Highlights of the Digital Healthcare Equity Framework

Key Stakeholders: Digital Healthcare Developers and Vendors 

Purpose: To enhance access to care for underserved populations, software developers and vendors should engage marginalized communities, integrate cultural sensitivity, and ensure accessibility for users with disabilities.

Key Recommendations:

1. Engage potential users of the technology, especially those from marginalized communities: Developers should actively involve potential users of the technology, especially those from historically marginalized groups, during this phase to ensure the digital healthcare solution meets their unique needs. For instance, during the COVID-19 vaccination rollout, tailored approaches helped target elderly populations in the U.S., addressing challenges related to accessibility.
2. Understand cultural characteristics: Designing solutions that reflect the cultural beliefs and beliefs of the target population is essential for their success. Real-world examples, such as engaging black men to understand how racism influences their trust in the U.S. healthcare system, highlight the importance of cultural sensitivity in designing solutions that might require them to disclose sensitive information.
3. Design the technology in a manner that helps–and does not hinder–access to high-quality care. Solutions developers need to anticipate potential barriers to healthcare access that the digital tool might create. Some strategies that have proven useful include:
   1. Ensure inclusivity for disabilities: Incorporate features such as voice-activated technology and accessible interfaces, in digital healthcare solutions
   2. Test for racial, ethnic, and gender bias: Rigorously test digital health tools, such as medical devices, on diverse populations to avoid biases. For example, pulse oximeters were found to be less accurate on darker-skinned patients, highlighting the importance of unbiased testing.
4. Ensure equitable and transparent data use in solution design: To foster trust and accountability, digital healthcare solutions should apply policies and controls that protect patient data, including allowing patients to control data-sharing permissions. Moreover, when choosing data for training and testing their technologies, developers should use samples that are representative and inclusive of their user population as well as be transparent about which data models were used.

CGDHI Considerations for Low-Resource Settings:
In low-resource settings, engaging marginalized communities in the planning phase is crucial to address the digital divide and ensure that digital healthcare solutions meet their specific needs. Solutions must be adaptable offline to ensure functionality in rural or underserved regions. Moreover, developers must focus on scalable solutions that account for limited device ownership and internet access, while maintaining affordability to enhance inclusivity. The gender digital divide is also a significant consideration, making it essential to develop digital solutions that are fully accessible to women and girls. Incorporating account management functionality, privacy safeguards, and interoperability with existing systems is especially critical in contexts of limited device ownership, where device-sharing is common. Without personalized account management, privacy can easily be compromised when multiple users share the same device, which disproportionately affects women and youth who may have less control over devices. Additionally, interoperability ensures that digital health solutions can integrate with existing platforms, allowing users to access services seamlessly, even when sharing devices. Finally, it is important to remember that digital health equity can also be achieved through non-digital solutions such as a simple phone call for appointment scheduling. 

Key Stakeholders: Health Systems, Health Plans, and Clinical Providers

Purpose: To provide accessible, high-quality care for all populations, recommended steps include adopting digital inclusion strategies, engaging in participatory collaboration, assessing the impact of digital solutions on equity, and ensuring technical compatibility.

Key Recommendations:

1. Adopt digital inclusion strategies: Health systems and providers should implement digital inclusion strategies to reduce barriers and ensure equitable access to digital healthcare solutions. For example, the Affordable Connectivity Program helps U.S. households afford the necessary broadband for healthcare, work, and education.
2. Encourage participatory collaboration: A multisectoral approach engaging various stakeholders is vital for successful acquisition and maintenance of digital solutions. During the COVID-19 pandemic, Pima County Health Department in Arizona collaborated with housing departments to address health disparities and deliver crucial vaccination information to underserved populations.
3. Assess impact on equity across different types of health systems when implementing digital solutions: To avoid exacerbating disparities, healthcare solutions must be evaluated systematically on equity, especially regarding access and care quality before implementation.
   1. Ensure inclusivity of languages: Offering digital health platforms in multiple languages ensures that all patients can benefit from digital health technologies.
   2. Invest in community-based organizations and local partnerships: Community organizations may be available to assist in increasing access to digital healthcare solutions, by providing internet-enabled devices in underserved areas. 
   3. Designate personnel as digital literacy navigators: Train health professionals in digital health literacy sensitivity to help patients access, navigate and use digital healthcare technologies, to ensure equitable access to quality care as well as continuity of care.
4. Consider development and maintenance: Before acquiring a healthcare solution, it is essential for health systems to evaluate how it was developed, where and how it will be implemented and maintained, and how it will use, produce, or transmit data to ensure it aligns with equity goals.

CGDHI Considerations for Low-Resource Settings:
In the context of low-resource settings, we must consider infrastructural variability, where intermittent power and unreliable network coverage can significantly hinder the scalability of digital health solutions. Collaboration with local governments to subsidize essential digital infrastructure could enable long-term sustainability, while open-source platforms could drive down costs and encourage wider adoption. Furthermore, equipping community health workers or other frontline workers with mobile technologies can serve as a bridge to address gaps in digital literacy and technical expertise within the broader population. Addressing digital literacy through targeted training programs for providers and patients can help bridge gaps in understanding and utilization of such solutions, fostering long-term success in the adoption of digital healthcare tools.

Key Stakeholders: Health Systems, Health Plans, and Clinical Providers 

Purpose: To ensure continuous and equitable improvements in digital healthcare solutions, recommended steps include engaging communities through participatory approaches, requiring health systems to identify excluded populations, and addressing communication and accessibility barriers.

Key Recommendations:

1. Identify and address excluded populations: Health systems should assess which populations are using digital technologies and identify any groups that are excluded or not benefiting equally. For example, the California Department of Managed Health Care stratified data by race and ethnicity to understand equitable quality of healthcare delivery.
2. Use a participatory approach: Actively engage affected community members to gather input on the barriers to the usage of digital healthcare solutions. To do so effectively and inclusively, account for the users’ communication preferences. Offer translation services, gather input through surveys, virtual focus groups or other appropriate methods, and provide  accommodations for people with disabilities to ensure their voices are heard.  
3. Ensure digital solutions facilitate access: Continuously evaluate how the digital solution impacts access to quality care. Establishing long-term partnerships with community organizations for digital literacy training, collaborating with experts to identify underserved groups, and implementing applications that promote user self-sufficiency and engagement can help ensure that all community members benefit equally from new technologies.
4. Address data gaps for continuous monitoring: Identifying and addressing data gaps is essential for comprehensive monitoring and equity assessments of digital health solutions. To do so, review data for patterns of missing data points and disaggregate data by key demographics such as race, gender, and socioeconomic status.   

Comment from the Center for Global Digital Health Innovation on Considerations for Low-Resource Settings
Monitoring and improving digital healthcare equity in low-resource settings requires innovative approaches to data collection and community engagement. Identifying excluded populations can be challenging due to the lack of comprehensive data systems, making the integration of offline and low-tech solutions essential. For instance, community health workers can bridge digital gaps by manually gathering health data and providing services in areas with limited digital access. Moreover, participatory approaches should be adapted to local contexts, through the use of face-to-face consultations or SMS-based surveys in regions with low internet penetration. To ensure continuous improvement, local health systems need to develop low-cost, scalable methods to disaggregate and analyze data, particularly for two factors often overlooked in traditional health metrics: gender and socioeconomic status. This emphasis on offline and low-tech methodologies would create a more equitable digital health landscape, tailored to the realities of low-resource settings.