Closing the digital divide

As recently as September 2000 a scientist from the World Health Organization wrote that global inequity in access to the internet was greater than any other inequity.¹ Less than three years later more than 100 health institutions in the developing world have free electronic access to over 2000 journals—access that is equal, and sometimes better, than in institutions in New York, London, and Paris. This week access is being extended beyond the 68 countries with incomes of less than $1000 (£612; €922) a head to 42 countries with incomes between $1000 and $3000 a head.

Until very recently health institutions in low income countries had almost no access to international journals, and the few textbooks available were often years out of date.²,³ These institutions simply couldn't afford the journals. Many small organisations worked hard to try to provide information, but international organisations such as the World Health Organization and the World Bank did not give high priority to improving access to information. Access to drugs, supplies, and technical support seemed to be more important.

But this is the information age, and we have all understood increasingly that access to information is essential for development and improvement in health services.⁴ WHO decided a few years ago to give higher priority to improving access to information. In July 2001 Gro Harlem Brundtland, the director general of WHO, announced the launch of HINARI (Health Internetwork Access to Research Initiative, www.healthinternetwork.org).⁵ This is a voluntary partnership between WHO and 28 publishers to provide free or nominally priced access to health information to institutions in the developing world.

The first phase launched on 31 January 2001, supplying 68 countries with free access to 1400 journals. A total of 438 institutions in 56 countries have registered, and more than 100 institutions are accessing the journals regularly. The number of institutions accessing material is growing, and the number of journals has increased to over 2000 since 18 further publishers have joined the programme. All the major weekly medical and scientific journals can be accessed for free.

On 31 January 2003 access was extended to another 42 middle income countries. Institutions in these countries must pay $1000 for access to all the journals (which would buy subscriptions to about three journals at normal prices), but the publishers are donating the revenue to WHO to use for training librarians in using HINARI. In future HINARI should include electronic books, bibliographical databases, and continuing education programmes. There is also a plan to copy the programme for information on agriculture and the environment.

HINARI has transformed information access in a very short time, but it is no panacea. Access to the internet in the developing world is still limited, expensive, and far from robust—although it is increasing exponentially in many poor countries. HINARI is aimed at researchers and policy makers. Further steps—perhaps using paper—need to be taken to reach front line health workers. Librarians and others need training in how to find the best information. Ironically, some in the developing world are now suffering from the information paradox familiar in the developed world—drowning in information, much of it irrelevant, and yet being unable to find answers to the questions that arise all the time in health care.

The programme is also primarily about supplying information from the rich world to the poor world. It's equally important to increase the flow of information in the developing world and from the poor world to the rich world. Most important of all is to create cultures of reading, questioning, debating, researching, and publishing. An improved information supply is a necessary but not sufficient condition for creating such cultures.