Introduction
Digital health refers to a category of tools and practices that use digital technologies in health. It encompasses a wide range of phenomena, from the online sharing and consumption of health information and telemedicine platforms to the use of electronic health records, health data, and emerging technologies such as wearable devices and generative artificial intelligence in medical diagnostics and interventions (Lupton, Reference Lupton2017). The impact of digitalisation on health systems is often portrayed not as adoption of specific tools, but as a fundamental transformation that reshapes care models, data infrastructures, and power relations (Mitchell and Kan, Reference Mitchell and Kan2019). Scholarship on digital health has evolved such that digital determinants of health are now given separate attention alongside social, genetic, and environmental determinants (Chidambaram et al., Reference Chidambaram, Jain, Jain, Mwavu, Baru, Thomas, Greaves, Jayakumar, Jain, Rojo, Battaglino, Meara, Sounderajah, Celi and Darzi2024).
Health digitalisation, regardless of the scale of change, introduces new actors, risks, and challenges into health governance. Newcomers include big tech companies (Ozalp et al., Reference Ozalp, Ozcan, Dinckol, Zachariadis and Gawer2022), venture capitalists (Kampmann, Reference Kampmann2024), and digital health start-ups (Lehoux et al., Reference Lehoux, Miller and Daudelin2016), which simultaneously contribute to health digitalisation and are empowered by its unfolding. These actors are arriving at a health governance landscape, which is long shaped by professional authority, state regulation, and established private actors such as private healthcare sector organisations and civil society actors including professional organisations, health-focused non-governmental organisations, and health movements (Carpenter, Reference Carpenter2012). These actors extend beyond national actors to include intergovernmental organisations, philanthropic foundations, and bilateral development agencies (Wenham et al., Reference Wenham, Busby, Youde and Herten-Crabb2023).
Proponents expect a wide range of benefits from digital health (Meskó et al., Reference Meskó, Drobni, Bényei, Gergely and Győrffy2017; Eastburn et al., Reference Eastburn, Fowkes and Kellner2024). These include advances in diagnosis and treatment, greater continuity of care, and increased facilitation of off-site treatment (Abernethy et al., Reference Abernethy, Adams, Barrett, Bechtel, Brennan, Butte, Faulkner, Fontaine, Friedhoff, Halamka, Howell, Johnson, Long, McGraw, Miller, Lee, Perlin, Rucker, Sandy, Savage, Stump, Tang, Topol, Tuckson and Valdes2022). They also cite patient and physician empowerment, reductions in errors and waste in healthcare delivery, and advances in public health through better data and surveillance (Abernethy et al., Reference Abernethy, Adams, Barrett, Bechtel, Brennan, Butte, Faulkner, Fontaine, Friedhoff, Halamka, Howell, Johnson, Long, McGraw, Miller, Lee, Perlin, Rucker, Sandy, Savage, Stump, Tang, Topol, Tuckson and Valdes2022). Such perspectives align with venture capitalist Marc Andreessen’s (Reference Andreessen2023) Techno-Optimist Manifesto, in which he asserts that “Medicine […] is in the stone age compared to what we can achieve with joined human and machine intelligence.” Techno-optimistic discourses are also present in the policy field, as exemplified in the UK’s digital health policies (Rich et al., Reference Rich, Miah and Lewis2019), which frame these technologies as a panacea for health systems.
Others have highlighted the need for caution when assessing the purported benefits of digital health. Concerns include the potential spread of misinformation (Borges do Nascimento et al., Reference Borges do Nascimento, Pizarro, Almeida, Azzopardi-Muscat, Gonçalves, Björklund and Novillo-Ortiz2022), the expansion of various forms of surveillance (Lupton, Reference Lupton2012, Reference Lupton2016), and the shifting of responsibility for health maintenance onto patients (Lupton, Reference Lupton2017). Other issues relate to existing digital divides leading to access and health inequities (Richardson et al., Reference Richardson, Lawrance, Schoenthaler and Mann2022), cybersecurity and data privacy concerns (EPHA, 2020), negative public attitudes towards technologies that are seen as intruding on the patient–doctor relationship (Thornton et al., Reference Thornton, Horton, Hardie and Coxon2023) and the deskilling of healthcare workers as a result of overreliance on technological tools (Petersen, Reference Petersen2019).
