Although health policy and systems research has shown signs of steady improvement, the number of locally-led LMIC publications remains rather low when compared to those steered from the global North. This was also emphasized during HSR2016 in Vancouver,  where it was noted that research contributed (too) little to health in LMICs because it often matched poorly with needs in the global South, was still too dominated by researchers from the North, and often had a narrow biomedical focus. The dearth of locally-led studies (see Figures 1 and 2) may push LMICs to rely on “best practices” from other countries, when we know that one country’s initiative may not necessarily work in another, and even if every single report stresses nowadays that “one size fits all” and other “blueprints” won’t do it. True, the picture is slowly improving, and ‘embedded researchers’ from LMICs are increasingly getting their research out, but by and large, too many countries (and even regions) are still underrepresented, both in the literature and at global conferences. The Global Evidence summit was just the latest example.

In line with the global trend towards partnership, we believe that the Global North should increasingly become collaborators for change. By the way, such collaboration should also push countries in the Global South to be more open and transparent – and perhaps less bureaucratic as well. For example, in our experience, data are sometimes not even shared with people from the same country who are working or studying in the Global North. The main fear seems to be that the flaws of the current government could be exposed. In addition, researchers often face substantial bureaucratic hurdles.

Figure 1. Relative comparison of contribution to health policy and systems research versus all PubMed publications by authors from each country per low- and middle-income country income group

English KM, Pourbohloul B. Increasing health policy and systems research capacity in low- and middle-income countries: results from a bibliometric analysis. Health Research Policy and Systems. 2017;15:64.

Figure 2. Ranking of countries’ health systems research based on the number of abstracts involving primary data collection

Hasnida A, Borst RA, Johnson AM, Rahmani NR, van Elsland SL, Kok MO. Making health systems research work: time to shift funding to locally-led research in the South. The Lancet Global Health. 2016 5(1):e22-e4.

As we strive to strengthen collaboration between the Global North and South, we call for two things in particular:

Strengthening integration of different health system initiatives

As countries strive to achieve UHC – which is currently taking centre stage, as you might have noticed – it will be key to integrate UHC focused programmes and initiatives with country priorities, whether NCDs, HIV/TB, or even other programs that are not directly health related such as eradicating poverty and hunger. We believe that the integration of initiatives can also optimize the limited pool of research funding and capacity in LMICs and produce, in turn, more high impact and quality findings – focusing on “quality” and not simply on “quantity” of research outputs. This, however, is easier said than done, which is why we call not just on donors in the Global North but also on countries in the Global South to invest ( a lot more) in building capacity for research.  Such integration of initiatives will also require countries to focus less on donor interests, but more on country-identified priorities. Global reports from the SDG era and new “catalysing” global health initiatives all proclaim that the countries themselves should be in the driving seat, so it is time we live up to that and try to make it happen.

For evidence to be generated and rooted from LMIC priorities and concerns, the Global North should not only think in terms of transferring skills to LMICs or ensuring the latter’s adoption of interventions conceived in the North, but they should also learn from LMICs about their own (health system) constraints, as well as innovations and strengths that can be tapped to overcome complex issues in their own (Northern) settings. Reverse innovation and learning shouldn’t remain empty words. This also means that poor countries in the Global South should not only be considered as donor-dependent countries, but also as rich sources of evidence, requiring appreciation of country-specific contexts. Only then, they’ll really become “partners”, and will we have entered the SDG health era. Thus, researchers from the Global North must also invest in immersing themselves in the realities and complexities of the Global South before making sometimes sweeping assertions in their research. In other words, Global North researchers may need to spend a heck of a lot more time in the South, if they are going to draft recommendations. Or more bluntly: “capacity building” of Northern researchers who write about the South should also be a priority.

Transforming “brain drain” into “brain gain”

As mentioned above, the Global South should make research a priority, which requires substantial investment in their local researchers, research institutes and think tanks. According to a UNESCO report, the USA, China, EU and Japan account for nearly 77% of global investment in R&D. As a result of limited investment in LMIC, only 1.3% of the world share of researchers in 2013 came from low income countries, while 6.4% belonged to lower middle and 28% to upper-middle income countries.

Most “global” conferences are (still) held in countries that are too expensive for junior researchers or practitioners from LMICs. Visa requests can be a painful (expensive and tedious) process, and in these “assertive nationalism” times that isn’t likely to get any better any time soon. In short, early-career researchers need more support from organizers of international summits, symposiums and conferences to both attend and actively participate (and not only to turn the conferences into more lively affairs!)

Furthermore, in quite a few countries in the Global South, research funding is not always based on competence and relevance of the researcher’s role. Often, the position in government matters more, and researchers from private institutions may have less chances to apply to certain calls. It is also common that Global South governments send people in senior leadership roles to international conferences. Again and again. Even local researchers who are working directly with data may not be selected for funding or enjoy sufficient support.

