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Public Health

Public Health

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Public Health
10 years ago, a meeting to review global access to healthinformation concluded that most health professionalsin developing countries had inadequate access toinformation and that the information available to themwas often unreliable or irrelevant.
1
At that time, therewas optimism that, by 2004, all—or nearly all—healthprofessionals in developing countries would haveaccess to the information they needed to provide themost effective health care possible with the resourcesavailable. The world was at the cusp of the informationage: information and communication technologieswould mean that lack of access to reliable relevantinformation would no longer be a barrier to effectivehealth care. Although other factors such as lack of drugs and infrastructure might hinder provision of health care, this would not be the case withinformation. What then has been achieved in the past 10 years?What have we learnt? And if providing access to reliableinformation is the single most cost-effective andachievable strategy for sustainable improvement inhealth care,
2
what steps can we now take to bring usnearer to health information for all (panel)?
What has been achieved?
Important progress has undoubtedly been made.Information and communication technologies areincreasingly available; more and better content isavailable to a growing number of people, especially thosein tertiary hospitals, academic institutions, and urbansettings; there are more and better free resources on theinternet; there is a larger and wider range of health-information support programmes; an internationalcommunity has evolved that is committed to improvinghealth-care information, with governments and otherbodies in developing countries playing an increasinglyactive part; and politically, access to health-careinformation has become a key international developmentissue. Equitable and universal access to health-careinformation is recognised in the latest draft of WHO’s
World Report on Knowledge for Better Health
3
as animportant part of worldwide strategies to reduce globaldisparities in health and to achieve the health-relatedMillennium Development Goals. Progress has been patchy, both geographically (withsub-Saharan Africa generally falling far behind mostother regions) and across different health sectors(specialist and academic health care is much betterserved with information than rural primary care), andoverall there is little if any evidence that the majority of health professionals, especially those working inprimary health care, are any better informed than theywere 10 years ago. The few empirical studies weidentified
4–7
and many anecdotal reports suggest thatlack of physical access to information (absent, slow, orunreliable internet connectivity, expensive paper, andhigh subscription cost of products) remains the majorbarrier to knowledge-based health care in developingcountries. However, there are now many successful initiativesthat could be extended or replicated. An example isBIREME (http://www.bireme.org), the Latin American
Can we achieve health information for all by 2015?
Fiona Godlee, Neil Pakenham-Walsh, Dan Ncayiyana, Barbara Cohen, Abel Packer 
Universal access to information for health professionals is a prerequisite for meeting the Millennium DevelopmentGoals and achieving Health for All. However, despite the promises of the information revolution, and somesuccessful initiatives, there is little if any evidence that the majority of health professionals in the developing worldare any better informed than they were 10 years ago. Lack of access to information remains a major barrier toknowledge-based health care in developing countries. The development of reliable, relevant, usable information canbe represented as a system that requires cooperation among a wide range of professionals including health-careproviders, policy makers, researchers, publishers, information professionals, indexers, and systematic reviewers.The system is not working because it is poorly understood, unmanaged, and under-resourced. This Public Healtharticle proposes that WHO takes the lead in championing the goal of “Universal access to essential health-careinformation by 2015” or “Health Information for All”. Strategies for achieving universal access include funding for research into barriers to use of information, evaluation and replication of successful initiatives, support for interdisciplinary networks, information cycles, and communities of practice, and the formation of national policieson health information.
Published online July 9, 2004http://image.thelancet.com/extras/04art6112web.pdf See
CommentBMJKnowledge, BMAHouse,Tavistock Square, LondonWC1H 9JR, UK
(FGodlee MRCP)
;INASP, Suite B, 58StAldates,Oxford OX11ST, UK 
(NPakenham-Walsh MBBS)
;Durban Institute of Technology, POBox 1334,Durban 4000, South Africa
(Prof DNcayiyana PhD Med)
;Public Library of Science, 185 Berry Street, Suite 1300,San Francisco, CA 94107, USA
(BCohen PhD)
; and BIREME,Rua Botucatu 862, 04023-901Sao Paulo, Brazil
(A Packer MLS)Correspondence to:DrFionaGodlee, Head of BMJKnowledge, BMJ PublishingGroup, London WC1H 9JR, UK
fgodlee@bmjgroup.com
www.thelancet.com
Published online July 9, 2004 http://image.thelancet.com/extras/04art6112web.pdf 1
Panel:
Background
This paper is adapted from a discussion papercommissioned by WHO in preparation for the MexicoSummit on Health Research in November, 2004.Publication in
The Lancet
coincides with the launch of theGlobal Review of Access to Health Information inDeveloping Countries (http://www.inasp.info/globalreview). Building on a series of existing conferencesworldwide in 2004–05, the review will bring togetherpeople from all stages of knowledge creation anddissemination, to understand more about progress, lessonslearned, and ways forward. To get involved, join the e-mailforum HIF-net at WHO (health@inasp.info).
 