As enthusiasm for digital health among some stakeholders contrasts with others’ concerns that it may exacerbate existing problems or generate new ones in health systems, policymaking in this landscape becomes difficult. This heightens the importance of global health institutions, such as World Bank (WB), World Health Organisation (WHO), as well as United States Agency for International Development (USAID), which has since been disbanded, as their ongoing and completed work can help governments make sense of this evolving landscape and develop their own approaches to navigating it. It is in this context we examine how digital technologies in health and framed within the global health policy sphere.
Against this background, this article addresses the following questions: How do global health institutions construct health digitalisation in their discourse? Do they predominantly endorse techno-optimistic narratives, or do they critically interrogate the risks and political implications of digital health? From 72 policy documents on digital health published by WB, WHO, and USAID, we purposefully selected three for close analysis. These were chosen to reflect distinct institutional approaches to health: WB embodying a multilateral development perspective, WHO representing a health-focused multilateral agency, and USAID exemplifying a bilateral development approach. This paper examines Digital-in-health, published by WB in 2023; Global strategy on digital health 2020–2025, published by the WHO in 2021; and A vision for action in digital health, published by USAID in 2020.
Politics and ideas in global health
Health is a political matter (Bambra et al., Reference Bambra, Fox and Scott-Samuel2005), as are digital technologies (Winner, Reference Winner1980). However, the dominant discourses of health digitalisation are technocratic (Petersen, Reference Petersen2019). In this paper, we adopt Hay’s (Reference Hay2007, p. 77) definition of politics as “the capacity for agency and deliberation in situations of genuine collective or social choice,” and argue that such technocractic framings obscure the political by limiting digital health to matters of technical expertise, thereby downplaying questions of political agency, power, and choice. Given the extent to which digitalisation has captured the imaginations of policy actors, health professionals, and the public, we believe that it is necessary to reintroduce this political dimension into digitalisation discourses.
The Political Determinants of Health (PDoH) approach serves as a useful signpost that can help us to explore the content of global health institutions’ digital health discourses. This approach maintains that politics has traditionally remained peripheral (Brooks et al., Reference Brooks, Godziewski and Deruelle2024) or been subsumed in the social determinants of health (Rigney and Bignall, Reference Rigney, Bignall, Sendall, Mutch and Fitzgerald2024) as a dimension in explanatory models of health. In response, PDoH seeks to centre political determinants as one of the “causes of the causes” (McKee, Reference McKee2017). However, much of the empirical PDoH literature focuses narrowly on formal political processes (Mackenbach, Reference Mackenbach2014). While these processes are undoubtedly important, it is equally crucial to examine the ideas that actors develop and the broader policy paradigms that shape discussions within these processes. We, therefore, advocate for a broader perspective on PDoH, one that considers the ideas and paradigms, that inform, and often constrain, what actors express within formal political processes.
We combine PDoH with the ideational approach to policy analysis, treating digital health as a policy idea. Ideational scholarship brings the role of ideas, or “the changing and historically-constructed ‘causal beliefs’ of individual and collective actors” (Béland, Reference Béland2016, p. 736), to the forefront of public and social policy research. This scholarship highlights that ideas and the discourses built around them play a central role throughout the policy process by shaping how problems are defined, why they require policy action, and what policy responses are deemed appropriate to address them (Béland, Reference Béland and Greve2018).
Health digitalisation constitutes a policy idea around which global health institutions produce discourses that operate as political determinant of health. Digital health discourses these organisations produce, and the ideas expressed in them are both an expression of the goals their power is exercised towards realising and a source of that power. Ideas play an important role in the work of global health institutions as they constitute “a crucial vehicle through which they can influence domestic policy development” (Béland and Orenstein, Reference Béland and Orenstein2013, p. 127). The recognition of the expertise and competence of these organisations by actors with decision-making power is a key source of their authority and influence (Barnett and Finnemore, Reference Barnett and Finnemore1999; Ecker-Ehrhardt, Reference Ecker-Ehrhardt2012). The importance of the global health institutions’ ideational power is particularly evident in the mid-2020s, amid broader hostility towards international governance platforms and organisations, and increasing funding constraints (Dakowska, Reference Dakowska2022).
The discourses of global health institutions are most often embodied in the impressive variety and volume of documents produced by them. These documents do not simply convey information but act as a “nexus of social practice” (Freeman, Reference Freeman2006): they generate, reproduce, translate, and set in motion vocabularies and ways of thinking. As per the mandates of the organisations producing them, they are often meant to act as a bridge between research and policy, interpreting data and findings into policy recommendations to be taken up by governments or other actors.
