Who governs when care is organised by digital platforms?

KEY MESSAGES

• Digital platforms increasingly shape how people access health services, how care is organised and how it is paid for. Many of these decisions have long been made outside government. What is changing is that platforms bring them together, automate them and create new dependencies. Governments retain stewardship of the health system and remain responsible for public health objectives, including universal health coverage (UHC), but they increasingly rely on information and capabilities held by organisations they do not directly control. 
• Governing does not mean making every decision. It means putting arrangements in place so that others' decisions support public objectives and can be examined, challenged and changed when necessary. The question is whether existing governance arrangements reach the decisions that digital platforms now make. 
• Health law and regulation have largely developed around facilities, professionals, products and purchasing arrangements. Digital platforms cut across these boundaries, connecting services and decisions that are governed separately. Each part of a care pathway may comply with its own rules, while no one is responsible for examining how the pathway as a whole affects access, quality, equity and cost.
• Digital platforms, algorithms and artificial intelligence (AI) present related but distinct governance challenges. Many arise from how platforms organise services, control information and influence decisions, whether or not they use AI. AI can speed up and scale decision-making and make the basis for decisions harder to understand or challenge. WHO guidance calls for AI in health to be transparent, explainable and accountable, and for humans to remain in control of health care decisions (WHO,
• 2021a).
• Governments have responded most readily where digital activities fit existing regulatory categories, such as medical devices, prescribing, health information systems and pharmacies. Less attention has been paid to how platforms determine who receives care, where patients are directed, which services are made visible, how payments are organised and what happens when a platform changes or withdraws its services.
• The evidence on what works remains limited. In the literature examined for this paper, we found no evaluation showing whether governance arrangements for digital platforms or AI improved access, quality, equity or financial protection in a low- or middle-income country. This reflects the limits of the evidence identified, not necessarily the absence of relevant research or practice.
• Digital technologies can support progress towards UHC and stronger primary health care when they are governed in ways that put people's needs, equity and public accountability first. This is the vision WHO Member States endorsed in the Global Strategy on Digital Health (WHO, 2021b).