The majority of health workers in lower tiered positions, such as within primary health care provision, are women. Despite women making up a significant proportion of health care workers, they are grossly underrepresented in leadership positions across the world. This is not unique to the health sector. In the corporate world, for example, the report on The State of Women in Healthcare: 2015 indicates that only 4% of CEOs are women.

Greater participation of women at the leadership level has been shown to result in policies which enhance the position and rights of women. For instance, Rwanda which has the highest level of women parliamentarians of any country, has also over the years invested in policies on ending violence and discrimination, investing more in health services, and investing more in improving women’s participation in the workforce. In the case of Rwanda, the participation of women at the political level went way beyond the 30% quota instilled in 2003. Contrast this to the Kurdistan Region of Iraq, where despite a similar quota women constitute only 3% of leadership positions. This raises the question of the need for, and role of, quotas for women at the leadership level.

Encouraging women’s representation through quotas?

Deliberate efforts like putting quotas, reservations, and affirmative action to ensure participation of people from marginalized, vulnerable or less vocal sections of the populations could encourage more women’s participation at multiple levels of policymaking and the workforce. But do they really work? Are quotas a legitimate way to reach equilibrium and ensure at best some form of equal representation at the top? While quotas might ensure that more women have a seat, do they actually increase women’s meaningful and effective participation? If not, what is needed alongside quotas to ensure women’s meaningful and effective participation?

While a quota system may provide a way to encourage women’s representation at the leadership level, it is only a short-term solution. If women’s participation at the top is going to be meaningful and effective, longer-term strategies are needed to transform the unequal gender norms, roles, relations which perpetuate and reinforce gender inequities within the health system and inhibit women’s participation at the leadership level.

Increasing women’s value within the health system

Community health workers –the cornerstone of early primary health service programs, and for many people their only contact with the health system – are largely women. Women who take on this position often do so for little or no pay. Even as one acknowledges the role of the female community worker, we wonder if they would be better paid and organized if the majority of the workforce were men. Studies have found, however, that even within the same occupation (including those that are female dominated) not only are women promoted less frequently than men, but they also earn less. Gender inequities within the health system are a reflection of gender inequity within society. Gender pay inequity can therefore been seen as a reflection of the value placed on women’s work and their overall status within society. Women’s work is often seen as less important or worthwhile, and their role has health workers is no exception. As we usher in the Sustainable Development Goals, we should strive to progressively change the value placed on women’s work and role within the health system, and offer equal opportunities and compensation to reflect this.

Minimizing gender bias within the health system

The issue of women’s role within the health system is becoming increasingly important, especially as we start to see a feminization of the medical workforce. In many countries, for example, the number of medical graduates are increasingly female. It will be interesting to see if the feminization of the health workforce translates to the top – as more women enter the health workforce will this be reflected at the leadership level? This is unlikely if we do not first minimize gender bias within the health system (and society more generally), which devalues women’s work, leads to lower compensation, and means that less women are given the opportunity to advance within their career.

Minimizing gender bias within the health system “requires systematic approaches to building awareness and transforming values among service providers,” along with developing policies and strategies to remove barriers to women’s career advancement and ability to engage in leadership roles. Women make up a large majority of the health care profession – it is time that they are recognized for their contribution and adequately represented at the top.

Note:  This blog is based on an online discussion with 14 members of the new cohort of the Emerging Voices. Over the past few weeks we engaged in a discussion on gender in health systems (one of three parallel discussions) with these 14 EVs. One of the most visible themes to have emerged from the discussions, and also perhaps an instinctive reaction of health system practitioners was that of gender (here mostly in the context of women) within the context of human resources for health and human resources in general.  The blog presents reflections on the issue of leadership and HRH from our discussions.

“We have to be very careful when we say that a better health system is the answer,” said Prof. Dr. Peter Piot, the director of the London School of Hygiene & Tropical Medicine (LSHTM) at a recent symposium in Antwerp. “They are part of the answer but not the whole answer. They can also do a lot of harm.”

Ironically, in South Korea – which has a very sophisticated health system- , hospitals amplified the Middle East Respiratory Symptom (MERS) epidemic in 2015, Piot explained at the 8th International Symposium on Filoviruses hosted by the Antwerp Institute of Tropical Medicine (ITM).

