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      Article processing charges are stalling the progress of African researchers: a call for urgent reforms

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          Introduction The recognition and progression of an academic or research career is hinged on the number and quality of publications in high-impact journals. Open access publication, especially in high-impact journals, confers a significant citation (ie, recognition and progression) advantage.1 However, there is increasing demand for publication fees or article processing charges (APCs), by high-impact open access journals. Where does this leave African researchers who earn too little (personal income or research grants) to publish in such top-tier open access journals? Already, Africa contributes much too little (1.3% in one estimate) to research publication output globally,2 of which 52% are accounted for by just three middle-income countries—South Africa, Nigeria and Kenya. The local and global challenges that limit the publication and citation potential of African researchers are well known. For example, at the local level, there are very few full-time researchers (5 per million people in low-income countries vs 363 per million people in high-income countries),3 with weak investment in research (and academic writing) capacity,4 research infrastructure and research governance.5 And at the global level, there are exploitative international research collaborations, gender constraints affecting female researchers6 and inability to attract global research funding. Now, APCs are systematically excluding African researchers from publishing in high-impact open access journals. Researchers in Africa are typically not in a position to win or have access to grants that cover APCs as eligible research expenditure. A 2018 analysis showed that countries of the WHO African region received only 0.65% of global research grants.3 This is not peculiar to Africa—for example, in Pakistan, only 2% of researchers had received more than two research grants 15 years after doctoral training.7 In 2008, WHO African region adopted the Algiers Declaration—to invest 2% of member countries’ national health budget in health research. But an assessment in 2014 showed that only 2 out of 39 countries met that commitment.5 Local research grant initiatives have been hard to sustain.8 And so, researchers are left ‘hanging in there’ through self-sponsored studies, or riding on international collaborations often driven by the interest of funders—which may be exploitative,9 or have limited local relevance.10 In this editorial, based on our collective and diverse experiences as African researchers, editors and funders, we highlight the plight of fellow African researchers whose desire to contribute to global knowledge, progress their careers and gain recognition for their work is hampered by deterring APCs in the face of meagre resources. In addition, to address this pressing challenge, we offer and call for urgent reforms by governments, local and international funders and donors, and the scientific publishing industry. Open access as a solution and a problem The traditional model of high-impact journals has not been open access—individuals pay directly to access an article or gain access through institutional subscription. But these tend to be unaffordable for individuals and institutions in low- and middle-income countries. To address the persistent problem of limited access to scientific publications, the Hinari Access to Research for Health programme was set up by WHO together with major publishers. The Hinari programme enables researchers in low- and middle-income countries to gain free access to one of the world’s largest collection of biomedical and health literature. However, this provision excludes countries with a gross national product per capita of US$1500.11 In part, open access publishing emerged as a solution to this problem, with journals requiring that authors pay APCs to publish their papers. However, the value of open access publishing (ie, facilitating free access and inclusion in the dissemination and use of scientific research) exists in tension with its financing model (ie, publishers may need to ‘raise publishing fees well beyond the level that scientists are willing [and able] to pay’).12 Journals considered to charge lower than industry rates, charge average APC between US$1350 and US$2250, premium journals charge up to $3900,13 14 and some charge even more for research papers—for example, £3000 in BMJ Global Health and US$5000 in Lancet Global Health. In some cases, partial or full waivers are granted to researchers from low- and middle-income countries, thus helping to improve the meagre research output from Africa. However, researchers in Africa are often so poorly supported that they are unable to afford partial waivers or discounted APCs when granted. Very often, they are not eligible for waivers, because they are based in a country with high enough per capita income, even though such high per capita income may not reflect in the extent to which the country’s government supports researchers. In other instances, researchers from low- and middle-income countries may be ineligible for waivers because they have a named high-income country coauthor on their manuscript, even when they have received little or no financial support through such a coauthor, thus constituting a potential disincentive for collaboration. In many other instances, the waiver process is not transparent. Publication fees versus salaries Fee waiver decisions are typically based on measures of per capita income of the country in which (all) the authors are based. Without access to research grants that cover publication charges, African researchers are often left with no option but to pay out of pocket to cover APCs. This is a