benefit-cost ratio of replacing electric water heaters with solar water heaters is the most cost-effective. It was also found that the introduction of Compact Fluorescent Light (CFL) and Variable Refrigerant Volume (VRV) air conditioners surpasses the projected cost of increased electricity consumption due to climate change, and provides an economic rationale for the adoption of these adaptation options even in a situation of increased electricity consumption occasioned by climate change. Finally, the conversion of motor fleets to Compressed Natural Gas (CNG) is a cost-effective adaptation option for the transport sector, although it has a high initial cost of implementation and the highest per capita among the four adaptation options evaluated. To investigate the effect of climate change on the health sector dengue fever, leptospirosis, food borne illnesses, and gastroenteritis were examined. The total number of new dengue cases for the period 2008 to 2050 was 204,786 for BAU, 153,725 for A2 and 131,890 for the B2 scenario. With regard to the results for leptospirosis, A2 and B2 seem to be following a similar path with total number of new cases in the A2 scenario being 9,727 and 9,218 cases under the B2 scenario. Although incidence levels in the BAU scenario coincided with those of A2 and B2 prior to 2020, they are somewhat lower post 2020. A similar picture emerges for the scenarios as they relate to food-borne illnesses and to gastroenteritis. Specifically for food-borne illnesses, the BAU scenario recorded 27,537 cases, the A2 recorded 28,568 cases and the B2 recorded 28,679 cases. The focus on the selected sources of morbidity in the health sector has highlighted the fact that the vulnerability of the country’s health sector to climate change does not depend solely on exogenously derived impacts, but also on the behaviour and practices among the population. It is clear that the vulnerability which became evident in the analysis of the impacts on dengue fever, leptospirosis and food-borne illnesses is not restricted solely to climate or other external factors. The most important adaptation strategy being recommended targets lifestyle, behaviour and attitude changes. The population needs to be encouraged to alter their behaviours and practices so as to minimise their exposure to harmful outcomes as it relates to the incidence of these diseases.
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This report analyses the agriculture, health and tourism sectors in Saint Lucia to assess the potential economic impacts of climate change on the sectors. The fundamental aim of this report is to assist with the development of strategies to deal with the potential impact of climate change in Saint Lucia. It also has the potential to provide essential input for identifying and preparing policies and strategies to help advance the Caribbean subregion closer to solving problems associated with climate change and attaining individual and regional sustainable development goals. Some of the key anticipated impacts of climate change for the Caribbean include elevated air and sea-surface temperatures, sea-level rise, possible changes in extreme events and a reduction in freshwater resources. The economic impact of climate change on the three sectors was estimated for the A2 and B2 IPCC scenarios until 2050. An evaluation of various adaptation strategies for each sector was also undertaken using standard evaluation techniques. The key subsectors in agriculture are expected to have mixed impacts under the A2 and B2 scenarios. Banana, fisheries and root crop outputs are expected to fall with climate change, but tree crop and vegetable production are expected to rise. In aggregate, in every decade up to 2050, these sub-sectors combined are expected to experience a gain under climate change with the highest gains under A2. By 2050, the cumulative gain under A2 is calculated as approximately US$389.35 million and approximately US$310.58 million under B2, which represents 17.93% and 14.30% of the 2008 GDP respectively. This result was unexpected and may well be attributed to the unavailability of annual data that would have informed a more robust assessment. Additionally, costs to the agriculture sector due to tropical cyclones were estimated to be $6.9 million and $6.2 million under the A2 and B2 scenarios, respectively. There are a number of possible adaptation strategies that can be employed by the agriculture sector. The most attractive adaptation options, based on the benefit-cost ratio are: (1) Designing and implementation of holistic water management plans (2) Establishment of systems of food storage and (3) Establishment of early warning systems. Government policy should focus on the development of these adaption options where they are not currently being pursued and strengthen those that have already been initiated, such as the mainstreaming of climate change issues in agricultural policy. The analysis of the health sector placed focus on gastroenteritis, schistosomiasis, ciguatera poisoning, meningococal meningitis, cardiovascular diseases, respiratory diseases and malnutrition. The results obtained for the A2 and B2 scenarios demonstrate the potential for climate change to add a substantial burden to the health system in the future, a factor that will further compound the country’s vulnerability to other anticipated impacts of climate change. Specifically, it was determined that the overall Value of Statistical Lives impacts were higher under the A2 scenario than the B2 scenario. A number of adaptation cost assumptions were employed to determine the damage cost estimates using benefit-cost analysis. The benefit-cost analysis suggests that expenditure on monitoring and information provision would be a highly efficient step in managing climate change and subsequent increases in disease incidence. Various locations in the world have developed forecasting