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To advance digital health equity, we need systems thinking

We can’t conclude a technology, program or initiative will be successful and sustainable based on the needs of one group of actors; a wider systems shift towards health for all requires a more holistic view.
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The COVID-19 pandemic massively accelerated digital innovation and adoption in health. Today, technology has a crucial role to play in advancing health systems equity and, accordingly, is threaded throughout the Johnson & Johnson Center for Health Worker Innovation’s (the Center) two key goals: closing a 10 million health worker shortage and equipping all frontline health workers to thrive. Yet, within this tech-enabled health ecosystem, a glaring inequity exists when it comes to accessing digital health tools. 

What is digital health equity? 

Digital health equity encompasses equitable access to digital healthcare; equitable outcomes from, and experience with, digital healthcare; and equity in the design of digital health solutions. 

It acknowledges all the different conditions, barriers and facilitators in a person’s digital environment that affect their health, functioning and quality of life outcomes and risks—otherwise known as the Digital Determinants of Health (DDoH). These operate at the individual, interpersonal, institutional and societal levels, and include factors like digital literacy and access to technological tools, as well as community infrastructure like broadband internet. All of this has an impact on their overall digital healthcare opportunities, which in turn has a knock-on effect on their healthcare as a whole. 

To address these barriers holistically, we must avoid designing in a vacuum, be willing to go deeper and not go alone by collaborating with stakeholders across sectors at various levels—in in other words, apply systems thinking. 

Applying systems thinking to digital health 

Systems thinking is at the heart of the Center’s approach to closing the healthcare gap and building a thriving health workforce. This approach to problem-solving views every challenge as part of a wider, dynamic system. 

In order for a health system to function properly, a number of interconnected factors must work in harmony: trained and motivated health workers, a well-maintained infrastructure, and a reliable supply of medicines and technologies, backed by adequate funding, strong health plans and evidence-based policies. To design effective solutions, we must keep these differing yet intersecting stakeholders and factors in mind. 

When we think about a technology, program or initiative, we can’t conclude that it will be successful and sustainable based on the needs of one group of actors. Nor should we assume that technology is a silver bullet. We have to take a holistic view, asking a number of questions, such as: 

  • Individual – Who is the audience or population for whom we’ve identified a need that needs tackling? How are we considering their differing needs, their opportunity to access digital healthcare, their skill set? How confident is this person at using technology and what is their attitude towards it?
  • Interpersonal – How does this technology enable or block the relationship between an individual and their community caregiver
  • Community – How well connected are different partners connected across the community? Will this further perpetuate fragmentation of the community?
  • Societal – How does this technology intersect with the major digital initiatives pushing societal change? Is there governance and wider policies in place?

Guiding principles

By layering this thinking across our program design and partnerships, we can ensure that our actions are contributing to a wider systems shift towards more equitable healthcare for all. This approach manifests in three clear principles.

  1. You cannot design digital interventions in a vacuum. Working with our partners across the digital portfolio, we generate evidence and undergo testing, and bring the voice of the users in as soon as possible.
  2. You must be willing to go deeper. Rather than taking a pre- and post- approach to measuring the impact of each digital intervention, we work to uncover what does and does not work, for whom, when and under what circumstances.
  3. You cannot go alone. Collaboration is at the heart of systems thinking and so we are always looking for opportunities to pull partners together around a common vision and shared objectives.

Guiding principles in action
(Programs below were funded by Johnson & Johnson Foundation)

 Individual & Organizational
We collaborated with tech-for-impact company Dimagi to launch The Resilience Message Program, a resource designed to improve health worker resilience and wellbeing via locally-adapted, evidence-based messages delivered to health workers’ cell phones. We’re testing the program across three different contexts, including an IRB-approved pilot in Brazil with the Institute for Healthcare Improvement. Advanced analytics exploring who does and, perhaps more importantly, does not engage with the solution will allow us to create user segments, capture any unintended consequences, identify barriers and adapt the program for different user types and settings.

Individual & Societal
With Reach Digital Health, we collaborated to adapt OpenWHO content, a series of free online courses with life-saving health knowledge from the World Health Organization. The team is now adapting OpenWHO for a Chatbot environment, a process that will be simplified with the help of AI platform ChatGPT. The new version of OpenWHO will have a segmentation avenue within the app so that we can begin to characterize health workers using the platform, understand what is and isn’t working for them, and tailor their journey based on their preferred learning style.

The Resilience Collaborative (TRC), is a global learning community that aims to advance learning and drive adoption of evidence-based strategies for health worker resilience, particularly in low-resource settings. TRC was launched by the Johnson & Johnson Center for Health Worker Innovation in 2021 to support health workers and the organizations that care about them, including the likes of Dimagi. Now, the Center is excited to support TRC’s evolution with The George Institute of Global Health, an internationally renowned research organization with a mission to improve the health of millions of people worldwide.

The George Institute stood out for their ability and ambition to apply evidence-based rigor, balanced with real-world implementation insights. The team also has a collaborative spirit, genuine desire for partnership and commitment to driving social impact globally. They will inject a fresh new perspective, alongside new relationships and partnerships that bring more visibility and joint advocacy to the community. You can join the community here: