National free access to The Cochrane Library in India: Freedom may end at midnight…
Prathap Tharyan is the Director of the South Asian Cochrane Network & Centre, based in Vellore, India, and a longtime contributor to the work of The Cochrane Collaboration. Here he reflects on the importance and impact of access to The Cochrane Library to all Indian citizens since 2007, and discusses the status of the national provision, currently being negotiated.
Cross-posted, with permission, from Prathap's blog, Evidence-Informed Musings.
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 synthesise 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 31 March 2013.
Why should India renew the national license to free, one-click access toThe 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 health care, 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 organisations 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; generalisable; 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 organised 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 Centre 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 containsThe Cochrane Central Register of Controlled Trials (CENTRAL), the world’s largest database of published and un-published randomised 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.
Its 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 synthesise 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 accessto 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.
Investing in evidence for better health: Evaluating the impact of the national subscription to The Cochrane Library in India
Negotiations continue, I am given to understand, between the ICMR and Wiley-India on renewal of the national subscription for India. Meanwhile, I invite your comments on what you consider was the impact of spending hard-earned, tax-payers’ money to provide free access in India toThe Cochrane Library. I shall enumerate herein different ways that I consider that this impact can be measured. I request your additional contributions, as well as alternative, even if contradictory, views by which this re-investment in reliable evidence should be evaluated.
These comments may help the ICMR to fully appreciate the impact that their initiative has had on the health of people in India, and in other parts of the world; and also reveal the views of people who use this evidence, so that decisions regarding the renewal of the national subscription may be better informed.
1. Compiling and comparing statistics on usage of The Cochrane Library
Compiling and comparing incremental statistics of the number of page views of each of the online databases of The Cochrane Library, and the number of full text-downloads of Cochrane Reviews from the CDSR, provides valuable data on the interest people in India have shown in accessing these resources.
The problem with this traditional approach to evaluating the impact of the national subscription is that reliable statistics are only available for those accessing The Cochrane Library directly from the online Wiley-interface (www.thecochranelibrary.com) and not from other sources by which readers can access The Cochrane Library such as PubMed, PubMed Health, the OVID platform, the EBSCO platform, summaries viewed in www.cochrane.org, those accessing Cochrane Reviews on handheld/mobile devices, etc. These statistics do not also include access to individual reviews from institutional or other repositories that authors may have deposited their reviews in; or from the DVD version of The Cochrane Library that the contact authors of new and updated reviews are provided. It is therefore an under-estimate of the usage and impact of Cochrane evidence.
Figure 1 (provided by Wiley-India) records the dramatic increase in the number of full text articles downloaded from The Cochrane Library by users in India over the six years of the national provision.
Figure 1: Usage statistics for full text downloads from The Cochrane Library in India (2007-2012)
The growth in full text downloads mostly relate to full texts of Cochrane Reviews (~85%) and reflects an absolute increase of 162,401 reviews downloaded by people from all regions in India in 2012 compared to the 9338 reviews downloaded from 11 institutions in India with an institutional subscription in 2006. This represents an 18-fold increase in downloads of the full-text of Cochrane Reviews, over a wider geographical spread in India, through the six years of the national provision.
Before the national subscription was purchased in 2007, downloads of full-text articles averaged around 500 per month (in 2006). By 2009, at the end of the first contract for national provision, this had increased to an average of 4500 per month. In 2012, the last year of the second national license, on average 14,311 full text articles per month were downloaded from The Cochrane Library in India. This represents a 29-fold increase in downloads per month over the six years of the two periods of national provision, compared to 2006.
The Cochrane Library is accessed by numerous users from all walks of life in India. Wiley-Blackwell, the publishers, estimated that in 2009 someone in India downloaded an article from The Cochrane Library every 12 minutes; this is likely to have been considerably more frequent in 2012.