systems for dengue fever and other vector-borne diseases that could be mirrored and implemented. Combining such macro-level policies with inexpensive micro-level behavioural changes may have the potential for pre-empting the re-establishment of dengue fever and other vector-borne epidemic cycles in Saint Lucia. Although temperature has the probability of generating significant excess mortality for cardiovascular and respiratory diseases, the power of temperature to increase mortality largely depends on the education of the population about the harmful effects of increasing temperatures and on the existing incidence of these two diseases. For these diseases it is also suggested that a mix of macro-level efforts and micro-level behavioural changes can be employed to relieve at least part of the threat that climate change poses to human health. The same principle applies for water and food-borne diseases, with the improvement of sanitation infrastructure complementing the strengthening of individual hygiene habits. The results regarding the tourism sector imply that the tourism climatic index was likely to experience a significant downward shift in Saint Lucia under the A2 as well as the B2 scenario, indicative of deterioration in the suitability of the island for tourism. It is estimated that this shift in tourism features could cost Saint Lucia about 5 times the 2009 GDP over a 40-year horizon. In addition to changes in climatic suitability for tourism, climate change is also likely to have important supply-side effects on species, ecosystems and landscapes. Two broad areas are: (1) coral reefs, due to their intimate link to tourism, and, (2) land loss, as most hotels tend to lie along the coastline. The damage related to coral reefs was estimated at US$3.4 billion (3.6 times GDP in 2009) under the A2 scenario and US$1.7 billion (1.6 times GDP in 2009) under the B2 scenario. The damage due to land loss arising from sea level rise was estimated at US$3.5 billion (3.7 times GDP) under the A2 scenario and US$3.2 billion (3.4 times GDP) under the B2 scenario. Given the potential for significant damage to the industry a large number of potential adaptation measures were considered. Out of these a short-list of 9 potential options were selected by applying 10 evaluation criteria. Using benefit-cost analyses 3 options with positive ratios were put forward: (1) increased recommended design speeds for new tourism-related structures; (2) enhanced reef monitoring systems to provide early warning alerts of bleaching events, and, (3) deployment of artificial reefs or other fish-aggregating devices. While these options had positive benefit-cost ratios, other options were also recommended based on their non-tangible benefits. These include the employment of an irrigation network that allows for the recycling of waste water, development of national evacuation and rescue plans, providing retraining for displaced tourism workers and the revision of policies related to financing national tourism offices to accommodate the new climate realities.
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Water security which is essential to life and livelihood, health and sanitation, is determined not only by the water resource, but also by the quality of water, the ability to store surplus from precipitation and runoff, as well as access to and affordability of supply. All of these measures have financial implications for national budgets. The water sector in the context of the assessment and discussion on the impact of climate change in this paper includes consideration of the existing as well as the projected available water resource and the demand in terms of: quantity and quality of surface and ground water, water supply infrastructure - collection, storage, treatment, distribution, and potential for adaptation. Wastewater management infrastructure is also considered a component of the water sector. Saint Vincent and the Grenadines has two distinct hydrological regimes: mainland St Vincent is one of the wetter islands of the eastern Caribbean whereas the Grenadines have a drier climate than St Vincent. Surface water is the primary source of water supply on St Vincent, whereas the Grenadines depend on man-made catchments, rainwater harvesting, wells, and desalination. The island state is considered already water stressed as marked seasonality in rainfall, inadequate supply infrastructure, and institutional capacity constrains water supply. Economic modelling approaches were implemented to estimate sectoral demand and supply between 2011 and 2050. Residential, tourism and domestic demand were analysed for the A2, B2 and BAU scenarios. In each of the three scenarios – A2, B2 and BAU Saint Vincent and the Grenadines will have a water gap represented by the difference between the two curves during the forecast period of 2011 and 2050. The amount of water required increases steadily between 2011 and 2050 implying an increasing demand on the country‘s resources as reflected by the fact that the water supply that is available cannot respond adequately to the demand. The Global Water Partnership in its 2005 policy brief suggested that the best way for countries to build the capacity to adapt to climate change will be to improve their ability to cope with today‘s climate variability (GWP, 2005). This suggestion is most applicable for St Vincent and the Grenadines, as the variability being experienced has already placed the island nation under water stress. Strategic priorities should therefore be adopted to increase water production, increase efficiency, strengthen the institutional framework, and decrease wastage. Cost benefit analysis was stymied by data availability, but the ―no-regrets approach‖ which intimates that adaptation measures will be beneficial to the land, people and economy of Saint Vincent and the Grenadines with or without climate change should be adopted.