cause for concern. Low salaries in African universities is a major reason why researchers leave academia for consultancy or migrate to high-income countries.15 16 Even top earning academics in Africa (ie, in South Africa) earn an average of 53% (range: 45%–60%) of what their counterparts earn in high-income countries like the USA—and are much worse off when compared with Australia, Hong Kong and Singapore.17 To illustrate the gravity of this issue, we use income data of top medical consultants or specialists (some of whom double as researchers) in nine African countries as a marker of earnings of health researchers (table 1). They earn US$449–US$5987 per month, depending on the income status of their country and the priority their country gives to their income. If a journal levies APC of about US$2600 per article (as is common), researchers in some countries may have to give up nearly 6 months of their entire earnings (before tax) to finance one publication—and even when 50% waiver is granted as done in some cases, between 1 and 3 months’ income has to be forgone per publication. In such instances, anything short of a full waiver is inappropriate. Table 1 Average income of medical specialists/consultants in selected countries (before tax) No Country Average annual income (US$) Average monthly income (US$) Source 1 Ethiopia 5391 449 HLMA, 2020 2 Botswana 68 601 5717 SADC, 2019 3 Eswatini 31 959 2663 SADC, 2019 4 Ghana 29 821 2485 Estimated 5 Kenya 49 800 4150 HRH strategy, 2019 6 Namibia 71 841 5987 HLMA, 2019 7 Seychelles 63 303 5275 NHWA, 2020 8 Sierra Leone 28 720 2393 HLMA, 2019 9 Zambia 26 450 2204 NHWA, 2019 Mean 41 765 3480   Lowest 5391 449   Highest 71 841 5987   HLMA, health labour market analysis; HRH, human resource for health; NHWA, national health workforce account; SADC, Southern Africa Development Community. The constraint posed by publication fees limits the volume of publications by African researchers, especially in high-impact open access journals. They may choose to publish in obscure journals that are not accessible in frequently searched electronic databases; they may fall prey to predatory journals who bait researchers with significantly lower publishing fees; or they may not publish at all, or publish only infrequently.18 While national income status is a predictor of publication outputs,2 it is only a partial determinant of the ability of individual researchers to pay APCs. There is the additional factor of the extent to which a country supports researchers (with their salary as a proxy). Both factors do not always align. A call for urgent reforms Even though unmatched with commensurate investment, adopted resolutions and declarations dating back two decades19–24 testify to the broad agreement that research is important for health and development in Africa. Why invest so little and so inequitably? Constraints on the ability of African researchers to publish in high-impact journals are dire and go beyond APCs, but APCs are an increasingly serious, stalling constraint. Where do African researchers turn for a solution? To their governments, to the scientific publishing industry, or to local and international donors and funders? What reforms are necessary to support African researchers? We offer three sets of urgent and necessary reforms. First, to provide fair and equitable opportunity for researchers in Africa (but also more broadly for researchers across many low- and middle-income countries), the stifling effect of APCs on publications must now be considered a crisis. Governments, funders and donors need to play their part by investing in health research, and supporting researchers with grants, and remunerating them as appropriate. Governments, funders, and donors should also strengthen research governance and foster mutually beneficial partnerships in collaborative research—for example, international research grants should come with funds to cover APCs, and provide capacity building and mentorship support for participating African researchers to publish their work in high-impact open access journals as lead authors. Second, the fee, discount and waiver policies of open access scientific publishers need to incorporate considerations of capacity to pay. It is not fair to impose flat fees, or discount and waiver conditions. The profit margin in the scientific publishing industry is estimated at 20%–30%, so there is much room to make concessions for African researchers.14 Policies that limit the participation of African researchers in the global academic discourse are inconsistent with the mission of academic (and especially global health) journals. In addition, the ‘public’ has a major stake in scholarly publishing. Much of the costs of peer review (a major contributor to the costs of scientific publishing) are covered by researchers, essentially at ‘public’ expense. Hence, the rationale for fees, discounts and waivers should be more transparent, and should take into consideration salaries earned by researchers and their ease of accessing grants. Third, there is a need to diversify the range of high-impact open access journals available to African researchers, as an essential pillar of ongoing efforts to decolonise academia (and global health).25 There is now no reason why African journals should not be archived in frequently searched electronic databases. Like journals based in London, Boston or Geneva, African journals should aspire to be high-impact open access journals that have a global reach, with fees, discount and waiver policies set with African researchers at the centre of consideration. Building such African academic publishing infrastructure will require concerted efforts led by African researchers, in partnership with colleagues all over the world, and supported by the scientific publishing industry, by African governments and by local and international funders and donors.

