National free access to The Cochrane Library in India: Freedom may end at midnight.

Professor (Dr) Prathap Tharyan *

The Indian Council of Medical Research (ICMR) created history in February 2007 when India became the first and only low-income country in the world with a national subscription to The Cochrane Library. This initiative of the ICMR to purchase a national license was widely hailed as an exemplar of responsible leadership in health-research governance, as it gave all people in India with an internet connection free access to the online collection of reliable evidence-based resources to aid health decisions. Easy access to trust-worthy summaries that synthesize all relevant evidence, and that is not influenced by the marketing manipulations of drug companies, is the key step in evidence-informed health care; as it facilitates the working together of public and private health providers and their patients to better understand treatment options.

The increased use of the resources in The Cochrane Library over the three years of the national provision led to the ICMR renewing the subscription for India-wide free access for a further three years to January 2013. This renewal created history again, since India became the first middle-income country in the world with a national provision; having moved in the interim from being a low-to a middle-income country. The current national provision expired on 31 January 2013, and is up for renewal.

Unless the national license is renewed, before the two-month extension granted by the publishers also expires, people in India will have free access to The Cochrane Library only till midnight on March 31, 2013.

Why should India renew the national license to free, one-click access to The Cochrane Library?

Access to trusted evidence to inform decisions for better health.

The Cochrane Library is a collection of six databases that is the world’s single best source of reliable and timely evidence for the effects of interventions used in healthcare, and of the accuracy of tests used to diagnose health problems.

One of these is the Cochrane Database of Systematic Reviews (CDSR) that is produced, updated, and disseminated by The Cochrane Collaboration. This global organisation, founded in 1993 and registered as a charity, is a partnership of more than 30,000 active contributors, nearly 25,000 of who are authors of Cochrane Reviews. Many are world leaders in their disciplines and work in reputed academic institutions and organizations in over 100 countries. These researchers work with editorial teams (Collaborative Review Groups) to produce high-quality summaries of the evidence in the form of systematic reviews. Systematic reviews are scientific studies that follow transparent and pre-stated methods to identify all relevant research studies on a specific topic; assess them for limitations in their methods that could result in misleading results; and, if appropriate, combine the results of similar studies using statistical techniques called meta-analyses that provides averaged estimates of the effects of the interventions compared in all the relevant studies. The results for important outcomes are also summarised in tables that link the numerical results with the confidence that these estimates are likely to be true; generalizable; and not altered significantly by further research.

Cochrane Reviews compare the effects of pharmacological, non-pharmacological, and public health interventions, as well as the manner in which health services are organized and delivered. Some assess the accuracy of tests used for screening and diagnoses of health conditions. Cochrane Reviews are powered by rigorous, constantly evolving methods that have pioneered and driven the field of research synthesis. Cochrane Reviews are also independent of funding from the pharmaceutical industry, and are judged to be more reliable than non-Cochrane systematic reviews.

The Database of Abstracts of Reviews of Effects (DARE) contains abstracts of systematic reviews published in other journals; many provide a quality-appraised, structured summary prepared by the Center for Reviews and Dissemination at York in the UK.

The Cochrane Library is thus a one-stop portal to the full records or abstracts of most of the systematic reviews published in the world.

The world’s largest database of controlled clinical trials

The Cochrane Library also contains The Cochrane Central Register of Controlled Trials (CENTRAL), the world’s largest database of published and un-published randomized controlled trials. This register is compiled through contributions from Collaborative Review Groups; the Cochrane Centers and their branches worldwide; and others within the international Collaboration.

Other databases provide records of economic evaluations, health technology assessments, and of studies evaluating research methods.

No other single resource can match The Cochrane Library for the scope and quality of data provided to guide health decisions.

The Cochrane brand: Trusted evidence for better health

The Cochrane Collaboration represents the health-research and health-services equivalent of The Human Genome Project, according to an article in The Lancet. The Cochrane Collaboration is a Non-Governmental Organization in Official Relations with the World Health Organization (WHO) and has a seat on the World Health Assembly. This provides the Collaboration an opportunity to influence the way research evidence is generated and used by the WHO in developing policies and guidelines for use worldwide.

The Cochrane Collaboration enters the 21st year of its existence as the world’s leading provider of independent, trusted, high-quality systematic reviews, and derivative products, to inform health decisions.

It’s steady growth and global influence is a vibrant testament to the view that, “with collaborative partnerships, rigorous scientific methods and a principled approach, evidence of, by, and for the people, can indeed be a reality.”

Evidence of the people, by the people, and for the people

The evidence in The Cochrane Library is about the health conditions that affect all people; and embodies the efforts of many millions of people with diverse health conditions who consent to participate in research that may, or may not, directly benefit them. It also reflects the efforts and skills of researchers who conduct the primary studies and of those who synthesize the results. To ensure that this collaboratively-generated body of evidence is actually made available to everyone is a priority for The Cochrane Collaboration. The abstracts of all Cochrane Reviews are free to everyone in the world to read, but access to the full text of these high-quality reviews and to the other content in The Cochrane Library requires a subscription. The Collaboration and its publishing partner, Wiley-Blackwell, have promoted various funded initiatives since 2007 to ensure that people in 109 countries in some of the most impoverished parts of the world have free one-click access to reliable evidence regarding their healthcare needs.

Ensuring that reliable evidence is accessible to all people, particularly to those living in low-income countries with a disproportionate burden of disease and who are most in need of this evidence, yet who have competing priorities for their limited resources, is a major challenge. This is because some countries, who fall in the category of upper, low-income countries, in the World Bank listings, like India did in 2007, do not qualify for free access. This challenge of ensuring wider global access has been complemented by the increasing numbers of provisions funded by governments or other agencies in middle- and high-income countries that now ensure that more than half the world’s population have free access to Cochrane evidence. For example, in 2012, new national provisions were funded by governments in Oman and Egypt; and the National Health and Medical Research Council of Australia funded the renewed licence for Australia-wide access to The Cochrane Library for the next five years.

These examples signify the importance placed by governments, of ever increasing numbers of countries, in Cochrane evidence; and for wide-spread access to this evidence.

True leadership facilitates the realisation of the vision of others that are aligned to achieve mutual objectives. The SASIANCC salutes the ICMR and the Department of Health Research for exemplary leadership in research governance that facilitated considerable progress towards achieving the vision of The Cochrane Collaboration: that all health decisions (in India, the region, and the world) will be informed by reliable evidence. So much more remains to be done and world continues to need visionary leadership to achieve better health outcomes for all people.

For value of money, I believe that the ICMR and the Department of Health Research can do very little to better the impact on health that renewal of the national license can achieve in India.