For personal use. Only reproduce with permission from Elsevier Ltd Public Health
and Caribbean Centre For Health SciencesInformation. Established in 1967 following anagreement between the Pan American HealthOrganization (PAHO)/WHO and the BrazilianGovernment, BIREME has shown how significantgovernment funding across a region can successfullyovercome the phenomenon of the “lost science of theThird World”.
8
In collaboration with the Foundationfor the Support of Science of São Paulo (FAPESP) andthe Chilean National Council of Sciences, BIREME setup SciELO (the Scientific Electronic Library Online,http://www.scielo.org), which was the first and is nowone of the largest sources of free full-text access tohealth research information. BIREME also set upLILACS (http://lilacs.bvsalud.org), which indexesjournals from Latin America and the Caribbean, andthe Virtual Health Library (http://www.bvsalud.org),which provides free online access to a range of evidence-based resources that support health-caredecisions.EMRO (World Health Organization EasternMediterranean Regional Office) has also developed araft of initiatives to improve access to healthinformation and to build capacity in health researchand the production and dissemination of health-information materials. It provides training forresearchers at country and regional level, helpscountries develop research policies, directly sponsorsresearch, and has developed a regional journal as anavenue for dissemination and academic recognition.EMRO Index Medicus indexes over 310 journals in theregion and is published in print, CD-ROM, and on theinternet. EMRO maintains a database of locallyproduced books and journals from the region,maintains a core list of recommended resources forsmall libraries, and provides financial support forlibraries to procure such core resources. These initiatives, and many others, show what ispossible given political support, internationalcooperation, clear leadership, good management, andadequate funds—and what might be possible forimportant initiatives such as the Association for HealthInformation and Libraries in Africa (http://www.ahila.org) and the African Index Medicus (http://www.who.int/library), which are currently struggling partlythrough lack of sustained national and internationalpolitical and financial commitment.
What have we learnt?
The past 10 years have taught some crucial lessons.One is that “pull” is better than “push” when it comesto information transfer. The meeting 10 years ago toreview global access to health information recognisedthe huge importance of information flows within andamong developing countries and the limitations of pushing information to health-care professionals. Areport of the meeting concluded that: “People in thedeveloping world should be given the chance to saywhat they want rather than simply be sentinformation.”
1
Despite growing understanding of theneed for exchange of knowledge between countries andwithin regions, there is a continuing tendency to pushinformation out to people rather than strengtheningand responding to the pull of their information needs. Another lesson is that sustainable development isachieved only through building local capacity. Moreand more initiatives have shown the wisdom of actinglocally. Healthlink Worldwide (http://www.healthlink.org.uk) has shifted from being a publisher anddistributor of international newsletters (
Dialogue onDiarrhoea
,
AIDS Action
, etc) to enabling developingcountry producers and distributors (publishers,ministries of health, library services, local and regionalnon-governmental organisations) to publish anddistribute their own health learning materials. TheEffective Health Care Alliance Programme
9
helpsindividuals and groups in middle and low-incomecountries to prepare and update systematic reviews.INCLEN (the International Clinical EpidemiologyNetwork; http://www.inclen.org) provides long-termfunds, training, peer support, and mentoring to buildcapacity in clinical epidemiology in developingcountries.Thanks to the Council on Health Research forDevelopment (COHRED) and the Global Forum forHealth Research, we have learnt that less than 10% of health-research funding is targeted to the healthproblems that account for 90% of the global diseaseburden.
10
This 10/90 gap is a fundamental cause of lackof access to relevant health information. It isexacerbated by problems in getting developing worldresearch published, indexed, incorporated intosystematic reviews, and integrated into accessiblelearning and reference materials. The 10/90 gap inresearch probably translates into a 1/99 gap in healthinformation.We have learnt that most health professionals stillprefer print.
7,11,12
We have also learnt that most healthworkers in developing countries will not or cannot payfor information themselves and that as muchinformation as possible should therefore be free to use.In its draft report, WHO argues that “knowledge mustbe accessible to all in a form which is useful and can beacted upon by different people and groups”.
2
“Freeaccess” and “open access” initiatives have greatlyimproved availability of the biomedical literature,
13
which is the crucial building block for evidence-basedhealth care. In particular, HINARI (HealthInterNetwork Access to Research Initiative; http://www.healthinternetwork.org), a partnership initiativeled by WHO, now provides developing countries withaccess to nearly 2300 online journals. But we have alsolearnt that journals are one of the least usefulinformation sources for health professionals in
2
www.thelancet.com
Published online July 9, 2004 http://image.thelancet.com/extras/04art6112web.pdf
 
