Gender Dynamics in Digital Health: Overcoming Blind Spots and Biases to Seize Opportunities and Responsibilities for Transformative Health Systems

"Gender inequalities operate in health systems at multiple levels and must be addressed at individual, community, program and policy levels if digital health is to achieve its full potential."

This commentary highlights key gender dynamics in digital health, including blind spots and biases, as well as transformative opportunities and responsibilities. It draws on experiences from research projects carried out under the Strengthening Equity through Applied Research Capacity building in eHealth (SEARCH) cohort, funded by Canada's International Development Research Centre, in Bangladesh, Burkina Faso, Ethiopia, Kenya, Lebanon, Peru, and Vietnam. These projects examined if, how, and in what contexts digital health can meet key challenges faced in delivering quality health services and inform policy discourse to ensure that no one is left behind.

In being blind to social relations, digital health interventions may miss key intended populations. The analysis found that women in low-income countries, while not a homogenous group, are overall far less likely to own or have independent control over mobile and wireless technologies than men. As a result, men can sometimes dominate digital health programmes, even if they were primarily intended for women. The failure to understand existing gender dynamics when designing digital programmes may also potentially place women at risk. For example, despite their potential to increase women's self-efficacy to breastfeed newborns or practice family planning, digital health programmes that provide mobile health information content to pregnant and postpartum women may threaten broader familial relationships if the messaging empowers practices in conflict with prevailing social norms. One way to prevent such issues from occurring is to foreground the voice and agency of marginalised populations in shaping digital health programme design and delivery strategies.

Despite these risks, a systematic literature review found that digital health initiatives can improve couple communication, women's decision-making, social status, and access to health resources. The latter is particularly important for remote rural areas. Apart from addressing gender dimensions on the demand side of health care services, digital health solutions also have positive implications for supply-side gender dynamics. Several examples from the SEARCH cohort are provided in the commentary to illustrate this.

To further prioritise and strengthen gender analysis in the projects and across the SEARCH cohort as a whole, the commentary recommends:

• Involve men, leaders, decision makers, and gatekeepers and garner their support for the overall digital health initiative, and also their gender transformative potential.
• Explore how gender intersects with other social stratifiers to influence experiences of marginalisation, including among frontline workers.
• Provide sustained support over time, across health system stakeholders and levels, to ensure that transformative change with one set of actors is replicated and reinforced elsewhere in the health system.
• Given that there is no prescriptive formula or checklist, be aware that incremental learning and reflection is required to nurture ownership and respond to unanticipated reactions over time when transforming gender and its multiple intersections with inequality.

As noted here, the evidence base on how digital health addresses gender relations and supports gender equality is relatively thin. The authors call for ongoing monitoring, evaluation, and research in this area, posing several key questions. For example: How can use of digital health impact on and change existing gender power dynamics and relationships among key gender stakeholders at home, in communities, markets, or health services? What kinds of engagement with those who enforce gender power relations are necessary to transform gender relations in a positive way that increases both the effectiveness of digital health and improves the status of those marginalised by gender power relations?

In conclusion: "Ongoing engagement with intended beneficiaries to understand and respond to the social relations and contexts they are embedded in, sustained over time with critical review and reflection, is vital for ensuring that digital health solutions actually support gender equality, rather than assume to do so."