Peoples-uni (http://peoples-uni.org) strongly supports the proposed action to improve access to health information for all. As providers of low-cost online education for Public Health capacity building for health professionals in low income settings, we would make the point that in order to turn information into action, an educational component is required. Peoples-uni stands ready to help support the goal expressed by Smith and Koehlmoos, as I am sure will other educational initiatives and organisations.

Dear Editor

We welcome Smith and Koehlmoos's call for a major funding agency to support HIFA2015 (Healthcare Information For All by 2015; www.hifa2015.org). [1] In 2006, when HIFA2015 was launched, Dr Tikki Pang of the World Health Organization said "HIFA2015 is an ambitious goal, but it can be achieved if all stakeholders work together". [2] The full range of stakeholders - from the World Health Organization in Geneva to grassroots organisations in Uganda - are indeed now working together. What is needed now is for a single major funding agency to commit to the HIFA2015 goal - to commit to a world where the availability and use of basic healthcare knowledge are no longer a major contributing factor to avoidable death and suffering.

Smith and Koehlmoos focus on the modest financial needs of HIFA2015 itself. HIFA2015 needs funding to expand from its current staffing level of one person. We shall then be able to build on what we have achieved (bringing together over 5000 providers and users of health information globally, nationally and across different languages), and develop the second and third components of our strategy: a specialised knowledge base of information needs and how to meet them, and an advocacy programme to raise awareness of the importance of healthcare information and the need for increased political and financial commitment to support the diverse efforts of health information services and projects worldwide.

In 1993 the late James Grant, former Executive Director of UNICEF, said: "The single biggest piece of unfinished business of the 20th century is to extend the basic benefits of modern science and medicine... The most urgent task before us is to get medical and health knowledge to those most in need of that knowledge. Of the approximately 50 million people who were dying each year in the late 1980s, fully two thirds could have been saved through the application of that knowledge." [3] Since then, as Smith and Koehlmoos point out, there has been 'little progress in meeting the information needs of frontline healthcare providers and ordinary citizens'. A recent literature review by us, with a focus on Africa, confirmed 'a gross lack of knowledge about the basics of how to diagnose and manage common diseases, going right across the health workforce and often associated with suboptimal, ineffective and dangerous health care practices'. [4] This is not due to the health workers themselves. It is due to lack of financial and political commitment to address their information and learning needs. The unfinished business of the 20th century has carried forward to the 21st, largely unaddressed. 'It is unlikely that this ambitious goal [HIFA2015] will be achieved', say Smith & Koehlmoos. If it is not achieved, it will be, again, because of lack of financial and political commitment.

Similar calls have been made repeatedly since 1993, including that in 2006 by the international health leaders Pang, Gray and Evans: "The Gates Foundation identified fourteen challenges but a fifteenth challenge stares us plainly in the face: The 15th challenge is to ensure that everyone in the world can have access to clean, clear, knowledge - a basic human right, and a public health need as important as access to clean, clear, water, and much more easily achievable." The authors emphasise that access to healthcare knowledge is 'critical for achieving the Millennium Development Goals'. [5]

We call on funding agencies and governments to commit to the goal of healthcare information for all by 2015.

Neil Pakenham-Walsh (Global Healthcare Information Network & Coordinator, HIFA2015) and Frederick Bukachi (Senior Lecturer, University of Nairobi Medical School, Kenya)

On behalf of the HIFA2015 Steering Group [6]

1. Smith R & Koehlmoos T P. Provision of health information for all. BMJ 2011;342:doi:10.1136/bmj.d4151 (Editorial, Published online 30 June 2011) http://www.bmj.com/content/342/bmj.d4151.full?sid=5748dbb0-459d-4f56-81cc- 91568fac317e

2. http://www.hifa2015.org/resources/letter-of-support/

3. Grant J. Opening Session, World Summit on Medical Education, Edinburgh 1993. Medical Education 1994; 28 (supplement 1): 11.

4. Pakenham-Walsh N & Bukachi F. Information needs of health care workers in developing countries: a literature review with a focus on Africa. Human Resources for Health 2009, 7:30doi:10.1186/1478-4491-7-30 http://www.human-resources-health.com/content/7/1/30

5. Tikki Pang (WHO), Muir Gray (NHS, UK), and Tim Evans (WHO): A 15th grand challenge for global public health. The Lancet 2006; 367:284-286. http://www.thelancet.com/journals/lancet/article/PIIS0140673606680501/fu...

6. http://www.hifa2015.org/about/administration/

Dear Editor,

This editorial and added comments confirm the view taken by such organisations as EIFL and the Electronic Publishing Trust for Development (EPT) 'that knowledge starvation has an adverse effect on mortality and ill health in resource-poor settings'. It is true that it is difficult to put figures on the impact on health of lack of access to knowledge, but new assessment tools are under development and will perhaps provide the figures that would prove the point. While we wait for these developments, HIFA2015 has made an enormous contribution towards raising awareness about the need for information in parallel with the need for medical treatment.

Such initiatives are at the forefront of the drive towards open access to all publicly funded research - the starting block for the development of effective treatments at the front line.

The following articles consider this issue and may be of interest:

"Excluding the poor from accessing biomedical literature: A rights violation that impedes global health", http://www.hhrjournal.org/index.php/hhr/article/view/20/88;

"The chain of communication in health science: from researcher to health worker through open access", Open Medicine 2009; 3(3):111-119, http://www.openmedicine.ca/article/view/298/245

Leslie Chan, Barbara Kirsop, Subbiah Arunachalam,
Trustees of the EPT

Language is a key issue in access for information. Speakers of a dominant language like English - including most of the highly educated professionals in developing countries - can too easily overlook the fact that the people who most need healthcare information are not likely to have a good understanding of English (nor of French, Spanish, or Portuguese).

Language is a significant obstacle to comprehension, whether we're talking about training community healthcare workers with varying levels of educational achievement, or simply delivering information to the end consumers - frequently people in rural communities.

Ironically, people with scant knowledge of English tend to be those who need access to information the most. If we take just Africa alone, with 25% of the world's disease burden and only 2-3% of its doctors and nurses, well informed healthcare workers are critical. However, if neither the people themselves, nor the village healthcare workers meant to help them, have strong English skills, the information they have access to will be understood imperfectly, or not at all. And the whole information access chain breaks down.