Open access: a giant leap towards bridging health inequities

Bulletin of the World Health Organization 2009;87:631-635. doi: 10.2471/BLT.09.064659

Health knowledge generated in the world’s laboratories is passed down the information chain through publications, through its impact and application, its subsequent “translation” into appropriate contexts for different user communities, arriving finally with health workers and the general public, as the diagram of the knowledge cycle from the Canadian Institutes of Health Research has shown.1 Studies have shown that access to published health research by the research communities in developing countries is no longer “fit for purpose”.2 As has been well documented, rising costs of subscriptions and permission barriers imposed by publishers have barred access to the extent that local health research and health care have been damaged through lack of information.3,4 For example, Yamey5 tells of a physician in southern Africa who could not afford full access to journals but based a decision to alter a perinatal HIV prevention programme on one single abstract. The full text article would have shown that the findings were not relevant to the country’s situation.
With the advent of the internet there is little justification for continuing to create barriers to access. Richard Smith, as the former editor of the British Medical Journal, said, “Most research is publicly funded, and when the internet appeared it made no sense for research funders to allow publishers to profit from restricting access to their research”.6 This is true not only for publicly funded research but for private health charities around the world. As the Open Access Policy of the Wellcome Trust states, “We . . . support unrestricted access to the published output of research as a fundamental part of its charitable mission and a public benefit to be encouraged wherever possible”.7
Science is a collaborative process and openness is fundamental to knowledge advancement. Nowhere has this been shown more clearly than by the 2003 outbreak of SARS (severe acute respiratory syndrome) during which, at the height of the epidemic, there was unprecedented openness and willingness to share critical research information, leading to the identification and the genetic mapping of the responsible coronavirus by 13 collaborating laboratories from 10 countries.8 The recent release of essential H1N1 data published in several toll-access journals relevant to the H1N1 influenza pandemic points to the recognition that access to health research information is critical in the containment of infectious outbreaks.9
It is difficult to see how the United Nations’ Millennium Development Goals can be achieved without free international access to the world’s publicly funded research findings or without collaborative initiatives. Goals 4 to 7 depend on the sharing of research findings for success, while Goal 8, which emphasizes the need for global partnerships for development, recognizes that sharing knowledge and capacity building establish the infrastructure for building future aid programmes.
Any solution to the inequality of access to health-care information must be based on the development of an independent and sustainable national research base. Lessons in development aid from the past few decades clearly show that mechanisms that reinforce the dependency culture are no longer appropriate.10,11
The United Nation’s HINARI, AGORA and OARE programmes, whereby registered libraries or qualified institutions in countries with a Gross Domestic Product (GDP) of < href="">12 However, such donor programmes have several limitations.13 They are not driven by science (journals are donated by publishers at their own discretion rather than selected by researchers); they are only available to the poorest countries (as countries’ economies improve, they no longer qualify); some low-income countries are excluded (e.g. India, even though its GDP level qualifies it for access) because publishers fear damage to their existing sales; access is only available from registered libraries and on provision of a password controlled by libraries; publications may be withdrawn and there are no contractual arrangements regarding content continuity.
In a letter to PLoS Medicine, Villafuerte-Gálvez et al. said that, since 2003, Peruvian medical students and health professionals have substantially benefited from access to high-quality scientific information through HINARI but that recently students and faculty had not been able to gain access to several top journals that were available at the launch of the programme.14 Moreover, the number of users had dropped by 52% in 3 years. Such was the value of the donor material that copies were made available to colleagues unable to access them.
