IGF 2023 – Day 2 – WS #54 Equi-Tech-ity: Close the gap with digital health literacy – RAW

The following are the outputs of the captioning taken during an IGF intervention. Although it is largely accurate, in some cases it may be incomplete or inaccurate due to inaudible passages or transcription errors. It is posted as an aid, but should not be treated as an authoritative record.



>> MODERATOR: Ensuring holistic understanding of individuals' abilities in navigating services, what strategies towards health equity can be adopted to ensure digital health literacy programmes and challenges faced by marginalized communities, promote inclusivity and access to digital health sources?  How can partners in between key stakeholders including healthcare providers, educational institutions, technology companies and Governments be leveraged to enhance digital health literacy skills, foster collaboration and knowledge sharing to advance health equity?

Our panelists will be addressing issues today.

I would like introduce our esteemed panelists who are share insights on these matters.  We have Ms. Geralyn Miller, innovation leader driving change in healthcare and life sciences through AI.  She is a Senior Director at Microsoft in product incubations, Microsoft healthcare and life sciences Cloud, data and AI and cofounder of AI for Health, which is Microsoft AI for good research lab.

Then we have professor Rajendra Gupta joining us online, a leading policy expert with vast experience in policymaking and he has been involved in major global initiatives on digital health and holds key positions in the digital health arena.

Next, we have Ms. Debbie Rogers, she's an experienced leader in the design and national digital mobile health programmes and the CEO of Bridge Digital Health aiming to harness existing technologies to improve healthcare and create societal impact.

Last but not least, we have Ms. Yawri Carr joining online.  She is also a digital youth envoy for the ITU, and a global shaper of the World Economic Forum with her work centring on responsible AI and data science for social good. 

Let's begin session 1 of today's workshop on low digital health literacy and strategies. I would like Ms. Geralyn Miller to take the floor first.

What research and development initiatives, for example, including the creation of comprehensive frameworks and assessment tools is Microsoft pursuing to address multifaceted challenge of low digital health literacy?  Can you highlight your thoughts and innovative strategies and partnerships that Microsoft is employing or supporting to enhance digital health literacy among marginalized populations with focus on inclusivity especially in low income and rural areas?

>> GERALYN MILLER: Thank you for inviting me to participate in this.  So the lens I will take from this is based on something that is known as social determinants of health.  Advocate determinant of health is a noun medical factor that influences health outcomes.  So this is the conditions that people are born, work and live in, and the wider set of forces that shape conditions of our daily lives.

This includes things like economic policy and development agenda, social norms, social policies, racism, even climate change and political systems.  And this affects about, from research we know that this is about 30% to 55% of health outcomes are actually really dependent on social determinants of health.  When you want to think about health equity, it's important to understand the problem based on data, and I will share about what Microsoft research is doing in that area, and second, is to open your mind and have willingness to address underlying systematic problems that affect health outcomes, and that includes social determinants of health.

Microsoft has some things to understand the problem of data including the Microsoft AI for Good team has built something we call a met equity dashboard.  That is essentially a Power BI dashboard that takes a number of public data sets and allows one to look at them from a geography perspective, slice and dice the data by rural, suburban and urban populations and also examine different health outcomes, including things like life expectancy.  That's the first thing is really being able to understand and visualize the problem itself.

So I would invite you to actually have a look at that information.  There is a number of other things from a Microsoft perspective we are doing to look at on the social determinants of health side.  So I will point, for example, to some of the work we are doing on climate change.

We announced a climate change research initiative that we all MCRI which is really a multi‑ disciplinary research initiative that is focusing on things like carbon accounting, carbon renewal and environmental resilience.  We have Microsoft AI for Good research lab and our humanitarian action program.  They have, for example, worked with a group called humanitarian OpenStreetMap or HOT which partnered with big maps to map areas vulnerable to natural disaster and poverty.

That is an example of some of the work out of the research lab in the humanitarian action program coming together to help give relief teams information to respond better after disasters.

There is a lot of work we have happening from a Microsoft perspective that ties more directly to economic development and digital skilling.  So we have work on something called the economic graph which is a perspective or review based on data with 150 million professionals and 50 million companies.  LinkedIn which is a Microsoft company also has data for impact program.

This program makes this type of professional data available to partner entities including entities like the World Bank group, the European bank and others.  So data on more than 180 country and regions at no cost to the partner organisations.  An example of the impact of this type of data, this data for impact information was able to advise and inform a $1.7 billion World Bank strategy for the country of Argentina.

And then there is also the Microsoft Learn program which is a free online learning platform enabling students and job seekers to expand their skills so role‑based learning for things like AI engineer, data scientists and software developers, hundreds of learning paths and thousands of modules localized in 23 different languages.

So in summarizing, I just want to say that we look at this from a holistic broad perspective as digital health literacy and digital skills as part of the social development, social determinants of health and the work we are doing to support those.

>> MODERATOR: Thank you very much Ms. Miller.  Now, moving onto Ms. Debby as an experienced leader in the design and management of national and health programmes and the CEO of Reach digital health can you share thoughts on digital health literacy, digital divide and health equity, effective strategies for addressing digital health literacy among marginalized populations particularly in resource constrained settings and how can partnerships between nonprofit organisations like Reach and private sector mobile operators be strengthened to promote digital health literacy among women and marginalized communities address gender based resources while contributing to bridge the digital divide?

>> DEBBIE ROGERS: The first thing to talk about is the context.  We work primarily in after a so give you an idea around inequality in health in Sub‑Saharan Africa, we have 10% of the world's population, 24% of the disease burden, and only 3% of the health workers.  And so we really do have the odds stacked against us in a time when we are supposed to be going towards universal healthcare, which quite honestly is a pipe dream if you look at where things are at the moment.  While we have made some progress in addressing maternal and child health and addressing infectious diseases such as HIV, we are getting an increased burden when it comes to non‑communicable diseases.  So the burden is just increasing, not decreasing.

