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For some years it has been the policy of the BMJ Publishing Group to give free subscriptions to journals, including QHC, to people working in the developing world. An editorial in BMJ sets out the arguments for doing this very clearly.1 We know that the gap between the rich and poor countries is widening but, while those of us in the developed world have information overload, in some developing countries libraries are empty. However, in practice there have been difficulties—for example, postal services may be very unreliable and getting the printed journal to its destination can be difficult and expensive and, to some places, impossible at times. The marginal costs of sending one year's subscription of QHC to Africa is around £25, but the marginal cost of giving access to the electronic edition of QHC is close to zero.
As many journals are now on line, the internet provides the opportunity to narrow the information divide. Under the auspices of the WHO, leading medical publishers including the BMJ Publishing Group have agreed to provide free access to electronic versions of journals to people working in developing countries.2 Access to electronic journals happens at exactly the same time throughout the world. By having access to a range of e-journals, colleagues working in developing health systems will be able to access what is relevant to them and not simply what is provided or what happens to make it through the postal system. Best of all, anyone with electronic access to journals, wherever they work, can participate in debate through the rapid response facility on the web site, something that was not possible in printed journals.
Access to the electronic edition of QHC will automatically be provided free to those from countries defined as poor under the human development index by the United Nations (URL http://www.undp.org/hdro/HDI.html/). The BMA and several societies that co-own BMJ Publishing Group journals have funded the installation of Digital Island on all BMJ Publishing Group journal web sites. This clever piece of software recognises where a user is coming from and provides unrestricted access to the whole web site to those from countries we designate. BMJ.com will continue to be free to those in the developing world, whatever happens in the developed world. Facilitating access to information should help to encourage informed debate and may even contribute to improvement in health care.
Limited access to the world wide web in some countries is the main barrier. Tens of millions in the USA but only a few thousand in some African countries have access to the web and, compared with the USA, access in Africa may be slow, intermittent (power cuts may happen daily), and relatively expensive (it is often free in the USA). Yet it is likely that access will increase rapidly—for example, currently a million people in India have internet access but this is expected to rise to 40 million within 5 years. Similar increases are expected in Nigeria. Technological developments including better access to radio and the proliferation of satellites will obviate difficulties with telephone access in Africa. Many international organisations including UNESCO, the British government, the World Bank, and the Bill and Melissa Gates Foundation are working towards improving access to information in resource poor countries.
The challenge of all of this is sustainability, and this is a matter that goes beyond providing electronic access to journals. Donors can easily invest and reap rewards of short term success. But enhancing information flow will make no impact on health if projects continue only as long as their funding lasts. Information cannot be separated from the capacity of a healthcare system to work effectively over time. How is it possible to influence the context within which information will flow, the apparently intractable political, economic, and organisational constraints that disable rather than enable information to work for people? Publishers in the rich world have a part to play, and we hope that by making access to QHC on line free to those in the developing world, we are making our own small contribution. We hope that this will encourage readers to use the rapid resource facility to discuss and debate issues relevant to quality improvement world wide.