The symposium reviewed the long journey and global progress against Ebola forty years after the first outbreak of the disease was reported in September 1976, in Yambuku, Zaire (now the Democratic Republic of the Congo (DRC)).

Prof. Piot explained that although countries clearly need good health systems and primary health care that is not enough to control epidemics. Emphasizing “the basics” and “public” health systems in particular, he mentioned there should be good laboratories, thorough surveillance, infection control, but also public preparedness and community engagement. “We talk health systems but it is also political and social systems as well as public trust that are a key element here,” said Prof. Piot.

He has a point. As the epidemic ravaged West Africa there was also an outbreak in DR Congo but the latter was controlled in the absence of a good or sophisticated health system.

However, you can argue that the environment was also very different. As Piot himself pointed out in his presentation, the Ebola crisis in West Africa is the story of a “perfect storm” creating a major epidemic. The crisis hit states that were unfamiliar with Ebola till then, were not well governed, just came out of civil war, lacked health staff, showed strong cross-border migration,…. Importantly, they were also countries in which (big parts of) the population lacked trust in government. The tragedy that unfolded was unprecedented, claiming 11,000 lives in 3 countries in just about two years.

DR Congo with seven Ebola outbreaks under its belt has experience, an equipped laboratory in Kinshasa and leadership headed by Prof. Dr. Jean-Jacques Muyembe, the director of the National Institute of Biomedical Research (INRB) who has been around since Yambuku. Prof. Muyembe concurs that indeed Africa needs to strengthen health systems but in addition to good surveillance systems, community engagement and trained health workers, above all epidemics like Ebola require leadership. “One of the things that went wrong in West Africa is that they did not have a national coordinating body,” Prof. Muyembe told me. At the peak  of the Ebola epidemic in DRC (during the Kikwit epidemic that happened way back) he declared himself a coordinator and he has since lived up to the job.

So are we prepared for the next epidemic? “We are not prepared. The high risk of a major health crisis is widely underestimated and the world’s preparedness is still insufficient. That is not only the case for developing countries, although they are more vulnerable, but it is also the case here in Europe,” said Prof. Piot .

WHO reform, one of Piot’s recommendations for the world to get its act together in time for the next epidemic, is already ongoing. For example, the emergencies programme at WHO and the humanitarian and outbreak departments have been merged, said Dr. Rick Brennan, director of emergency risk management and humanitarian response, WHO, Geneva. In this sense, WHO will have one approach to a response: if it is an outbreak they’ll   bring in a disease specialist, if they have to deal with a conflict they’ll fly in a humanitarian expert, and in the case of an emergency a manager.

Dr. Brennan said they are working to strengthen preparedness at the country level and not just for outbreaks. WHO has been working with some other actors  on a ‘unified framework of preparedness.’ Regardless of the event, this will involve some basics like good medicine management, information and communication capacities, strong logistics.

He said WHO will borrow a leaf from the formal mechanism the international community uses to manage humanitarian emergencies and apply it to outbreaks. “The WHO is working to leverage these to create a system to support a more predictable mechanism with better leadership and coordination to manage large scale outbreaks.”

Prof Piot warned that although we need experts they are not necessarily the best managers. In emergencies we need perhaps more the experience of the humanitarian sector which is dominated by logistics, organization & coordination. “They may be more boring and bureaucratic but I believe we need more of that in the first place. The key to success is strong management. We should form a core of people who can do that and support them and value them.” And he concluded: “We need to strengthen the public health core capacities in such a way that not just Ebola outbreaks can be dealt with but that they benefit the entire health and social infrastructure.”

It has been said before, and it appears to have been proven once again this week: social media can be used for the good, the bad and the ugly. In these times of increasing polarization and xenophobia, we’ve seen plenty of the latter (social media often seem to further increase polarization, rather than boost empathy for the downtrodden), but this week we saw some positive examples of the impact of sustained social media and mass campaigns. ‘Clicktivism’ is often ridiculed, but it remains a vital tool in the 21^st century, especially if combined with mass media attention and grassroots action.

