How digital technology can create unhealthy inequalities

Digital health programmes may involve the collection of huge amounts of personal data, and because it passes through so many channels this can create major privacy risks along with the temptation to sell the data.

Advances in medical care delivery are often least accessible to the poor and uneducated, say Asha George, Amnesty LeFevre, and Rajani Ved

DIGITAL technology is revolutionising our lives. Mobile devices monitor our movements, marketing algorithms guide our consumption, and social media shape our worldviews and politics.

The risks include an increase in societal inequalities, particularly in global health.

Sustaining and scaling digital health innovations is hardly easy. Of the more than 600 pilot mobile-health initiatives of the last decade, few reached delivery at scale, and even fewer were sustained.

Nonetheless, some high-profile digital health initiatives — such as MomConnect, in South Africa, and Mobile Academy, TeCHO+, and ANMOL, in India — shifted, at least partly, from donor to government funding.

This change is part of a wave of enthusiasm for new technologies’ potential to improve health systems and, in turn, health.

It reflects key opportunities to shape the digital health sector in ways that benefit all of society.

To be sure, steps are being taken to position health-related digital technologies as a force for good. The World Health Organisation (WHO) has announced the creation of a Department of Digital Health, along with guidelines on digital health interventions.

And some initiatives that have already been rolled out globally hold significant promise. For example, the governments of Ghana, South Africa, and Tanzania are taking advantage of near-ubiquitous mobile-phone access to deliver health information to patients who have limited interactions with healthcare providers.

Initiatives focused on equipping healthcare providers with digital tools — in India, for example — are enabling them to eliminate cumbersome paper-based records and to improve the clinical content of service delivery (with decision-support algorithms, videos, and other content that may enhance patient-provider interactions).

Efforts are also under way to use blockchain technology to track funding flows and facilitate the timely payment of frontline health workers.

But there is no guarantee that digital innovations will bring shared benefits. That is why, before moving forward with any new digital tool, it is vital to consider who it will reach, the motivations of the parties involved in its development and deployment, and the implications and opportunity costs for users and health systems alike.

Start with reach. If a product requires a high level of digital literacy, it might be inaccessible to people who already lack education or healthcare; as a result, adopting it would exacerbate and entrench inequalities.

To optimise the design, reach, and effectiveness of digital-health programmes, user capabilities and technology requirements must be aligned. Innovation should be accompanied by humility about the limits of technology and the need to strengthen health systems to ensure that they serve all members of society.

Then, there are the questions of who is designing and delivering health innovations and who is accountable for them. In the past, innovation entailed collaborations between governments, donors, NGOs, and research organisations. In the digital age, new actors — such as mobile network operators and technology companies — have joined this process, each one with its own language, agenda, and incentives.

Without mediation, this can distort power dynamics, with some initiatives becoming “too big to fail” and governments struggling to exercise oversight.

The broader potential effects on users must also be debated. Consider the data-privacy question. Digital health programmes may involve the collection of huge amounts of personal data.

As that information is collected, it passes through an array of channels, making it increasingly difficult to de-identify. This can create major privacy risks, compounded by the temptation to commodify and sell patient data.

While this might seem like a simple way to generate more revenue for health programmes, the sale of private data runs counter to building trust.

Fortunately, some governments recognise this, and efforts are underway to mitigate data-privacy risks. The EU has led the way, with its General Data Protection Regulation. A number of low and middle-income countries are now following its example.

But regulating existing activities is only the first step. Given the impossibility of anticipating all the ways in which data might be used in the future, robust governance structures that promote transparency and accountability must be established.

Otherwise, digital innovation could quickly turn into a sort of “Wild West”, a lawless environment in which people are at the mercy of whatever powerful new innovator comes to town.

Next year’s Sixth Global Symposium on Health Systems Research will focus on the nexus between government stewardship, innovation, and accountability. Only with a clear-eyed assessment of a new technology — including who is responsible for it and who could be left behind if it is deployed — can we ensure that the digital revolution delivers on its promise to improve global health.

Asha George is chair of Health Systems Global and a professor at the School of Public Health, University of the Western Cape, South Africa. Amnesty LeFevre is an associate professor at the School of Public Health and Family Medicine at the University of Cape Town. Rajani Ved is director of India’s National Health Systems Resource Centre. Copyright: Project Syndicate, 2019

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