And so really if we follow the same patterns over and over again, and we keep just training more and more health workers and not addressing systematic issues or relieving the burden from the health system, then there is absolutely no way we are going to be able to improve these stats.  We are going to go backwards and not forwards.

So I think I'm fairly optimistic actually because I think, I think that digital and particularly mobile has the opportunity to really address some of these issues in a way that many other interventions don't.  Reach Digital Health was founded in 2007 with the idea that the massive increase in access to mobile technology in Africa at the time more people in Africa had access percentage‑wise to mobile technology than in the so called Global North or western countries, was a way for us to leapfrog some of the challenges we've had in the Global South, and to actually address some of these issues.

And we have been able to see that.  We have been able to see, we have been able to see how the access to information and services through a small device that's in the palm of many people's hands has been able to improve health both from a personal behavior change perspective but also health systems as a whole.

And so what we primarily focus on is using really, really low tech but highly scalable technology, so things like SMS, Whatsapp.  These are the things that everybody uses every day to communicate to their family and friends.  And we use that to empower them in their health, help them to practice healthy behaviors, to stop unhealthy behaviors, and to access the right services at the right time.

And with fairly ubiquitous nature of mobile technology in Africa, we have been able to reach people at a massive scale, so, for example, we have a maternal health program with the Department of Health in South Africa.  It's been running since 2014.  We have reached 4.5 million mothers on that platform, but that represents 60% of the mothers who have given birth in the public health system over the last eight years which percentage‑wise is huge.

And we have been able to see that this has had impacts such as improved uptake of breast feeding, improved uptake of family planning, and really has seen not just an individual change, but a more systematic change with the ability to understand what is the quality of care on a national scale for the Department of Health in South Africa?

And so we really do believe that if you around he is the power of the simplest technology, if you design for scale with scale in mind, if you design with understanding the context, then you can actually use digital to be able to increase health literacy, and so it's not all doom and gloom.  It's not just about the fact that digital is always excluding other people.  It can be an enabler, but only if we can consider the wider context and we don't go blindly into things and ignore the fact that this could be something that increases the divide.

So I think I will talk a little bit later more about some of the strategies that can be used, but I think two things to remember is design with the human, not patient.  I don't like the word patient, but in digital health we tend to use that word, with the human at the center of what you are trying to do, and design with understanding that you are part of a bigger system and this is not something that exists by itself.

If you do those two things, not only will you be able to improve health literacy but you will do so in a way that doesn't widen the divide that many technologies already put in place.

>> MODERATOR: Thank you very much.

Moving onto Professor Gupta with your extensive experience in policy development, digital health education and founding the world's first digital health university, can you share thoughts and offer key policy recommendations that Governments and international organisations should prioritize to comprehensively enhance digital literacy especially amongst marginalized populations?  Additionally, can you share insights into successful and scalable educational strategies and approaches that have effectively improved digital health literacy with a focus on meeting goals globally?

>> RAJENDRA GUPTA: I'm a little worried for such a long question, but after 5:00 p.m. I am half asleep.  There have been many engaging sessions, but this is an important topic that keeps me awake, but pardon me for my incoherence.  Let me give you a backdrop of why this topic is important.

There is an international society called international society of telemedicine and E‑health that has been around a quarter of a century and has memberships in several countries.  In 2018 I said that digital health has two opportunities and two challenges but the two challenges are we have reached the stage of technical maturity.  Give me a challenge, I will give you 100 solutions, but where we lack of oppositional maturity.

So 2019 they formed capacity building Working Group which I Chair and post that we have done two papers on capacity building.  One is listing the kind of people we need to train across digital health, and second we have done a deep dive release that in partnership with the World Health Organization.  So there is for those looking at what kind of capacity we need, the update website has at least two papers written on this topic, and in 2019, WHO set up their capacity building department which is a very decent thing, so I think there is a lot of focus.

And now coming back to what my experience is.  So having pushed various organisations to do that, but we were just doing policy papers and policies take time to translate.  People like Debby will need people to help her and technology.  A policy paper can't help her.  She needs people trained to help.

So in 2019 I started the digital health academy which is now the academy of digital health sciences.  We have started a course for doctors and for people in healthcare. It's a global course, fully online, as digital course should be, but to your point, that also would not solve my biggest overall challenge.  I am training doctors, you know, it is so shocking, and I will put a context to that that we have maintained a leading edge paper in India, a very senior doctor called me and said I didn't know digital health is.  So I was shocked that even doctors need to be first apprised of what does world digital health mean.

I give you another example.  There is a company that works exclusively in data domain.  So I called the founder who is a doctor and said do you do digital health and he said, no, I said do you use data?  He said, we only use data.  So the people should know the definition of digital health.  That is the level which is needed across the ecosystem.

So right from the bureaucracies and the Ministers and ministries of health they need to understand what is digital health was they come or they get transferred if at that level they are sensitized, things flow down the line.  Government makes policies which get implemented as programmes.

That's one level of competencies that I have told WHO to look at because my experience in WHO meetings is that bureaucrats come, they spend two, three days in Geneva or New York and they go back and forgot it.

There has to be course for policy maker at highest level.  The second level is what we need to do is the courses for doctors and health professionals.  Third, and the most important which we are launching in the next two months is front line health workers.  Understand the challenge that front line health workers are either doing voluntary service like you have the ASHA workers in India which is a million workers.  They are our first responders.

Don't expect them to pay you a thousand dollars or a $100.  So we had to innovate and national importance that we need to bring out $1 trainings.  We should train people for as low as $1.  So front line health workers if I am able to train, I think I would have addressed the biggest challenge for healthcare.

Now, one of the Government agencies has approached us to work with us.  So as such on the capacity building I think Governments just focus on the program minus capacity building, which is a serious lapse.  This is across the board.

We are focused on saying maternal health, mobile application, child health, mobile application, but who will do it?  We don't know.  But people don't even know how to use a mobile phone.  They don't know how to log in on the account.

So they need basic training.  I think this is what private organisations, not for profits, and then Governments step in very late.  Let me tell you that.  They are not the ones that are initiators.

