We welcome this re-visit by HIFA to discussion on Open Access and are particularly impressed by the many comments posted so far. In 2018, when HIFA deliberated on Open Access, one of the questions was ‘What other steps (other than Open Access) are needed to increase the availability and use of health research information?’. The discussion drew attention to a particular hindrance to leveraging on the benefits of Open Access, namely, ‘access to citations in publications, which are not available because they are behind pay walls. To understand why this hindrance persists, we need to understand the origins of Open Access, the progress made so far, and why fully achieving the initial aim has eluded many efforts.
To its credit, HIFA forum has hosted discussions on the advantages of Open Access and obstacles that beset the model which hinders achieving access to and use of information especially in LLMICs. I recall our discussing one significant hindrance: ’access to citations in publications’. Meanwhile to make Open Access even more open, researchers and clinicians, policymakers, and implementers should be able to access references (citations), but often these citations are not available because they are behind pay walls!
Even before the internet there were efforts to both share knowledge for the good of all (‘Common Knowledge’) and reduce the quantity of low quality information (publisher-pays model was the physicist ‘Leó Szilárd’)
The ‘social movement’ idea and practice of providing free online access to journal articles Open Access (which initially refers to unrestricted online access to scholarly research, primarily intended for scholarly journal articles) can be traced back to at least the 1950's. From the 1990s, with availability of Internet access, it became possible to publish a scholarly article and also make it instantly accessible anywhere in the world, so long as there are computers and Internet connections. It impacted on the fixed cost of publishing which was rising and the cost of the online distribution which became much cheaper. At this time the traditional, print-based scholarly journals system was in serial crisis, the number of journals and articles produced had been increasing at a steady rate but the average cost per journal had been rising at a rate far above inflation for decades, and budgets at academic libraries have remained static. The result was decreased access – ironically, just when technology (internet) has made almost unlimited access a very real possibility, for the first time. Libraries and librarians played significant part in the open-access movement, alerting faculty and administrators to the serials crisis and developing the Scholarly Publishing and Academic Resources Coalition (SPARC), in 1997.
The first online-only, free-access journals (eventually to be called "open-access journals") began appearing in the late 1980s and early 1990s, using pre-existing infrastructure such as e-mail without any intent to generate profit.
Coupled with the explosion of interest in the 1990’s, and emergence of the internet. ‘the term "Open Access" itself was first formulated in three public statements in the 2000s: the Budapest Open Access Initiative in February 2002, the Bethesda Statement on Open Access Publishing in June 2003, and the Berlin Declaration on Open Access to Knowledge in the Sciences and Humanities in October 2003.’ These are seminal, must-read statements! The same momentum led to HINARI (Health InterNetwork Access to Research Initiative) was formed by World Health Organisation in 2001 with the purpose, ‘To provide free or low-cost online access to academic journals in Biomedicine and Social science’. The online Open access Books in 1994 provided free online full-text editions books alongside priced, printed editions. In 2025, according to the Directory of Open Access Books, there are over 99,000 academic peer-reviewed books.
The Journal of Clinical Investigation became the first major non-profit biomedical journal to be freely available on the web in 1996. Other pioneers in open-access publishing in the biomedical domain included BMJ, Journal of Medical Internet Research, and Medscape, who were created or made their content freely accessible also in the late 1990s. By 2001, dozens of for-profit open access Journals were launched by what was then the Current Science Group (the founder of the Current Opinion series and now known as the Science Navigation Group). Thus, two groups had emerged: non- profit free and for-profit Open Access Journals. In 2001, the Public Library of Science (PLOS), an advocacy organization emerged after many scholars around the world signed "An Open Letter to Scientific Publishers", calling for "the establishment of an online public library that would provide the full contents of the published record of research and scholarly discourse in medicine and the life sciences in a freely accessible, fully searchable, interlinked form". Some of the signatories decided to stop publishing or peer review for the for-profit (commercial) Journals, while others continued to publish and review for non-open-access journals. ‘PLOS launched its first open-access journal, PLOS Biology in 2003, with PLOS Medicine following in 2004, and PLOS One in 2006. Critics have argued that, equipped with a $10 million (seed) grant, PLoS competes with smaller open-access journals, especially LLMICs, for the best submissions and risks destroying what it originally wanted to foster.’