Social media, often used for crowdfunding can also be used to highlight social causes and advocate for issues.  It offers an opportunity for civil society, including consumers to engage with others and reach out to a wider audience, as well as, bring people together for a common cause. Sometimes it takes a while before social media commotion and campaigns have an impact, but eventually, in some cases, the resilience of committed citizens pays off (like on the issues of TTIP and tax optimization by Apple & co, where substantial “progress” was made this week!). In the US, the EpiPen story seems to be heading in the same direction. The (ongoing) EpiPen story could provide lessons relevant to the numerous ‘access to medicines’ battles that lie ahead in the coming years, in developing and in developed countries.

Over the last two months, social media campaigning and the resulting uproar held one big pharmaceutical company accountable to its consumers, for the price of the (now notorious) “EpiPen” – a drug used to tackle severe allergic reactions by Mylan Pharmaceuticals that has gone up by a handsome  450% since 2004. This week, Mylan Pharmaceuticals announced it will launch, and make available, a generic version of the drug within the next two weeks at approximately $300 (as compared to the branded product priced at $608). Still a hefty sum, but hey, it’s a start.

The cost of an EpiPen at $608 for a 2-pack today is prohibitive for many, including those with health insurance, but in an interesting turn of events, a petition against price gouging by actress Mellini Kantayya on Petition2Congress, early July,   gained momentum on social media and brought discussions on the prohibitive profit margins of pharmaceutical companies  into the mainstream (including in the media and, hitting the jackpot from a campaigner’s point of view, in the US presidential campaign, with the likes of Bernie Sanders and Hilary Clinton also taking a stance). In order to quell the negative attention or perhaps pacify outraged consumers, Mylan already announced coupon and patient assistant initiatives to lower out of pocket payment on EpiPen, and announced a generic version of the drug. Let’s hope more is in store.

Of course, campaigning for more ethical pricing by pharmaceutical companies isn’t new. Take the (now somewhat old) news of the case of Gleevec – a cancer drug by Novartis – for which a seven-year litigation (Novartis v. Union of India & Others ) was fought on whether the patent for the drug was valid or not. Over the last few years, activism by medical professionals in the US, highlight 5- to 10-fold increases in cancer medicines, and their impact on the outpatient expenditure. Doctors, researchers and others have called for better regulation of drug prices within the context of improved access to medicines and better health policies. Increasingly, access to medicines is becoming an issue in both developing and developed countries.

This particular petition was unique, though, in that it harnessed the tools offered by the internet and social media, and was largely led  by family members of those with life-threatening allergies, particularly parents, and not patient advocacy groups or larger organizations working in the area of access to medicine. The case is also interesting as the issues of affordability and ethics of drug pricing feature here within the context of a society (and consumers) from a high-income country, many with health insurance. Development of generic drugs is one of the ways, though not the only way, to improve access to medicines – but it certainly remains a key tool for those in low resource settings. One may also wonder why regulatory agencies and government would not engage in in the evaluation of pricing policies, based on the assessment of the real development costs.

The discussions on the pricing of EpiPen by Mylan in the media, and more so on social media, might have started in the US, but the platforms on which they were conducted indicate the role of these  tools to fight injustices all around the world, even for those living in low resource settings. With the Internet now available to almost all, including some of the poorest who can’t afford basic medicines and face daily injustices, the use of social media offers the possibility to have their voices heard. Still, while this blog echoes articles similar in their congratulatory examination of the role played by social media in this (early) victory, it would be unfair to ignore the other factors which might have led to Mylan introducing a generic version of the medicine, as well as offering other mechanisms to reduce the out of pocket costs on the EpiPen. For one, the cause was relatively easy to “sell” – the little children, the fact that it wasn’t just the poor who have to cough up the high cost of the EpiPen, and thus the ease of identifying with users might all have garnered greater empathy. We wonder if policymakers, civil society and the media would have been equally “emphatic” had it been an NGO or an activist organization advocating for ethical drug pricing and consumer rights, say, for the homeless.  Clearly, also, in many settings across the globe, social media are far less “free”, and the strategic use of social media for a cause, certainly in combination with grassroots action, is thus less obvious.