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          Decolonising global health: if not now, when?

          Summary box The current global health ecosystem is ill equipped to address structural violence as a determinant of health. Histories of slavery, redlining, environmental racism and the predatory nature of capitalism underpin the design of global and public health systems, resulting in structural, racial and ethnic inequities within Black, Indigenous and People of Color (BIPOC) communities globally. While the manifestation of inequity in individual countries or regions is bound up in the local-to-global interface of historical, economical, social and political forces, COVID-19 disproportionately affects BIPOC and other marginalised communities. Aside from direct health impacts on marginalised communities, exclusionary colonialist patterns that centre Euro-Western knowledge systems have also shaped the language and response to the pandemic—which, in turn, can have adverse health outcomes. Decolonising global health advances an agenda of repoliticising and rehistoricising health through a paradigm shift, a leadership shift and a knowledge shift. While the global response to COVID-19 has so far reinforced injustices, the coming months present a window of opportunity to transform global health. Introduction The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak has grinded the world economy to a halt and upended health systems across the globe, contributing to disruptions in routine health services and skyrocketing rates of death.1 Against this backdrop, the pandemic highlights with renewed clarity the way structural violence operates both within and between countries. Defined as the discriminatory social arrangement that, when encoded into laws, policies and norms, unduly privileges some social groups while harming others, this concept broadens our thinking about drivers of disease.2 While the manifestation of inequity in each country or region is bound up in the local-to-global interface of historical, economical, social and political forces, COVID-19 disproportionately affects the world’s marginalised, from Black, Indigenous and People of Color (BIPOC) communities in North America to migrant workers in Singapore.3 Health outcomes related to SARS-CoV-2 infection such as access to emergency services and prolonged intensive care, capacity to prevent infection through non-medical countermeasures like handwashing and social distancing, and economic security while in lockdown are all mediated by the confluence of global, regional and local systems of oppression. This reality shows that the current global health ecosystem is ill equipped to address structural violence as a determinant of health, and the system itself upholds the supremacy of the white saviour. As early career global health practitioners, we see this pandemic as an opportunity to critically appraise what is not working and to offer an alternative vision for the future of global health. Global health needs integrated, decolonised approaches—advanced by individuals and institutions—that address the complex interdependence between histories of imperialism with health, economic development, governance and human rights. The global movement to Decolonize Global Health, led by students and other professionals, is one step towards this vision.4–8 In this commentary, we draw on examples that show how the most vulnerable and marginalised in society are ignored and exploited by design and in context-specific ways in the pandemic response. Through these examples, we call for a threefold shift in global health research, policy and practice. Structural determinants of health for the marginalised majority The disadvantaged and marginalised make up the global majority. This ‘marginalized majority’ is strategically divided and disempowered by deep-seated racial, ethnic and financial inequities that fuel structural determinants of health. These kinds of power imbalances are by design and are by no means unique to the field of global health, yet health is often the locus of where many of these inequities intersect. Globally, histories of slavery, redlining, environmental racism and the predatory nature of capitalism underpin the design of global and public health systems, resulting in structural, racial and ethnic inequities within BIPOC communities. This pandemic widens these pre-existing inequities even further. Black and Brown people make up a significant portion of the essential workforce in many settler colonial states.9 10 Yet, they are often underpaid, underinsured and more likely to live in overcrowded, polluted and food insecure conditions that further increase their risk. Consequently, these communities have faced disproportionate rates of severe outcomes and deaths due to COVID-19.11 Without acknowledging these oppressive forces, the pandemic response will lack context-specific and targeted policies to address the structural racism that enforces these health disparities. For example, Singapore’s treatment of migrant workers illustrates how ignoring structural determinants of health has disastrous consequences for both those marginalised and the broader society. Singapore’s 1.4 million migrant workers from India, Bangladesh, China and other nearby countries encompass one-third of the country’s workforce. They leave their home countries for a better chance to sustain