Like in the Global North, junior or private researchers suffer restrictions, but due to their limited number we think they can act as an important bridge between organizations, and  they might eventually also contribute to the health sector in their country as part of the government or a public university. But even if they do not, just like any other professional, they need to expand their networks and improve their skills. Otherwise, their research may stagnate and become stale. It is thus vital that they also have the opportunity to attend global conferences.

Early-career researchers need to raise their voices in their own countries while becoming globally involved. A pooled registration fund could perhaps help to progressively offer a special discount or even a fee waiver to junior experts from the Global South. Anyhow, we are sure health economists can come up with a more equitable “scheme” than the current one!

Some may fear that emphasizing (more) South-North exchanges could result in further brain drain or, at least, brainwashing. But, as proposed here, we tend to see this differently, as an opportunity rather – more in particular as a way to improve mutual understanding.

What’s next?

Our plea is simpler said than done: achieving change in health systems requires active commitment and participation from both the Global North and South. A global symposium on health systems research is precisely the place to discuss how this can be achieved. In fact, ideally, in the months ahead, everything should be done so that participation will be as inclusive and diverse as possible in Liverpool.

As HSR2018 launches the call for abstracts this month, now is the time to boost engagement of researchers and other global health practitioners from the Global South, especially from countries and regions that have been underrepresented since Montreux.

Reflections on the 2017 Consortium of Universities in Global Health held in Washington DC, USA (April 6-9)

Health systems are getting more complex than ever, encompassing no longer just the typical building blocks of health systems and their interactions, but also venturing to include areas of study on planetary health – or “galactic health” as some speakers called it – at the recent 2017 Consortium of Universities in Global Health (CUGH) Conference held in Washington DC, which we were fortunate to attend. Indeed, the realm of health systems has expanded more than ever to highlight the importance of framing human health within the wider context of the environment and Earth’s natural ecosystems, focusing on how vital this is to save current and future generations. Unfortunately, while ecosystems are undeniably important to the future of humanity, efforts to protect them are continuously threatened by changing political paradigms. Most recently, at the pinnacle of concerns about environmental impacts on health (and related policies) is the new US administration. Coincidentally, the 2017 Annual CUGH Conference was held in the epicentre of U.S. (and to some extent also global) politics – Washington D.C.

Here, we outline our top three takeaway messages for health systems researchers from the conference.

1. Calling upon health systems researchers to become ecosystem advocates: The current political climate in the United States means there are threats to the funding of key U.S. institutes and agencies involved in global health activities. U.S.-based attendees were urged to contact their Congressperson to advocate for continued funding of global health. We wondered, are there opportunities for other health systems groups to also join this call? More broadly, a strong case has been made for the political argument for investing in global health. Political will and international collaboration led to the MDGs, the SDGs, and even the eradication of smallpox. Public policies affect global health outcomes, and academia (in any field or expertise) has a moral obligation to engage politically, to present the science and evidence that can guide policymaking. As Richard Horton said in the closing plenary session of the Conference, “Science can be a lever for holding those with power accountable for their commitments.” Health systems researchers around the world should heed this message. In the planetary health era, this not only implies advocacy for global health funding and commitment, but also ecosystem advocacy based on the best available science.

2. Integrating ecosystems in service delivery: Under the planetary health framework, we need a genuinely multi-scalar, transdisciplinary approach to achieve substantial health and environmental gains. EcoHealth and One Health approaches have long since tackled local-level challenges including micro- and macronutrient deficiencies, livestock health, infectious diseases, and land-use change – themes that underscored several conference sessions. Local efforts are best supported by complementary national and international policies – a key principle underlying the planetary health approach. For example, researchers at EcoHealth Alliance highlighted the Global Health Security Agenda, suggesting we can build stronger health systems by accounting for local socio-ecological practices, and incorporating ecosystem and biodiversity disturbance indicators. These systems would in turn be better able to swiftly address pandemic threats on a regional or global level. Without collective action, annual costs of zoonotic spillover events will continue to rise. In this case, a clear economic rationale exists – the hefty cost of inaction far outweighs the cost of cooperative pandemic prevention. The next challenge is to examine the trade-offs and develop the economic rationale for each scenario that contributes to the broader planetary health framework. Ultimately, the goal is to incentivize the global community to adopt and integrate a “planetary health ethos” from consumer behaviour to international policymaking.

3. Adding environmental vulnerability as a mark of health system resilience: More and more countries are making evidence-based policy decisions on priority-setting of health needs. The Global Burden of Disease (GBD) Collaboration is responding to this need by releasing GBD results yearly, developing more subnational estimates, and refining their methods. As countries focus more of their resources on tackling high-burden diseases, it is important that they do not neglect low-burden diseases that disproportionately affect vulnerable populations, such as neglected tropical diseases that may not rank high in terms of overall burden, but often rank high among the poor or those living in urban slums or hard-to-access rural areas. Investing in upstream policies is also important, such as those addressing planetary health. A health in all policies approach with the inclusion of environmental vulnerability discussions should be the guiding framework, not just in the health sector, but all other related sectors.