For personal use. Only reproduce with permission from Elsevier Ltd Public Health
practice.
4,11,12
In information-rich industrialisedcountries, clinicians often rely largely on two or threeessential information resources—basic reference andlearning materials such as handbooks and drugformularies. A community health worker may find asingle copy of
Where there is no doctor 
,
14
adapted andwritten in the local language more useful than access tothousands of international journals. More attention isneeded to ensure free access to such resources for thevast majority of developing-world health professionalswho work in primary and district care. We have learnt that funders’ behaviour is critical.Despite increasing recognition of the importance of information, communication, and networking, manyfunding agencies are reluctant to support these typesof activity, whose impacts are more diffuse and lesseasy to define and measure than those of discrete,short-term “practical” projects. Funding agencies tendnot to like providing small grants, and they oftenprefer to fund new rather than establishedprogrammes, even where these have been successful.As a result, health-information funding often fallsbetween the cracks: between project-based andinfrastructural support, between health and education,and between international and country approaches. Finally, we have learnt about the existence andimportance of local information cycles or communitiesof practice. Complete sustainable information cyclesare those in which readers/users are also writers/contributors. A completely inclusive information cycleexists within the world of academic research, where allauthors are readers and all readers are potentialauthors. But information cycles also exist, or can beestablished, between researchers, scientific publishersand editors, systematic reviewers, funders of research,health professionals, policy makers, and patients.These information cycles have the potential to greatlyincrease the relevance and reliability of informationabout health care, and to build skills, understanding,and ownership that will help to increase the use of thatinformation. Experience at BIREME and elsewhereshows that local information cycles and communities of practice can be facilitated and strengthened by givingpeople the chance to use virtual forums, chat rooms, and discussion lists. HIF-net at WHO (http://www.inasp.info/health/hif-net) and the World Association of Medical Editors (http://www.wame.org) are examples of virtual communities of practice that have the potentialto build local capacity in the developing world.
What needs to happen now?
It is not the place of this article to make detailedrecommendations on the way forward. However, wesuggest four broad issues around which future activitycould be focused, and we propose a framework withinwhich more detailed ideas could be formulated,implemented, and evaluated. The first issue is improved access to essentialinformation for health professionals, such as drugformularies and evidence-based handbooks. This maybest be achieved through strengthening of local andregional publishers, libraries, and informationservices. With access to electronic resources (andadequate financial support for training andequipment), libraries can make information availableto end-users in a range of formats (printed, electronic,digital, and broadcast media). At the moment there arestark regional differences in library support. In manydeveloping countries it is difficult, if not impossible,for librarians and others to find out—and certainly toafford—the full range of relevant publications availablenationally or internationally. But much has beenlearned about the development of libraries andresource centres, particularly through the work of Healthlink Worldwide and its partners. WHO’s BlueTrunk Library may be a model that should bereplicated more widely; it has provided over 1000 mini-libraries for use by district hospitals and other frontlinefacilities, providing access to a selection of essentialhealth-information materials.The second issue is improved connectivity.Clinicians may still generally prefer paper, but amongcurrently available technologies only the internet hasthe potential to deliver universal access to up-to-datehealth-care information. Connectivity is vital forefficient information flows among librarians,publishers, and all others responsible for developingand distributing materials. Internet connectivity hasincreased dramatically over the past 10 years, but it isstill unavailable to most health professionals.
15
Accessto e-mail is spreading faster than the internet,especially in Africa. E-mail provides new possibilitiesfor publishing and distributing practical health-careinformation and for networking with other healthprofessionals, as evidenced by the success of regionalnetworks (eg, AFRO-Nets; http://www.afronets.org),publisher networks (eg, Forum for African MedicalEditors),
16
librarian networks, and multidisciplinaryhealth-information development networks (eg, HIF-netat WHO). E-mail has also enabled one-to-one commu-nications, both professional and personal, facilitatingdevelopment of relationships and reducingprofessional isolation.Significant problems to overcome in some countriesinclude inadequate power supply; lack of computerequipment and information technology support; thefact that the necessary software is mainly in English;lack of computer skills; and resistance to use of technology among health professionals. Improvementsin connectivity will require a major global informationcommunication technology initiative, which itself willrequire substantial and sustained financing. The third issue is the need to identify and overcomebarriers to the use of information in different settings.
www.thelancet.com
Published online July 9, 2004 http://image.thelancet.com/extras/04art6112web.pdf 3

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