A key to resolving the deep knowledge gap lies in creating a global knowledge base that includes essential research emanating from both research communities in developing countries as well as from “international” research. Without regional knowledge, the picture is incomplete and may result in inappropriate programmes. As an example, bacille Calmette–Guérin vaccine developed in Europe for combating tuberculosis is of limited efficacy in China and India, the countries hardest hit.15 Molecular typing studies by van Embden of the Netherlands have shown that the Indian tuberculosis strains are different from those in western countries.16 Similarly, as Andrew Hattersley has pointed out, effective treatments for diabetes in the United Kingdom may not work in India and vice versa, as environmental and genetic factors can affect the success of treatments.17
It is equally crucial to ensure distribution of publications between neighbouring countries since they may share similar health problems that are seldom covered by established international journals. A study by Lown & Banerjee to assess the New England Journal of Medicine’s coverage of health issues of the developing world, found that in 416 weekly issues over an eight-year period < href="">18 Other studies have shown similar evidence of systematic bias by medical journals from developed countries against highlighting diseases of poverty, and recent reports have documented the problem of neglected tropical diseases.19,20
Overcoming the limitations
The statement and recommendations of the Budapest Open Access Initiative on which all subsequent open access developments are based, is concerned with free public access to peer reviewed publicly-funded research publications.21 It recommended two routes to achieving open access: (i) deposit author’s copy of already published articles in the author’s institutional repository (or a subject-based central repository where an appropriate one exists); or (ii) publish in an open access journal.
Both these routes have the major advantage of being driven by science and building research capacity as researchers can compile personal collections of material specific to their work, regardless of whether it has been published in local or international journals.22 Open access is sustainable as the establishment of institutional repositories is low cost in the developing world and publishing in open access journals is mostly free to authors (only a minority of commercial journals charge a document management fee, usually waived for authors from developing countries). Services that have focused on providing maximum visibility to regional journals, such as Bioline International23 (70 open access journals from 17 developing countries), SciELO24 (approximately 500 journals from Latin American and other Spanish and Portugese-speaking countries) or MedKnow Publications25 (79 journals mainly from India), show high usage both from neighbouring developing countries and from wider international communities alike. The example of Bioline International usage in 2008, showing 4.2 million full-text downloads from a global audience, is typical. Usage from the interoperable institutional repositories is equally high, and rising. The usage of full-text material from institutional repositories that have installed statistical data packages shows low-income countries are among the top users – again demonstrating a real need for previously unattainable information.26,27
As open access has become established, major international institutes and funders have begun to require that copies of articles that result from their support are deposited in institutional repositories or published initially in open access journals. In the United Kingdom, more than 90% of publicly funded medical research is covered by open access mandates. In the United States of America, the research access policy of the National Institutes of Health promises to make available publicly about 80 000 articles per year. Globally, as at 5 June 2009, there were 84 open access mandates28 from such prestigious organizations as Harvard University, Massachusetts Institute of Technology, Southampton University, all the United Kingdom Research Councils, the Wellcome Trust and many other institutes, universities and departments, 17% of which are from developing countries. There are now 4184 open access journals published,29 15% in developing countries and 1351 institutional repositories30 – approximately 17% of these are located in developing countries. At the same time, there is much supporting infrastructure activity – developing institutional repository networks, developing software that allows harvesting between repositories and similar regional developments.31,32 These figures demonstrate the increasing global acceptance of open access policies as a way to enhance research around the world.
