Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of International Health, 615 N, Wolfe St,, Baltimore, MD 21205, USA.
Global Health. 2013 Nov 7;9:56. doi: 10.1186/1744-8603-9-56.
External challenges to health systems, such as those caused by global economic, social and environmental changes, have received little attention in recent debates on health systems' performance in low-and middle-income countries (LMICs). One such challenge in coming years will be increasing prices for petroleum-based products as production from conventional petroleum reserves peaks and demand steadily increases in rapidly-growing LMICs. Health systems are significant consumers of fossil fuels in the form of petroleum-based medical supplies; transportation of goods, personnel and patients; and fuel for lighting, heating, cooling and medical equipment. Long-term increases in petroleum prices in the global market will have potentially devastating effects on health sectors in LMICs who already struggle to deliver services to remote parts of their catchment areas. We propose the concept of "localization," originating in the environmental sustainability literature, as one element of response to these challenges. Localization assigns people at the local level a greater role in the production of goods and services, thereby decreasing reliance on fossil fuels and other external inputs. Effective localization will require changes to governance structures within the health sector in LMICs, empowering local communities to participate in their own health in ways that have remained elusive since this goal was first put forth in the Alma-Ata Declaration on Primary Health Care in 1978. Experiences with decentralization policies in the decades following Alma-Ata offer lessons on defining roles and responsibilities, building capacity at the local level, and designing appropriate policies to target inequities, all of which can guide health systems to adapt to a changing environmental and energy landscape.
卫生系统面临的外部挑战，如全球经济、社会和环境变化所带来的挑战，在最近关于中低收入国家（LMICs）卫生系统绩效的讨论中很少受到关注。未来几年的一个挑战将是石油基产品价格的上涨，因为常规石油储量的产量达到峰值，而快速增长的 LMICs 的需求稳步增长。卫生系统是石油基医疗用品、货物、人员和患者运输以及照明、加热、冷却和医疗设备燃料等形式的化石燃料的重要消费者。全球市场石油价格的长期上涨可能对已经难以向其服务范围内的偏远地区提供服务的 LMIC 卫生部门产生毁灭性影响。我们提出了“本土化”的概念，该概念源自环境可持续性文献，是应对这些挑战的要素之一。本土化赋予地方一级的人们在生产商品和服务方面更大的作用，从而减少对化石燃料和其他外部投入的依赖。有效的本土化将需要改变 LMIC 卫生部门内部的治理结构，赋予当地社区以参与自身健康的权力，自 1978 年《阿拉木图初级卫生保健宣言》首次提出这一目标以来，这一直是一个难以实现的目标。自《阿拉木图宣言》以来几十年的权力下放政策经验提供了关于确定角色和责任、在地方一级建设能力以及制定针对不平等现象的适当政策的经验教训，所有这些都可以指导卫生系统适应不断变化的环境和能源格局。