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Changing precipitation patterns and temperature relate directly to water resources and water security. This report presents the findings of an assessment of the water sector in Grenada with respect to the projected impact of climate change. Grenada‘s water resources comprise primarily surface water, with an estimated groundwater potential to satisfy about 10%-15% of the present potable requirement. On the smaller islands Carriacou and Petite Martinique, domestic water is derived exclusively from rainwater catchments. Rainfall seasonality is marked and the available surface water during the dry season declines dramatically. Changing land use patterns, increase in population, expansion in tourism and future implementation of proposed irrigation schemes are projected to increase future water requirements. Economic modeling approaches were implemented to estimate sectoral demand and supply between 2011 and 2050. Residential, tourism and domestic demand were analysed for the A2, B2 and BAU scenarios as illustrated. The results suggest that water supply will exceed forecasted water demand under B2 and BAU during all four decades. However under the A2 scenario, water demand will exceed water supply by the year 2025. It is important to note that the model has been constrained by the omission of several key parameters, and time series for climate indicators, data for which are unavailable. Some of these include time series for discharge data, rainfall-runoff data, groundwater recharge rates, and evapotranspiration. Further, the findings which seem to indicate adequacy of water are also masked by seasonality in a given year, variation from year to year, and spatial variation within the nation state. It is imperative that some emphasis be placed on data generation in order to better project for the management of Grenada‘s water security. This analysis indicates the need for additional water catchment, storage and distribution infrastructure, as well as institutional strengthening, in order to meet the future needs of the Grenadian population. Strategic priorities should be adopted to increase water production, increase efficiency, strengthen the institutional framework, and decrease wastage. Grenada has embarked on several initiatives that can be considered strategies toward adaptation to the variabilities associated with climate change. The Government should ensure that these programs be carried out to the optimal levels for reasons described above. The ―no-regrets approach‖ which intimates that measures will be beneficial with or without climate change should be adopted. A study on the Costs of Inaction for the Caribbean in the face of climate change listed Grenada among the countries which would experience significant impacts on GDP between now and 2100 without adaptation interventions. Investment in the water sector is germane to building Grenada‘s capacity to cope with the multivariate impact of changes in the parameters of climate.
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The economic impact of climate change on root crop, fisheries and vegetable production for Trinidad and Tobago under the A2 and B2 scenarios were modeled, relative to a baseline ―no climate change‖ case, where the mean temperature and rainfall for a base period of 1980 – 2000 was assumed for the years up to 2050. Production functions were used, using ARMA specifications to correct for serial autocorrelation. For the A2 scenarios, rainfall is expected to fall by approximately 10% relative to the baseline case in the 2020s, but is expected to rise thereafter, until by the 2040s rainfall rises slightly above the mean for the baseline case. For the B2 scenario, rainfall rose slightly above the mean for the baseline case in the current decade, but falls steadily thereafter to approximately 15% by the 2040s. Over the same period, temperature is expected to increase by 1.34C and 1.37C under A2 and B2 respectively. It is expected that any further increase in rainfall should have a deleterious effect on root crop production as a whole, since the above mentioned crops represent the majority of the root crops included in the study. Further expected increases in temperature will result in the ambient temperature being very close to the optimal end of the range for most of these crops. By 2050, the value of yield cumulative losses (2008$) for root crops is expected to be approximately 248.8 million USD under the A2 scenario and approximately 239.4 million USD under the B2 scenario. Relative to the 2005 catch for fish, there will be a decrease in catch potential of 10 - 20% by 2050 relative to 2005 catch potentials, other things remaining constant. By 2050 under the A2 and B2 scenarios, losses in real terms were estimated to be 160.2 million USD and 80.1 million USD respectively, at a 1% discount rate. For vegetables, the mean rainfall exceeds the optimal rainfall range for sweet peppers, hot peppers and melongene. However, while the optimal rainfall level for tomatoes is 3000mm/yr, other vegetables such as sweet peppers, hot peppers and ochroes have very low rainfall requirements (as low as 300 mm/yr). Therefore it is expected that any further decrease in rainfall should have a mixed effect on individual vegetable production. It is expected that any further increase in temperature should have a mixed effect on individual vegetable production, though model results indicated that as a group, an increase in temperature should have a positive impact on vegetable production. By 2050, the value of yield cumulative gains (2008$) for vegetables is expected to be approximately 54.9 million USD under the A2 scenario and approximately 49.1 million USD under the B2 scenario, given a 1% discount rate. For root crops, fisheries and vegetables combined, the cumulative loss under A2 is calculated as approximately 352.8 million USD and approximately 270.8 million USD under B2 by 2050. This is equivalent to 1.37% and 1.05% of the 2008 GDP under the A2 and B2 scenarios respectively by 2050. Sea Level Rise (SLR) by 2050 is estimated to be 0.255 m under A2 and 0.215 m under B2. GIS estimation