Digital technologies and data offer unprecedented opportunities to tackle health system challenges, to enhance the quality and coverage of health services, and to empower individuals to better manage their own health. However, without concerted efforts and strong political leadership, the digital transformation of health systems and the accelerated use of digital technologies could increase health inequities and undermine the ‘leave no one behind’ agenda. Building on a session held at the Global Digital Health Forum (GDHF) in 2019, Transform Health convened a panel of thought-leaders at the 2020 GDHF for a lively discussion on the conditions that need to be in place for digital technology and data to support universal health coverage (UHC) by 2030. The session was moderated by Richard Dzikunu from Young Experts: Tech 4 Health and featured three panelists, each bringing a unique perspective to the topic:
Opening the session, Richard Dzikunu tested the pulse of the audience by asking whether they thought that digital technologies and data can help or hinder UHC. Just under half of the audience (42%) said that they can help. The remaining 58% said that it depends.
 

DIGITAL DIMENSIONS OF UHC

 
Dykki Settle opened the session by unpacking the digital dimensions of UHC. He explained how digital technologies can help to expand UHC along the three dimensions of population coverage, service coverage and cost coverage. To give just some examples: data analytics can help policymakers better understand who is not being covered by health services or who is receiving poor quality care; digital technologies can be used to increase the quality of existing services and introduce new capabilities; and digitalisation can improve management of financial resources, and make healthcare more affordable.
 
Noting that in many countries, only a small proportion of the total population is effectively covered by health services, Dykki questioned whether UHC can be achieved by 2030 without digital technologies and capabilities. To realise the potential of digital health, however, countries need to remove digital inequities and close the digital divide. Investments in ICT infrastructure are a necessary foundation for digital health.
 

BARRIERS TO DIGITAL HEALTH BENEFITTING ALL

 
Jess Morley offered a more skeptical perspective on the potential of digital health technologies and data to benefit everyone equally. She outlined three main concerns. Firstly, that digital tools are being used as an excuse to shift responsibility away from the healthcare sector to the individual without ensuring that people have a good understanding of how digital health apps work, for example, and the baselines they are being measured against. She argued that the primary use of digital tools should not be for empowering the person, but rather for enabling the group and getting a better understanding of public health and population health.
Her second concern was that there is insufficient safety testing of digital tools launched directly to consumers. Whilst formal medical products must undergo rigorous testing, the same measures are not required for digital health interventions, particularly those tools that are categorised as supporting wellness.
Finally, Jess raised a concern that digital tools may increase people’s access to health information but the tools alone are insufficient for people. Varying socio-economic circumstances and levels of eHealth literacy affect an individual’s understanding of health information, their ability to distinguish reliable information, and their power to act on it.
 

DATA AND DATA USE NEEDS TO BE MORE REPRESENTATIVE

 
Dr Carlos Acosta echoed concerns raised by Jess about who is designing digital tools for who. He argued that not enough is being done by the digital health community to ensure that no one is left behind. The data that drives digital health technologies is rarely reflective of the full population. For example, there is often little consideration of marginalised and minority groups’ experiences of using a digital tool in the development process, or of the potential repercussions of using it.
Carlos also highlighted that analysis and interpretation of health data – and health-related data – often reinforces social constructs and biases which can result in discriminatory decisions. He gave examples of ways that AI and data collection practices can undermine privacy, expose vulnerable people to harm, and be used to discriminate and even persecute social minorities. Developers of data-driven technologies, he argued, must proactively include social minorities in the design of algorithms and digital tools. Carlos’ urged people to be skeptical about data and to always question the purpose of any data collection exercises and how data will be used.
 

CHANGING DYNAMICS BETWEEN DIGITAL AND HEALTHCARE

 
All panelists agreed that digital technologies and data are tools that can reduce or increase health inequities depending on how they are used. Digital solutions are not necessarily the answer to all health problems, and finding the optimal combination of digital and non-digital approaches is something that requires further exploration by the UHC community.
 
Dykki encouraged the audience not to think about digital health but health in the digital age. He noted that 2020 and the COVID-19 pandemic had created a tremendous shift in the dynamics between digital technologies and healthcare. For the first time, we are seeing a bi-directional relationship between the two: digital continues to drive transformations in health, and the response to health challenges is also accelerating transformations in the digital sphere.
 

STRONGER GOVERNANCE NEEDED

 
The extent to which digital technologies and data can support UHC, the panelists agreed, depends very much on how they are governed. The current policy and governing environment around digital health technologies and data doesn’t enable everyone to benefit equally. Furthermore, regulation and governance of digital health remains reactive rather than proactive because of the speed at which technology is moving.
Challenges to effective governance include clarifying the mandate and responsibilities of governments to govern elements of digital health that fall outside of formal health systems, such as technologies that are deployed under the wellness sector. Another challenge is governing the informational space – or infosphere – which can benefit and harm both physical and mental health.
A key message to policymakers, echoed by all the panelists, was that greater attention must be given to governance of digital health – the guardrails and the enabling environment – that can help us mitigate the risks and maximise the benefits of digital technologies and data for all. Stronger governance frameworks must be developed to ensure that approaches to digital health support UHC. In closing, Richard stated that we have a long way to go to ensure that digital technologies and data support empowered communities and create equitable access to affordable and high quality healthcare for everyone. He encouraged everyone to embrace digital health technologies and data and to work together to establish stronger and inclusive mechanisms for accountability and oversight. UHC is achievable by 2030 but only if we all collaborate to ensure no one is left behind.