Keywords

1 Introduction

Inaccessibility to healthcare services in Low- and Middle-Income Countries (LMICs) (World Economic Outlook Update 2013; Word Data 2022) has a detrimental impact on the standard of living and quality of life of their citizens. Addressing this challenge effectively requires comprehending and addressing the specific needs and applications of healthcare, medicine, and medical research in these regions. Limited healthcare access and high costs are the key factors that contribute to deficiencies in the provision of effective health services and perpetuate poverty among marginalized and disadvantaged populations (Smith 1999). Global income inequality contributes to healthcare provision disparities, with approximately 71% of the world’s population living in countries with high levels of inequality and where out-of-pocket payments for healthcare are a common practice (Gottret and Schieber 2006). Urbanization further contributes to growing disparities within cities, where wealth and modern infrastructure coexist with severe deficiencies in proper healthcare. Consequently, this societal gap generates a healthcare gap directly affecting the overall quality of life in citizens of developing nations. Therefore, despite global improvements in life expectancy (Crimmins 2015), infant mortality rates, and cancer outcomes, these positive trends are not uniformly observed globally (Fauconnier 2019; Roser et al. 2013).

To bridge the healthcare gap, LMICs cannot rely solely on their own resources. A coordinated global effort that will advance key components and digitalization mechanisms of existing healthcare systems is a critical step to ensure that LMICs can keep pace with the rest of the world in providing satisfactory healthcare services and extend their involvement in scientific excellence. In this regard, it is essential to highlight the several needs of such healthcare systems, including the establishment of suitable infrastructures, enhancement of the healthcare workforce, increase in health education and awareness, and adoption of relevant digitalization mechanisms such as EHRs, telemedicine, and healthcare mobile applications. Strategic implementation of such requirements is crucial to effectively address the specific challenges faced by these countries. Likewise, it is essential to address the issue of digital literacy of the population, particularly among healthcare professionals. While this chapter focuses on medical digitalization mechanisms, it is important to note that physical infrastructures, including medical equipment and hospitals, are essential components of this endeavor, as they play an equally significant role in achieving the equitable provision of healthcare services and supporting the effective implementation of these digital mechanisms.

This chapter initially explores how the concepts of healthcare inequality and inequity are exerted and provides examples of how medical digitalization is implemented in LMICs. International and national responses to health inequalities that are impacting digitization efforts and the role of human rights towards achieving the effective and widespread provision of high-quality healthcare services are also addressed.

2 The Concepts of Health Inequality and Inequity: Their Role and Impact

The concepts of health inequality and health inequity play a vital role in the global effort to support LMICs in achieving satisfactory healthcare services and improving healthcare systems. These concepts have gained broad recognition and are addressed by various international organizations, such as the World Health Organization (WHO) (WHO 2023), United Nations Development Programme (UNDP) (Kivioja et al. 2023) and United Nations Children’s Fund (UNICEF) (UNICEF 2016). Health inequalities, as defined by WHO “are the differences in health status between groups of people which are important, unnecessary, unfair, unjust, systematic, and avoidable by reasonable means. They can be observed between populations and groups within populations and as a gradient. They can also be observed between countries and regions. They are linked to social, economic, and environmental conditions, the conditions in which we are born, grow, live, work and age”. On the other hand, “health inequities are differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work and age. Health inequities are unfair and could be reduced by the right mix of government policies” (World Health Organization 2023).

The distinction between healthcare inequalities and inequities stems from their underlying causes and the implications they have on fairness and justice in healthcare. Failure to comprehend the concept of health inequity in LMICs can perpetuate systemic disparities, hinder policy responses, misallocate resources, erode social cohesion, impede economic development, and undermine international cooperation (Andermann 2016). For example, maternal and child health disparities remain prevalent in LMICs due to limited access to healthcare services, malnutrition, low educational attainment, and poverty (World Health Organization 2015). Likewise, disproportionate rates of the prevalence of infectious diseases such as HIV/AIDS, tuberculosis, and malaria, persist among disadvantaged populations (World Health Organization 2021). Non-communicable diseases, including cardiovascular diseases, diabetes, and cancer, disproportionately impact marginalized groups on top of an underlying gender dimension (Namasivayam et al. 2012). Moreover, exposure to environmental health hazards, such as air and water pollution, poses additional health risks in communities where relevant regulations or monitoring are not a state priority (UN DESA 2020; Scheil-Adlung and Kuhl 2011). To this end, recognizing and proactively addressing health inequities is crucial for addressing deep-rooted health disparities.