So  as a policy, I'm glad, Connie, that you put a session on this.  Something that our Dynamic Coalition should have done, but they only allow one session for a Dynamic Coalition, so we had our session which we are doing tomorrow.  But it puts spotlight on this important topic.  There are policy papers geared to WHO.  WHO set up the capacity building department, but nothing much has moved between  '19 and  '23, four years.

They are still to look at and still forming a Committee.  So it's mostly going to be the civil society organisations and private sector that will take the lead.  On policy side I have not seen documents that talk about it so far, so we will have to wait for normative guidance from WHO, which will be still a few years away.  It takes time to build a document in the WHO.

How this will happen first is like this.  In India, we have Digital Health Mission which has rolled out 460 million health IDs.  In this year we will roll out one billion health IDs.  Our health consultations have crossed 120 million.  So I think that is the first point.  So I'm inverting the process from policy to let's first have implementation.  So when the Government rolls out at such level and scale, automatically you will start filling the need of bringing people in this.  So I think this is one thing, but more than structured courses, it will be more of continuous upskilling.  Until last year know one talked about Generative AI.

So I think we need to keep that training and make it more as continuous upskilling program for people across healthcare.  We are not waiting for Government policies we are rolling out as academy of digital health sciences.

We are making it affordable as $1 training for front line health workers, for doctors and for industries, the postgraduate program.  We will announce undergraduate programmes as well.  This is where we need to build capacity.  So for now, I think policy interventions will happen, I think overall a part of the health policy everyone should put capacity building and digital health is part of health.  So digital upskilling is required for digital scaling so I think this is something that Governments have to look at.

WHO takes a frontal role so more to WHO and organisations like the one that Debby runs, organisations like the ones that I run with my team and more importantly there are two people sitting in this room, even if you train doctors, industry and different Lynn health workers, if patients are not trained, who will use this?  At the end of the day they have to open an app and use it.  So the onus is on people like them to go and train patients for how to use digital technology.  It's a multidimensional topic.

I'm happy there is a session dedicated to this.  Unless we address this in a complete ecosystem perspective we will not bring justice to this topic.  Thank you.

>> MODERATOR: Now, to someone with expertise in responsible AI, digital rights and passion for the intersection of technology and society.  How can policymakers craft regulations to ensure possible development and deployment of digital health technologies especially for marginalized communities?  What role do you see for youth‑led initiatives in enhancing digital health literacy, bridging the digital divide and engaging policymakers to drive policies that support equitable access to digital health resources?

>> YAWRI CARR: Hello, everyone, dear organizers, participants and guests.

Thank you very much for the organisation and thank you for inviting me.  So in a world where technology and healthcare are more intertwined than ever, the responsible development and deployment of digital health technologies are paramount importance.  This is especially true when considering marginalized communities where equitable access is a moral imperative.

So in this case, I would like to mention the responsible research and innovation framework as one of the guiding philosophies that serve as a roadmap for navigating the intricate terrain of AI in healthcare.

It places premium transparency and accountability recognizing them as pivotal elements in the responsible development and deployment of AI technologies.  In the realm of healthcare ASRI advocates for policies that do not only uphold digital rights, but also establish mechanisms to hold AI systems answerable for their decisions.

It is a holistic approach that seeks to ensure that benefits of innovation are realized with a compromise in ethical standards are jeopardizing individual rights.  Who should be involved in a process of responsible research and innovation.

Societal actors and innovators, scientists, business partners, research funders and policy makers, all stakeholders involved in research innovation practice, funders, researchers and stakeholders in the public, large community of people, early stages of R and I processes, and the process as a whole.

And when through the entire innovations lifecycle.  And to do what?  So it is important to anticipate risks and benefits to reflect on prevailing concepts and beliefs to engage stakeholders and members of the wider Republic to respond to stakeholders public value and the changing circumstances that are present in these kinds of processes to describe and analyze potential impacts, reflecting on underlying purposes, motivations, uncertainties, risks, assumptions and questions and a huge amount of dilemmas that could emerge in this kind of circumstances, and open to reflections and to have a collective deliberation and a process of reflexivity and to integrate measures throughout the whole innovation process.

So these are also in which ways should we do this working together, becoming mutually responsive to each other, and, of course, in an open, inclusive and timely matter.  And to what end?  What this framework proposes is that it's allowing appropriate vetting of scientific of technological advances in society to better align the progresses and expectations of society to take care of the future to ensure desirable and acceptable research outcomes, so a set of moral problems and, well, also protect the environment and consider impacts on social and economic dimensions, also promote creativity and activities for science and innovation undertaking public interest and how this can be applied specifically in a context of healthcare technologies.

For example, there is academic projects and also social health projects.  One example is one from the technical University of Munich in which I am now studying.  We have a project that's an AI‑driven innovation including a robotic arm of a prosthesis and a manual mobile service robot.  So ensure the responsible and integration into broader healthcare applications the developers from the Maternal Intelligence Institute have collaborated with the Institute of History and Medicine.  And these things are employing embedded ethics, incorporating ethics, social scientists and legal experts into the development processes.

So they have initial onboarding workshops where these experts have become integral members of the development team, they have been actively participating in regular virtual meetings to discuss technological advancements, algorithm minimum deployment and interdisciplinary.  And when ethical challenges are raised, they are addressed as part of the regular development process leading to adjustments in product design.

  Embedded ethics is highlighted in this case potential challenges for an elderly population unaccustomed to such arrangements.  Also taking into consideration that these kinds of projects in this specific case was, had a target population of the elderly population, so this is why it is very important to look at this target population and actually see if they are prepared and if they could be adapted to this kind of technologies.

So insights from this discussion influence the process emphasizing the importance of directly seeking future inhabitant perspectives in layout planning.  And simultaneously the project also involves interviews with various stakeholders including developers, programmers, healthcare providers.  Workshops participant observations of development work and collaborative reflection and case studies contribute also to active ethical consideration, and while the product is also aiming to develop a tool box to facilitate implementation embedding ethics into the future.