A key strategy through which global health institutions assert relevance is by technising policy domains (Louis and Maertens, Reference Louis and Maertens2021), thereby engaging in depoliticisation. Depoliticisation has been pointed to as “one of the most, if not the most, important devices for understanding contemporary patterns of governance through advanced industrial societies” (Foster et al., Reference Foster, Kerr, Byrne, Flinders and Wood2015, p. 116). Despite this salience, the same authors argue that there is little consensus around the meaning of the term.
Depoliticisation is meaningful only when situated in its historical and contextual setting; outside of such grounding, the concept becomes analytically hollow. Furthermore, the ideas of depoliticisation and politicisation are always based on a specific understanding of politics (Hay, Reference Hay2014). The first wave of depoliticisation scholarship, for example, emerged in response to the rise of neoliberal hegemony in the 2000s, with technocratic economic policymaking at its centre. In this study, we examine depoliticisation in the context of techno-optimism surrounding health digitalisation in the early 2020s.
In the context of this study, we find Wood and Flinders’s (Reference Wood, Flinders, Wood and Flinders2015) broader approach to depoliticisation most useful. They define a discursive depoliticisation that “occurs when the debate surrounding an issue becomes technocratic, managerial, or disciplined towards a single goal, and hence changed in content” (p. 34). In the context of global health institutions’ digital health discourses, we believe depoliticisation operates through a tacit denial of the political relationships and situations of social choice inherent in and built by digitalisation processes, in favour of a technocratic presentation.
Louis and Maertens (Reference Louis and Maertens2021) identify three depoliticisation practices that international organisations commonly employ: expert-based, format-based, and time-based. International organisations use expert-based practices to depoliticise issues by framing them in technical terms. Through format-based practices, they depoliticise by over-abstracting and stripping issues of context. With time-based practices, they do so by manipulating the timing of discussions, decisions, and implementation, thereby diluting political momentum and undermining political interest. We employ this typology as a framework for our analysis.
Methods
This study offers an exploratory, qualitative analysis of digital health discourses in global health policy in the early 2020s. It does so by using Political Discourse Analysis (PDA) (Fairclough and Fairclough, Reference Fairclough and Fairclough2012) to critically and closely review select policy documents produced by WB, WHO, and USAID. It focuses on the substance of digital health discourses in flagship reports, leaving their production, reception, and use by different policy actors for future research.
The document selection and analysis process were undertaken iteratively. First, we read and discussed policy documents from various actors to familiarise ourselves with digital health discourses. We then chose to focus on WB, WHO, and USAID as examples of global health institutions that engage closely with digital health discourse. As discussed in the introduction, we selected these three organisations to reflect the diversity in their mandates.
We developed and implemented a systematic procedure to create the data corpus using three inclusion criteria: the document is published by WHO, WB, or USAID, it is published in the last 5 years (between January 2019 and June 2024), and it explicitly uses digital health either in the title, subtitle or as one of its major sections. To access documents, we used the official websites of these organisations. Although the review focused on 2019–2024 publications, three documents, namely the WB’s Data governance in health (2025), WHO’s Monitoring and evaluating digital health interventions (2016), and the 71st World Health Assembly agenda on digital health (2018), were included due to their direct relevance. This produced 72 policy documents (List of documents can be found in Supplementary Appendix A). The formats and purposes of these documents range from framework documents such as global strategies, policy briefs, technical papers, and monitoring reports. We then read each document in this corpus to select one document from each organisation for closer analysis. The choice to select one document was based on the necessities of our chosen method; PDA requires close reading, deconstruction, and reconstruction of texts, definitions of which follow shortly. We chose the documents that most clearly embodied each organisation’s digital health vision.
We then analysed these documents using PDA. In their elaboration of this method, Fairclough and Fairclough (Reference Fairclough and Fairclough2012) put forth that political texts can be seen as a type of practical argument, and that analysing them as such allows researchers to uncover how the text constructs circumstances (problems), goals, values, means, and claim for action (solution). The definitions of these components are provided in Table 1.
Table 1. Components of practical arguments, adapted from Fairclough and Fairclough (Reference Fairclough and Fairclough2012) by the authors.
This method helped us to deconstruct, then reconstruct and summarise the argument of each organisation’s digital health discourse around PDA’s key analytical components. By deconstruction, we refer to breaking the document down around its main claim for action, examining how it justifies digitalisation in health, what policy designs are promoted, and by whom and through what mechanisms implementation is pursued. By reconstruction, we mean synthesising the document around the claim for action identified at the deconstruction stage, organising the analysis into its circumstances (problems), goals, values, and means. To present the reconstruction of the claim for action in each document, we used extended tables of the reasoning in the selected policy documents, developed using direct quotes from each report (tables are provided in Supplementary Appendix B).
