Digital technologies are often embraced as the solution to global challenges within health and development, but rampant commercialisation and weak regulation challenge the ideal of digital public goods capable of reducing inequalities.
Many express confidence that digital technologies available through mobile phone, tablets and computers will improve population health and contribute to reducing vast global health inequities. The World Health Organization’s Director General Dr. Tedros Adhanom Ghebreyesus recently proclaimed for instance that digital technologies are essential for achieving Universal Health Coverage. Consequently, the WHO is developing a new global digital health strategy to be considered at next year’s World Health Assembly.
Colossal investments are being made to develop apps capable of diagnosing, monitoring and facilitating treatment of a range of conditions; digital financial services for the payment of health insurance and direct healthcare costs; or algorithms and artificial intelligence tools drawing on ‘big data’ to improve health care.
This enthusiasm for digital health solutions reflects the broader technological optimism that has long characterised the global health field, founded in the belief that market-based solutions and innovation-driven development will produce cost-effective solutions to solve the world’s problems.
At the recent Tek4HealthEquity conference (1-2 Nov) organized by the Independent Panel on Global Governance for Health at the New School in New York City, we discussed the conditions upon which technologies might serve health equity. Presentations highlighted that discriminatory design, high costs and weak regulations are just some of the challenges to the idea of digital public goods capable of reducing global and national-level inequities in health.
Discrimination by design?
The conference’s starting point was that digital technology is not neutral, but is developed and deployed in specific social and political contexts, and is therefore susceptible to built-in biases, which can become embedded in the technology itself. A study recently published in Science revealed that an algorithm used by American hospitals and insurance companies to enable treatment that is more efficient systematically discriminates against black patients.
At the conference, UN special rapporteur on human rights, Philip Alston, argued that the rise of «the digital welfare state» not only enables commercial actors to digitally surveille populations, but also involves in-built mechanisms for perpetuating discrimination, for example in individual access to welfare payments.
Medical anthropologist Nora Kenworthy, studying the explosive growth of medical crowdfunding globally, noted how profit-driven digital platforms like GoFundMe provide “the world’s least effective but most profitable social safety net “, while reflecting and reinforcing inequities by favouring “deserving” patients (vulnerable groups who often suffer from complex, chronic conditions rarely succeed at raising sufficient funds).
The notion of digital public goods is also challenged by the high costs associated with digital innovation, whether for individual users or for societies. Sociologist Marine Al Dahdah showed that while commercial actors often reap heavy rewards, the solutions are not necessarily cost-effective for public authorities, nor do they always have proven health benefits. As such, technologies may present high opportunity costs when prioritised over public investment in less costly (and more efficient) interventions addressing the social determinants of health.
Perhaps the biggest challenge to digitalization as a public good is the lack of global governance mechanisms for the commercialisation and use of digital technologies. Global financial structures and commercial incentives have created a “technological wild west” in which ownership is concentrated among a few, dominant tech companies like Google, Facebook and Amazon combined with non-existing or inadequate legal and regulatory frameworks. This is particularly worrisome for health data, constituting huge commercial interests that potentially threaten privacy.
Weak regulation of digital tech companies is a global challenge that affects low- and middle-income countries disproportionately. In LMICs, companies can take advantage of weak state regulatory capacity and fragmented health systems to fill gaps in public provisioning of health services. In India, the combination of a strong tech sector and a chaotic health system marked by unregulated privatization has made the country a centre for the development of artificial intelligence aimed at the health sector. The problem is that there are no clear norms or frameworks for ensuring that this burgeoning technology reduces rather than increases India’s vast health inequities.
Navigating the digital Wild West
How should we navigate the digital Wild West? A first step would be to pay more attention to the global power structures and strong commercial interests that shape the development of investment priorities, rules for ownership and access. Thorough cost-benefit analysis of expensive investments in digital solutions ought to be weighed against more basic investments in public health interventions and infrastructure.
A second step would be to develop political frameworks for incentives and regulation of new digital technologies. Where the market incentives are weak, public authorities should provide incentives to develop technologies with wide public benefit. Stronger anti-competition legislation can weaken the chokehold of market dominance enjoyed by big tech firms, and thereby temper their power to set the terms for the future direction of digital health globally.
Before we conclude that digitalization benefits vulnerable individuals and accelerates improvements in global health equity, we need a closer look at which kinds of technologies are developed, for whom and with what purpose.
The Independent Panel was established in 2016 to follow up on the work of the Lancet-University of Oslo Commission on Global Governance for Health. It aims to advance debate on the political determinants of health inequities, the transnational norms, policies and practices that arise from political interaction across all sectors that affect health.
The #Tek4HealthEquity conference programme, summary of the presentations and video recordings from the conference are available here.