The World Health Organisation’s Director-General Dr. Tedros Ghebreyesus has set universal health coverage as one of the main priorities for his term.
Universal health coverage is defined by the WHO as free access to promotive, preventive, curative and rehabilitative health services. These have to be of a sufficient quality to be effective but without causing unnecessary financial hardship when paying for the services.
But Ghebreyesus’s goal is a challenging one, especially for low and middle income countries which make up around 84% of the world’s population. Yet they only have access to half the physicians and a quarter of the nurses that high income countries have access to.
Similarly low and middle income countries only spend around US $266 per capita on health care. In contrast, high income countries spend a whopping US $5 251 per capita.
This means that attaining universal health coverage in poorer settings is challenging to say the least. Large cuts to foreign aid investment from a number of high income economies only compound this challenge.
To address this, affected countries need to start thinking smarter, and not simply work harder. Optimising available resources requires local researchers to apply themselves. In other words, these countries need to grow their knowledge economies.
High income countries already have access to significant resources. This is mainly due to their own knowledge economies flourishing. To match this low and middle income countries need to increase the investment in their research activity. This includes increasing the number of institutions and supervisors that support research.
Although low and middle income countries have seen an increase and improvement in all these areas, access to existing knowledge remains poor. Particularly when compared to access in higher income countries.
A healthy knowledge economy needs:
investment (funding set aside for generating knowledge),
people who create research and consume information,
higher education institutions, and
reasonable access to knowledge (existing, published research).
Low and middle income countries invest around a third of what high income countries invest in research. They also have access to around a fifth of the researchers high income countries have access to. To top it off, less than a quarter of the Times Higher Education ranked universities are located in low and middle income countries.
Yet of all the cogs that make up the knowledge economy, access to knowledge is likely the easiest to achieve. Although accessible knowledge remains a problem, strides have been made with increased support of open access publication on a global scale.
Given the growing penetration of the internet into low and middle income countries, information has never been more accessible at any point in history than today. Yet access to a sizeable and ever growing bulk of health care research remains poor.
Open access publishing has become a strong global movement. Roughly 20% to 50% of all published research is currently freely available online - depending on its year of publication.
Some have remained sceptical of open access publishing. Despite that many funding agencies and higher education institutions now insist on accessible research reporting from their beneficiaries, staff and students.
It’s hard to argue the possibilities if the 2.7 million plus health care publications published within the last three years were freely accessible in low and middle income countries. It would likely confer a tremendous benefit to both health care professionals and patients (or even universal health coverage).
It is important to understand that the purpose of access to knowledge generated in high income countries is not simply to copy it verbatim into lower income settings. The comparative resource restrictions that apply renders direct implementation largely unfeasible. However, accessible knowledge, wherever generated, provides the references needed to generate locally appropriate applications thereof.
For many low and middle income countries, open access comes with barriers as a result of infrastructural challenges.
The Hinari programme is an example of this. It has been around since 2002. It’s supported by the World Health Organisation along with a large number of publishers and provides access to a substantial amount of published material for researchers from low and middle income countries.
But during its 15 year existence it has remained poorly supported. Ironically, for a programme that has existed so long, the main reason for this appears to be poor access.
To solve this problem publishers could easily provide equitable access for low and middle income countries using geolocation internet protocols in the same way Netflix does. As a video streaming service, Netflix controls the content its users can access based on where they are accessing the service from. If geolocation is now an industry standard for various similar information sharing, internet based services, why not also for publication?
For publishers contributing to Hinari, such a step should be fairly straight forward. Use of geolocation internet protocols will allow researchers in eligible countries to access to research from participating publishers on any device, anywhere where they have an internet connection. This would include the patient’s bedside - not just the academic library.
Much of the knowledge required to establish the universal health coverage Ghebreyesus wants, already exists. Poor access to this knowledge presents a major barrier to achieving universal health coverage.
To unlock this knowledge for everyone’s benefit, policymakers and publishers need to seriously consider more innovative ways to provide access. Ironically, these solutions probably already exist as well.
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