Digital technology’s role in achieving health for all
The historic Alma Ata Declaration of “Health for All” marked its fortieth anniversary in 2018. This major public health milestone prioritized health as a human right and emphasized the importance of community participation to strengthen primary healthcare for all.
At the Fifth Global Symposium on Health Systems Research in October, there were many discussions about the relevance of the Alma Ata Declaration today. How does the 1978 Declaration compare to the current vision of the Sustainable Development Goals (SDGs) to “leave no one behind”? What has changed and what has remained the same in global health?
Noteworthy changes that come to mind include the role of government, communication technology, and access to information. The rapid spread of mobile phones and digital technologies, more citizen-generated data sources, new vulnerabilities resulting from conflict and displacement, and the changing role of governments and non-state actors are transforming how health services are delivered and accessed. What hasn’t changed is the politicized nature of health, inequity in access to resources and services, and growing health disparities within and across countries.
I am left wondering how we can best harness new innovations to leave no one behind. Specifically, can the use of digital technology in health help overcome the persistent challenges? And if so, how? A new peer-reviewed open access supplement titled “Advancing health equity and gender equality: Digital health in the Global South” in the Journal of Public Health provides some grist for the mill to answer this question, using results from five years of IDRC-supported research.
Promise and pitfalls of digital health
Digital health, including electronic health (eHealth) and mobile health (mHealth), did not exist when the Alma Ata Declaration was signed in 1978. By contrast, today it is difficult to go to any corner of the globe without encountering some form of digital health. Even in contexts with severe health workforce shortages and large distances to travel, health workers use mobile phones to report data about disease outbreaks, make informed decisions, and show up-to-date life-saving information to patients at their doorsteps.
Digital health has opened up vast possibilities to overcome distances and time barriers, improve the quality and use of data, and reduce fragmentation through greater operational integration of health systems, known as interoperability. Conversely, it also increased the workload of frontline health workers, diverted resources from other functions, and led to increased duplication from the creation of new digital systems working in parallel with paper-based systems.
Like any resource, digital technologies are deeply contested and can present great opportunity or significant damage. They shape and are shaped by existing social structures, systems, and practices. This is why any study of the role of technology in health should follow the Alma Ata spirit by investigating their effect, especially within resource-strapped settings.
With this in mind, IDRC recognized it was necessary and timely to understand the underlying power dynamics — including gender relations, governance, and health inequities in digital health — from a developing country perspective.
Forty years on: What have we learned?
IDRC support for research on digital health from the mid-1990s to 2010 focused on building research capacity; supporting technical innovations, including some of the earliest work on interoperability in developing countries; promoting changes in behaviour among health workers and beneficiaries; improving disease prevention and treatment; and informing nascent digital health policies.
As the reach and sophistication of digital technology continued to spread, IDRC supported the exploration of social and technical innovations from 2013 to 2017. Now featured in the Journal of Public Health supplement, this group of seven projects — in Bangladesh, Burkina Faso, Ethiopia, Kenya, Lebanon, Peru and Vietnam — explored digital health implementation research with strong community participation and leadership to improve quality care for all.
Challenging the assumption that everyone will reap the same rewards when digital health is introduced in marginalized communities, these projects explored concepts such as quality, reasonable cost, and transformative change toward gender equality that spanned income levels, age groups, ethnicities, linguistic barriers, refugee populations, and geographies.
A Southern perspective on digital health
Among the rich findings, three stand out as key take-home messages:
- Digital health can positively influence health equity: In Burkina Faso, pregnant women and people living with HIV showed impressive improvements in health when they received customized health messages over mobile phones in their local language.
- Gender and power analyses are essential: In Vietnam, ethnic minority women in a remote mountainous province improved their health behaviours based on targeted information they received on mobile phones, and showed more demand to engage with health workers for additional knowledge and services.
- Digital health can be used to strengthen upward and downward accountability: In Ethiopia, upward and downward accountability from an all-female cadre of health extension workers to communities, as well as to their supervisors, was improved because of mobile technology.
In 1978 it would have been difficult to imagine the state of digital technology and its influence today, but the Alma Ata Declaration laid a solid foundation for public health. Through the SDGs and the Declaration of Astana, signed in October 2018 at a meeting in Astana (formerly Alma Ata), Kazakhstan, there is a renewed commitment to the principle of health for all.
Despite greater digital technology use, especially among the poorest populations, more research is needed using a power relations lens to understand who is benefiting in the short-term and in the long-run. Without this, the SDGs and its shared ideals with Alma Ata will not be achieved.
Chaitali Sinha is a senior program specialist in IDRC’s Maternal and Child Health program.