Against this backdrop, it was no doubt appropriate that, for the first time, the conference was co-chaired by a member institution from a low- and middle-income country, a practice which they intend to continue in the coming years – the 2018 CUGH conference will take place in New York. As a side note, perhaps this kind of commitment to representation of LMIC institutions as co-organizers or conference hosts could be considered by other upcoming global health conferences, since it exposes participants to the struggles in LMICs (including visa concerns faced by many participants from LMICs when attending conferences in high-income countries).

The need to integrate environmental issues into health systems is more critical than ever. While many engaging and thought-provoking discussions occurred during the conference, some sessions still felt too focussed on the problem, without due attention to the potential solutions. Academics are accustomed to clearly defining the problem, but often feel hesitant to venture into the policy domain. However, as the underlying message of the Conference emphasized, we as academics and as part of the global health community need to engage in political advocacy for better global health policies, inclusive of planetary health. Human wellbeing and health, indeed, are ecosystem services. It is vitally important to keep it that way for the generations that follow.

First, recent political events have threatened the value of evidence for decision-making, resulting in misleading and even false claims. Some examples (out of the hundreds or even thousands from this year alone), perhaps. For many years, climate scientists have been defending the reality of climate change and although I’m generally not pessimistic about this battle (unlike some other contributors to this website, I’m a “glass half full” person  ), the struggle will definitely continue in the years to come. With one of the most powerful leaders in the world now arguing against global warming, calling it a “hoax” (invented by China), promising to cancel the historic Paris climate agreement, and appointing a climate skeptic in the Environmental Protection Agency, the picture for climate change suddenly looks even worse than it already did. In any case, Trump doesn’t seem to give a damn about evidence (as is the case with daily intelligence briefings, it seems). Also, reproductive rights in the US are on the brink with more restrictions for women’s healthcare access and potential budget cuts for family planning funds. Similarly, the bigoted immigration plans (of his campaign) seem to remain largely unchanged despite the unnecessary billions of dollars of spending it may cost the government, not to mention the countless lives of people that might be affected. And of course, the list goes on and on.

Will other countries follow the path of the superpower (now clearly in decline) and ignore evidence? We don’t know yet. Zooming in on my country, for example, no matter how much a new influential leader like Duterte lambasted the US (Obama, notably) for not supporting the Philippine war on drugs, it seems like the ties with the new US leader will remain steady in the years to come. Trump and Duterte seem to get along just fine.  Both Trump and Duterte seem to also enjoy the company of their new Russian ally, Putin – who suddenly seems to have a lot of friends (Erdogan comes to mind). In these volatile times, I wonder how many more prime ministers will resign next year for whatever reason, and how many more regimes will take an authoritarian turn, with ever more people seeming to root for ‘strongmen’. With the rising political volatility and uncertainties, evidence-informed decisions seem even more important than before, when Fukuyama still seemed to get it right.

Second, funding is political. As such, the failure to use evidence in informing political decisions will have detrimental effects to global health funding schemes. Many global health players were already frightened when the UK, a global leader in international aid and development, voted for Brexit. Now the US, another key player, pledges to also ‘stop sending aid to countries that hate us [the US]’, promising to redirect funding to the US instead. Against that backdrop, more than ever, information about the benefits, risks, and cost-effectiveness of resource allocation decisions are needed. We will probably never be able to convince the far right on this issue, given the way they’re “wired”, but leaders and even the general public should stop looking at aid recipient countries as leeches and parasites, and refrain from dehumanizing jargon and harsh policies. Those living in the comfort of their posh homes with a nice Christmas tree and sumptuous meal should stop believing that they can forever live in a so-called “bubble”, no matter how “state of the art” that notorious US-Mexican wall (“The best ever”, no doubt) will turn out.

While the picture for 2017 and the years after thus looks bleak, we need champions to change the course of our global landscape before we all go downhill. Fortunately, Justin Trudeau has said at least that he will defend Canadian interests if Trump goes too far despite the latter calling him ‘Canada’s worst President yet’. In the current circumstances, that’s certainly a compliment.  Likewise, Angela Merkel pledged to cooperate with Trump, but only if he adheres to the values of democracy and equality. With the upcoming WHO Director-General elections, I wonder who will be the next Halfdan Mahler to champion our cause for global health. Whoever will emerge as triumphant later this year, if he or she is a great communicator of evidence – perhaps learning how to best do elevator pitches for a business-focused US leader?  – that would be a great asset. Similar reflections are needed for us, health systems researchers, and the rest of the scientific world. We need to be active not just within the four corners of our office walls or laboratories, but also in shaping the global political landscape that was subjected to relentless perils this year, with probably worse to come. So I suggest a competition next year for “the best innovation to communicate research in the post-truth post-fact era”!