There are several unresolved issues that remain, and that are also with cultural setting and with corporate and organizational structures.  Because even a research setting funded by public resources, the development of AI is predominantly situated in a competitive landscape prioritization, with prioritization of efficiency, speed and also profit.

So also in the case of health, so ethical considerations might be normally an isolated or like are normally like not so taking into importance when they directly clash with profit‑driven motives.  So taking ethical concerns seriously creates a tension with industry objectives and faces the risk of being assimilated into broader corporate commitments, to concepts like technological solutionism, fundamentalism that at the end prevents ethicists to do their work and to do responsible healthcare technology.

Normally embedded ethicists may find themselves working in contexts characterized by pronounced power imbalances, particularly those of a financial nature.  And it is probable that some form of infringement measures will become very necessary in such environments.  So not just for the development of the technical aspects but also for the work of the persons that, working on the responsible development and deployment so that maybe regulatory frameworks certification processes or even voluntary initiatives into the organisation can make an awareness of this kind of issues that are arising in these situations.

And I also needs to talk about youth‑led initiatives, right, if I still have time.  Okay.  So there are also a lot of ways in which youth‑led initiatives and also marginalized community could also engage with responsible research and innovation.  So, for example, youth‑led initiatives could connect or could try to participate in events such as this one, but also try to that universities or centers of education could inspire the youth so that they can also learn about telemedicine, how can they develop telemedicine initiatives in countries and also in special rural areas as the professor was mentioning about in India that this kind of populations don't have the same access.

Also, for example, community‑based participatory research projects that are involved in communities in their research process ensuring that interventions are culturally sensitive and address the specific needs of a population, also detail health literacy programmes, and also like innovation challenges could be motivated between students and youth so that they can also engage and I also consider the mentorship that these students or youth can also gain from experienced people is also very important because they need guidance and also like a foundations and also examples of how can they develop their ideas.

So thank you.

>> MODERATOR: Thank you very much.  So while health literacy is a challenge for populations it is particularly harmful for marginalized communities.  In this section we will discuss strategies for addressing health equity and the digital divide in the context of digital health.  Let's start off with Ms. Geralyn Miller.  So in light of the session's focus on health equity and the digital divide could you share thoughts and elaborate on specific policy measures and initiatives that Microsoft is advocating for or actively participating in to bridge the digital divide and promote equitable digital health access and also how is Microsoft addressing barriers faced by diverse populations and how are these efforts contributing to advance is health equity?  Over to you?

>> GERALYN MILLER: Thank you for the question.

I want to respond in this context to some of the comments that Dr. Gupta and Ms. Carr mentioned and shine a light on the concept of artificial intelligence, Generative AI, and what we at Microsoft call responsible AI as an example of policy.  So one of my favorite quotes in this area is a quote by our chief legal officer and President, Brad Smith, and I'm going to paraphrase the quote.  Brad has a quote that basically says that when you bring a technology into the world and your technology changes the world, you bear a responsibility as a person that created that technology to help address the world that the technology helps create.

So from a Microsoft perspective, we look at this under the lens of something that we call responsible AI.  Our responsible AI initiatives date back far before the birth of ChatGPT and Generative AI and large foundational and large language models back to 2018, 2019.

And we have a set of principles that we have established that are around how you design solutions that are worthy of people's trust.  So this is our, these are our principles, what we call our responsible AI principles.  There are many people who have different principles around responsible AI.  I will share with you ours.

I would offer that it's something worthy of thought and very often when I work with academic medical centers or healthcare providers who are starting to use AI or build and deploy AI models, I also offer to them, hey, you should have a position on responsible AI.  Do your thought work, do your homework.

You should have something that is consistent with your own values, your own entity’s values.  Going back to from a Microsoft perspective what we believe those principles are, the principles are based on fairness, so treating all stakeholders equitably, and not ‑‑ making sure that the models themselves don't reinforce undesirable stereotypes.  Transparency so this is about AI systems and outputs being understandable to relevant stakeholders and relevant stakeholders in healthcare means not only patients who may be receiving the output of this, but also clinicians who may be using these as decision support tools or to do some type of prediction.

Accountability and so people who design and deploy AI systems have to be accountable for how the systems operate.  I will do a click down on accountability in a second.  Reliability, so systems should be designed to perform safely even in worst‑case scenarios, privacy and security.  That goes, those are underpinnings behind any technology, and AI systems as well should protect data from misuse and ensure privacy rights and inclusion.  This is all about designing systems that empower everyone regardless of ability and engaging people in the feedback channel in the creation of these tools.

And there are some things I will drill down in a little bit on the inclusion front as well.  Still, when you, an example as I mentioned of the accountability I would like to share some things that are President Brad Smith was offering when he testified before the U.S. Senate Judiciary Subcommittee, this is back in the beginning of September around September 12th on hearing entitled the oversight of AI, legislating artificial intelligence.  See Brad highlighted a few ears that he is suggesting help shape and drive policy.  One is about accountability in AI development and deployment, things like ensuring that the products are safe before they are offered to the public, building systems up with security first, earning trust.  So this is things like provenance technology and watermarks, so people know when they are looking at the output of an AI system.

Disclosure of model limitations, and also really channeling research, energy and funding into things that are looking at societal risks associated with AI.  He also suggested that we need something called what he termed safety breaks for AI that manages any type of critical infrastructure or critical scenarios including health.

When you think today we have coalition avoidance systems in airlines, we have circuit breakers in buildings that help prevent fire due to, for example, power surges, right, AI systems should have safety brakes as well.

So this involves classifying systems so you know which ones are high risk, requiring these safety brakes, testing and monitoring to make sure that the human remains in control, and licensing infrastructure for the deployment of critical systems.

And then from a policy perspective, ensuring that the regulatory framework actually maps to how the systems are designed so that the two flow together and work together.

