Digital health is an important frontier in innovative health care. We speak with a digital healthcare leader, the CIO of the World Health Organization, to learn what's happening in this crucial field.

Bernardo Mariano, Junior is the Chief Information Officer at the World Health Organization. In this role, he is responsible for coordinating WHO’s digital health vision and strategy. He leads and oversees all aspects of information technology, data security, and enterprise applications, to ensure that WHO advances its digital capabilities to deliver its global health goals effectively.

Prior to joining WHO, Mr. Mariano was the Senior Regional Adviser to the Director General at International Organization for Migration (IOM), where he was responsible for strategic oversight of IOM’s activities within the Sub Sahara Africa region and advised on emerging trends and developments including regional and national policy initiatives. Mr Mariano also held the position of Regional Director for the Southern African Office, where he was responsible for the management of the IOM field office operations, overseeing activities in 15 countries. Before that, he held two strategic roles at IOM as the Chief Information Officer (CIO) and Director of Information Technology and Communications.

Transcript

This transcript has been lightly edited.

Introduction

Michael Krigsman: We're exploring digital health, the digital transformation of healthcare with a senior leader of the World Health Organization. Bernardo Mariano is Chief Information Officer and Director of Digital Health and Innovation at WHO.

Bernardo Mariano: The World Health Organization, which I will refer to as WHO, is a 194-member-state organization with over 150 offices around the world. Our main strategic targets for the next 4 years, up until 2023, are centered around what we call the triple billion target.

The triple billion target basically is the aspiration and our strategy to make sure that, by 2023, one billion more people enjoy better health coverage and health services; one billion more people enjoy better health emergencies and one billion more people have better health and wellbeing. Around this triple billion target, there are 46 outcomes, result outcomes that drive the work of the organization.

Michael Krigsman: What is your role?

Bernardo Mariano: My role as a chief information officer and director for digital health and innovation is really to ensure that the digital WHO supports the digital transformation, the digital healthcare transformation, to ensure that as the world goes digital and healthcare goes digital, the quality of healthcare deliverables, the quality of health services, the expansion, the accessibility of health services is enhanced. The achievements of our sustainable development goals by 2030 are accelerated with the digital transformation, so my role is to cut across all areas of WHO and within the triple billion targets to make sure that digital health and digital transformation accelerate the achievement of the triple billion targets but also of the (United Nations) sustainable development goals.

Michael Krigsman: How does digital health achieve these goals or support the achievement of these goals?

Bernardo Mariano: The digital healthcare sector is quite behind compared to other sectors that have gone already to digital transformation. We have some that have gone smoothly, but also we have some that have gone through that transformation with some unintended consequences.

As a normative agency and a scientific organization, we want to make sure that the global issues such as interoperability, the health data regulations, how AI is used to offer technologies, how we ensure that, as the world goes and transforms into this digital ecosystem, all the gains that we achieved on elimination of diseases, all the gains that we want to achieve to eliminate the existing diseases, we do it better, we achieve it quicker, and we really meet our targets, the triple billion target, but also this SDG targets.

Partnership and Ecosystems in Digital Health

Michael Krigsman: One of the key issues is this notion of partnership and ecosystem. When we talk about the digital transformation of healthcare, there are now many parties that are involved. I know that this is something that you've given quite a bit of thought to.

Bernardo Mariano: Partnership is key because the ecosystem is composed of companies, people, government, things that are connected through a platform to share an outcome. If these different parts of an ecosystem—be it infrastructure, be it regulation, be it the people—are not connected, then they are not delivering the best in that particular area of the ecosystem they are responsible for. Then we will have not so good outcomes. We might have, actually, unintended consequences.

I could give you an example of an ecosystem that somehow was created to bring benefit, but we had a negative, unintended consequence. For instance, the reappearance of measles in countries that the measles was already eliminated. The antivaccine movement used platforms such as Facebook, Google, and Amazon, the tech giants, to really campaign against vaccines, which resulted in the reappearance of measles in countries that had eliminated it.

An unintended consequence of the ecosystem, if the ecosystem's different entities of the ecosystem do not work together, then we will have problems. Therefore, in my view, I think if we don't look at the digital health through a whole ecosystem and the partnership of the players of that ecosystem is not addressed correctly, we will not achieve the gains or the promises of the gains such as AI, blockchain, precision medicine, or even genomics can bring. We really need the best partnership to look at all angles of the ecosystem.

Michael Krigsman: Bernardo, you've just raised two distinct issues. Number one is technology. You mentioned AI, machine learning, and blockchain. At the same time, you've just been describing, could we say, what are really social dimensions, these dimensions of use of social media, sharing information, and the use of these ecosystem platform companies who are not healthcare providers but they are playing this crucial role.