indicated that for a 0.255 m sea level rise, combined with a 0.5 m high tide, there would be no permanent inundation of agricultural land in Trinidad. The total inundation area is 1.18 km2. This occurs only in the Caroni Watershed, on the western coast of Trinidad, and the areas are outside the Caroni Swamp. Even with an additional rise of 0.5 m to simulate a high rainfall event, the estimated inundated area is 4.67 km2, but with no permanent inundation, though likely to be subject to flooding. Based on eleven (11) evaluation criteria, the top potential adaptation options were identified: 1. Use of water saving irrigation systems and water management systems e.g. drip irrigation; 2. Mainstream climate change issues into agricultural management; 3. Repair/maintain existing dams; 4. Alter crop calendar for short-term crops; 5. Adopt improved technologies for soil conservation; 6. Establish systems of food storage; 7. Promote water conservation – install on-farm water harvesting off roof tops; 8. Design and implement holistic water management plans for all competing uses; 9. Build on- farm water storage (ponds and tanks); 10. Agricultural drainage; and 11. Installation of greenhouses. The most attractive adaptation options, based on the Benefit-Cost Ratio are: (1) Build on- farm water storage such as ponds and tanks (2) Mainstreaming climate change issues into agricultural management and (3) Water Harvesting. However, the options with the highest net benefits are, (in order of priority): (1) Build on- farm water storage such as ponds and tanks, (2) Mainstreaming climate change issues into agricultural management and (3) Use of drip irrigation. Based on the area burnt in Trinidad and Tobago between 2005 and 2009, the average annual loss due to fires is 1717.3 ha. At US$17.41 per carbon credit, this implies that for the total land lost to forest fires on average each year, the opportunity cost of carbon credit revenue is 74.3 million USD. If a teak reforestation programme is undertaken in Trinidad and Tobago, the net benefit of reforestation under a carbon credit programme would be 69 million USD cumulatively to 2050.
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The present volume captures the results of the studies conducted during Phase 2 of the RECCC project to date. Chapter 1 provides the contextual framework within which the assessments were conducted and Chapter 2 focuses on the emissions scenarios as set out by the Special Report on Emissions Scenarios by the Intergovernmental Panel on Climate Change (IPCC). The results of the economic assessments of the impacts of climate change on the agricultural, coastal and marine, energy and transportation, health, freshwater resources and tourism sectors in the Caribbean subregion are presented in Chapters 3 to 9, respectively. The report concludes with an examination of adaptation strategies and key policy recommendations for policymakers, in Chapter 10.
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The United Nations Economic Commission for Latin America and the Caribbean (ECLAC) is seeking to provide support to the Governments of Guyana, Jamaica and Barbados in researching the potential for employing renewable energy technologies to mitigate climate change. This exercise involves the study of different types of renewable technologies and mitigative strategies, with the aim of making recommendations to the governments on the development of their renewable energy sector. The recommendations may also assist in achieving their long-term objectives of reducing poverty and promoting healthy economies and sustainable livelihoods in keeping with the Millennium Development Goals. Guyana, Jamaica and Barbados each face common and specific challenges in their efforts to adequately define and implement their energy and climate policies, in a way that allows them to contribute to the mitigation effort against climate change, while promoting sustainable development within their countries. Each country has demonstrated an understanding of the global and national challenges pertaining to climate change. They have attempted to address these challenges through policies and various programmes implemented by local and international agencies. Documented and undocumented policies have sought to outline the directions to be taken by each territory as they seek to deploy new technologies to address issues related to energy and the environment. While all territories have sought to deploy multiple alternate and renewable technologies simultaneously, it is clear that, given their sizes and resource limitations, no one territory can achieve excellence in all these areas. Guyana has demonstrated the greatest potential for hydro energy and should pursue it as their main area of expertise. The country also has an additional major strategy that includes forest credits and the Reduced Emissions from Deforestation and Degradation (REDD) programme. This approach will be brought to the negotiation table in the upcoming climate change meeting in Copenhagen in December 2009. Of the three countries, Jamaica has the only active significant wind farm deployment, while Barbados has a long tradition in solar energy. Each country might then supplement their energy and fuel mix with other energy and fuel sources and draw from the experience of other countries. Given the synergies that might accrue from adopting a regional approach, the Caribbean Community Climate Change Centre (CCCCC) might be well positioned to play a coordinating role. This focus on renewable energy and biofuels should yield good, long-term results as it relates to mitigation against climate change, and good, short- and medium-term results as it relates to the development of sustainable economies. Each country might also achieve energy security, reduced oil dependence, significant reduction in harmful emissions and better foreign exchange management if they pursue good policies and implementation practices. Human and financial resources are critical to the success of planned interventions, and it will be necessary to successfully mobilize these resources in order to be effective in executing key plans.