For the moment though, we’re happy for all the reasons which might have led to the rise of the issues of ethical pricing for medicines, monopolies by the medical sector, generic medicines and access to medicines into the mainstream discussion. At a time when ‘resilient health systems’ are favoured by key global health stakeholders, it’s perhaps good to keep in mind that another kind of resilience might be even more important – that of the voice of the people, as Owen Jones put it earlier this week in an eloquent Guardian op-ed on TTIP & Apple, people who are determined in their protest against injustice. Perhaps, electronic and internet platforms provide a more affordable and accessible mechanism for effective social mobilization, with all the caveats mentioned above.

Acknowledgment: The authors thank  Raffaella Ravinetto for her important inputs

The GTS was founded in May 2015 at the 68th World Health Assembly on the vision of a world free of malaria and consists of four goals and related targets to be achieved by 2020, 2025 and ultimately by 2030.

The framework for instance aims to reduce malaria mortality rates and case incidence by at least 90% by 2030 as well as eliminate malaria from at least 20 malaria endemic countries. It also aims to prevent re-establishment of malaria in all Member States that are malaria-free.

A press release from WHO AFRO says this framework’s priority interventions and actions have been organized according to programme epidemiological strata in order to engender evidence-based targeted interventions.

The GTS has guiding principles like country ownership and leadership with involvement and participation of communities within a multisectoral context. It also encourages mobilizing and working with other sectors in malaria control and elimination.

To an extent some of these goals are achievable. Six countries (Algeria, Botswana, Cape Verde, Comoros, South Africa, Swaziland) have the potential according to the WHO to eliminate local transmission of malaria by 2020.

Meanwhile, two countries, the Democratic Republic of the Congo (DRC) and Nigeria alone account for more than 35% of the global estimated malaria deaths so if efforts are concentrated here that would give a lot of mileage I suppose.

But how possible is it that the African region can be malaria free by 2030?

Well, there is some impressive progress so far in controlling it. Since 2000, malaria death rates have plunged by 66%, translating into 6.2 million lives saved, most of them children. Between 2000 and 2015, the number of malaria cases and deaths within the African Region declined by 42% and 66% respectively, says the WHO.

In addition, more people with suspected malaria get tested before treatment and many more are sleeping under insecticide-treated mosquito nets.  In 2014, 65% of the suspected malaria cases got tested before treatment compared to only 41% in 2010. In 2015, two in three households in Africa had their own insecticide-treated mosquito net, compared to only 2% back in 2000.

And like Dr Matshidiso Moeti, the WHO Regional Director for Africa said, “Malaria is no longer the leading cause of death among children in sub-Saharan Africa. More and more children get to sleep under a net.”

Malaria is still on top of the global and regional agenda and so it remains a priority, identified in target 3.3 of the Sustainable Development Goals (SDGs) which commits to end it by 2030. The WHO also reaffirmed to end it by then.

However, in spite of these lofty goals, and the undeniable and significant progress made, malaria continues to be a major health and development problem in Africa. The region still bears the biggest malaria burden with about 190 million cases (89% of the global total) and 400 000 deaths (91% of the global total) in 2015 alone.

We cannot talk about a malaria free Africa without talking funding which the World Malaria report 2005 says increased substantially by 410% between 2005 and 2013 for programme financing. Overall, international financing for malaria control increased from US$ 100 million to US$ 1,640 million in 2013.

But the report also shows that even with these increases the annual investment per person at risk remained low at US$ 2 in the year 2013 and this funding situation is further threatened by low domestic financing.

So in the period 2005-2013, the proportion of total malaria funding contributed by national governments in Africa stagnated at less than 10% and many of these continue to rely on external funding.

Meanwhile, based on GTS cost estimates and at a fixed 2013 population at risk of malaria in Africa of about 830 million, the total cost of malaria elimination in Africa by 2030 is a whopping US$ 66 billion. There is thus a funding gap, and it will not suddenly disappear magically.

Furthermore, implementation of the GTS will necessitate addressing some key challenges like weak health systems (which were tested during the Ebola outbreak in some of these countries).

There is also the threat of resistance to the medicines combined with a lack of a vaccine and the adverse effects of climate variability and change.