The increase in usage was appreciably greater during the period of the second national provision (2010 to 2012) compared to the first three years of national access. This could partly be due to the publicity that accompanied the 2nd South Asian Regional Symposium on Evidence-Informed Health Care and Health Policy hosted by the South Asian Cochrane Network and Centre (SASIANCC) at the Christian Medical College, Vellore in January 2010 that saw over 650 participants and witnessed 44 plenary talks (including one by the Department of Health Research and the ICMR) and 22 skills-building workshops. Other dissemination workshops organised by Wiley-India, and also by Network Sites of the SASIANCC and the Centre in various parts of the country through 2011 and 2012, undoubtedly contributed to increased usage of The Cochrane Library during the last two years. This suggests that usage over the next few years is likely to grow rapidly, especially with the publicity and participation envisaged by the 22nd Annual Cochrane Colloquium that will be hosted by the SASIANCC at the Hyderabad International Convention Centre from 21-25 September 2014.
Figure 2: Full text downloads from 2006-2012 from the top ten countries with a national provision
India ranked fourth worldwide in 2012, after the UK, Australia, and Canada (all countries with a longer history of engagement with Cochrane), for the number of full text articles downloaded from countries with a national provision. India ranked fifth when downloads were compared overall for all countries; with the US that has a mixture of academic subscriptions and funded provisions in some states and provinces leading the list of countries accessing Cochrane content worldwide (Figure 2: courtesy Wiley-Blackwell).
India does not figure so prominently in any other worldwide ranking of indicators of good health, health care, or healthcare governance.
These statistics do not completely capture the usage of the resources in The Cochrane Library in India: during 2009, 47,024 additional visits were made in India to The Cochrane Library and 84,441 abstracts were viewed. During 2012 there were 55,096 additional visits from readers in 20 Indian states and union territories to The Cochrane Library homepage.
Surveys using Google-analytics as a proxy indicator of interest in Cochrane in India, and to reflect healthcare information-seeking behaviour of healthcare professionals, researchers, students, and consumers, were presented during the regional symposium at Vellore in 2010. They revealed that “Cochrane‟ consistently scored more frequently than the four top-ranked Indian health portals (MedInd, Health Library, Doctor NDTV and Web Health Center, over the period 2004 to 2009; with a dramatic increase following the national provision, and periods of increased activity reflecting national Cochrane-related workshops or symposia.
“Cochrane‟ also scored above Indian journals (Indian Journal of Medical Research, National Medical Journal of India, Journal of the Association of Physicians of India, the Postgraduate Medical Journal and others) and international journals (NEJM, The Lancet, BMJ and JAMA) for the most commonly-searched term in Google during these years.
These surveys mirror data from Wiley-Blackwell on usage of The Cochrane Library from 2007-2009.
However under-estimated these statistics are of actual usage, they nevertheless do tell us that people in India are increasingly using The Cochrane Library to access and download Cochrane Reviews.
2. Providing clinicians and patients with information relevant to their evidence requirements
Indian users of The Cochrane Library are reading Cochrane Reviews on a range of topics relevant to their needs. Table 1 (provided by Wiley-India) below, shows the 10 most downloaded Cochrane Reviews in India in 2012.
Table 1: Top 10 downloaded Cochrane Reviews in India: 2012
Cochrane Review Title
Green S, Buchbinder R, Hetrick SE.
Panpanich R, Garner P.
Pollock A, Baer G, Pomeroy VM, Langhorne P.
Galappaththy GNL, Omari AAA, Tharyan P.
Waters E, de Silva-Sanigorski A, Hall BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD.
Heart & Circulation
Holloway EA, Ram FSF
Lungs & airways
Li Y, Tang X, Zhang J, Wu T.
Bleakley C, McDonough S, Gardner E, Baxter GD, Hopkins JT, Davison GW.
Orthopaedics & trauma
Teixeira LJ, Valbuza JS, Prado GF.
Rutjes AWS, Nüesch E, Sterchi R, Jüni P.
Complementary & alternative medicine
This table also demonstrates the range of clinical topics provided by Cochrane Reviews that Indian readers consider relevant; they differ considerably from the top 10 reviews accessed worldwide (Table 2- courtesy: Wiley-Blackwell).
