Letter: Can Tanzanian Neurosurgeons Access Tanzanian Neurosurgical Literature? A Systematic Review and Survey of Neurosurgical Publications

To the Editor: We commend Sabas et al1 for their important and timely work, “Can Tanzanian Neurosurgeons Access Tanzanian Neurosurgical Literature?”. Their systematic review and survey provide compelling evidence of a critical paradox: although neurosurgical research in Tanzania is growing rapidly, those most in need of access to this knowledge, Tanzanian neurosurgeons themselves face systemic barriers to accessing their own data.1 In this article, we reflect on how these findings extend beyond Tanzania and highlight the structural reforms needed to improve neurosurgical research access globally. Through a systematic review of 96 Tanzanian neurosurgical publications and a national survey of nearly all Tanzanian neurosurgeons, the authors offer a grounded analysis of access disparities. Notably, only 62% of articles were open-access at the publisher level, and almost 40% of respondents reported relying on Sci-Hub or informal networks. Even more concerning, just one had access to a local institutional library service.1 This underlines the importance of examining how structural barriers shape leadership and access in global neurosurgical research. Structural barriers to equitable research: These findings challenge the assumption that collaborations between low- and middle-income countries (LMICs) and high-income countries are inherently equitable.2 Although 77% of studies involved foreign institutions, Tanzanian researchers were listed as first or last authors in only approximately one-third of cases.1 When local researchers are not leading, they often have less influence over decisions such as journal selection, open-access fees, and dissemination strategies. The study found that articles led by Tanzanian authors were significantly more likely to be published as open access, suggesting that when local researchers guide the work, it is more likely to be shared in a way that benefits their own communities.1 We believe this article should catalyze action beyond Tanzania. In Uganda, where our team has conducted neurosurgical research, clinicians report similar challenges. These access gaps stem from both infrastructural limitations, including the lack of institutional email addresses, library systems, and digital infrastructure- and policy shortcomings, including minimal investment in research accessibility and the absence of national mandates for open-access publication.1,3 Sabas et al1 quantify a reality long experienced by clinicians in many LMICs. Moreover, their findings highlight the inadequacy of relying on HINARI and similar initiatives as a panacea.1 Although theoretically comprehensive, these platforms often fail in execution, as they require institutional enrollment, consistent credentialing, and stable digital infrastructure that may be lacking in LMIC institutions. Even in countries technically eligible for free access, neurosurgeons often lack the institutional support to enroll or maintain access. As the authors rightly observe, such gaps risk institutionalizing scientific inequity and perpetuating knowledge asymmetries.1 Redefining access and authorship: The broader lesson here is that open access must be decoupled from charity and redefined as an ethical imperative. Although article processing charge (APC) waivers exist for low-income countries, many middle- and even high-income countries with limited access to medical education, research infrastructure, and healthcare funding remain excluded.4 Expanding and refining APC waiver policies to account for structural disparities rather than relying solely on national income classification, is essential. Initiatives such as Plan S and Research4Life help but must be paired with long-term investment in local research infrastructure and autonomy. Journals should prioritize full APC waivers for LMIC-led research, especially when local investigators are listed as first or last authors, as part of a broader commitment to equitable participation in global academic publishing.1 At the same time, funders should go beyond mandating open access alone and require commitments to equitable authorship structures and meaningful dissemination within the countries being studied. Furthermore, research funders, especially those in high-income countries, must enforce open-access mandates for all global health research they support, with specific attention to equitable authorship and in-country dissemination. This study provides a replicable model for other low-resource regions to assess disparities in research access.1 We encourage similar evaluations across neurosurgical networks in Latin America, Southeast Asia, and Sub-Saharan Africa, to both expose persistent access gaps and support targeted, data-informed reform. If we believe in the principle that surgical systems must be locally led and contextually grounded, then we must ensure that the knowledge base informing those systems is fully accessible to those who live, work, and operate within them. Equity in access is essential to advancing global neurosurgery in a meaningful and sustainable way. Conclusion: In closing, Sabas et al1 have offered more than a valuable publication. They have issued a challenge to the global neurosurgical community to ensure that the knowledge informing surgical systems is accessible to those directly involved in care. Access to knowledge must be recognized as a foundational component of progress, not an optional ideal.