One of the reasons for reversing the malaria deaths as mentioned earlier was, as expressed by Dr Moeti, that ‘more children slept under a net but there is need to continue to invest in changing people’s behaviours.’ She also said more people with suspected malaria got tested before treatment.

It is only if people in the region change their behavior, sleep under treated nets and also seek treatment within 24 hours after testing for example, that the gains achieved will be sustained and that the African region can continue to  move forward in the malaria battle.

All in all, I have to say I’m not quite sure whether the glass is half full or half empty.

The newsletter is an initiative of the Health policy unit at the Institute of Tropical Medicine (ITM) in Antwerp, Belgium and has been in existence since 2009. It is published in English (there is also a French newsletter, with Basile Keugong in charge) and basically focuses on international and global policy issues that dominate the global health agenda, with some bias towards Africa and emphasis on policy and systems research, ideally research with implications beyond just one (country) setting.

To compile this weekly digest, Kristof checks plenty of (international) peer reviewed journals on a regular basis, as well as mainstream media (including African media), grey reports, Twitter, …  but as he acknowledged in a personal conversation, he almost never includes articles from African public health journals in the weekly digest. There’s a simple reason for that: he hardly ever checks African journals. He admits this is a bias, even if he tries to follow debates in Communities of Practice, media reports, African conferences,…  to partially overcome this problem. (PS: Part of the aim of my stay here in Antwerp is to do something about this bias )

Kristof is certainly not alone when it comes to the relative neglect of African journals. Reasons vary, but naturally African health systems researchers like others in general  prefer publishing in high impact international journals. Even African government research agencies and universities consider peer-reviewed (international) journals to be of more value in evidence-based decision-making and most policy documents also tend to cite them.

“I have published primarily in international journals because there are not very many African journals in health systems research,” said Dr. David Musoke from the department of disease control and environmental health, school of Public Health, Makerere University.

For the few African journals that Dr. Musoke chances on they are not ‘as much’ recognized at his university, Makerere, in Uganda because they have a low impact factor. “From my experience, the African journals’ impact on the global scene is minimal and their citation is also not as much as international journals,” said Musoke.

Popular search engines used in academic settings for finding and accessing articles rarely list African journals either. “Traditionally, the Western journals appear first,” said Shakira Choonara, a PhD fellow, Centre for Health Policy; school of public health, University of the Witwatersrand.

Access is another challenge: one of the ways to access African journals is to go directly to their websites but most of them are not open access due to their business or funding models.

For instance in spite of the partnerships with western journals at the African Journal Partnership Project (AJPP), about only half of the 517 journals on the website are open access. Some of them have embargo periods of 1-3 years.  AJPP is a collaboration between international journals partnered with African journals funded by the U.S National Library of Medicine and National Institutes of Health with the aim to increase the visibility and quality of the African journals. Naturally, if these are invisible then the chances that their content is being used for decision making and influencing policy is also limited.

“The extent to which such journals are being used for decision making and policy making remains questionable and unclear. I have looked in a number of policy documents and most of the documents that I have read do not refer to African journals as source documents,” said Joseph Mumba Zulu, PhD from the University of Zambia.

Focusing more on the South-African picture (where unlike in many other sub-Saharan countries, there are actually a few local HPSR journals), Choonara said: “The African journals do have excellent context-specific information and there is definitely some impact, however they are not as well known to researchers or even decision-makers due to having low impact factors.”  She continued, “In South Africa, some of the context specific journals may feed into decision-making as well as follow-up policy briefs and some authors are engaging directly with the ministry”.

So with all these issues what is the way forward? One African well-published researcher, who does cite local journals from time to time, asked a pertinent question: ‘if we are concerned about getting greater visibility for our local journals how do they increase impact if no one wants to publish in them?’ A vicious circle, in other words, that needs to be broken.

Well, at least on the open access front, there is now a growing movement of African journals transitioning towards open access especially for those published by scientific societies. Young African researchers are following suit by publishing in them.

The Malawi Medical Journal (MMJ) which partnered with the Journal of the American Medical Association (JAMA) under the AJJP programme may set the pace. After seven years of the AJPP and MMJ marriage, submissions have soared from 42 in 2008 to over 150 in 2015. The impact factor of 1.00 remains wanting but it is a progressive process.

