BACKGROUND
Antibiotics are indispensable to modern healthcare, yet their equitable access remains a pressing global challenge. Factors contributing to inequities include insufficient evidence for optimal clinical use, limited registration, pricing for Reserve antibiotics, and supply chain challenges. These issues disproportionately affect low- and middle-income countries, exacerbating antimicrobial resistance burdens.
OBJECTIVES
This paper explores the multifaceted dimensions of inequitable antibiotic access and proposes a comprehensive framework to address the crisis.
SOURCES
Published articles, grey literature analysis, and the authors' own expertise contributed to this article.
CONTENT
While much attention has been paid to push-and-pull incentives for antibiotic development, these interventions are inadequate to reach sustainable and equitable access to antibiotics. Improving equitable antibiotic access requires an ecosystem approach, involving multiple stakeholders and including public–private partnerships. The paper advocates for initiatives spanning research and development, regulatory pathways, procurement strategies, and financing mechanisms and suggests concrete interventions in each of these areas. The specific interventions and mix of public and private actors may vary according to antibiotic, market, and health system context, but must be designed to meet public health needs while also supporting a market that will sustain quality-assured production and delivery of antibiotics.
IMPLICATIONS
Addressing the challenge of equitable antibiotic access requires coordinated efforts across sectors and regions. By embracing an ecosystem approach centred on public health priorities, stakeholders can pave the way for a sustainable supply of antibiotics, and equitable access, safeguarding the future of global healthcare amidst the growing threat of antimicrobial resistance.
Unfair knowledge practices easily beset our efforts to achieve health equity within and between countries. Enacted by people from a distance and from a position of power (‘the centre’) on behalf of and alongside people with less power (‘the periphery’), these unfair practices have generated a complex literature of complaints across various axes of inequity. We identified a sample of this literature from 12 journals and systematized it using the realist approach to explanation. We framed the outcome to be explained as ‘manifestations of unfair knowledge practices’; their generative mechanisms as ‘the reasoning of individuals or rationale of institutions’; and context that enable them as ‘conditions that give knowledge practices their structure’. We identified four categories of unfair knowledge practices, each triggered by three mechanisms: (1) credibility deficit related to pose (mechanisms: ‘the periphery’s cultural knowledge, technical knowledge and “articulation” of knowledge do not matter’), (2) credibility deficit related to gaze (mechanisms: ‘the centre’s learning needs, knowledge platforms and scholarly standards must drive collective knowledge-making’), (3) interpretive marginalization related to pose (mechanisms: ‘the periphery’s sensemaking of partnerships, problems and social reality do not matter’) and (4) interpretive marginalization related to gaze (mechanisms: ‘the centre’s learning needs, social sensitivities and status preservation must drive collective sensemaking’). Together, six mutually overlapping, reinforcing and dependent categories of context influence all 12 mechanisms: ‘mislabelling’ (the periphery as inferior), ‘miseducation’ (on structural origins of disadvantage), ‘under-representation’ (of the periphery on knowledge platforms), ‘compounded spoils’ (enjoyed by the centre), ‘under-governance’ (in making, changing, monitoring, enforcing and applying rules for fair engagement) and ‘colonial mentality’ (of/at the periphery). These context–mechanism–outcome linkages can inform efforts to redress unfair knowledge practices, investigations of unfair knowledge practices across disciplines and axes of inequity and ethics guidelines for health system research and practice when working at a social or physical distance.
Women researchers find it more difficult to publish in academic journals than men, an inequity that affects women's careers and was exacerbated during the pandemic, particularly for women in low-income and middle-income countries. We measured publishing by sub-Saharan African (SSA) women in prestigious authorship positions (first or last author, or single author) during the time frame 2014-2016. We also examined policies and practices at journals publishing high rates of women scientists from sub-Saharan Africa, to identify potential structural enablers affecting these women in publishing.
METHODS
The study used Namsor V.2, an application programming interface, to conduct a secondary analysis of a bibliometric database. We also analysed policies and practices of ten journals with the highest number of SSA women publishing in first authorship positions.
RESULTS
Based on regional analyses, the greatest magnitude of authorship inequity is in papers from sub-Saharan Africa, where men comprised 61% of first authors, 65% of last authors and 66% of single authors. Women from South Africa and Nigeria had greater success in publishing than those from other SSA countries, though women represented at least 20% of last authors in 25 SSA countries. The journals that published the most SSA women as prominent authors are journals based in SSA. Journals with overwhelmingly male leadership are also among those publishing the highest number of SSA women.
CONCLUSION
Women scholars in SSA face substantial gender inequities in publishing in prestigious authorship positions in academic journals, though there is a cadre of women research leaders across the region. Journals in SSA are important for local women scholars and the inequities SSA women researchers face are not necessarily attributable to gender discrepancy in journals' editorial leadership.
Community engagement (CE) rose to prominence with the Alma Ata Declaration in 1978, and remains a concept lauded by global health actors, including MSF. CE is often described as being linked with accountability, ownership, and sustainability of health programmes. It is also linked with social determinants of health through its empowering principles. Despite the recognition of its importance, challenges remain in incorporating
CE into programmes.
METHODS
We used a qualitative, case-based approach to explore how community engagement is defined, perceived, and evaluated in MSF contexts. Our aim was to identify challenges and opportunities in truly integrating communities into humanitarian health interventions. Three projects were purposively selected, in Democratic Republic of the Congo, Lebanon, and Venezuela, aiming to represent a variety of health programmes, as well as societal diversity. Document review and 55 semi-structured interviews were conducted. Participants represented different institutional levels and positions, as well as national and international staff. Interviews were transcribed and coded iteratively, as were the operational and technical documents, institutional policies, and reports included in the document reviews. The themes that emerged in the iterative coding were
then analysed.
ETHICS
This study was approved by the MSF Ethics Review Board, and by the Institutional Review Board at the Institute of Tropical Medicine, Antwerp, Belgium.
RESULTS
We found disparity between MSF institutional policy, operational documents, and incorporation of CE at programme level. While there is policy acceptance of CE as essential, interviews show that MSF barely engages with communities in a participatory process. There is little prioritisation of CE, and lack of guidance on the processes needed to involve communities in decision making. Our results also show that despite shared claims of the importance of CE, definitions, objectives, and evaluation all vary significantly. Tensions emerge between seeing communities as active participants or as passive beneficiaries. Additional tensions appeared around whether CE was perceived as an approach for promotion of quality of care and accountability of operations, or purely as an activity to reach the organisation’s goals. Finally, while field projects may establish links with communities, MSF remains the sole decision-maker on the overall medical-humanitarian strategy. Interviewees questioned the capability of MSF to work within this community engagement approach, due to inherent power asymmetries and the predominant use of western-centred biomedical approaches. Inequalities and misconceptions between international and national staff created an additional barrier to bridging with
local communities.
CONCLUSION
If MSF is interested in improving its approach to CE, there should be a concerted effort to change the way communities are viewed with respect to the organisation‘s interventions. While a single model of CE is not possible, MSF needs to set up training on CE approaches and develop frameworks and clear objectives for CE, through dedicated resources at headquarters and field levels.
CONFLICTS OF INTEREST
None declared.