In 2011, at the BioMed Central (BMC) OA conference at the Kwame Nkrumah University of Science and Technology, Kumasi Ghana (KNUST), I ended my presentation on Open Access Challenges, with a quotation that sadly still resonates today: ‘----- in many developing countries, research has limited social and economic impact because doing it is not widely available and accessible. Restricted access to research is also an obstacle to the production of new knowledge. Open access (OA) provides a solution by making scientific research visible and freely available online’ (https://www.eifl.net/eifl-in-action/open-access-ghana); AND that “Africa cannot attain sustainable development without access to knowledge and information sharing. Knowledge sharing is also important to higher education to facilitate national development” (Professor Olugbemiro Jegede, Secretary General of the Association of African Universities). At the conference, and I don’t think that the situation has changed much, the participants were unanimous about how importantly Africa needs OA, but also how University Appointment and Promotion panels (A&P) were discriminating against, and stigmatising OA publications, in their procedures: claiming that OA was inferior and apportioning higher scores/grades to papers carried in the traditional model publishing print journals against OA journals papers, even if the OA journals fulfilled all the accepted international (and local) parameters and indicators for quality publishing and papers. Across the LLMICs, as researchers and authors seek to publish in proper, high impact, visible journals to disseminate their work such stigmatisation is a big handicap. Money is also scarce for most of these researchers, authors and institutions because most of them are in the LLMICs where pay remains low, investment in research and education generally very low, and poverty for even educated scientists is worsening.
Groups like HINARI and some OA journals that offer targeted free access, in the form of waivers, or reduced Author Pays Charges (APC) have helped, but if a researcher is from a LLMIC country he/she may face another unique challenge: if the country works to increase its GDP, the researchers/authors/institutions suddenly cannot access HINARI, e.g. Nigeria. It appears that it has become a ‘crime’ for a country to make economic progress, even if notionally, because the lag-time that takes place between the GDP going up and people, including researchers, seeing the money in their wallets is not taken into account, as the country is excluded from accessing OA (e.g. HINARI) before the lag-time is over. Some commentators have stated that ‘even though it does not excuse the criminality, the emergence of multiple predatory journals is partly to fill the gap that the huge global appetite for research and knowledge has created, and partly due to the challenges to access and use of accurate information and evidence caused by traditional print journal model.
To conclude, we advocate that one additional measure needed to make Open Access even more open for researchers and clinicians, policymakers and implementers should be ability to (availability to) access citations (references) that is to eliminate paywalls particularly for LLMICs. Billions are spent in public for information creation, but most global research remains locked behind corporate paywalls, whereas publishers’ profit, students and researchers are denied access. Many scientific journals, rated as high-impact journals, will publish outside of their paywall only if one pays a hefty fee, often unaffordable for LLMIC practitioners. Journal subscriptions cost millions of dollars a year for institutional access and hundreds to thousands of dollars for individual access. It is re-assuring that Open-Access initiatives, that are an alternative to paywalled journals, e.g. arXiv and PubMed Central, are rising. Removing paywalled access to research creates an ethical way to access currently restricted research and enhances equity in knowledge acquisition and its application everywhere.
Joseph Ana
Prof Joseph Ana
Lead Senior Fellow/ medical consultant.
Center for Clinical Governance Research &
Patient Safety (ACCGR&PS) @ HRI GLOBAL
P: +234 (0) 8063600642
E: info@hri-global.org
8 Amaku Street, State Housing, Calabar, Nigeria.
www.hri-global.org
HIFA profile: Joseph Ana is the Lead Senior Fellow/Medical Consultant at the Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria, established by HRI Global (former HRIWA). He is a member of the World Health Organisation’s Technical Advisory Group on Integrated Care in primary, emergency, operative, and critical care (TAG-IC2). As the Cross River State Commissioner for Health, he led the introduction of the Homegrown Quality Tool, the 12-Pillar Clinical Governance Programme, in Nigeria (2004-2008). For sustainability, he established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria. His main interest is in whole health sector and system strengthening in Lower, Low and Middle Income Countries (LLMICs). He has written six books on the 12-Pillar Clinical Governance programme, suitable for LLMICs, including the TOOLS for Implementation. He served as Chairman of the Nigerian Medical Association’s Standing Committee on Clinical Governance (2012-2022), and he won the Nigeria Medical Association’s Award of Excellence on three consecutive occasions for the innovation. He served as Chairman, Quality & Performance, of the Technical Working Group for the implementation of the Nigeria Health Act 2014. He is member, National Tertiary Health Institutions Standards Committee of the Federal Ministry of Health. He is the pioneer Secretary General/Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. Joseph is a member of the HIFA Steering Group and the HIFA working group on Community Health Workers. (http://www.hifa.org/support/members/joseph-0 http://www.hifa.org/people/steering-group). jneana AT yahoo.co.uk