So that's an example of the policy in action side of things, and from a Microsoft perspective, we put our responsible AI principles that I mentioned into action through our commitments at a policy level, our voluntary alignment, for example, here in the U.S. out of some of the things coming out of the White House, so voluntary alignment with commitments around safety, security and trustworthiness of AI.

One last point I did want to go back to the responsible AI principle and talk about inclusion.  And so we are doing some work from a Microsoft perspective in the health AI team that I'm a product manager on to really look at how when we have data that guides models in, and this is either custom AI models or when we are grounding large foundation models or large language models with data, how do we make sure that we understand the distribution and makeup of the data to ensure that their bias doesn't creep in from the data perspective.

We are doing work, for example, on the deployment models.  How do you understand if models are performing as they intended?  How do you monitor for things, something called model drift.  So when models start to perform in a manner that isn't how you think, right, when the accuracy starts to decline and then what do you do when the models don't perform that way.

This last part the model monitoring and drift is some of the things we have happening out of our research organisation.  Thank you.

>> MODERATOR: Thank you very much.

So now I want to move back to Ms. Debbie. Drawing from your experience in developing the digital strategy for a major teleco in South Africa, how can telecommunication companies play a more significant role in advancing health equity and bridging the digital divide through innovative approaches and digital solutions and what lessons can be learned  from your work in South Africa that can be applied globally to improve digital health access?

>> DEBBIE ROGERS: Thanks.  I think one of the most interesting examples of how mobile network operators have really had a big impact on decreasing any inequities around health is the Facebook Free Basics model.  You may not know what that was, but Facebook basically put together simple information through what looked like a little Mobi site, and this was essential information that they felt everybody should have access to.

And they work with mobile network operators to zero rate access to only that portion of Facebook, just that portion, not to everything, but just that portion.  And they were able to show that by providing essential information that is free to access, they were able to improve people's literacy, and use of data so they then went on to use more data and to use the Internet more often, therefore, become more valuable customers to the M and O’s.

So by doing something like providing free access to essential information, there was also an increase in profit for the mobile network operators.  And I think that's a really interesting model to look at.  I think very often we forget that it's just as important for mobile network operators to be reaching as many people as possible as it is for those of us who are trying to improve health through something like digital health.

So if there are aligned priorities then there are very good ways you can work together.  One of the ways that we've worked with mobile network operators in South Africa has been to reduce the cost of sending messages out to citizens of the country, and that's been done not in a way that prohibits the mobile network operators from making a profit, but what it does do is makes it completely free for the end user.

If it's completely free for the end user, you are reducing barriers for them to be able to access this kind of information, but the reduced cost is then something that can be brought to the table because of the increased size of access.  So the more we scale out these programmes, the more we are able to see economies of scale and the more worthwhile it then becomes for mobile network operators to engage with us.

So one of the very interesting models that's used is to reduce churn.  If people can only access information, say, using an MTN card, they are less likely to change to other SIM cards if that is the case.  So being able to align the desires of a digital health organisation or Government with those of mobile network operators is incredibly important for being able to ensure that you are working towards the same goal, but without anyone asking for any handouts because that's not going to work.

I think when it comes to strategies for decreasing inequity, the one that we really need to talk about more is about being human centred, and that doesn't just mean designing for people and occasionally having them attend a focus group.  It means designing with them and ensuring that the service is actually something that they want to use, something that they love using.

Make it easy and intuitive for them to use.  No one starts a course on how to use Facebook before they use Facebook.  We shouldn't create services that need so much upskilling, we should create services that are simple and easy to use.  You need to use appropriate language and literacy levels.  This is something that the medical fraternity often forgets about because it is a very patriarchal society.

Make it something that is easy, is at least close to free for people to access.  We find that access to a mobile device is less of a problem than the cost of data, for example.  So just because somebody has access to a device doesn't mean they are going to be able to go and look up information because they may not have data on their phones.

So you can work very closely to reduce the cost or make it zero cost, and that's really going to ensure that you reduce the barrier to access.

And then you have to try and think about the system that you are in.  By creating a digital health solution, are you overburdening the health system that already exists?  So are example, or are you reducing the burden on it?  Are you creating feedback mechanisms that you can understand what the impact is on the system itself?  Are you making sure that where a digital health solution may not be accessible to somebody, there is an alternative in place that does not rely on the digital health solution?

We can't just operate within silos, we have to think about the fact that digital health is just as much a part of health infrastructure as the physical facilities, for example.  And until digital health is seen as just as much of an infrastructure, it's going to be a fun project on the side and not something that's going to have systematic change.

So it's really important for us to think about that system.  And then recognizing biases, I think Geraldine mentioned this, very often the people who are creating digital health services are not the people that are using the digital health services.

So this goes back to why human‑centred design is important, but it's also important to understand that you will be introducing biases if the people who are building the system are not the people whoever using the system.

And so you have to look more systemically.  Look at the makeup of your team.  How diverse is the makeup of your team?  I would assume having been an electrical engineer myself, that it's probably not going to be representative from a gender or race perspective.  So look at the team you have.

How are you working to make your team more representative, and, therefore, address some of the biases that are going to be put in place by having a non‑representative team building out the systems.  So there is a bunch of things in there, but I guess in summary, build for the end user in mind.  Make it human centred.  Make it easy to use, appropriate, and intuitive.

Design with the understanding that you work within a system, and make sure that you don't have unintended consequences, and that you are always feeding back to understand what the impact on the broader system is, and ensure that you think about the biases that are going to be inherent in the fact that the people building the system are not necessarily the people using the system.

>> MODERATOR: Thank you very much.  Now moving onto Professor Gupta.  So based on your background in drafting national policies, how can Governments play a pivotal role in addressing the intersection of health equity and the digital divide particularly in the context of healthcare access for marginalized communities and also what policy measures should be prioritized to ensure equitable digital health access?