Visions of digital health: Why, how, and by whom?
In this analysis, we treat discourses as articulations of the digital health visions of three selected global health institutions. Our analysis addresses questions corresponding to these three components of digital health discourses: Why do global health institutions claim that digitalisation in health is necessary? How do these organisations promote particular policy designs to put health digitalisation into practice? By whom and through what mechanisms (e.g., consultation, engagement, and participation) do these organisations promote the implementation of health digitalisation?
At the reconstruction stage, we derived the following summary of the core arguments presented in the three policy documents. These include all components of a political argument in PDA approach and represent the reasoning behind the policy document at hand in our own words. The article then continues with a focus on the questions of why, how, and for whom.
WB argues that in the face of continued and compounded challenges, and cultural and technological changes [circumstances], stakeholders must adopt a “digital-in-health” approach focused on prioritisation, integration, and scalability in digital health interventions [means-goal] to deliver new, more, better, and seamless services [goal] that are inclusive, equitable and fair [values].
The WHO argues that while digital health technologies provide new opportunities for extending health services to more people, the current state of ill-coordinated or disjointed digital health initiatives have led to poor service delivery [circumstances]. National governments must develop and implement digital health strategies to build scalable, interoperable, secure, and integrated digital health systems [means-goal] that are people-centred, ethical, transparent, equitable, sustainable, and reliable [values] to strengthen health systems and achieve the vision of health for all [goal].
USAID argues that legacy global development funding practices in digital health involved investment in siloed and disjointed systems that produced subpar results for health systems, in which they were implemented [circumstances]. Funders must change their funding approach to focus on strategic, systems-level planning for the use of digital health technologies [means-goal] to sharpen investments, improve health outcomes and make people more self-reliant [goal] in a way that puts stakeholders in partner countries at the centre of decision making and is in line with US values and national security [values].
Why digitalise health?
The reports frame the impetus behind digitalisation in connection to a variety of values and expected outcomes. There are two important points of consensus that can be found here. The first is that overall all three documents are broadly in agreement in their positioning of digital health tools as a way of creating integrated health systems that can provide a continuum and higher quality of care. However, it is possible to speak of differing approaches in the specifics of the role digital health will play to achieve this, and what other benefits it may have. The second point of broad agreement is the inevitability of the digitalisation of healthcare. This is more explicit in WB’s argument and more tacit in the texts produced by the WHO and USAID, but present in all three none the less.
A major point made in favour of digital health is its potential to solve protracted challenges facing health systems. Interestingly, the way WB presents digitalisation in this context is similar to the presentation of these challenges: digitalisation reads closer to an external factor that must be responded to by governments and health systems than a process that they bring about. Health system transformation is framed in biological terms – “like the human body, health systems are involved in constant change: cycles of organic growth, adaptation, stagnation, apoptosis, and renewal” (WB, 2023, p. 48) – and described as “characterised by rapid technological advances not seen in a generation” (2023, p. 49). Written exclusively in the passive tense, WB’s framing of the ongoing digital and “existential” (2023, p. 48) transformation in health systems does not delineate causation clearly. “Cultural transformation in healthcare,” which is defined as “person-centered healthcare that embraces new medical and health discoveries, the integration of once separate disciplines, and an expanded understanding of what is necessary to live life well” (2023, p. 48), is presented almost as a fait accompli or a rising tide that must be kept up with.
In contrast to the existential bent of WB, the WHO primarily frames digitalisation in an instrumental way. Digital health is an “essential enabling factor” (WHO, 2021, p. 7) that will help achieve WHO’s triple billion targets: 1 billion more people benefitting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being. At the national level, the use of appropriate digital health technologies is presented as a key component of national health strategies, and the focus is on the potential to “strengthen health systems through the application of digital health technologies for consumers, health professionals, healthcare providers and industry towards empowering patients and achieving the vision of health for all” (2021, p. 11). In other words, the desirability of digital health stems from its role as a tool rather than some inherently transformative potential. While WB treats the transformative potential of digital health as end in and of itself, WHO approaches this with more scepticism, yet maintains an optimistic outlook, noting that digitalisation “can be disruptive; however technologies … have proven potential to enhance health outcomes” (2021, p. 4, emphasis added).