On that note, a happy holidays to you all!

In recent years, universal health coverage (UHC) has become a buzzword in the global health arena, with Margaret Chan regarding it as the “single most powerful concept public health has to offer” – a global coalition is strongly pushing it further and the global momentum seems unstoppable. However, the road towards UHC remains difficult in many countries. Given finite resources, a critical issue on the path towards UHC pertains to deciding which services and policies to prioritize. As most of us don’t exactly live in a Garden of Eden (see the intro), hard choices have to be made. How countries make these choices was a key debate at the recently held Prince Mahidol Award Conference (PMAC) in Bangkok, given this year’s theme ‘Priority setting for UHC’.

Perhaps, if you’ve been tackling this area for a long time already, PMAC can seem initially like a reunion for many – on the first day, the “big ones” seemed very enthusiastic  to reconnect with their old colleagues! Yet, people were coming from different backgrounds this year – many academics, yes (many also from Health Systems Global), but also NGOs, civil society groups, journalists, and decision makers – all flew to the Thai capital last week to debate issues on priority setting for UHC. The diversity in the room was overwhelming. We all became impatient spectators, waiting for each high level panel of experts to traverse the treacherous pathways towards UHC and unravel their own practical recommendations.

So how do countries prioritize for UHC? Optimizing care using available finite resources requires the most effective health interventions to be evaluated properly. There is generally a strong consensus that Health Technology Assessment (HTA) including cost-effectiveness analysis is the main tool for critically evaluating knowledge; and hence, potentially leads to more informed decision-making regarding what health goods and services to provide in order to achieve UHC. However, a key question is whether HTA can really meet the high expectations and do what it claims to do. HTA reports may always include scientific evidence on cost-effectiveness, but they seldom take into account socio-political factors, as well as societal values that are also very critical for decision-making. The development of systematic and practical approaches to generate evidence on effectiveness of health interventions and on bridging the gap between such evidence and policy-making still remains a challenge. And thus we started wondering again: In priority-setting, whose priorities are we talking about? Since priorities may differ across countries, there is an extreme need to contextualize evidence and that evidence should be locally generated. However, demands for locally-driven HTA also require more investments – a further burden to many countries.

Yet, despite the lack of expertise in many countries, we learned how our colleagues have started to capacitate themselves in this highly technical field through hard work and painstaking commitment. The conference provided a precious opportunity to update our knowledge with insights from and exchanges with colleagues from world-renowned academic and research institutions such as the Thai Health Intervention and Technology Assessment Program (HITAP), University of York, International Information Network on New and Emerging Health Technologies and WHO among others.

The current crop of health economists and HTA fans also pushes for linking of inputs in the health system (i.e. money, capital, goods and services) with health outcomes. They aim to break the old habit of repeated budget spending cycles, routine financial administration and running of health service providers as an exercise of managerial prowess. They force us to think whether we are still making an impact on the health status of the population. And because of the explicit link between cost and health outcomes, we are compelled to spend resources wisely and get optimum value for our money.

Thumbs up for getting back in the field!

After long hours of listening to panels and being trapped in the four corners of the (admittedly, posh) Centara Conference Hall with the overflowing coffee conversations, we also got to see a bit of the Bangkok area. We didn’t engage in sightseeing, though. Six sites were available for us to choose from and we picked the Ramathibodi Hospital to see how Thailand manages essential high cost medicines.

Site 2 of the PMAC Field Trip program: Management of high cost essential medicines in the UHC context, Faculty of Medicine, Ramathibodi Hospital, Mahidol University

We were very impressed at how logically Thailand has organized the steps for generating evidence of effectiveness of new drugs, including them in the National List of Essential Medicines (NLEM), and then introducing them in the wider health system. Equally important, patients shared with us their experiences and we also did a quick site tour of the pharmacies in the hospital. So we were reminded that priorities should not only be based on the budget thresholds of the government, but on voices of the people themselves – not far at all from our people-centered health systems discussions in Cape Town, isn’t it? Maybe there really wasn’t anything new, but it was definitely great to be listening to stories from the people themselves rather than seeing them just as a number or as part of a synthesis in a case study (so still, thumbs up for that).

Challenges ahead and the link with the upcoming HSR symposium in Vancouver

As we strive to move towards UHC and make our health systems more responsive, a key challenge is: how can we improve transparency, multi-stakeholder involvement, ethics and human rights considerations in our decisions for the population? While predominant concerns revolve around which interventions to prioritize over others and whether it is acceptable to remove items from the current basket of services that are no longer cost-effective, we should not forget the dynamic changes and new challenges that will confront our health systems.