There have been many misconceptions about open access that have retarded its acceptance. It has been said that open access is equivalent to “vanity press” and that it lowers scholarly standards, but this is not the case since copies of author’s final accepted articles deposited in institutional repositories have already been accepted for publication following review and open access journals incorporate rigorous peer review. Again, whereas it had been feared that the imposition of author-fees by some commercial open access journals would disenfranchise authors from developing countries, it is now clear that revenues can be maintained in alternative ways, such as print subscriptions, other publishing services or reprint sales. As has been shown by the MedKnow Publications service, Mumbai, there has been an increase in subscriptions to the hard copy version since providing open access to the online version.25
It is also incorrect to say that self-archiving automatically infringes copyright in all cases. The majority (63%) of non-open access journals allow deposit of copies of published articles in institutional repositories (sometimes with an embargo period) and most open access journals allow authors to retain copyright (see statement on copyright from Science Commons and the Scholarly Publishing and Academic Resources Coalition, SPARC).33 It has been said that the connectivity problems in developing countries render open access inappropriate, yet these problems, while real, apply equally to non-open access online publications. Moreover, the International Development Research Centre (IDRC) recently reported that the research needs for access to new information drive connectivity and vice versa.34 While much remains to be done, both connectivity and access to broadband are improving globally, and new mobile technology is beginning to play a major role in health care communication. It has been said that research information is not appropriate for health workers, yet access to new research drives development of new health applications and builds a strong national science base which in turn strengthens medical services and national economies.35
The way ahead
It is our view that the United Nations and other international organizations should give strong support to the open access movement, which holds such promise for both research and public health. In this respect, it is gratifying to see that one of the stated objectives in the report of the Intergovernmental Working Group on Public Health, Innovation and Intellectual Property is to “promote public access to the results of government funded research, by strongly encouraging that all investigators ... submit to an open access database an electronic version of their final, peer-reviewed manuscripts”.36 It is hoped that this will translate into action in the form of vigorous support for low-cost institutional repositories and local open access journals, as well as by raising awareness of the many benefits of open access. Initiatives such as TropIKA,37 incorporating open access medical publications for tropical diseases that are most prevalent in developing countries, are encouraging, as is the recent announcement by the Council of Scientific and Industrial Research in India, urging the establishment of institutional repositories in each of its more than 35 laboratories as well as conversion of all their journals to open access.38 The recent adoption of an open access mandate by the University of Pretoria in South Africa again demonstrates recognition of the importance of open access for developing regions.39
While it may be helpful to continue the donor programmes as long as they are needed, it is only through removing the barriers to access to global research that health improvements can be accelerated. Open access delivers free access to millions of research articles for all with Internet access regardless of institutional affiliation or national GDP. It builds research and health-care independence and replaces the dependency culture that is now widely criticized.40 The report of the Global Forum for Health Research states, “Strengthening research capacity in developing countries is one of the most effective and sustainable ways of advancing health and development . . . and of helping correct the 10/90 gap in health research”.41 Open access is a necessary first step. ■
Competing interests: None declared.
Sudsawad P. Knowledge translation: introduction to models, strategies and measures. Ottawa, ON: Canadian Institutes of Health Research;2007. Available from: [accessed 29 June 2009].
Aronson B. Improving online access to medical information for low-income countries. N Engl J Med 2004; 350: 966-8 doi: 10.1056/NEJMp048009 pmid: 14999107.
Zerhoni EA. Access to biomedical research information. Bethesda, MD: National Institutes of Health; 2004. Available from: [accessed 29 June 2009].
INFOcus. Rising journal costs limit scholarly access. Atlanta, GA: Emory University Libraries; 2007 Available from: [accessed 29 June 2009].
Yamey G. Excluding the poor from accessing biomedical literature: a rights violation that impedes global health. Health and Human Rights 2008:10. Available from: [accessed 29 June 2009].
Smith R. A great day for science. The Guardian, 11 October 2008. Available from: [accessed 29 June 2009].
Position statement in support of open and unrestricted access to published research. London: The Wellcome Trust; 2008. Available from: [accessed 29 June 2009].
SARS. how a global epidemic was stopped. Manila: World Health Organization Regional Office for the Western Pacific Region; 2006.
American Society of Microbiology makes 14 research publications of Influenza AH1N1 freely available [media release], 4 May 2009. Available from: [accessed 29 June 2009].
Thorbecke E. The evolution of the development doctrine and the role of foreign aid, 1950-2000. In: Tarp F, Hjertholm P, eds. Foreign aid and development. Routledge; 2000. Available from: [accessed 29 June 2009].
Riddell RC. Does foreign aid really work? New York, NY: Oxford University Press; 2007.
Developing countries’ access to the world’s leading journals. [HINARI/OARE/AGORA programmes information leaflet]. Available from: [accessed 29 June 2009].