Table 2: Top 10 most accessed Cochrane Reviews worldwide in 2012 with comparative 2011 ranking
3. Dissemination of news in the Indian media about the results of Cochrane Reviews
International newspapers and other media channels regularly carry stories based on Cochrane Reviews. Indian media are consistently among the top five countries that carry news about Cochrane Reviews. This ensures that readers from a wide-spectrum of the public are regularly informed about the evidence (or lack of evidence) for benefits and harms regarding health interventions that they might be prescribed. Many of these news stories are archived in web pages of The Cochrane Collaboration, and reflect the in-depth understanding of these reviews that go into the preparation of these reports. The media has also seen debates around the relevance of evidence-based medicine in India that have provided opportunities to educate the public on the nuances of evidence-informed health care.
4. Contributing to global evidence for better health: from passive recipients to active contributors
India is considered by many, including its politicians and many of its business leaders, as an emerging economy with an impressive record of domestic growth, and with an increase in its demands for inclusion and influence in global politics and commerce. Moving out of the World Bank listing of low-income countries to the status of a middle-income country requires a change in mind-set: from being a passive recipient of foreign aid, to assuming greater responsibility for ensuring equity and quality in healthcare for its people. Contributing to building the evidence-base to inform health decisions that affect its people is an important part of this greater responsibility; contributing evidence to inform the health of people in other parts of the world is an extension of this responsibility.
The national provision to The Cochrane Libraryprovided clinicians and researchers in India free access to the best that research synthesis could offer, and stimulated interest in them to contribute to this global collection of reliable evidence.
In February 2013 the Information Management System (IMS) of the Collaboration listed 75 Cochrane Reviews and 73 published protocols of reviews with a contact author living in Bangladesh, India, Pakistan, Nepal and Sri Lanka (countries represented by the SASIANCC). The contact authors of 59 full reviews and 48 protocols of reviews in progress were from India. In contrast, in 2006 there were 11 reviews and protocols with a contact author from India.
However, the numbers of authors who are involved in producing Cochrane Reviews as co-authors (and not the contact author) are far greater. In February 2013 there were 186 protocols and 185 Cochrane Reviews listed in the IMS that had an author from one of the countries represented by the SASIANCC; authors of 110 Cochrane Reviews and protocols were living in India. This system also listed 435 people from India as registered active authors in February 2013; this represents a 36-fold increase in the number of authors compared to the 12 authors from India in 2006.
There are also 10 editors of Cochrane Review Groups in India. India now hosts the South Asian Cochrane Centre, one of the 13 independent Cochrane Centres around the world that advocates regionally for evidence-informed health decision making.
None of these would have been possible if India did not have universal free access to the reliable evidence from Cochrane Reviews.
Cochrane Reviews with Indian authors are contributing to global evidence for better health. The Cochrane Review “Zinc for the Common Cold” authored by Prof Meenu Singh and Rashmi Das from the Post Graduate Institute (PGI), Chandigarh received 6886 full-text downloads globally in 2011, and was also the most widely disseminated news report of a Cochrane Review in the world, “getting over 800 mentions across various media in the first two days after publication, and about 1000 mentions by day 10 in newspapers, television and radio (including in about 21 non-English languages)”.
The Cochrane Review “Corticosteroids for acute bacterial meningitis” that lists Prof Kameswar Prasad from the All India Institute of Medical Sciences (AIIMS), New Delhi, as an author, has been cited 184 times. One of the top 10 most-accessed reviews globally in 2008 (Ayurvedic medicine for schizophrenia) was authored by Indian contributors, further evidence of The Cochrane Library’s role in extending the global reach and international profile of medical research from India.
5. Influencing local, national and international health policies
Cochrane Reviews, with and without Indian authors, have influenced decisions in Indian medical institutions; and have contributed to Indian and International health policies and health decisions. An example of a local decision where Cochrane evidence helped was presented by Dr Kadhiravan Tamilarasan, a Cochrane author who is on the faculty of the nationally-funded Jawaharlal Institute for Postgraduate Medical Education and Research (JIPMER) at Pondicherry, and was a member of a institutional committee formed to rationalise the use of free prescriptions for intravenous immunoglobulin that were being used for a variety of conditions. Evidence from 35 Cochrane Reviews on the effects of intravenous immunoglobulin for various indications, and of alternatives, was used to generate a list of conditions where immunoglobulin therapy was reported to be effective and safe, and to drive a policy that provides free immunoglobulin treatment only for these indications.
