Open access and global health inequity: a clinical perspective

Akhil Bansal

Inability to access and publish publications relating to clinical practice is a key driver of health inequity. Further work on open access will be a crucial part of the solution.

In the centre of Gohana, India, a small town of 70 000 in the state of Haryana, sits the Abhishek Memorial Hospital, run by a husband-and-wife cardiologist–obstetrician duo Dr Varun Gupta and Dr Saloni Gupta. The hospital treats nearly 100 patients a day; outpatient clinics are located downstairs, and upstairs is a cardiac catheter laboratory and four beds for inpatient admissions. Like many doctors’ offices, there are mammoth leather-bound medical textbooks and neatly stacked editions of journals on the shelves throughout the hospital. But unlike the predominantly decorative function they often serve, the Guptas use these textbooks frequently. 

When I ask Dr Varun Gupta about where he sources his up-to-date clinical information from, he tells me, “For routine cases and best-practice guidelines, these textbooks and a few major journals will suffice. But there are some cases when we need more specific information.”

He recalls a recent patient, a new mother who had just given birth by Caesarean section and was experiencing postoperative fever and sepsis within 24 hours of delivery. Both Dr Gupta and his wife were confident in managing the patient but wanted to reference best-practice information to ensure that there weren’t any differentials or investigations that they might be missing for this specific presentation. An Internet search revealed an article that, from the title and abstract, appeared to have some content that might benefit them. Unfortunately, they could not access the article.

For the Guptas, it is predominantly in such complex clinical scenarios that access to recent academic publications is most needed, but often is not accessible. Compounding this, it is these complex patients whose conditions are often time-critical and high-risk.

Open access (OA) is increasingly acknowledged as a vital step in the translation of knowledge from research to clinicians in low- and middle-income countries (LMICs).1 There has been significant progress in expanding OA, particularly in LMICs and for public health research. Initiatives such as Plan S, Research4Life, Hinari (which unfortunately does not cover India), the TDR Gateway and the work of organizations such as Open Pharma have made significant advances in increasing access to scientific and clinical communication. However, access to OA literature in LMICs is insufficient and unstable2 and there is still a wealth of clinical best-practice evidence and academic publications that is subscription-based only.

The broader impact of this is the perpetuation of health inequity, both between rural and urban areas, and between LMICs and developed countries. Rural and LMIC clinicians are less likely to be associated with academic centres that have institutional access to publications and are far less likely to have the financial means to access subscription-only articles when they need to. Because of this inequity of access to information, these clinicians are less able to provide up-to-date and best evidence-based clinical care in every circumstance.

Further to this, the ‘pay-to-publish’ systems of many OA journals has a relatively greater burden in LMICs,3 given that researchers from these countries are not used to paying or able to pay publication costs, and owing to insufficient knowledge or access to subsidies and waivers for LMIC clinical researchers. Subsequently, such clinicians are less likely to share and disseminate their clinical experience, meaning that research on LMIC patient populations is likely to be under-represented in academic literature.

Clearly, the struggle that the Guptas face in accessing and publishing clinical information is not unique and it perpetuates existing health inequities. Working towards sustainable and far-reaching OA globally, as well as educating clinicians about OA and the existing initiatives that might be available to them, are crucial in bridging current health inequity divides.


1.           Chan L, Arunachalam S, Kirsop B. Open access: a giant leap towards bridging health inequities. Bull World Health Organ 2009;87:631–5.

2.           Tennant JP, Waldner F, Jacques DC et al. The academic, economic and societal impacts of Open Access: an evidence-based review. F1000Res 2016;5:632.

3.           Matheka DM, Nderitu J, Mutonga D et al. Open access: academic publishing and its implications for knowledge equity in Kenya. Global Health 2014;10:26.

Akhil Bansal is a medical doctor and an associate medical writer at Oxford PharmaGenesis.