While the concepts of healthcare inequality and healthcare inequity are closely related and are often used interchangeably, they have distinct roles in promoting understanding and impacting the development of healthcare policies, particularly in LMICs. This includes the introduction and implementation of digitalization mechanisms in medicine. Introducing the concept of equity as a core value in the digitalization of medicine, we can actively promote social responsibility, inclusivity, and ethical practices in the digital health domain (Yao et al. 2022). Equity may serve as a motivation for societies, policymakers, and stakeholders to not only promote the digitalization of medicine but also to consider and prevent any adverse effects that may arise from technological interventions (Yao et al. 2022). Emphasizing equity in digitalization efforts plays a crucial role in creating more just and inclusive healthcare systems. Thus, to narrow the healthcare gap, it is crucial to comprehend the role and impact of each concept. This understanding will enable policymakers and healthcare stakeholders to advance appropriate and targeted interventions and policies.

3 International and National Responses to Health Inequalities

Despite the acknowledgement of the distinction between health inequalities and health inequities in several published documents, there is lack of sufficient reflection regarding this issue in the international and national responses aimed at tackling these challenges. Efforts to address health inequalities have been evident at both the international and national levels since the 1980s (Albert-Ballestar and García-Altés 2021). Due to the complexity of the factors contributing to this challenge, no single solution is available, and it is now clear that collaborative efforts are needed from world citizens, private entities, and a plethora of government sectors such as finance, economics, social welfare, and healthcare (World Health Organization 2023). To strengthen these collaborative efforts, international and national organizations work together with governments for creating and implementing policies aiming to deliver the essential conditions for a healthy living environment. The United Nations and WHO play a critical role in coordinating global initiatives and in supporting the global community to gain access to data from various sources that revealed and produced renewed evidence about the magnitude of health inequalities and the disparities that are on the rise (Barreto 2017).

In 2015 the United Nations adopted 17 Sustainable Development Goals (SDGs) as a universal call to action towards eradicating poverty, protecting the environment, and enhancing the quality of life for all people worldwide with a 15-year plan to achieve them (United Nations 2023). Each goal is accompanied by a set of indicators that aim in measuring progress made in the 193 countries that have agreed to work toward achieving the goals, and a report on global and national progress is released annually. The SDGs serve as a framework for addressing health and social inequalities on a global, national, and local level. All the goals aim to address the root causes of health inequalities in such sections as poverty, justice, peace, climate change, and environmental degradation. Significantly, one adopted goal focuses directly on health (SDG3 Good Health and Wellbeing), and among others a target (3.8) has been set for it to achieve Universal Health Coverage (UHC) for all including financial risk protection, access to quality essential health-care services and access to safe, effective, quality, and affordable essential medicines and vaccines (UN 2022).

In addition, WHO created a Health Equity Policy Tool (2019) to assist Member States and partners in monitoring, implementing, and enhancing policy actions to address the five identified fundamental conditions for a healthy living (including access to health care services), ultimately leading to a reduction in health inequalities (World Health Organization 2023). Furthermore, WHO regional offices (e.g., Europe (World Health Organization | Regional Office for Europe 2023), Pan-American (Pan American Health Organization (PAHO) 2023), and Africa (World Health Organization | Regional Office for Africa 2023)) have examined the primary causes of health inequalities in their regions, evaluated the available factors contributing to these inequalities, and launched regional programs to target them.

Even though most countries have not given health inequalities a prominent position on their political agenda, numerous policy suggestions have been put forward on an international and national level and available evidence has been utilized for incorporating actions into country healthcare policies that in some cases were able to partially diminish inequalities (Barreto 2017; Mackenbach 2020).

4 Digitalization Levels and Initiatives

While LMICs actively strive to address health inequalities and improve healthcare access, quality, and cost-effectiveness, the digitalization of medicine and healthcare stands as a crucial factor. However, the availability of digitalization in these countries depends on various factors including limited internet accessibility and bandwidth, funding, availability of experts, and policy support. Nonetheless, once digitalization and new technologies such as EHRs, telemedicine, and healthcare mobile applications are successfully implemented, many of these challenges could be overcome (Holly et al. 2022; Devi et al. 2020).

