Digital Transformation for More Equitable and Sustainable Public Health in the Age of Digital Interdependence

Abstract

This article describes 8 guiding principles for the digital transformation of the health sector and identifies their relationship with the COVID-19 pandemic, as well as highlights their importance to countries undergoing digital transformation processes. In the Region of the Americas, among other gaps, 30% of people do not have access to the Internet, which is why it is mandatory to develop policies and actions to deliver public health interventions equitably and sustainably to ensure that no one is left behind. The 8 principles focus on the 4 areas of a sustainable health system—human, social, economic, and environmental—and highlight the broader possibilities for using digital technology to have an impact on the sustainability of health systems. (Am J Public Health. 2022;112(S6):S621–S624. https://doi.org/10.2105/AJPH.2022.306749)

The current coronavirus disease 2019 (COVID-19) pandemic has exposed structural deficiencies in health, social, and economic leadership globally and especially in the World Health Organization’s Region of the Americas, highlighting the lack of resilience of health systems and societies. In this context, information exchange and information systems have proved crucial to the delivery of care at all levels of the health care system: the patient, the care team, the health care organization, and the encompassing political and economic environments. Overlooked for decades, information exchange and information systems have now emerged as a cornerstone for providing universal access to health care and ensuring continuity of care, drastically changing the way we think about the delivery of health services.

A more holistic approach is needed in public health to ensure effective responses to current and new threats. Putting information systems at the center of the game so they act as both an orchestrator and catalyst of responses will enable us to successfully engage and have greater possibilities for dealing with health emergencies by using modern tools that complement the traditional approaches epidemiologists have used for centuries. A truly digital society can enable a remarkably better understanding of people’s health through real-time epidemiological surveillance, as well as provide precise data registration and disaggregation, all without neglecting particularly vulnerable at-risk populations.

The objective of this article is to describe the 8 guiding principles for the digital transformation of the health sector and identify their relationship with the COVID-19 pandemic, as well as highlight their importance for countries undergoing digital transformation processes.

DIGITAL TRANSFORMATION AND PUBLIC HEALTH

Implementing digital transformation for health means standing at the vanguard of the age of digital interdependence. This new approach to public health is fully aligned with the United Nations Secretary-General’s Roadmap for Digital Cooperation.¹ This report reinforces a series of regional and global commitments made by the Pan American Health Organization, the World Health Organization, and the United Nations.^2–4 Interdependence among stakeholders becomes essential in the digital age, given that no single entity has all the required knowledge, creativity, or human, financial, or technological resources.

ENSURING NO ONE IS LEFT BEHIND OR DISCONNECTED

In a region where 30% of people do not have access to the Internet, it is crucial to ensure that no one is left behind by ensuring that public health interventions are equitable and sustainable.⁵ The path to a truly digital society requires a sensitive balance between state-of-the-art technology and striving to connect the unconnected. It will also require global agreements on new indicators that will allow progress toward an inclusive digital transformation to be measured.⁶

EQUITABLE AND SUSTAINABLE DIGITAL TRANSFORMATION IN HEALTH

Frequently, those who need the most from the health system are those who have the least access to it. In digital health, this is amplified because the vulnerability of the population and their lack of connectivity usually go hand in hand, and a nonequitable approach could end up being counterproductive, pushing vulnerable populations into an even more precarious situation, thus increasing the generational, economic, and geographical gaps for entire population groups. We are proposing an equitable approach to digital inclusion that has a strong focus on connecting the 250 million unconnected inhabitants in our Region. This approach can also help accelerate the reach of universal health access and coverage through faster, cheaper, and more efficient health processes, from the use of teleconsultations in primary care facilities to the automation of drug manufacturing and the delivery and logistics of health services.

GUIDING PRINCIPLES FOR THE DIGITAL TRANSFORMATION OF HEALTH

The proposed principles focus on the 4 areas of a sustainable health system—human, social, economic, and environmental—and these highlight the broader possibilities for using the digital transformation to have an impact on the sustainability of health systems. This approach specifically focuses on building local capacity in digital public health goods and human resources through continuing professional development and local training. New societal capabilities must be developed to capitalize on the full potential of these digital tools. However, today in health informatics we lack the shared goals and common language that we take for granted in other spheres. Table 1 describes the proposed guiding principles and their relationship with the COVID-19 pandemic.⁷