Differently from both WB and WHO, USAID points to self-reliance of aid recipient countries and their health systems as a motive. Although not defined explicitly in the text, self-reliance takes up important space in its background. The document is presented with the subtitle “Accelerating the journey to self-reliance through strategic investments in digital technologies” (USAID, 2020a, 2020b). “The journey to self-reliance” refers to a reorientation of USAID “work toward a time when foreign assistance is no longer necessary” (USAID, 2017). Taken together, the four strategic priorities outlined in the report are meant to centre national stakeholders, particularly governments, in a way that facilitates a rationalised and planned digitalisation that will promote “financial sustainability, … and the skilled management and use of digitized data by governments, civil society, and the private sector in support of their own health and development objectives” (2020, p.25).
The presentation of the justifications of digitalisation in these documents exemplifies two of Louis and Maertens’ (Reference Louis and Maertens2021) depoliticisation practices. The first is through format-based practices. The term digitalisation includes an immense range of practices and tools, each with particular benefits and drawbacks, arguably to the extent that it is unreasonable to make catch-all statements about the implications of “digitalisation” without specifying the particular tools in question – the impact of smartwatches capable of monitoring health data and the impact of automated diagnostic tools, for example, will not be the same. The reducing of this multiplicity into the broad concept of digitalisation serves to at best delay and at worst obscure questions around the impact of specific tools and how they will transform healthcare.
The second occurs through practices asserting expertise and providing technical interpretation. Digitalisation is mostly presented as an inevitable social transformation, framing the question as not whether to digitalise, what to digitalise in health systems or what to leave un-digitised. This framing constrains political choice over the necessity and desirability of digitalisation across different aspects of health systems, thereby effectively depoliticising the issue. USAID discourse is the only exception, overtly highlighting the strategic decisions required for health digitalisation and acknowledging that otherwise the process could fail to deliver benefits.
How to digitalise health?
The three documents presented their visions for the implementation of digitalisation with varying levels of detail and specificity. WB’s portrayal of digitalisation as a transformative force is apparent in the aspects of design presented in the document. It differentiates between three modes of digitalisation on an evolutionary continuum in three stages, moving from “digitalisation” (the use of digital tools as a way to facilitate the normal business of a health system with a focus on data, reporting and process efficiency) to “digital for health” (the integration of digital tools into clinical and administrative processes, where digital technologies become part of daily operations), and further to “digital-in-health,” where “technology and data become indistinguishably embedded and assimilated in transformed health systems and healthcare” (2023, p. 56). “Digital-in-health” represents a dual expansion of the role of digital technologies. The functional role of digital technologies expands to encompass the entirety of the health system, and the ontological role expands from instrumental to a more foundational role guiding the ethos of new health systems.
The WHO provides guiding principles, strategic objectives, a framework for action, and implementation principles to advance digital health at national and global levels. The four guiding principles are to acknowledge that institutionalisation of digital health in the national health system requires a decision and commitment, recognise that successful digital health initiatives require an integrated strategy, promote the appropriate use of digital technologies, and highlight the urgent need to address the major impediments faced by least-developed countries implementing digital health technologies. The four strategic objectives are to promote global collaboration and advance the transfer of knowledge, support the implementation of national digital health strategies, strengthen governance for digital health at global, regional, and national levels, and advocate people-centred health systems that are enabled by digital health.
The main concern of USAID’s Vision is to move donor practices away from legacy practices that invested in disjointed, siloed digital health interventions towards a holistic approach to health systems that considers national digital health strategies, integration of digital health interventions, and the sustainability of investments and interventions. To do so, the report puts forward four interconnected strategic priorities: advancing and supporting national digital health capacity, supporting and aligning investments to strong national digital health strategies and implementation plans, supporting the development of and aligning investments to national digital health architectures (which are defined as blueprints used to design how, in a specific context, digital applications and other core functionalities will interact), and supporting and propagating global goods.
There are shared aspects in how the three documents address how to implement digitalisation. The first is the focus on national strategies. In all three documents, governments – with input from relevant stakeholders – are tasked with creating and committing to such a strategy. This type of central planning is given paramount importance. Committing to a strategic plan is seen as the way to avoid siloed and fragmented digital health systems, which is problematised across all documents.