>> RAJENDRA GUPTA: This depends on the economic status of the country.  When you have an LMIC country like India.  We understand that there is a sizable population which is under privileged which is marginalized, so there is a scheme that was launched for 550 million people, and you have to understand that countries are different phases of development and they require investments on infrastructure, they require investments on health and education, and it's not possible to give the amount that the sectors actually deserve.

So what was done very carefully since I was in drafting the health policy, I played a role in that. So we carefully treaded the path of saying let's first make primary care to guarantee primary care.  And then let's convert the private centers into health and wellness centers.  So what happens is 160,000 health and wellness centers around the country offer telemedicine.

Then we created a program which is you can get a doctor consolation for free.  That is across specialties.  That is 120 million consultations.  Now, what will happen is we are putting AI and NLP in that, given that India has 36 states, dialects are different, so persons talk from a southern state talking to a doctor in a northern state, they will hear in their own language.

I think India has planned its strategy for addressing the vulnerable and under privileged sections as it charts its course of development.  One is that integrate technology and care delivery right from the primary care.  So that has proven, as I said, 460 million health records, 550 million people given insurance, which is a very decent amount, I would say, which is typically middle class would afford.

So on the policy side, on digital health India as we speak is probably the largest implementation of digital health in the country that is happening.

I would bring here one point that the Government has not only to take the stewardship, but the ownership of investing in digital health.  They would understand it very well that digital health is still figuring out the business model.  That's why you see the largest companies have withdrawn digital health and they can give talks on the forum but investments are on futuristic technologies, but the companies that went into it years ago don't exist on the map.

Governments have to play frontal role in investing like Indian Government has done they set up national Digital Health Mission, rolling it out in states and ensuring everyone has the health account number, and we were probably the first country to work towards what I have championed is that let's work to make digital health for all by 2028.  And it's for those that work in healthcare and more so in public health, 45 years back we promised health for all by 2000.

It's 23 years after the deadline that we are still not close to that.  At least we can champion digital health for all by 2028.  If that is one objective we sure sue as Governments across the world, I think a lot of issues will get addressed because there is a whole lot of planning and it is doable.

The practical part is that doctors who study in urban areas do not want to go to rural areas.  They will not.  I mean, even if you push them to do, they will find a way to scuttle that.  You way you can do is get technology into their hands with mobile phones.

The systems are fairly advanced.  Tomorrow we are hosting a session on the conversational AI in low resource setting.  You can have chat bots interacting with people addressing basic problems, and even if their problems are routine.  So we need to leverage technology not only as a policy but as a program.  There are best practices available.  India and parts of Africa have but these are islands of excellence.

Forums like this are good to see if it can be mainstreamed and we can scale those programmes.  India probably would have a good story as we speak about scalable virtual health program but the key point is that the federal Government has to be the funder for the program, and where do you start is health help line, if you want to address inequities start health help line that people can pick up the phone, talk to a paramedic and get consultation free of Government.

You connect to hospitals and tell doctors to look at time for doing digital consultations.  So these programmes multiply.  You bridge the digital divide and health and wellness centers, a phenomenal experience of 60,000 health centers.

I would say it's time for implementation for policy wide we think we know that.  If you are not into digital health, you are not into healthcare, don't talk healthcare.  That's the truth actually.  Thank you.

>> MODERATOR: And finally, drawing from your experiences in speaking about youth in cyberspace and Internet Governance, how can young advocates actively participate in shaping Internet Governance policies to ensure that digital health resources are accessible and equitable for all regardless of socioeconomic status or geographic location?  What are some successful examples of youth‑driven initiatives in this context?  Over to you.

>> YAWRI CARR: In the realm of youth in cyberspace empowering young advocates to actively shape Internet Governance is critical for ensuring digital access to digital health resources.

So young advocates it play a role in policy discussions by engaging in ways such as participating in the IGF because with this active participation, we start to break the ice in how to discuss how to have dialogues, how to ask questions and all of this activities even though they are seen daily for experienced people, for youth this is ways to break the ice and gain confidence in how to participate in public debates.

They also gain insights into current challenges and opportunities in digital health and governance.  Second formation of youth coalitions, young advocates can form coalitions or networks dedicated to digital health equity and these coalitions can amplify collective health of young people advocating for policies that prioritize accessibility in digital health.

For example, we have the intern society youth group or we have regionally different youth initiatives and a chapter could be opened so that coalitions in this specific topic can deepen into these kind of topics.

Also, third, it would be engagement with multi‑stakeholder processes.  So not just the IGF, but also in other kind of processes that are led by Governments, NGO or industry stakeholders.  And their participation ensures that diverse voices contribute to shaping policy that consider the needs of all, and it is also important that in this circumstance, so public sector and industries and NGO's can also open this kind of opportunity for youth and that they actively seek for youth that could participate into their processes as well.

Because if they don't do it in such direct way, so youth as I mentioned before, they could feel intimidated and think that they are not experienced enough to participate.

The fourth, youth led policy research, young advocates can initiate research projects to address specialized challenges of marginalized communities.  Evidence‑based research can be a tool for implicating target policy changes.  I think this is something that is a situation, it is a possibility in many countries that have the resources for research, but it's still very, it's still very behind in countries, for example, in Latin America where we don't have so much support from public foundations or from the Government to do research and we also do not have so big research focus in our university.

So I think maybe one Professor can bring this kind of perspective that can inspire the students to make a research group, for example, universities in Brazil, they have like student groups in which they meet some day of the week or some day monthly and they discuss specific topics.

So I think this is a good practice so that youth can start to create, that they can start to discuss, and that they can start to bring this to university and to other colleagues and classmates.  Of course, it would be great if some countries could also start to help other Global South countries in order that they can have more research and that the students can participate more in this kind of initiatives in their own countries.

Also innovation hubs for digital health, so, for example, in which hubs in which young innovators, healthcare providers and policymakers can create solutions together.  In this sense it would be also good to have a funding from an organisation or a company that can also collaborate so that these kinds of innovations at the end can also maybe have starting amount of financial resource so that they can start with this kind of innovation and the youth can feel that they are able to become innovators in this kind of field.