A crucial step towards achieving digitalization is to replace the traditional paper-based health records with Electronic Medical Records (EMRs) and thereinafter to EHRs. This shift is expected to reduce bureaucracy, and operational costs, and contribute towards achieving effective healthcare. Electronic systems offer numerous advantages like scalability, backups, enhanced security, time efficiency, consistent layouts, clear audit trails, and version history (Mathioudakis et al. 2016). They address concerns regarding the availability and accessibility to services like scheduling appointments, accessing medical records and obtaining medical advice. For example, effective access to medical records in many countries can often be challenging due to inefficient technologies or limited funding. Therefore, the development of cost-effective health information systems (HIS) (Koumamba et al. 2021) and integration of the information through an EHR, along with the establishment of regulations for data privacy and security will consequently elevate patient healthcare (Akwaowo et al. 2022).

One of the most significant benefits of digitalization is its potential to increase access to healthcare services. Telemedicine is a cost-effective technology compared to traditional in-person visits and can help bridge the gap and increase access to healthcare services. In particular, 3.4 billion people (around 45% of the global population) who live in rural areas of LMICs can have access to medical care by using telemedicine tools or applications, and dedicated support is further available for chronic patients through at-home monitoring systems (Ftouni et al. 2022). Telemedicine can also help in resource allocation with higher effectiveness, by minimizing the number of unnecessary visits and tests, while putting high-risk patients who need timely intervention in priority (Lupton and Maslen 2017; Combi et al. 2016).

Another significant mechanism is the development of healthcare mobile applications (mHealth) designed for various purposes, including clinical reference, telemedicine, health management, and to track wellness and fitness levels (Ventola 2014). These applications improve patient engagement through mobile apps or text messaging, reduce the risk of misdiagnosis, provide immediate access to care, offer automated reminders, enhance data management by integrating with EHRs, and enable real-time monitoring through healthcare Internet of Things (IoT) implementations (Dendere et al. 2019). These apps contribute to personalized healthcare by allowing patients to access their medical records, communicate with healthcare providers, and manage their health conveniently and efficiently.

In addition, the significant challenge posed by the limited accessibility of many LMICs to essential medications can be addressed through digitalization, especially for the improvement of supply chain management. Inevitably, digitalization maintains a crucial role in ensuring transparency and accountability for supply chain procedures, mitigating potential delays and inefficiencies, and in preventing the illicit diversion of drugs to the black market (Beaulieu and Bentahar 2021).

Rwanda is an example of a country that made significant investments in electronic health infrastructure, including the implementation of electronic medical records and a national health information exchange. Such interventions include the mHealth RapidSMS and the TRACnet platforms, which allow healthcare workers to collect and share healthcare data in real-time and to track disease outbreaks and monitor patients’ health, respectively. This advancement has enabled healthcare providers to access patient health information from anywhere in the country and has improved the quality of care for patients. Kenya is a developing country that also implemented several digital health initiatives, including the National Hospital Insurance Fund (NHIF) mobile platform, which allows patients to access healthcare services and make payments through their mobile phones. Moreover, Kenya has brought forward additional solutions, such as the application of several mHealth initiatives, including the mPedigree platform, which enables patients to use their mobile phones for verifying the authenticity of their medications (Hategeka et al. 2019; Kizito et al. 2013).

In conclusion, the importance of digitalization for medicine/healthcare cannot be overstated. Healthcare systems have the potential to be revolutionized through the application of digital technologies for improving healthcare access and enhancing health outcomes. While there are many promising initiatives aimed at promoting digitalization in healthcare, there is still a long way to go in terms of achieving universal access to digital health services in LMICs. All countries, irrespective of income levels, must continuously invest in digital technologies to improve their healthcare systems by ensuring adequate funding to develop and maintain a digital health infrastructure and align with current technological advancements (Drury et al. 2018). Addressing the barriers to digitalization in healthcare will require a collaborative effort among governments, healthcare providers, and other stakeholders, as well as a commitment to ensuring that the benefits of digitalization are accessible to all.