Library Connect [Internet site]. Available from: [accessed 29 June 2009].
Villafuerte-Gálvez J, Curioso WH, Gayoso O. Biomedical journals and global poverty: is HINARI a step backwards? PLoS Med 2007; 4: 220- doi: 10.1371/journal.pmed.0040220.
Arunachalam S, Gunasekaran S. Diabetes research in India and China today: from literature-based mapping to health-care policy. Curr Sci 2002; 82: 933-47.
Van Embden JD, Cave MD, Crawford JT, Dale JW, Eisenach KD, Gicquel B, et al., et al. Strain identification of Mycobacterium tuberculosis by DNA fingerprinting: recommendations for a standardized methodology. J Clin Microbiol 1993; 31: 406-9 pmid: 8381814.
Hattersley AT. Multiple facets of diabetes in young people. Curr Sci 2002; 82: 273-8.
Lown B, Banerjee A. The developing world in The New England Journal of Medicine. Global Health 2006; 2: 3- doi: 10.1186/1744-8603-2-3 pmid: 16542448.
Horton R. Medical journals: evidence of bias against the diseases of poverty. Lancet 2003; 361: 712-3 doi: 10.1016/S0140-6736(03)12665-7 pmid: 12620731.
Sumathipala A, Siribaddana S, Patel V. Under-representation of developing countries in the research literature: ethical issues arising from a survey of five leading medical journals. BMC Med Ethics 2004; 5: 5- doi: 10.1186/1472-6939-5-5.
Budapest Open Access Initiative [Internet site]. Available from: [accessed 29 June 2009].
Chan L, Arunachalam S, Kirsop B. Open access archiving: the fast track to building research capacity in developing countries. Sci.Dev Net, 11 February 2005. Available from: [accessed 29 June 2009].
Bioline International [Internet site]. Available from: [accessed 29 June 2009].
SciELO [Internet site]. Available from: http:/ [accessed 29 June 2009].
MedKnow Publications [Internet site]. Available from: [accessed 29 June 2009].
Institutional repository statistics. Dunedin: University of Otago. Available from: [accessed 29 June 2009].
Institutional repository usage statistics. Merida: Universidad de Los Andes. Available from: [accessed 29 June 2009].
Registry of Open Access Repository Material Archiving Policies (ROARmap) policy register [Internet site]. Available from: [accessed 29 June 2009].
Directory of Open Access Journals [Internet site]. Available from: [accessed 29 June 2009].
Registry of Open Access Repositories [Internet site]. Available from: [accessed 29 June 2009].
Digital Repository Infrastructure Vision for European Research [Internet site]. Available from: [accessed 29 June 2009].
Online Research Collections Australia (ORCA) Project [Internet site]. Available from: [accessed 29 June 2009].
Science Commons and the Scholarly Publishing and Academic Resources Coalition (SPARC) statement on copyright. Available from: [accessed 29 June 2009].
The International Development Research Centre (IDRC) [Internet site]. Available from: [accessed 29 June 2009].
Inventing a better future: a strategy for building worldwide capacities in science and technology. Amsterdam: InterAcademy Council;2004.
Resolution WHA61. 21. Global strategy and plan of action on public health, innovation and intellectual property. In: 61st World Health Assembly, Geneva, 19-24 May 2008. Geneva: World Health Organization; 2008. Available from: [accessed 29 June 2009].
TropIKA [Internet site]. Available from: [accessed 29 June 2009].
Suber P. India’s CSIR asks its labs to adopt OA mandates. Open Access News, 9 February 2009. Available from: [accessed 29 June 2009].
Open access self-archiving policy. Pretoria: University of Pretoria. Available from: [accessed 29 June 2009].
Harris E. Building scientific capacity in developing countries. EMBO Rep 2004; 5: 7-11 doi: 10.1038/sj.embor.7400058 pmid: 14710175.
10/90 report on health research. Geneva: Global Forum for Health Research; 1999.