But also I think that this kind of innovation addresses gaps in digital health accessibility.  Some kind of examples of youth‑driven initiatives are, for example, digital health task forces because in separate regions youth‑led task forces focus on creating policy recommendations for integrating digital health Internet Governance frameworks.  Also youth‑led data privacy campaigns in which youth can also, for example, create dialogues in various communities and they can make, provide awareness about the importance of data privacy measures and digital melt technologies that people and common patients can also understand why it is important to protect their privacy when they go to, when they access some kind of digital health tool, and global youth hackathons for health in which there are health challenges that can develop on innovative apps and address specific healthcare needs that are specifically related in the communities of these youth.

I also consider another action, it's this movement also of paid internships that students can also have access to internships that are paid so that they can equally participate in a practical application of what they are learning at university or what they are studying.  So I think that by actively participating in these initiatives and young advocates contribute with fresh perspectives, innovative solutions and commitment to digital health equities in Internet Governance policies because they are digital natives and they also could understand rapidly how the technologies can help them but also their challenges, their issues, and they can also become more active as they are not just the future but also the present.

>> MODERATOR: Thank you once again to the panel for their responses.  Now, we will move onto the Q and A session.  If any on‑site participants would like to raise questions, feel free to walk up to the mic.

>> AUDIENCE: Hello, I'm Nicole.  In case of another pandemic like COVID‑19 nowadays, how do you think the current digital health can be developed and improved and contribute to society in recovering and ensuring each individual can receive the accurate and same medical advice and treatment without physically visiting healthcare facilities as it would be crowded with a lot of people or elderly.?

>> I think looking at the work done during COVID‑19 is a good example of how we can use digital health to address issues that come up during the pandemic.  I think one of the things that has really been a challenge in the work that we do is we speak directly to citizens and empower them in their own health.

Given that the medical fraternity is quite patriarchal that is not usually a priority.  So what we have found is that when an issue is something that happens to somebody else, then there isn't, it isn't seen as a need to provide people with the right information, but when COVID‑19 happened everybody was affected.  Nobody had the information.  It didn't matter if you were the President of the country or if you were a student at a high school, no bun had the information about the pandemic that was needed.

So we were able to use really large scale networks, things that were already there like Facebook, like WhatsApp, like SMS platforms to be able to get information to people extremely quickly, and in a time when the information was changing on a daily basis.  This wasn't something where you could take a lot of time, think through things, and put up a website and think about how things are going to be talked about.  This was happening in real time.  So you continually had to be updating things.

People continually had to get the latest information, and without that, many people, many more people would have died than did already in the pandemic.  I think what's important is for us not to forget the lessons of COVID‑19.  We very quickly forget as human beings when things go back to so called normal, we very quickly forget the lessons that we learned.  So I think one of the really important things that needs to come, that needs to continue from COVID‑19 is an understanding that knowledge is power in the patient or citizen's hands, and this isn't something that needs to be horded by the medical fraternity, that by giving information to people at a large scale, you can improve their health and you actually make your life easier at a time when you are most needed.

Digital health can't replace a healthcare professional, but it certainly can reduce the burden for healthcare professionals.  And so that's a really important thing that we need to continue to consider as we move on from COVID‑19.  I think the other thing to remember is that we built up platforms, digital health platforms that solved problems during COVID‑19, screening for symptoms, for example, gathering data that could be used for decision making, sending out large scale pieces of information to people.

Many, many people in the digital health space reacted very quickly and created incredible platforms that could be used to solving the problems during COVID‑19.  Many of those no longer exist today.  And so we need to remember that there needs to be investment in digital health infrastructure in the long term so that we don't have to spin up new solutions every time there is a new pandemic because there will be another one.  It's not something that is going anywhere.

So how are we preparing so that when the next pandemic comes, we are not having to start from scratch all over again?  I think that's something that we are very quickly have forgotten.

>> GERALYN MILLER: I would love to address that as well.  A couple of things from the pandemic, and that's a great question because as a society.  First is that there is an incredible value in these cross sector partnerships so in public, private and academic partnerships.  We saw a lot of that during the pandemic, literally to light up research on understanding the virus to do things like drug discovery. 

Some of this was Government consortium.  Other were privately funded consortium, and third class was kind of similar groups of people coming together, what I would say almost community driven groups.

So really this cross sector collaboration, that's the first thing.  The second thing is there is some good standards work that was done during the pandemic that could be brought forward.  So we saw the advent of something called smart health cards during the pandemic.

Smart health cards are a digital representation of relevant clinical information.

During the pandemic it was used to represent vaccine status.  So think of it as information about your vaccine status encode in a QR code.  There has been an extension of that, something called smart health links where you can encode a link to a source that would have a minimum set of clinical information, and it's literally encoded in a QR code that can be put on a mobile device or printed on a card for somebody to take if they don't have access to a mobile device.

A smart health card also reinforces the concept of some of the work being done by the IPS or international patient summary group.  It is a group trying to drive a standard around representing a minimal set of clinical information that could be used in emergency services.  And so some of those things that happened in the standards bodies I think were very powerful during the COVID‑19 pandemic, and would love to see more momentum around driving those use cases forward and also expanding them.  Thank you.

>> RAJENDRA GUPTA: I don't think that technology at any time failed.  Actually it proved that it was ready.  So whether you looked at the fast track development of vaccine which was collaborating searches across the world, repurpose drug use, artificial intelligence, our country used COVID app we delivered 2.2 billion vaccinations, totally digital.

So digital health proofs it is ready.  Challenges will come but technology is the only one that saved the life.  We wouldn't be sitting in this room if technology wasn't around.

The only thing we should do through forums like it is keep the momentum going.  What we want to do is forget COVID and go back to old ways.  I think under are incentives given by the Government.  There were flexibilities in terms of continuing the telehealth in the United States, that should become permanent.  Technology has already proved.  We were waiting for COVID to be shaken and start using it.  Technology is ready.  It will be ready with us for anything that comes our way.

Thank you.