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This paper focuses on several key economic issues relevant to climate change. Given the fact that changes in climate are projections using the best available data, it examines the economic principles of uncertainty and the precautionary approach, and then continues to address the key drivers of climate change. Climate change is expected to result in negative impacts and, in this regard, the consequences of anticipated rising temperatures and sea levels as well as changes in precipitation that may result in flooding and/or drought are addressed. However, the situation is not all negative and, as such, the opportunities that are likely to arise through adaptation and mitigation are discussed especially with respect to the Caribbean. In this regard and recognizing that it would be useful to Caribbean policymakers to utilize these opportunities and to address the negative impacts, the Economic Commission for Latin America and the Caribbean (ECLAC), through its subregional headquarters for the Caribbean, is spearheading a review of the economics of climate change in the Caribbean with a view to providing quantitative information to stakeholders in dealing with climate change. The paper makes recommendations for the Caribbean to address climate change at the national level. These include macroplanning; promotion of energy efficiency; creation of incentives to obtain support for implementation of alternative energy technologies; maintaining the will among stakeholders on a sustained basis for addressing climate change; and the conduct of relevant research into varieties of plants and animals that could adapt to changing climatic conditions. Finally, it must be recognized that to successfully combat climate change, the threats and opportunities must be properly assessed as part of an ongoing region-wide system of risk management, which should not be incidental, but integral, to national and regional planning and forecasting for the future.
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Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)
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Pós-graduação em Geografia - FCT
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Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)
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Many dog owners see homemade diets as a way of increasing the bond with their pets, even though they may not have the convenience of commercial diets. Modifications of ingredients, quality and proportion might change the nutritional composition of the diet, generating nutritional imbalances. The present study evaluated how dog owners use and adhere to homemade diets prescribed by veterinary nutritionists over an extended period of time. Forty-six owners of dogs fed a homemade diet for at least 6 months were selected for the present study. Owners were invited to answer questions by first reading all possible answers and then selecting the one that best indicated their opinion. The results were evaluated through descriptive statistics. Thirty-five owners (76·1 %) found that the diets are easy to prepare. Fourteen owners (30·4 %) admitted to modifying the diets, 40 % did not adequately control the amount of provided ingredients, 73·9 % did not use the recommended amounts of soyabean oil and salt, and 34·8 % did not correctly use the vitamin, mineral or amino acid supplements. Twenty-six owners (56·5 %) reported that their dogs refused to eat at least one food item. All of these alterations make the nutritional composition of the diets unpredictable and likely nutritionally imbalanced. Although homemade diets could be a useful tool for the nutritional management of dogs with certain diseases, not all owners are able to appropriately use this type of diet and adhere to it for an extended period of time and this limitation needs to be considered when recommending the use of homemade diets.
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Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)
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In the context of medical school instruction, the segmented approach of a focus on specialties and excessive use of technology seem to hamper the development of the professional-patient relationship and an understanding of the ethics of this relationship. The real world presents complexities that require multiple approaches. Engagement in the community where health competence is developed allows extending the usefulness of what is learned. Health services are spaces where the relationship between theory and practice in health care are real and where the social role of the university can be revealed. Yet some competencies are still lacking and may require an explicit agenda to enact. Ten topics are presented for focus here: environmental awareness, involvement of students in medical school, social networks, interprofessional learning, new technologies for the management of care, virtual reality, working with errors, training in management for results, concept of leadership, and internationalization of schools. Potential barriers to this agenda are an underinvestment in ambulatory care infrastructure and community-based health care facilities, as well as in information technology offered at these facilities; an inflexible departmental culture; and an environment centered on a discipline-based medical curriculum.