5 Human Rights as a Supportive Mechanism to the Digitalization of Medicine in LMICs

Human rights are universally applicable and can play a key role in advancing equity in LMICs through the digitalization of medicine. States assume obligations and duties under international law to respect, to protect and to fulfil human rights by ratifying international treaties and conventions. The principle of universality is a core principle of human rights recognized and endorsed by the international community (UN 1948). Universality ensures that human rights apply to all individuals, irrespective of their nationality, race, gender, religion, or any other characteristic and varying levels of development, political systems, and socio-economic conditions of countries (UN 2023). Human rights also enshrine other principles such as indivisibility, equality, and non-discrimination, participation, accountability, transparency, rule of law, and human dignity. These principles provide a just and fair regulatory framework to facilitate responsible and ethical utilization of digital technology in medicine and biomedical research. Such a framework is critical in these countries, where the vulnerabilities within their populations and healthcare systems are significantly diverse and more pronounced than elsewhere in the world. The right to health and the right to private life, for example, can be instrumental in narrowing the healthcare gap through the digitalization of medicine and biomedical research.

The right to health stands out as one of the most significant human rights and it is recognized as a fundamental human right under international law by several international human rights instruments (UN 1948, 1966a). Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) recognizes ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.’ This includes the right to access quality healthcare services, medicines, and facilities without discrimination, as well as the right to information related to health, participate in decision-making about one’s health, live in a healthy environment and have an adequate standard of living. The right to health plays a crucial role to the digitalization of medicine and biomedical research by embedding relevant human rights principles into the regulatory frameworks. By doing so, it would promote effective and proper digitalization of medicine in LMICs, aligning with core values and standards. The rights to health and digitalization of medicine are mutually supportive. Digitalization can contribute to the implementation of this right by improving access, quality, and affordability of healthcare services. Significantly, it ensures that the benefits of digitalization are accessible to all, with particular attention to marginalized and disadvantaged populations.

The right to private life assumes particular significance in the digital era, where health data can be easily accessed and shared, necessitating special safeguards and attention for LMICs. Article 17 of the International Covenant on Civil and Political Rights (ICCPR) explicitly states ‘No one shall be subjected to arbitrary or unlawful interference with his privacy, family, home or correspondence, nor to unlawful attacks on his honor and reputation’ (UN 1966b). Similarly, the right to respect for private life is guaranteed at the European level under Article 8 of the European Convention of Human Rights (ECHR) (1950). In May 2018, the General Data Protection Regulation (GDPR) (2016) was put into effect providing comprehensive data protection in Europe and establishing principles for processing of health data. Digitalization of medicine raises ethical, legal, and social issues (ELSI) that require careful consideration. These concerns encompass issues related to data privacy and security, the potential for bias and discrimination in algorithms and decision-making, and the need to ensure that digital health technologies are accessible and affordable for all individuals.

Both the right to health and the right to privacy are important in the global efforts to narrow the healthcare gap. To promote and implement digitalization in medicine, it is imperative to establish a regulatory framework rooted in human rights principles. Such principles ensure the responsible and ethical use of digital technology in medicine and biomedical research, while fostering its acceptability due to the universal applicability of human rights. In addition, concerns regarding data protection and informed consent in the utilization of digital technology can be effectively addressed and at the same time they will promote trust within the society.

6 Conclusion

Moving towards the era of precision and personalized medicine, the concept of digitalization in medicine, and in extent of biomedical research, inescapably becomes critical. As LMICs employ smart, user-friendly, and interoperable digital solutions to bolster healthcare services, matters of inequality and inequity impede LMICs from being at the forefront of modern advancements. Consequently, such barriers create gaps in the application of medical services despite the efforts accounted for by relevant coordinating organizations. It is imperative that to achieve a certain degree of backbone digitalization in healthcare services, LMICs must instigate a holistic and multileveled approach. This involves engaging all key components and digitalization mechanisms discussed in this chapter, requiring a coordinated global effort from various stakeholders and patient advocacy groups and necessitating the establishment of a regulatory framework to safeguard the responsible and ethical utilization of the digital world in medicine by being essentially based on human rights’ principles. Additionally, the concept of health equity should be embedded as a fundamental principle to bring recognition towards the obligation of states worldwide to provide equal opportunities for individuals in attaining optimal health outcomes, regardless of their social or economic status, and at the same time in fostering a fair and inclusive society that ensures access of citizens to healthcare services on an equitable basis. Therefore, it is emphasized that the adoption of policies based on social equity to achieve a high level of medical digitalization capacity, significant strides can be made in narrowing the existing healthcare gap. Such holistic approaches will in turn enable policymakers and healthcare stakeholders to develop and implement targeted and personalized interventions, to ultimately accomplish and maintain accessible, equitable, and ethically responsible healthcare systems in the developing world.