TABLE 1—

Eight Guiding Principles for the Digital Transformation of Health

Guiding Principle	Description	Relation to COVID-19
1. Achieving universal connectivity in the health sector by 2030	Connectivity for all must be a new social determinant of health because its establishment or lack of it will increasingly affect health outcomes. It is necessary to ensure adequate connectivity for both the beneficiary population and the health sector.	This pandemic caused many activities to be totally or partially transferred online quickly, and interventions were developed that depend on connectivity. However, because of a lack of infrastructure, knowledge, and opportunities, many people no longer receive essential services or are left out of epidemiological calculations.
2. Promoting digital public health goods to cocreate a more equitable world	Digital public health goods can increase the number and quality of services provided, and improve the accountability, collection, processing, and analysis of data crucial for health policy, as well as help reduce inequities in access arising from licensing and a lack of infrastructure and digital literacy.8	A good number of digital health initiatives to address the pandemic have been partially designed using the characteristics of digital public health goods. A particular example is the effort to ensure that data and content are freely accessible, downloadable, and analyzed using open-source software in a sustained and sustainable way.9
3. Ensuring inclusive digital health for all, including the most vulnerable people	Vulnerable populations, such as elderly people, indigenous and rural populations, or those with poor access to formal education, benefit less from digital health interventions because they are digitally excluded, meaning that they lack access to basic infrastructure (e.g., electricity) or they do not have the appropriate skill set (e.g., culture or literacy).	Various measures to address the health crisis depend on digital data from the Internet, social networks, and cell phones. Yet, in low-income areas, there are still gaps in access to these media and to the skills necessary to use them.10
4. Implementing interoperable, open, and sustainable digital health and information systems	Information systems provide immediate data and essential evidence for acting, informing decisions, and adjusting policies. With properly disaggregated data, it is possible to plan actions that give visibility to and reduce potential health inequities at all levels of care and that facilitate strategies to address such inequities.	During an emergency situation like a pandemic, more than in any other public health situation, information systems play a critical role in managing data and other information at the speed the situation requires. The use of technologies and automation have the potential to improve the public health response like never before.11
5. Mainstreaming human rights in all areas of the digital transformation of health	Health data are so sensitive, it is imperative to handle them safely and to prevent leaks, external attacks, and loss of confidentiality. This is challenging as the number of actors increases. Ensuring ownership of health-associated data by individuals presents a huge legal and logistical challenge.	Tools to help with contact tracing for exposure notification and symptom verification, and to check compliance with quarantine, among others, have been developed rapidly in response to the emergency. Therefore, there is a higher risk that they are a source of discrimination and digital inequity and may contribute to a loss of data privacy.
6. Participating in global cooperation on artificial intelligence and any emerging technology	Big data, artificial intelligence (including machine learning), the Internet of things, virtual and augmented reality, and blockchains are among the technologies that have emerged in recent years and can be used to revolutionize the well-being of people.	This pandemic has catalyzed the adoption of new technologies in health and also led to unprecedented collaboration and discussion about experiences and best practices. It has also increased access to research data and knowledge and to publications previously limited by licenses, among other examples.
7. Establishing mechanisms for trust and information security in the digital environment of public health	The integration of various information services has led to privacy and confidentiality concerns as well as concerns about the quality and veracity of the data shared. Thus, a robust scheme to ensure security and trust must exist to fight misinformation and ensure good-quality evidence is used for decision-making.	An infodemic developed parallel to the current pandemic in which an excess of valid information was shared together with incorrect information or fake news (i.e., a mixture of scientific and technical data shared along with purposeful disinformation) about treatments, vaccine development, and even doubts about the existence of the virus. This situation confuses the population, so the public is unsure which information to trust and which institutions to follow.12–15
8. Designing public health care architecture in the era of digital interdependence	Renewing public health architecture to aid digital cooperation means having processes, policies, human resources, infrastructure, and decision-support systems that permit effective and rapid adoption of digital solutions, whether transdisciplinary or interinstitutional, for public health.	The COVID-19 pandemic has shown the potential of digital health technologies, but it has also revealed the weaknesses of current public health architecture in various regions. This has had an impact on the timeliness and appropriateness of the interventions adopted for mitigation and containment.

CONCLUSIONS

The potential of the digital transformation for health during this and future public health emergencies is indisputable, yet it is essential that it is accompanied by digital inclusion and the goal of ensuring that no one is left behind. Agile digital systems are essential to facilitate cocreation and cooperation among all relevant actors regarding the development, evaluation, and safe adoption of innovative technologies. Sustainable strategies are key to strengthen information services and to ensuring the analysis of critical real-time and disaggregated data during a health emergency, especially in the areas of interoperability, data exchange, and the use of nontraditional data sources. Some challenges are associated with ensuring privacy and confidentiality, as well as the secondary use of data for which consent has not been obtained; thus, it is crucial to develop appropriate regulatory frameworks. A critical factor for success is the establishment of digital public health goods that support and promote technological development, including regulatory frameworks, to ensure an equitable distribution of these positive interventions. It is imperative to incorporate rapidly, but safely and ethically, open-source technologies to accelerate research, collaboration, and innovation in the public health sector as a whole. Finally, given current developments and looking ahead, the development of new public health digital competencies should be part of an ongoing educational strategy through continuing professional training for anyone who decides to work in this field.