Another similarity is the centring of principles over and partially in place of, policy design. Overall, certain principles stand out key to all three documents. The first is the focus on strategic approaches to digitalisation, guided by a government. The second, and the reason for the first, is interoperability, coordination and integration throughout the digital health infrastructure and overall health system. The third is accessibility and equitability, which is expressed both as a principle that should guide the digitalisation process and an outcome of it. The tendency to lean on principles as proxy for policy design is most clearly identifiable in WHO’s The Global Strategy, which not only begins and ends with the explicit elaboration of principles but also formulates the strategic objectives and framework for action in a way that points to a principles-first approach. While WB and USAID do not explicitly label their recommendations as principles, the formulation of these recommendations is also similar in that, for the most part, they function primarily as principles for policy design.
The principles-first approach of the documents is also visible in the choice of indicators for success. All three organisations endorse the Global Digital Health MonitorFootnote 1 as a tool for measuring digital health maturity. Built on the WHO/ITU eHealth Strategy Toolkit framework, the Monitor uses a series of 23 primary indicators to measure national digital health maturity (Global Digital Health Monitor, n.d.-b). The indicators are grouped under seven areas: Leadership and Governance, Strategy and Investment, Legislation, Policy and Compliance, Workforce, Standards and Interoperability, Infrastructure, and Services and Applications. While the indicators are comprehensive, they are also formalistic, with most basing their score on the existence of, for example, a national digital health strategy, rather than the substantive content of said strategy, or how and to what extent it is being implemented. This creates gaps between what is intended to be measured and the reality of what is actually measured.
These dimensions of the documents continue the depoliticisation practices identified in the previous section. The focus on principles abstracts the issue of policy design and implementation capacity, and strips away the particularities of local context and power asymmetries in digital health landscape. This context is immensely influential in determining the actual outcomes of digitalisation. Just as specific digital tools and practices will have different implications, the impact of a specific tool will also be shaped by the context in which it is deployed: a digital health record system deployed in a health system where access to electricity and internet is unreliable will not provide the same benefits as one implemented in a context without these issues, and moreover, may lead to disruptions in access and care.
Expert-based depoliticisation is undertaken in three ways here. The first is through the presentation of the content: these lists of principles and recommendations are offered as expert guidelines for how to best implement the necessary changes, originating from a position of authority conferred through the identity of the global health institutions. As such, although informed by normative values and frameworks, they are given the air of technical knowledge. The second is through the use of technical indicators. By suggesting that digitalisation in health in various country contexts should adhere to the Global Digital Health Monitor indicators, all three documents and the global health institutions that produced them implicitly circumvent political choices regarding how health digitalisation should occur in different contexts. The third is through the focus on national governments as drivers of digital transformation, a matter that is discussed in more detail below.
Who should carry out health digitalisation?
The three documents are strikingly similar in how they position actors in the process of digitalisation. Through the focus on national strategies, all three documents centre national governments as the primary driver of digitalisation. Virtually all of WHO’s recommendations are directed at Member States; WB speaks to industry actors to some extent but can still be seen as primarily prescribing recommendations mainly to governments; and while USAID is an outlier in speaking directly to development funders, two of its four strategic priorities are focused on aligning investments to national health strategies and architectures, and a third is focused on assessing and advancing national capacity, particularly in leadership and governance.
This focus on national governments can be related to two of the principles common to all three reports, strategicness, and integratedness. As stated above, the use of national digital health strategies is seen as necessary to avoid the creation of fragmented and siloed digital health systems. The use of these strategies also makes it possible to align the design of digital health systems and policies to specific needs of those who will be using them, rather than providing a one-size-fits-all model.
The second similarity is that while the government is centred, a broad range of other actors are given roles in the process. The creation of strategies is meant to be a participatory process, with input from all actors who may engage with the health system; for example, WHO states that national strategies are meant to be developed “through an all-inclusive multistakeholder approach” (2021, p.21), and WB points to end users co-designing digital health tools and interventions. However, except for government and industry actors, these roles – primarily given to patients, and civil society – are largely in name only. They are framed as being acted upon rather than acting; they are involved in the development of strategies by the government, which considers their needs and desires in policy and intervention design; and they are meant to be trained in digital literacy and the use of the necessary tools by experts. Their involvement in the process is passive and peripheral, with little opportunity for more direct involvement. This involvement is nonetheless tied to promises of empowerment, as the use of digital health tools is seen as a means of empowerment in and of itself. The sidelining of medical professionals and health workers – both as individuals and in organised forms such as trade unions or professional organisations – can also be seen as running parallel to this vision of digitalisation that argues for a healthcare process that is prima facie patient led and managed, decreasing the control and primacy of these actors over the process.