‘We are now indexed amongst others on: PubMed, PubMed Central (PMC), Bioline International, Thomson Reuters, and African Journals Online (AJOL)’, said Chiwoza Bandawe, the editor of MMJ, in a June 2016 Editorial.

Yet, open access international journals, targeting LMICs obviously still remain a very attractive option for young African researchers for a number of reasons, going beyond just the impact factor & citation.

“My experience in publishing in HPSR journals, especially in the Health Research Policy and Systems journal, has been very good, there are no publication costs for us, researchers from LMICs”, said Mumba Zulu. “The duration for receiving feedback is reasonably okay and the duration between acceptance and final publication of the article is good.”

“As a younger researcher I find it much more encouraging to publish in open access journals, rejections happen but not at the rate they do with the Lancet, BMC, BMJ etc… most of them also don’t require excessive payments so when funding isn’t available many researchers I know of also turn to them,” said Choonara.

As the open access movement slowly gains momentum in Africa, including for journals on health systems and policy, young researchers in Africa might decide to publish in them more and more. But the road ahead is still long.

My ITM experience will bring a “three-continent blend”, after being a two-time fellow in the US, at the Massachusetts Institute of Technology (MIT) for the Knight science journalism fellowship ’08 and at Oklahoma State University as a food security fellow ’11.

There is so much you learn from such experiences as I elaborated here, the confidence and credentials elevate your career to another level but the lasting connections that you can fall back to are just something legendary.

I am at  ITM as a journalist in residence which almost offers the same opportunities: meeting world-renowned scientists, auditing classes, participating in seminars, scientific meetings – the epic one for me during my stay will be on Ebola at the 8th International Symposium on Filoviruses & 58th ITM Colloquium in September. In addition, I am generally spending time in the company of a community of smart people and enjoying some quiet time for reading.

But the journalist in residence fellowship program also plays out differently. It is at a more symbiotic level. It also is solo (I am the only one), deadlines are still pretty much part of the game, it is focussed on tropical diseases and medicine as you may be aware that ITM is also one of the world’s leading institutes for training, research and assistance in tropical medicine and health care in developing countries.

Partly housed in a former monastery built in the 17th century, ITM has many synergies with other regions and continents as it works with many scientific institutions, governments and organisations from all over the world for a long-lasting improvement of health care and disease control in developing countries. Collaborations between the global West and South are intensifying and very fruitful, and ITM is certainly a key hub in this respect.

I am spending half of my time with the team working on International Health Policies (IHP) (Health Policy Unit) and the Communities of Practice (Health Economics unit), both key initiatives of the institute’s broader Knowledge Management (KM) Portfolio.

So far I am reading a lot of literature mostly recommended by Kristof Decoster (IHP) about international health policies, health financing and health systems strengthening. I am also working closely with him on the IHP weekly newsletter you should subscribe to if you have not already.

For the second month of my stay, I will switch to the communications unit headed by Roeland Scholtalbers. While there, the focus will change to interviewing, interacting with scientists and writing as well as blogging about research in biomedical sciences, clinical sciences and public health (i.e. the three ITM departments).

It is such a short time but I intend to fit in many ‘quirky’ experiences as well: visits by friends who were in Uganda for internships, like Anna Maria in Spain, Rossane in Holland, …. I also want to catch up with some language lessons  in French, which I last learnt many decades ago.   And of course drink at least one different type of Belgium beer every day, since the country has the greatest diversity of original beers in the world ! I certainly won’t forget the quality chocolate either, which is just awesome.

It appears Antwerp will mostly be wet for most of my stay, which I would trade for ‘blessing the rains’ back at home in Uganda where we badly need them since we rely on agriculture. I also  anticipated it as I was making preparations for my stay with the staff here keeping me updated with what to expect. Rain, clearly. And some more rain.

But while taking a “guided” tour of the ITM buildings in the company of Eline Van Meervenne, I soon realized the green neatly kept gardens also have something to smile about every day. I’m sure ITM staff feel the same, even if they – as I already noticed – like to grumble about the Belgian weather!