their families, break cycles of poverty and escape archaic forms of social hierarchies like the caste system. Despite playing a pivotal role in Singapore’s development, migrant workers live in the margins of society, often cramped in dorms with 10–20 people to a room. This marginalisation led to Singapore ignoring them in its pandemic response. Initially credited as exemplary, Singapore’s success has been reversed with a current infection rate of 1000 new cases per day, attributed to a spike in infections among migrant workers. Migrant workers are touted as ‘the invisible backbone’ of Singapore, yet SARS-CoV-2 has lifted the smokescreen to reveal how little these workers are actually valued, resulting in Singapore’s failure to protect them from the virus and to protect the entire nation from a resurgence in cases.12 The impact of SARS-CoV-2 on Indigenous peoples in the USA is another potent example of how structural violence prevents equal access to health and appropriate medical care, and leads to disproportionate suffering and premature death. The systematic destruction and dispossession of Indigenous communities through violent colonial practices in the USA has left communities like the Navajo, which has among the highest infection rates in the country,13 with poor access to healthcare and a higher prevalence of comorbidities that increase their risk of contracting and dying from COVID-19. Furthermore, contemporary policies governing ethnic and racial categories in health reporting—in which Indigenous communities are often categorised as ‘other’14—skew their official death rate from COVID-19 and result in the continued erasure of these communities. Not properly accounting racial and ethnic minorities in these totals ignores the severity of the pandemic’s impact on these communities and erases the historical injustices that put them at greater risk in the first place. Colonialist patterns shape the language and response to the pandemic Aside from direct health impacts on marginalised communities, colonialist patterns that centre Euro-Western knowledge systems have also shaped the language and response to the pandemic—which, in turn, can have adverse health outcomes. The occupiers of the highest tiers of the social hierarchy have long used scapegoating in times of crisis to divert attention from root causes of the crisis at hand. During the Black Death, Jewish communities were systematically targeted; during the AIDS pandemic, men who have sex with men and others in the lesbian, gay, bisexual, transgender and queer community were ostracised; and now, in 2020 with the outbreak of SARS-CoV-2, we see a repeat of history.15 With labelling such as the ‘Wuhan Virus’ or the ‘Chinese Virus’, Chinese and other East Asian populations worldwide are being scapegoated and facing discrimination. Another way COVID-19 has further been racialised to uphold colonialist beliefs is seen with international news headlines such as ‘Why don’t Africans have the disease?’ This attitude reveals an assumption that countries described as the ‘Global South’ could not be doing better than the so-called ‘Global North’.16 As another example, French scientists suggested that Africa be the testing grounds for SARS-CoV-2 vaccine trials, invoking imperialist and colonialist ideologies that ‘some lives were more valuable than others.’ How, in March 2020 when this statement was made, could anyone practising global health deem it appropriate to use Black and Brown communities as ‘guinea pigs’ to promote the health of white, colonialist counterparts?17 The answer lies in the persistence of racist patterns that have yet to be fully dismantled. Numerous success stories emerging from the ‘Global South’ counter this false narrative of Eurocentric superiority. Kerala, for example, a southwestern state in India, implemented highly coordinated state-wide lockdowns and test-and-trace strategies to effectively contain and control the virus.18 Among all the negative media coverage of India so far, however, this narrative of success is rarely highlighted or acknowledged. Likewise, in Africa, Senegal has become a leader in their pandemic response strategies, which include innovative technologies to reach entire populations with affordable tests for the virus. International coverage of the continent, however, instead has focused on the assumed inevitable failure of African nations to effectively respond to the pandemic, failures which are often caused by limited resources resulting from colonialism and modern-day imperialism. This representation is obviously biased, and is so because those with power to control the narrative around the pandemic continue to be disproportionately not from or based in the ‘Global South’.19 20 This imbalance, driven by what WHO Director General Tedros Adhanom Ghebreyesus termed a ‘colonial hangover’, also plays out in what gets recommended as a good pandemic response strategy.21 Global health institutions based in the ‘Global North’, often lacking representation of key communities at the decision-making table, end up perpetuating a Eurocentric worldview that does not adequately consider most of the world’s needs. The notion of simply ‘copy-pasting’ strategies like lockdowns and social distancing measures does not work in spaces like cramped migrant worker dormitories, refugee camps, urban slums or anywhere else the poorest and most marginalised are forced