One of the most down-loaded Cochrane Reviews in India in 2012 evaluated primaquine dosing for malaria due to Plasmodium vivax, with authors from Sri Lanka, UK and India, and was published in January 2007. The results were actively disseminated with the help of the ICMR, and were incorporated in the updated Indian Malaria guidelines in May 2007. The results of this review were also incorporated in subsequent editions of Park & Park’s textbook of community medicine that is widely used in medical schools in India. An updated version of this review will inform forthcoming revisions of the WHO malaria treatment guidelines.
A Cochrane Review with authors from South Africa, India and the UK, informed the Government of India’s decision to not provide nutritional supplements for people with tuberculosis (TB) in India, based on limited evidence of benefits. Updates of this review will also inform forthcoming revisions of the WHO guidelines on treating TB.
An updated Cochrane Review of deworming drugs in children that included primary studies from India demonstrated a lack of many of the postulated benefits; however, deworming programmes are still in vogue in many states in India. Access to the full content of this review was important in order to inform policy makers about considering changes to Indian policies regarding targeted deworming of children. Access also helped us in preparing and disseminating shorter evidence summaries of the rationale, methods, results and public-health implications of this review, accompanied by a commentary by a clinical expert.
Another Cochrane Review showed a lack of benefit on mortality and morbidity from routine health checks of healthy adults; yet such “master health checks” are very common, and are a source of considerable income to hospitals in the private sector in India; they are also funded by employers and by health insurance. Here too, access to the full text can inform policy revisions; and was used to prepare evidence summaries with a clinical commentary for dissemination.
These are but selected examples of Cochrane evidence informing policy decisions; and many other examples, no doubt, exist that you may be aware of.
6. Building capacity in India to undertake high-quality Cochrane Reviews and to use Cochrane evidence in informing health decisions
Forthcoming Cochrane Reviews with author teams from India will provide high-quality evidence on a variety of health questions of regional and global importance, such as alternatives to isoniazid in treating HIV-negative people with latent-TB infection; the role of intermittent treatments in treating childhood TB; interventions to prevent reactions due to anti-snake venom; and the role of Ayurveda in the management of rheumatoid arthritis. These and other such reviews of relevance to healthcare in India and other low- and middle-income countries are mentored by the Effective Health Care Research Consortiumthat is funded by UKaid (Department For International Development) to improve health outcomes in low- and middle-income countries.
The ICMR funded for five years an ICMR Center for Advanced Research and Training in Evidence-Informed Healthcare at CMC Vellore, and is currently funding a Center for Advanced Research in Evidence-Based Child Health at PGI Chandigarh. The main activities of these centers are to build capacity in India to undertake relevant systematic reviews.
The Cochrane Collaboration has also invested some of the royalties from the global sales of The Cochrane Library in funding four global projects that aim to increase the capacity in authors in low and middle-income countries to produce Cochrane Reviews that will impact on health outcomes locally and globally.
The South Asian Cochrane Centre is partnering the Centre for Innovations in Public Systems (CIPS) that functions out of the Administrative Staff College at Hyderabad, to ensure that health policy-makers in the Ministries of Health and Family Welfare at the national and state levels are familiar with the resources in The Cochrane Library and the role of Cochrane evidence in informing national and state health spending.
Full access to Cochrane content is crucial for these initiatives to have any of the intended benefits for people in India.
7. Identifying gaps in the evidence base and driving high-quality research
Cochrane Reviews also provide an opportunity to identify those interventions and conditions for which insufficient evidence exists to adequately inform health decisions; these interventions could be prioritised for funding and for undertaking primary research.
Examples of such evidence gaps that have spawned primary studies in India include two pragmatic trials evaluating the role of interventions used in the management of psychosis induced aggression. Insufficient evidence from a search of The Cochrane Library and other sources regarding the optimal dose of anti-snake venom to deal with snake envenomation, that claims the life of more than 50,000 people in India, led to the development of protocols for observational studies. These studies will see a unique partnership of herpetologists, clinicians, venom detection experts and anti-venom manufacturers collaborating to ensure better health outcomes for the many thousands of Indians in rural areas who are bitten, often fatally, every year by venomous snakes.
