The 2014 Ebola outbreak proved disastrous for nations such as Guinea, Sierra Leone and Liberia, which were already rife with civil unrest [1]. Yet, in 1982, knowledge that Liberia had a high potential of endemic Ebola had been published in the Annals of Virology [2]. Local public health institutions and officials were most likely unaware of these findings as they remained hidden behind a paywall in a subscription only journal. This may have contributed to the lack of preventative measures which could have mitigated the severity and magnitude of the eventual outbreak [3]. During the outbreak, understanding the evolution of the epidemic from an epidemiological standpoint was, in itself, difficult given the lack of investment in data collection, sharing and management [4].
As mentioned by WHO in their report entitled Research for Universal Health Coverage [5], accessible knowledge is an important first step in the translation of knowledge from research to policymakers and stakeholders in low- and middle-income countries (LMICs). Although access to knowledge would not of itself have prevented or averted the Ebola epidemic, better informed health officials might have taken timely preventive measures and been better equipped to mitigate risks during and after the outbreak [6]. Actually, in the recent Zika virus outbreak, research is more readily accessible, providing evidence-based knowledge faster to mitigate immediate and future harms [7]. This may be due to consensus reached by important stakeholders (British Medical Journal, the Nature journals, the New England Journal of Medicine, and the seven PLoS journals) during the 2015 WHO consultation promoting sharing of data, results and pre-prints during public health emergencies [8].
As international healthcare research has evolved over the past several decades, so has the sharing of knowledge. Prior to the 1990s, the involvement of multiple international collaborators was much less prevalent and usually limited to matters of complex disease control (e.g. smallpox) [9]. Generally, the scope of ‘public health’ was determined by the resource capacity and geographical reach of a specific country or community [10]. It was common practice for researchers from high-income countries (HICs) to study health issues in LMICs. However, this type of research in the field of ‘international health’ was exclusive in that it rarely included or considered the interests and needs of researchers and communities in LMICs [11]. Knowledge remained with HIC research groups and was published in subscription journals, held behind ‘paywalls’ – expensive subscriptions or toll access, affordable mainly for HIC researchers and/or institutions. Restricting access to knowledge from public health research that can have direct influence in life or death contexts remains a serious social justice concern [12].
The contemporary approach to global health research (GHR) promotes partnerships that meaningfully include researchers and communities from LMICs [13]. Research ethics has developed benchmarks for ethical global research to minimise exploitation of local players by including them and giving them fair recognition in collaborative research partnerships [14]. Mutual capacity building is encouraged so that researchers from both HICs and LMICs may learn from each other [15, 16]. These partnerships can facilitate knowledge translation among the diverse actors in LMIC health research, including researchers, non-governmental organisations and healthcare providers [17]. The intended outcome is greater health equity on a global scale among people and nations [10]. Since researchers in GHR are called upon to work in a collaborative fashion for health equity, sharing knowledge on a global scale is of central importance [6, 16, 18].
There are different ways to increase access to published knowledge. In LMICs, there are programmes such as the Health Internetwork Access to Research Initiative (HINARI), an initiative put together by WHO in collaboration with journal publishers, which provides greater access to many different research resources including e-books, textbooks and up to 14,000 journals, many of which are subscription based [19]. HINARI’s goal is to contribute to improving world health [19]. HINARI promotes ideals central to GHR, such as furthering equity in research access, but it does have important practical limitations. While HINARI provides free access to research institutions in low-income countries, it still requires that medium-income countries pay ‘low cost fees’ (US$1500 per year) for full access to HINARI resources [20]. Although these fees are indeed lower than the full price for HINARI resources through subscriptions or toll access, certain institutions – notably those that play many other roles such as healthcare provision and health prevention and promotion – have competing claims for limited funding, may not prioritise research funding within their institution, or may simply not have the necessary funding.
Moreover, since HINARI is a voluntary programme, publishers may choose to opt out or restrict free access status to specific countries; this creates uneven and uncertain access for users. This instability was well exemplified in 2011, when five publishers withdrew free access to more than 2500 biomedical and health journals including Elsevier’s Lancet journals from Bangladesh [21]. Although free access was soon reinstated after public outcry, the sustainability of such initiatives led by for-profit publishers remains questionable [22]. In fact, a similar withdrawal of access to various publishers in Nigeria in 2013 and 2014 has had the effect of reducing HINARI users in Nigeria [23]. It is noteworthy that the subscription journals are published almost exclusively by Western publishers such as Wiley, Taylor & Francis, Springer Nature, and Elsevier; the consequence of this is a financially induced knowledge inequality focused in the places where the research could have the highest impact.
Open access (OA) is another method where scholarly content is freely available online to all readers. Research has shown that OA is associated with higher citation rates [12, 24,25,26], likely as a consequence of wider accessibility. One main issue of certain high-profile OA journals is the existence of significant article processing fees (APCs) paid by authors, which may disadvantage researchers who are unable to cover these costs, emphasising the already significant inequity in research dissemination [27]. Although many funding institutions or universities may cover APCs [28], this is not systematically the case, especially in LMICs. To offset this financial barrier, certain journals offer OA waivers for researchers in low-income countries and in certain middle-income countries [29]; however, criteria to obtain waivers differ based on the journal.
It must be noted at the outset that the OA model has also led to the creation of a number of ‘deceptive publication practices’ often referred to as ‘predatory journals’ that do not follow standard peer-review process and often lack quality and transparency [12]. To ensure a level of quality control, journals do traditionally have an important role in managing the peer-review system where experts critically review research before it is made public. Regardless of the journal model – whether subscription based or OA – a certain level of peer-review is seen as essential [30].
Free access to knowledge may also be provided when researchers self-archive their papers, as we often see in public or institutional repositories. The copyright transfer agreements of many journals allow for the archiving of pre-prints and/or post-prints of journal articles, a practice termed ‘green OA’. Journal policies that do not allow for self-archiving often have an embargo period during which they control access to peer-reviewed articles for a specific range of time (generally 6 months to 1 year in journals publishing GHR papers); the impetus behind such embargos is to require institutions to purchase and thus fund subscription-based journals.
Over the last few decades, many studies have analysed the evolution of the OA availability of papers [31,32,33,34,35,36]. When one combines all different forms of OA, 50% of all biomedical research papers published between 2004 and 2011 were freely available in 2013 [24]. The same study shows that for the field of Public Health and Health Services, of which GHR can be considered a subfield, the share of OA is slightly higher, with 57.2% [24]. Given the importance of worldwide knowledge access in GHR, one might expect OA to be more prevalent in this field than in others. However, some may consider APCs to be simply too costly. The goal of this article is to (1) quantify the uptake of various types of OA used in GHR research, (2) calculate the financial costs of such practices from the authors’ point of view (paying for APCs), and (3) assess the impact of different OA models as indicated through citation analysis. Although there exist many other elements that influence the use of OA in GHR, such as journal prestige, general awareness, funder requirements and availability of repositories, these aspects are outside the scope of this specific research. Since the main goal of this paper is to assess the differences between different types of OA models, the comparison of subscription costs paid by university libraries and OA costs known as APCs paid by the author(s) is beyond the scope of this paper.