to reside. How can a family of 15 lock down in a slum complex that houses 700 000 others? How can you practise good hygiene such as handwashing when water itself can be a scarce commodity? When the people in power represent only those with social dominance, the health needs of the marginalised majority inevitably get overlooked. In the wake of the pandemic, these colonial trends that we see time and time again must be reversed. A decolonising agenda for health equity, beginning with COVID-19 To uproot these sources of health inequity, all practitioners and researchers should leverage the disruptions caused by this pandemic to more critically reflect on their actions. More and more voices call for recognising and redressing these imbalances in global health.22–24 From activists to professors, non-governmental organisation leaders to clinicians, a decentralised alliance is building, demanding that global health practitioners meaningfully engage with global and local structures that drive health inequities. Within that coalition, the student-led decolonising global health movement serves an important but limited function: to help create space for critical, anticolonial reflection within large, influential and privileged institutions, agencies and organisations, so far often in high-income countries (HIC), that are responsible for driving global health discourse, ‘knowledge’ and funding flows.25 This movement advances an agenda of repoliticising and rehistoricising health. We believe that the movement broadly calls for the following: Paradigm shift: Repoliticise global health by grounding it in a health justice framework that acknowledges how colonialism, racism, sexism, capitalism and other harmful ‘-isms’ pose the largest threat to health equity. Without confronting the impact these interlocking systems have on health, global health activity, despite best intentions, remains complicit in the ill health of the world’s marginalised. A paradigm shift involves individuals and institutions acknowledging that disease cannot be extracted or isolated from broader systems of coloniality.26 27 Organisations and donors should adapt their missions, programming and structures to account for this reality. Fundamentally, this shift means changing who sits at the table and rebuilding parts of the table itself. Leadership shift: Leadership at global agenda-setting institutions does not reflect the diversity of people these institutions are intended to serve. First, the ‘Global North’ needs to ‘lean out’ on an individual, national and institutional level to stop reproducing racist and colonialist ideologies.28 Unsurprisingly, experiences from the ‘Global South’ show that it is a hotbed of innovation, and leaders in the ‘Global South’ must be recognised and elevated for their contributions. Second, gender disparities in global health leadership need to be addressed and remedied. In many global health institutions, women, especially women of colour, are under-represented and their voices are excluded in policy and programmatic formulation.29 30 A leadership shift would include more equitable representation in academic journals, leadership roles and faculty make-up, reflected, for example, in equitable first authorship positions for collaborators from the ‘Global South’ and women.31 32 Knowledge shift: To avoid perpetuating the kind of racist and colonialist pandemic response we see with COVID-19, it is vital to ensure knowledge flow is not unidirectional, but instead reciprocal with contributions from the ‘Global South’ driving discussions and practice, both locally and globally; a twofold knowledge shift.33 The first includes teaching students about inequitable global disease burdens while creating an enabling environment for critical inquiry into the racist and colonial histories that gave rise to these disease burdens. The second is to bridge geopolitical imbalances in global health education. For example, global health training programmes and knowledge resources are mostly offered in the English language, in HICs and at great cost, thus limiting access for people of other languages, and from less privileged backgrounds. To promote anticolonial thought by encouraging training and knowledge sharing without these obstacles, we need to change existing platforms and create new learning platforms for global health. Conclusion The pandemic response reveals with stark and sobering clarity that current paradigms of global health equity are insufficient in counteracting structural oppression. By focusing on individual risk factors and siloing funding based on disease, global health agendas—including pandemic responses—ignore how health risks are shaped structurally by laws, policies and norms, ranging from regional trade agreements and immigration policies to racial discrimination and gender-based violence. Structural inequities reproduced within the global health system itself—such as over-representation of affluent white men from HICs in global health leadership positions34—highlight the lack of critical engagement with the geopolitical determinants of health disparities. While the global response to COVID-19 has so far reinforced injustices, the coming months present a window of opportunity to transform global health. A student-led decolonising movement is one step. Now, the movement must expand in numbers and scope to create a more just and equitable future.