The rigorous methods used in Cochrane Reviews ensures that those undertaking these reviews, as well as those using these reviews, learn about good research methods, such as assessing the risk of bias in primary studies; the importance of using appropriate outcomes and estimates of effects such as risk ratios with their confidence limits; and about assessing the overall quality of the evidence using the GRADE approach. These methods also stress the importance of incorporating the elements of transparent and reliable reporting of research that are specific for the type of research question, in study protocols. The Cochrane Handbook for Systematic Reviews of Interventions and of Diagnostic Test Accuracy, provided free for anyone to download and use, are excellent resources to understand the challenges and approaches to research synthesis. The proprietary software used to prepare Cochrane Reviews and for meta-analysis (Review Manager), and to prepare summary tables of the important findings of systematic reviews (GRADE Profiler), are also free to download and use by anyone. Many non-Cochrane reviews by researcher in India (and elsewhere) regularly search The Cochrane Library and its Central Register of Controlled Clinical Trials. Many also use the methods used in Cochrane Reviews and prepare their reviews using Cochrane software; thus improving the quality of their reviews.
The impact that The Cochrane Collaboration has had in India is exemplified by the ICMR’s recent call for proposals for researchers in India to undertake systematic reviews. The ICMR has invested in six funded-systematic reviews dealing with topics in maternal and child health, following a call for proposals, with members of the SASIANCC helping with the selection process. These reviews will be conducted by teams trained in Cochrane methods and will use Cochrane software to prepare these reviews.
Without free access to The Cochrane Library, these contributions to global evidence from India will decline considerably.
8. Inspiring initiatives to facilitate the practice of evidence-based medicine in India
The Cochrane Student’s Journal Clubis a student-led online journal club, launched by students in India and endorsed by The Cochrane Collaboration. It uses clinical scenarios to help students frame answerable research questions, and guides them in finding and interpreting evidence from a relevant Cochrane Review in order to help students understand the steps of evidence-based medicine (EBM).
Many leading institutions have training programmes for undergraduate and post-graduate students to ensure that tomorrow’s doctors will be better equipped to ensure the practice of EBM in India.
The International Society for Evidence-Based Health Care (ISEHC) held their inaugural conference at Delhi recently with the mission of developing, and encouraging research in, the appropriate usage of evidence in healthcare decision making and to promote and provide professional and public education in the field. The Indian Chapter of the ISEHC was also established to ensure better practice of EBM in India. These initiatives will complement that work of The Cochrane Collaboration in India and elsewhere.
None of these initiatives will succeed without the cornerstone of evidence-informed health care- reliable evidence from Cochrane Reviews.
Investing in a national provision to The Cochrane Library: the bottom line - value for money
The special introductory price that was brokered by the SASIANCC, and facilitated by well-wishers in The Cochrane Collaboration, and the World Health Organization, with John Wiley, the publishers in 2007, and the ICMR, was considerably lower than the astronomical initial asking price that was based on the formula used for other national provisions, where every head of the population is charged 10 to 15 US$ for national access. A realistic re-assessment of those among the over 1 billion Indians with sufficient literacy in English who also had regular access to the internet and were likely to access The Cochrane Library, reduced the pool of potential users of The Cochrane Library to around 60 to 100 million people. The introductory price was reflective of this reduced pool of potential users. The price for renewals follows the same principle, with marginal increases to account for inflation. Considering the number of full-text downloads in 2012 and the cost to India for the national license for 2012, the cost of each download works out to less than one US$. The cost of accessing an article in the Cochrane Database of Systematic Reviewscurrently is 35 US$.
The many instances detailed herein indicate that renewing the national license will provide richer dividends than can be evaluated by the usage statistics; or the cost per download; or impact factors - of which the CDSR has one of the fastest growing among medical journals.
The true impact lies in the lives saved through the use of effective treatments and the withholding of ineffective or harmful treatments.
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.
What do you think?
Declaration of Interest: I am the Director of The South Asian Cochrane Network & Centre (SASIANCC). Without free national access to The Cochrane Library, the SASIANCC will find its work largely irrelevant to the people of India. We are committed to finding ways to ensure nation-wide access in India continues.