While the documents position private industry as an important partner and potential source of innovation, there is little to no mention of how the relationship between private and public actors should be structured, or of the potential implications of monopolies or oligopolies by technology companies creating proprietary digital health tools. WB’s Digital-in-health is, to some extent, an exception to this, as it maintains that “the government must be able to monitor and measure contract delivery and solution performance against expectations” (2023, p.134), but it offers little further guidance on the concrete governance design and the feasibility of implementation.
The documents also converge in their recommendation of international cooperation and the use of global digital goods. In this context, global goods refer to digital health tools that are adaptable for use in other locations or contexts. These can be software, services, or content such as training materials or guidelines. Global goods are not always free of cost or proprietary content, but are often open source and easily adaptable to specific contexts. WHO notes that low- and middle-income countries (LMICs) may face difficulties implementing appropriate digital health technologies and argues that “exploring the potential of global solutions and shared services should be considered” (2021, p.10). This positions the development of global digital goods as a way to leverage international cooperation and knowledge sharing to bolster the development of digital health in LMICs. This reasoning is echoed by USAID, which explicitly recommends the use of such goods. While WB does not touch on global goods specifically, it does recommend global and regional cooperation and solidarity in pursuit of national digitalisation efforts.
In the previous section, we argued that the positioning of national governments as drivers of the digitalisation process was a form of expert-based depoliticisation. This is perhaps a particularly bold claim – by many approaches to depoliticisation, it could be argued that placing digitalisation so squarely in the hands of the government itself is politicising, rather than the opposite. The operation of this mechanism is fully understandable when all three aspects of the documents discussed in these findings are considered together. We may trace the arguments presented in these documents so far through the steps of first presenting digitalisation as an inevitable process that must be harnessed for better health systems, and then framing approaches to how this harnessing may be accomplished as a primarily technical process that is best managed in the realm of technical expertise. In this context, the role of the government as controlling the process can also be understood as a primarily technical one. The government is at the centre of this process not because it is perceived as being a political one, but because it is identified as the sole actor with the requisite influence to ensure the creation of integrated and interoperable systems, the technical prerequisites for the purported benefits of digitalisation. The role of the government in this process is tacitly framed as a technical and managerial one.
Let us return to Hay’s (Reference Hay2007, p. 77) definition of politics as “the capacity for agency and deliberation in situations of genuine collective or social choice.” Not only is the role of the government in this process not envisaged as one that is meant to open the process to public deliberation and political accountability, the sidelining of other stakeholders in the process makes the depoliticisation of digitalisation even more evident. The government is meant to guide this process based on expert advice, whereas other actors, are excluded from deliberations on whether and how digitalisation should be realised.
Discussion
We have analysed the flagship policy documents produced by WB, WHO, and USAID to examine their digital health discourses. We have paid specific attention to the justifications, (policy) designs, and interactions (among different stakeholders) presented in the documents. Although the visions presented differ in certain ways, it is possible to provide a loose sketch of a policy vision that is common to all three documents: a techno-optimist depoliticisation. All three organisations present a version of digital health that is inescapable and potentially transformative. They use principles-first discourses, where the digitalisation process is expected to be led by national governments with the nominal participation of other policy actors, including medical professionals, health workers, patients, and their organisations.
All three documents position national governments as the desired driving force behind digitalisation. However, only USAID’s Vision explicitly brings up digital authoritarianism as a threat. It is also worth noting here that USAID’s dissolution under second Trump presidency has thus created a notable gap in the global health and development landscape by removing an influential actor that explicitly addressed such concerns. The collection and consolidation of health data creates a treasure trove of data that governments can use to entrench their power and control. Such data can enable increased surveillance, manipulate access to healthcare and other services, facilitate ethnic and racial profiling, help target procedures such as abortions and gender reassignment, and target marginalised groups. Except for broad notions of data governance and security, framed mostly in terms of malicious external actors, both WHO and WB sidestep this issue completely, leaving gaps in how potential infringements of rights and liberties can and should be addressed. The aforementioned sidelining of non-state actors becomes particularly striking when considered together with the central role assigned to the government, which implicitly concentrates authority. Civil society, professional organisations, trade unions, health movements, and patient advocates could be expected to act as a vital check on the power of governments (and private digital health sector), but are only thought of as the end users of digital health tools and interventions. This is where the implications of the depoliticised approach to health digitalisation become particularly pernicious.