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            Open access: The true cost of science publishing.

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              Increasing the value of health research in the WHO African Region beyond 2015—reflecting on the past, celebrating the present and building the future: a bibliometric analysis

              Objective To assess the profile and determinants of health research productivity in Africa since the onset of the new millennium. Design Bibliometric analysis. Data collection and synthesis In November 2014, we searched PubMed for articles published between 2000 and 2014 from the WHO African Region, and obtained country-level indicators from World Bank data. We used Poisson regression to examine time trends in research publications and negative binomial regression to explore determinants of research publications. Results We identified 107 662 publications, with a median of 727 per country (range 25–31 757). Three countries (South Africa, Nigeria and Kenya) contributed 52% of the publications. The number of publications increased from 3623 in 2000 to 12 709 in 2014 (relative growth 251%). Similarly, the per cent share of worldwide research publications per year increased from 0.7% in 2000 to 1.3% in 2014. The trend analysis was also significant to confirm a continuous increase in health research publications from Africa, with productivity increasing by 10.3% per year (95% CIs +10.1% to +10.5%). The only independent predictor of publication outputs was national gross domestic product. For every one log US$ billion increase in gross domestic product, research publications rose by 105%: incidence rate ratio (IRR=2.05, 95% CI 1.39 to 3.04). The association of private health expenditure with publications was only marginally significant (IRR=1.86, 95% CI 1.00 to 3.47). Conclusions There has been a significant improvement in health research in the WHO African Region since 2000, with some individual countries already having strong research profiles. Countries of the region should implement the WHO Strategy on Research for Health: reinforcing the research culture (organisation); focusing research on key health challenges (priorities); strengthening national health research systems (capacity); encouraging good research practice (standards); and consolidating linkages between health research and action (translation).
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2020
                20 September 2020
                : 5
                : 9
                : e003650
                Affiliations
                [1 ]departmentUHC Life Course Cluster , World Health Organization Regional Office for Africa , Brazzaville, Congo
                [2 ]The European & Developing Countries Clinical Trials Partnership (EDCTP), Francie van Zijl Drive , Cape Town 7505, South Africa
                [3 ]departmentSchool of Public Health , University of Sydney , Sydney, New South Wales, Australia
                Author notes
                [Correspondence to ] Dr Juliet Nabyonga-Orem; nabyongaj@ 123456who.int
                Author information
                http://orcid.org/0000-0002-1061-8678
                http://orcid.org/0000-0003-0620-6010
                http://orcid.org/0000-0003-4727-7130
                http://orcid.org/0000-0003-1294-3850
                Article
                bmjgh-2020-003650
                10.1136/bmjgh-2020-003650
                7507337
                32958539
                2629b0a8-9a63-4d08-8da0-241d18786461
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 06 August 2020
                : 31 August 2020
                : 01 September 2020
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                Editorial
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                health policy,health services research,health systems

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