Hence, the Fourth Global Symposium on Health Systems Research (#HSR2016), scheduled for November in Vancouver, and its theme of “resilient and responsive health systems for a changing world”, will be a nice follow-up to PMAC. As Remco van de Pas pointed out in a previous blog on IHP, “the resilience discourse colonizes our political imagination. It hinders us to develop universal and strong systems based on the principles of health equity and to take action on the Social Determinants of Health”. It will come as no surprise that similar critiques were raised during PMAC. Priority setting exercises, while important, only take us that far, especially in the current, very unstable world. For example, now that we face a growing migration crisis all over the world and witness a surge of (post-) conflict systems, how should we address health equity for migrants? It will be interesting to see the dynamics across the different paths towards resilient, universal, and sustainable health systems. Can’t wait till Vancouver!

Bold promises: Keeping our heads up high

PMAC 2016 concluded with a “Bangkok Statement on Priority Setting for UHC”. Much emphasis went to building capacities across all sectors for evidence-informed UHC decisions. We were called to evolve from being spectators to becoming “architects for a better society” (as the PMAC laureates encouraged us to do). True, PMAC 2015’s resolutions didn’t sound all that different. We began writing this article pondering “what made our PMAC discussions unique this time?” and to our frustration we ended without a clear answer to that question. We may have been brainwashed into thinking that UHC is not just “old wine” in a “new bottle” (hopefully with a better taste), but the “triangle (or perhaps the cube?) that moves the mountain”.

Can triangles really move mountains? We keep our heads up high for PMAC 2017 (again in Bangkok); next year’s theme, “ Addressing the health of vulnerable populations for an inclusive society”  sounds again very promising. As spectators turned (hopefully) into key actors in this battle, how high should we set the bar for UHC next year? The journey to Bangkok is rather long for us (but the warmth of their welcome and the vibrant and bustling city certainly make up for that!), but the fight for health equity has always been so much harder and longer. Hopefully next year, we can have more definite answers to what made our discussions at PMAC unique. We keep our heads up high that it isn’t just a never ending discussion. Meanwhile, see you all in Vancouver!

Of course, you’ll always need a good narrative and pitch, but through visuals we can better engage our audience, explore our findings better, and more effectively communicate and translate evidence into policies/actions. For researchers, creativity ( call it a  “spark of genius”)  has always been a must. But our creativity shouldn’t stop with our research, or even with publishing and sharing within our networks, making ‘creative’ use of social media in the process. More efforts are also needed in how we can more effectively and efficiently disseminate such evidence to a wider audience.

This was a key takeaway – almost an epiphany – I had from participating at a recent  Gordon Research Conference on Visualization in Science and Education in Maine, USA . At the event, tools were showcased that researchers across various fields use to better visualize data. The overarching theme for the 2015 conference was “Grand Challenges in the Use of Visualization in Science and Education”, so I immediately felt at home there as a young global health voice.   Yet, it was very interesting to see how advanced technology is for other areas, whereas global health and health decision-making processes lag a bit behind (with the  IHME  team and Hans “public health wizard” Rosling as some of the notable exceptions).

Let me give you some examples of the fancy advances in other areas and sectors.

Nowadays, museums wouldn’t just show remains; if they have resources, they animate, for example, dinosaurs and how these creatures lived during their era. Museums allow the interface to interact. Or as the tagline goes for one case, “a vast collection of online experiences that feed your curiosity”.

Even the National Aeronautics and Space Administration (NASA) with all its outer space expeditions is putting emphasis on how these expeditions can allow us, humble “earthlings”, to better experience walking around Mars, Vesta, or the moon using “virtual reality” devices. Michael Jackson would have loved it.

Planetariums are now growing ever more gigantic with stunning visualizations of the latest discoveries about our universe – giving you a “flying” feel throughout. The (US) National Oceanic and Atmospheric Administration (NOAA) now shows its planetary data in a room-sized animated globe.

For Iron Man fans (and especially the fans of Tony Stark’s Jarvis, an intelligent voice-activated computer assistant of the main protagonist), check out similar innovations that automatically translate natural language queries into visualizations.

Medicine is following suit with animating and modeling biomolecular processes. Technology allowed us to explore the minutest things we can’t see with our bare eyes and better explore neurons, with bigger displays and navigation capacities.

Technology and the need for evidence-informed decision-making have also already sparked decision theatres, which actively engage researchers and leaders to visualize solutions (e.g. policy options) to complex problems.

Creativity (including visualizations) doesn’t necessarily have to be “high-tech”. Scientific American and National Academy of Sciences publish evidence with more creative and engaging infographics and covers.

In the 21^st century, “big data” is getting bigger and more complex, and technological advances are going faster than ever. Also, in the new SDG era, links and integration of health with other sectors and SDG goals and targets will become far more important. So we do have our work cut out if we want to convey our messages effectively and engagingly, whether we “embed”  decision makers in our decision theatres of the future or not. Data visualization is one smart way to do so, even if sometimes less will still be more.

But now over to the mundane world again. As the current global heath social media moderator for Health Systems Global, let me shamelessly take advantage of the IHP forum I get today, and advertise some of our upcoming activities.

