BLOG: Ethics in eHealth. Let's talk about equity

There is little doubt that the increasing access to, coverage and use of electronic tools for public health suggests that the future of healthcare is digital.


The eHealth revolution is on a full and unstoppable course of transformation, carrying a multi-dimensional and yet to be discovered potential for the organisation, planning and implementation of health services. Acknowledging that disruptive power, the urge to carefully consider the broader digital health impact on core public health and healthcare challenges appears timelier than ever before. One such challenge is reflected by the deeply rooted and persistiant social inequalities, directly and indirectly leading to those health inequities that numerous public health interventions are aiming to mitigate. Evidence suggests that a better socio-demographic background is generally associated with higher chances for a healthier, longer life. Is eHealth the solution we are looking for to address equity concerns and create universally accessible, fair and truly effective healthcare systems? In order to be able to provide a confident answer, we first need to ask whether we invest enough resources in capturing and understanding the potential equity effects of digital health innovations.

The digital value

The hypotheses and hopes of many scientists, public health professionals and political actors are clear: digital innovations carry an immense potential for identifying, targeting and reaching those marginalised and in highest need. As the increasing prevalence of chronic conditions poses new healthcare demands; gadgets, mobile phones, computers and wearables can yield a unique amount of information to support clinical decision making, identify high-risk groups and reach the most vulnerable. The Indian state of Uttar Pradesh is a unique example of successful eHealth scale up, incorporating smartphones and tablets in the daily workflows of rural community health workers. The project aimed to integrate and improve maternal health services, streamline reporting, reassure and monitor quality and enhance worker motivation. As those novel interventions emerge, capturing their effectiveness, understanding their dynamics and assessing their broader implications is essential for ensuring their fullest potential.

A digital cast system?

Decision makers and researchers should be reminded that the promising digitisation of health is not a smoothly emerging phenomenon. Instead, it is unfolding within a highly dynamic web of socio-cultural influences. Despite the undoubted  potential and several successes, we should be aware that the digital world is not immune to inequities. Ideally, effective public health programmes should improve overall health while meeting the needs of the most vulnerable. In reality, those two goals are not always operating in synergy. Unfortunately, socio-economically disadvantaged groups tend towards lower access to, use of and benefits of public and digital health initiatives, leading to interventions that might effectively improve average health outcomes, while failing to adequately reach those that need them most. The result is widening health inequity gaps and a digital divide that might rapidly lead to the establishment of a digital cast system; in which only those of socially advantaged backgrounds get to taste the benefits of technology.

Acknowledging that e- and mHealth do not automatically imply improved health equity, while health interventions might indeed widen the gaps; shouldn’t we, as researchers or policy-makers be extra vigilant about the equity implications of all those emerging eHealth innovations we implement or evaluate? Paradoxically, preliminary results from a currently ongoing review by researchers at the University of Oxford suggest that existing research evidence is in short supply. That gap should remind us, that before being capable of fully understanding the effects of eHealth, we might require higher research investments on capturing its ethically charged dimensions. Only then, might we speak of a digtal health ecosystem that is truly fair and fully effective.

Vasileios Nittas

Doctoral Researcher in Epidemiology & Health Policy, University of Zurich.

Vasileios Nittas received his BSc (First Class Honors) in European Public Health from the University of Maastricht (Netherlands) and completed his MSc in Evidence-Based Social Intervention and Policy Evaluation (with Distinction) at the University of Oxford in the UK. Nittas is primarily interested in the development, implementation and evaluation of digital health solutions for disease surveillance, prevention and control. 

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