The lack of further elaboration on the role of the private digital health industry is also striking. WB’s elaboration on nimble public-private partnerships is primarily framed in terms of the most effective way to structure such partnerships to avoid stagnation, wasted resources, or being locked into arrangements that are not providing results, rather than a serious engagement with public governance of the private digital health sector. Digital health tools and practices involve the generation and utilisation of a great deal of sensitive personal data and infrastructure. Control over this data and infrastructure is likely to prove very lucrative financially, politically, and socially. The past two decades have seen increasingly urgent concerns raised about the role of private industry actors who have control over most if not all of the digital tools used in a rapidly digitalising world and how this control is related to the outsourcing of key governmental functions to private industry and an attendant hollowing out of core capacities of the state (Schaake, Reference Schaake2024). Given this context, careful consideration of the exact role private digital health industry plays would be warranted.
The principles-first tendency of the documents deserves further consideration as a demonstration of format-based depoliticisation. This likely stems in part from the focus on national strategies, which centres the choices of national governments and leads to the documents functioning more as a series of guiding principles and considerations that are meant to shape these national strategies without prescribing specific policy design. In addition, the broad and global nature of the audiences addressed by the reports arguably makes it difficult and impractical to provide more specific and concrete components of policy design because of the varied nature of local needs and circumstances. However, the use of global strategy documents and uniform success indicators reflects a deliberate choice by these organisations, which limits the ability of the documents to address the political dimensions of digital health policy development and the concerns these raise in different contexts.
The construction of digitalisation as a broadly inevitable and necessary transformation that must be addressed using technical strategies shapes the discourses in question in technocratic terms. The nature of these global, broad documents further compounds this technocratic inflection. As stated above, part of the function of the document produced by these policy actors is to bridge the gap between research and policy, and act not only as a vehicle for information but also as a nexus of power. Understanding how these documents operate in their dissemination of ideas is important when considering how their recommendations should be or are taken up for implementation; and it is vital to be cognisant of how digital health discourses of global health institutions can contribute to the depoliticisation of an already broadly technocratic field.
Conclusion
The originality of this work lies in its treatment of digital health as a fundamentally political domain of global health. This article demonstrates how digital health discourses produced by global health institutions actively engage in discursive practices of depoliticisation. By analysing how risks and challenges are rendered invisible, the article introduces a more power-conscious, grounded, and context-sensitive approach to thinking about digitalisation in health as a political sphere, challenging the prevailing techno-optimistic discourses that dominate global health policy circles.
The significance of this work lies in its unique and critical contribution to burgeoning literature on digital health. By bringing political analysis into a field that is often approached in technical terms, the article invites scholars of health politics, policy, and governance to engage more closely with digital health, and suggests that this area would benefit from analytical tools commonly used in the ideational, PDoH, and depoliticisation scholarships. At the same time, the article speaks to researchers working in digital health across health sciences, health services research, and management studies, encouraging greater attention to the political, institutional, and governance conditions that shape whether and how digital health can serve public interests.
A further takeaway from this analysis should be the difficulties and drawbacks of speaking of “digital health” as a whole. Like global health institutions, much of the scholarly community addressing digitalisation, including the authors of this article, is willing to speak of it in broad terms. This is a tendency that reflects the practice of depoliticisation by abstraction. Although not every instance of this is depoliticising, it is still worth nothing that such broad discussions are limited in their ability to capture the nuances of digital health, digitalisation in health, and their implications. Even if this may come at a loss of comprehensiveness, focusing more closely on specific tools and practices and their implementation in particular circumstances will provide deeper insight as the critical digital health literature develops.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/ics.2026.10089.
Data availability statement
All data analysed in this study are publicly available policy documents.
Acknowledgements
We thank the Fondation Brocher for providing the time and space to collaborate during our stay. We further thank University of Southern California (USC) Annenberg for its support. One of the co-authors, Tugba Zeynep Sen, benefited from support provided by the USC Annenberg Graduate Fellows Journal Article Workshop. We wish to express our sincere thanks to Talita Cetinoglu for her valuable insights during our discussions.
Funding statement
This research did not receive any external grant. We acknowledge Fondation Brocher for providing a research stay that facilitated this work. We also acknowledge that Tugba Zeynep Sen benefited from support provided by the USC Annenberg Graduate Fellows Journal Article Workshop.
Disclosure statement
The authors declare that they have no conflicts of interest.
Ethical approval and informed consent statements
This study did not involve human participants and therefore did not require ethical approval or informed consent.
Open access