On August 20, Health Systems Global organizes a twitter chat on people-centered research methods for health systems development. Join the conversation by using the hashtag  #HSR2015 and you might also want to share your creative juices on how we can innovate more with our research (including via data visualization) using #HSRVis. We can start with infographics, photos, documentaries or animations about the research methods we use or to clarify what a “systems-thinking” approach is. How do we give others without any prior knowledge of our research a clearer picture of what we do? How do we creatively share basic concepts to engage our target audience(s) more? Join #HSR2015 and share your #HSRVis!

Speaking of innovation, Health Systems Global just got more creative with a revamped logo and website. Soon, a learning center  is to follow, which will include commentaries on new research methods from leading health systems researchers, insights from practitioners and policymakers, videos, webinars and other resources. You can also share thoughts with HSG’s various technical working groups. As we prepare for the Fourth Global Symposium on Health Systems Research in Vancouver, we can start thinking of how we can better use available tools to understand, explore and communicate evidence. How to be more inclusive and multidisciplinary? More informative yet engaging? With better visualizations of our health systems (research) universe, we should catch up with Hollywood, NASA and the rest of the world.

I challenge you, put effort in how we communicate and disseminate evidence. Be creative and innovative. Think out-of-the box. Go boldly where you hadn’t been before. Awaken the Hans Rosling hidden deep down in you. And of course, don’t forget to use #HSRVis in Vancouver!

you probably cannot help but think that I am a ‘happy flier’ like my compatriot Renzo Guinto  

So let me start by telling you the story of my first visit to SA – I participated at the AAUN forum, which was held at the university of Pretoria (4-7 April 2014). My five-day stay in Pretoria was exceptional and remarkable – leaving me a lasting and inspiring memory. Coming from the Philippines and arriving in Africa for the first time, I have to admit that I was weary to explore the area. Most of my friends from Africa were telling me about the very high security risks. A friend of mine who stayed there even said: “You can hear gunshots at night from the hotel… and chaos on the roads, violence, etc… I would advise you not to go alone… a wise option would be to play chess in the hotel room”.  In fact, the UN considers South Africa to have an extremely high crime rate. So why then do I say it has been exceptional and remarkable?

Upon my arrival in Pretoria, a city about an hour away from the OR Tambo International Airport in Johannesburg, I could not believe my eyes upon seeing highly gated communities in the area. Gated communities are believed to be a strong response to rising crime levels. Such gated communities would then have their own security controls and most strikingly, most houses would also be enclosed not only by high walls but also by electric fences with burglary gates, windows and doors. Some even have their own security response systems. Every house I saw had signs on their walls saying “armed response [call numbers]”. These led me to more puzzling questions: What happens if we cannot afford such security systems? Are people just paranoid about their safety? Why are they feeling this way?

Staying just a few minutes away from the conference venue, I decided to just walk going there (I also happen to be a happy walker). However, people kept on convincing me not to do so and instead asked someone else to drive me to the venue – for which I also had to pay a lot of bucks. From the venue, I decided to walk outside and buy some stuff in a nearby store. The traveler side of me kept on saying I have nothing to worry but I was always reminded of what everyone told me about safety. Turns out that I never looked at anyone and never even smiled at all. When a young boy approached me to ask if I was looking for something, I walked really fast to stay away, but he just kept on smiling and said, “I was just going to help you”. At that time, it was very hard to just show my friendly and approachable self to people; but looking back, I could have just even smiled and say thank you to that young boy, who may have just been concerned.  This made me think: Although taking the necessary precautions are needed, should we always keep ourselves hiding in fear? Why do we fear?

For the AAUN conference, most delegates came from other parts of Africa and only a few of us represented Australia. I eventually realized I was the only Filipino in the group. Although not affiliated with Africa by birth or blood, I have never felt as interested in this place. Issues not only in terms of healthcare, but also in politics, social development, and economics were exhilarating. I joined the workshop with a focus on public health and I then struggled to find words to describe how debilitating the reported health issues in Africa were. Returning to Africa a few months after, for the EV4GH venture and Cape Town symposium, I can recall how most health issues I have heard the first time I was there were the same health issues I heard in Cape Town – and even worse with the addition of the global health concern on Ebola. The difference was that during the first time I was there, our focus was mainly on Australia and Africa while in Cape Town our focus was on a more global response. Meeting people who had the same advocacies, commitment and passion for health and who were coming from all across the world was for me a great first step in addressing our many health concerns.

But the excitement (or should I say inspiration) grew after both conferences. In both instances, I noticed an undeniably strong segregation between the rich and the poor. In Pretoria, there were some areas that were called “townships” – I thought it was the counterpart of what we call “slums” back home. In Cape Town, we visited a similar area which my co-EV4GH fellows called “Khayelitsha”, one of the largest townships in South Africa. Most people I knew would advise me not to go in these areas. However, these areas were very significant in the history of South Africa, particularly in its liberation struggle during the apartheid. Although these areas are much feared by tourists, I see those in the townships as collective heroes that were vital in the fight of President Nelson Mandela. It would have been great to know them more and hear their stories. Just a week ago, an article of Public Radio International was titled “South Africa is a less equal place now than under apartheid, author says”. I eagerly wanted to know whether people from there felt the same.