>> GERALYN MILLER: I just wanted to say that I consider that in this situation of a pandemic, tell medicine and the implementation of robots as the case that I mentioned previously are of huge importance and could be very useful taking into consideration that it's very dangerous for humans to attend or to take care of people because of the contagious possibilities and risks.

I think in this specific scenario, the application of telemedicine is particularly useful.  Of course, take into consideration that it's an emergency that the robot should not be working allot.  They should also be guided by humans, but at least they are protecting also workers such as nurses that are commonly work and are not so valued in different societies because the tasks that nurses do, for example, are normally considered as dirty or not often great importance.

So I think actually these kinds of technologies can protect not just the health of the patients that are infected by COVID or other pandemic, but also the work of the medical professionals such as nurses that are normally very exposed.  And in the other side, I also remember the initiative of open science that my country, Costa Rica actually had proposed to the World Health Organization so that the initiatives, the projects and the research done in a context of a pandemic is opened and that it also is kept available for every person that's interested.

And the data can also be accessed without having to pay, without having to make a patent of that and I consider this also of extreme importance because in the case of emergency, we just don't have time for that, and we should really try to cooperate within each other and try to respond to the emergency in a holistic and collaborative way.  Thank you.

>> MODERATOR: Thank you very much for your responses.  Are there any other on‑site questions?  If not, then I'll take the question from the chat.  So what are some emerging trends and future directions in digital health literacy and what do you suggest to individuals to stay informed and up‑to‑date in this rapidly evolving field and ensuring they have accurate guidance and not outdated information.

>> RAJENDRA GUPTA: I will take that.  Because of the initiative we are learning.  So one is on the technical community side what we are doing is within the health Parliament with my team we have created co‑labs creating working with Google and others because we need to create developers to solve problems.  That's one initiative that people were enthusiastic about being technical contributors to digital transformation of health.  That's one.

The other thing and next three months we will be starting courses for students on artificial intelligence.  We want to educate them early on so they can choose what they want to do.  They will be aware of what the opportunities are, and the same way we know we are doing courses very elementary level for people to understand rather than going deep dive.  And everyone into health I would recommend that if you don't know digital health please update, whether you do a one‑week course, two week course make sure that you know digital health from an ecosystem perspective.  Thank you.

>> MODERATOR: Would any other speaker like it take the question?

>> GERALYN MILLER: A few comments on that.  I think it's always a challenge at the pace of innovation we are seeing today to keep current.  So I want to call on and acknowledge our panel here today and the people who put the panel together today and gave us this opportunity.  This is one way that the dialogue starts and that information is shared.  And so more opportunities for people of similar interest to come together I think will always help advance the state of where we are at from an understanding perspective.

So opportunities like this, training as well.  I know, and it's not just training from tech providers, it is training infused into the academic system as well.  So I would agree with what Dr. Gupta said there.  A call out to folks who put together this panel because I think this is one way that that starts.

>> MODERATOR: Thank you very much.  So we have about five minutes left, so maybe we could go with the closing remarks from each of the speakers maybe starting with Debbie Rogers.

>> DEBBIE ROGERS: I guess my closing remark would be that technology is a great enabler.  It can actually be used to decrease the inequity that we see in health but in digital literacy I am positive about the future that we see with digital health and I think Dr. Gupta is right, the technology is ready.  We have seen many case studies where things have been done at really large scale.

This is no longer a French ling area.  This is now a mature ‑‑ fledgling area, this is a mature and large scale area of practice so really excited to see what happens from this point.  And I'm excited to see that we have youth involved in this panel because, yes, absolutely, youth will be the people who will be building the next evolution in this space.

So really excited to see how that works and to see how things evolve from here.

>> RAJENDRA GUPTA: I would say that in this age where patients are more informed, if not than anyone about health conditions, about treatment options it is high time doctors know them before patients start telling them, you don't know about this, let me tell you this.  I saw this.

So one is that digital health is something that everyone who is into healthcare whether a clinician or a paramedic needs to learn this.  If you are talking on digital health scalability, scalability comes first.  So I think continuously upskill, cross skill yourself.  And lastly I must say thanks, Connie for putting together this panel discussion.

>> GERALYN MILLER: First off, I want to start by expressing my gratitude for being included in this.  It was a wonderful opportunity.  I want to echo the sentiment that youth play a huge role in this going forward and I'm very appreciative that you brought everybody together under this umbrella.

From a tech perspective, I agree with the panelists on digital health is here now.  One part that I would add to this is that when we are thinking about things, new, evolving technology like Generative AI, let's do this in a responsible way, opening the dialogue around policy discussion.  Discussion is always healthy.  Let's make sure that this technology that we are bringing to light with good intent benefits everyone.  Thanks.

>> YAWRI CARR: In conclusion, let us strive to be digital health leaders equipped not only with technical skills, but also with profound commitment to equity.  I consider of value the work of nurses.  It's very important even though the technology evolves, of course, professionals, humans will be very necessary, and it is a fact that technology can help to protect them and also the patients in situations of emergency, and also value, a value of the work of ethicists when they have something to say that they are not mis‑valued, that they can take into consideration and also when there are conflicts with, for example, a profit so that ethicists can have an opinion of that, and that they can also try to contribute in the mission of responsible AI.

So that they are not just there as a decoration, but they are actually taken into consideration.  And also, of course, the role of youth is fundamental.  As we see all of the youth‑led initiatives that could strengthen the mission of digital health literacy nowadays can in the future so developed in a very good environment that it's inclusive, that it's including marginalized communities and all of the population.

So I good that now healthcare and digital healthcare should not be more a privilege but also a right, and, yes, I'm very thankful also for the opportunity to be here and to express my opinions and to talk about youth as well.

Thank you very much.

>> MODERATOR: Thank you very much to the panel for your insightful responses, and the workshop has closed today.  Thank you very much for coming and together we hope we can create a future where digital health resources are accessible, equitable and can empower individuals to navigate their health journey confidently online.  Thank you.