Is it proper to keep ourselves away from them? Just recently, Pope Francis – also a happy flier – visited the Philippines and gave these lines that struck me most: “[All people are enjoined] by the duty to hear the voice of the poor. It bids us break the bonds of injustice and oppression which give rise to glaring, and indeed scandalous, social inequalities”.

I felt the desire then to go and listen and see beyond what my data (as a quantitative researcher) offers, but I never did – not on my first and second visits. I only had the chance to observe but I can imagine that stories of how they have lived before and the inequalities that exist now may have been almost the same. Are our problems cyclical? If we are making progress, can these people really feel it too? In one area in Pretoria, I remember I saw a long line of people gathering in a vacant lot. When I asked my local friends what these people were lining up for, they said these are people from other places in Africa who line up every single day to get their social grants from the government. These grants are then handed over as cash to vulnerable individuals – people with disabilities, the elderly, orphans – who either have to line up to receive their social grants or can do so through the bank. I was told it is such a huge progress with the government providing grants for their vulnerable despite their very limited resources. I also saw similar progress in Khayelitsha. I remember how I and my other Filipino co-EV4GH (Renzo and Mai) even said: “Our slums [in the Philippines] look worse than this!” In Khayelitsha, they have free water services (when in the Philippines you get billed no matter what) – and they have well-arranged water systems too! But as former South African President Thabo Mbeki has said, “poverty is not only expressed in shortage of food, shelter and clothing. It is also expressed in high levels of crime, including violence among the poor themselves, especially against women and children, in many instances accompanied by substance abuse”. Such cases are still indeed very visible in South Africa, but are we making progress? Are we doing it right?

Upon talking with the locals, statistical data may truly not be able to capture the whole situation in an area. Numbers are enriched by hearing people’s experiences and stories. Although HIV rates were reported to be declining in Africa, the way people saw it when I did talk to them (on a few rare occasions) was different. In one story of a local nurse in Pretoria, she mentioned an inexplicable child health situation – that in every group of children born in their hospital per day, more than half of them were HIV-positive. Worse than this is that although mothers were advised to breastfeed their babies to strengthen their children’s immunity, women will not do so due to fear of being stigmatized by others, who know that such breastfeeding is greatly recommended for HIV-positive mothers. How can this be? When can pride (and even status) weigh more than life?

Other than poor socioeconomic conditions, the stories I heard about politics in South Africa were very striking. Some even believed that the apartheid order may have been less susceptible to corruption than the current political system – I am not sure about that though! But people I met there all expressed how corrupt their government “was” (or “is”). Now, more than twenty years after apartheid, the country is still being headed by the African National Congress (ANC), which has been ever since the ruling party of post-apartheid SA. The ANC is a ‘happy ruler’, obviously. But if people believe that the government is corrupt, why then are the same leaders elected? (People told me that the ANC are actually quite proactive in trying to deal with poverty, and their policies are not all bad, it’s more the leaders posing the problem. But it’s not up to me to assess this.)

To conclude… South Africa is a very beautiful country with undeniably rich natural resources. I have never enjoyed nature as much I did in SA – while visiting the cradle of humankind, looking at big diamonds, and meeting its “Big five” (which is the collective term for their 1) African elephant, 2) black rhinoceros, 3) cape buffalo, 4) African lion and 5) leopard), among many others. Most especially, I have never found a country with such unforgettable history with a very diverse and unique heritage and with people so inspiring and hopeful. The place and much more the people I have met are truly remarkable. Indeed, South Africa has great opportunities, yet it is often mismanaged and challenged. The two visits I had may have not been enough for me to say I know South Africa very well – but I confidently believe that the country is faced not just with the challenge of continuously fighting for freedom but also by the struggle for liberation from poverty, lack of education, health and social inequalities, and huge income gaps between the rich and the poor. In South-Africa this fight seems even more pronounced and urgent than in many other places in the world.

War is not yet over in South Africa, so does it need another Nelson Mandela?  As these short visits raised more questions than answers, for sure I’ll go back to South Africa one day to find out more.

Hopefully by then, a new Mandela will have stood up.  Perhaps one from the townships?

Acknowledgments:

I just would like to thank Kristof Decoster and Shakira Choonara for providing valuable feedback to this article. Thank you as well to the Australia Africa Universities Network and the Emerging Voices for Global Health program of the Institute of Tropical Medicine for funding my trips to South Africa. I wouldn’t have had this lasting experience without their support.

On 29 September 2014, the emerging voices together with the emerging leaders held their pre-conference program at the University of Western Cape (UWC), South Africa. The program served as a unique platform for exchange of knowledge and skills and as a networking hub among emerging and leading researchers and practitioners working for global health. It started with welcome remarks and introductions from distinguished guests such as Prof Helen Schneider (UWC), Prof Lucy Gilson (UCT), Prof Bruno Marchal (ITM), Prof Meng (Peking University) and Upendra Bhojani (IPH Bangalore). Undoubtedly, the opening’s highlight was each thematic working group’s two-minute “teasers”, which included a whole range of video presentations, acting, singing and dancing. Many of them blew the audience away. The eight thematic working groups include: health financing, people as providers, patient perspectives, knowledge translation, governance and human rights, community health systems, quality of care and complex health systems.

Selected representatives from the thematic working groups also presented their research during the opening and closing plenaries: Bhaskar Purohit, Elena Vargas, Nasreen Jesrani, Marian Theresa Valera, Upasona Gosh, Erlyn Rachelle Macarayan (that would be me!), Anteneh Asefa and Sameera Hussein.  Concurrent sessions were held in two sets: morning and afternoon sessions. Although the creative teasers have been very successful in attracting guests to go into each of the sessions, what made the sessions very engaging were the stimulating discussions and thought-provoking questions after each presentation. Every emerging voice and leader excelled in presenting cutting-edge research and novel ideas on improving global health in different settings. Certainly, the day did not end without the cocktails to celebrate such a very successful pre-conference program, and then Emerging Voices turned again into Emerging Dancers (not for the first time this week, I have to say). After a week-long rigorous training prior to the pre-conference, each of the emerging voices and leaders, as well as their mentors, truly deserved this hour of celebration.

What’s next? The conclusion of the program did not just mean an end for the emerging voices and leaders. The program led to a new set of future health leaders inspired and passion-driven to create bigger and greater impacts through their very own ways. With a united voice for global health, these future leaders are now ready to tackle the world’s worst problems, create innovative ideas and revolutionize the way we think about global health. Don’t forget to keep yourself updated on many of our upcoming initiatives and events!

I am Erlyn Macarayan, one of the most recent Emerging Voices for Global Health. Having been privileged to be part of similar professional associations such as the University of Queensland Behavioural and Social Science Research Review Board and the Australian Political Studies Association, I hope to be able to further apply the knowledge and skills gained from such experiences and create significant impacts for global health.

Why am I joining the HS global board?

Just recently, a number of calamities hit my home country – the Philippines. Millions of our people were left homeless, while many others were missing if not dead. As we all know, such unbelievable catastrophic events do not happen just in the Philippines alone, but in many other areas around the world. As a health practitioner and community health worker back in the Philippines, I have seen the difficult situation of the many that are not just poor in their living conditions but are dying out of hunger and out of the many unimaginable diseases of the unprivileged. As said, we cannot just cure the diseases and send them back to the places that made them sick. I then joined in influencing national policies through working with the government, but realized that our health problems are not just at the local or national levels – we needed global collaborations to uplift the health situations of the many low and middle income countries. As a current PhD student, teacher and a health systems researcher here in Australia, I have learned so much more. It provided me opportunities to travel around the world and see the different faces of healthcare in Asia, Australia, Africa and in many others. Seeing the world outside the four corners of a researcher’s wall made me strongly believe in what the Health Systems Global Board can do – and I wanted to be involved not just by being part of it but in shaping what we can do as a global board.

What and how can I contribute?

Involving more and more youths to join us in the endeavour – students, young leaders, emerging researchers, policymakers and practitioners – I want to be their voice in the HS Global Board. All of us are working for global health and there is a very strong momentum to do so right now. The main challenge that I am seeing, however, is how we can all unite those efforts so that rather than working individually, we are then working as one community. I do believe that I am equipped to be able to do so having been privileged to meet a lot of inspiring health practitioners, researchers and policymakers from all over the world. This time, however, I wanted it to be more multidisciplinary by involving my other colleagues, particularly in the social sciences and political sciences, as well as environmentalists and people from many other fields. Global health is not just about the physical health. It is about addressing the many other facets of health and health systems. I wanted to be their voice while on our HS Global board. Rest assured that if selected, I will dedicate myself towards creating significant outputs with lasting outcomes and impacts, particularly for the resource-challenged communities.

Know more about me and the stuff that I do through any of the social media platforms below:

Facebook: https://www.facebook.com/macarayan.erlyn

Twitter: https://twitter.com/ev4gh

Linkedin: https://www.linkedin.com/home

Some recent articles that may give you more info about me are below:

http://www.studybrisbane.com.au/Living%20in%20Brisbane/Getting%20Involved/Latest%20News/Australia’s%20Most%20Inspiring%20International%20Student?utm_source=StudyBrisbane&utm_medium=Email_Students+&utm_term&utm_content&utm_campaign=EX_Enews_Brian_VIC_Aug_2014

http://www.issr.uq.edu.au/news/most-inspiring-international-student-of-australia-award

Thank you so much!