Bernardo Mariano: We see the two sectors, the tech giant or the technology sector and the life sciences and pharmaceuticals coming together. Those two sectors have different cultures. The tech giants, the technology is a culture of fast-paced, minimal viable product delivered. The life science and pharmaceuticals are highly regulated because they do no harm, ensure tests, and tests and trials.

By having these two industries coming together, it's important that the quality of the healthcare delivered is not affected. It's important that the positive health outcome is enhanced. It's important that the costs of healthcare are reduced because the global problems right now that we have include half of the world population that has no access to healthcare. It includes 100 million people per year that go out of pocket because of health expenses.

We want digital health and the transformation of digital health to ensure that the global issues that we are facing today, the challenges we have are addressed by the support of the technology. Therefore, organizations such as WHO, we are there to really strive to make sure that we find that TechQuilibrium between tradition and technology, digital transformation, to achieve the positive health outcomes, to really get the best out of technology, to really deliver the best value for healthcare. Health is important for all of us.

How do we Align Interests of Healthcare Ecosystem Partners?

Michael Krigsman: How do we accomplish this goal and align the interests? When you have any type of ecosystem such as you're describing, there must be some harmony among those ecosystem partners and the incentives. As you said, medical professionals have the goal of health and wellness, whereas platform companies have the goal of profitmaking. This seems like a tough bridge to overcome, or am I not correct in that?

Bernardo Mariano: It is. Today, I donate blood. People donate organs. As we go in the life science and healthcare sector, contribution to global health is enshrined in the culture of the health sector.

We have the tech giants that monetize on data: Google, Amazon, Facebook, and the others. How can we strike the right balance to ensure that, as data is seen as the new blood and is monetized by some while the academia needs research data to really bring about evidence of some of the gains that we need to make in some of the rare diseases? A right balance is important?

When I go to a conference where most government officials are there and they say, "Data should be demonetized," and everybody raises their hands and say, "Yes." If I go to the private sector meeting and say, "Data should be demonetized," they look at me as, where am I coming from?

We need to strike the balance between demonetization of data for research and monetization of data to ensure that we have an equitable share of that monetization. Currently, platform owners own and they basically take the biggest share. Now, to do that, we need to bring some sort of international standards on data regulations to ensure that, as we monetize the health data, we ensure that it also helps reduce health costs or health insurance costs of the people that will donate or will give data that is monetized.

We should not shy away and leave the principle of free data or free data flows for research to achieve health gains is important. We should not shy away from that. We need to strike the right balance. It's not an easy balance but, to do that, the partnership within the sectors is important.

What is the Role of WHO in Bringing Together Healthcare Ecosystem Players?

Michael Krigsman: What's the role of WHO, the World Health Organization, in helping bring these multiple parties together to strike this balance and align the incentives so that the ultimate benefactor is positive health outcomes?

Bernardo Mariano: We have a convening power to bring different stakeholders with different interests to the table to try to achieve that balance, no matter how difficult the balance is to achieve. To achieve the balance, to ensure that the interests of the different stakeholders are taken into consideration as we develop tools, systems, and solutions that improve health, improve health coverage, and improve healthcare services.

The power, the convening power of WHO is something that we believe all sectors should leverage and we are very much aware of and our member states actually ask us to ensure some of the key issues such as interoperability, such as minimum health records or minimum patient health records, as well as other issues around genomics and the ethical issues. Those are some very difficult issues that if we just leave them unattended, unintended consequences on health will make us move backward in time of the diseases that we already tackled.

Is Digital Transformation in Healthcare Mostly Technology or Process?

Michael Krigsman: We do have a question from Twitter. Arsalan Khan is asking. He says that digital transformation requires process optimization first and then technology implementation second. How does WHO look at these two things, the processes and then the implementation of technology?

Bernardo Mariano: In addition to processes and technology, we have people. The tech giants are currently reaching the consumer base; basically, reaching the people. The processes that the technology, the companies use is basically minimal viable product and adoption by the user.

On the other hand, if the World Health Organization does not operate in that space and we continue to say, "Look, we will just provide our guidelines, the recommendations, and normative standards for policymakers," we will miss a large set of population.

In the end, between technology and processes, we have a person at the end of the line. We have somebody who is worried about their health and wellbeing. We have somebody that has health issues.

We want to make sure that process, technology, and people strike the right balance to achieve the wellbeing or to achieve a better diagnosis, to achieve that better outcome, health outcome, and to make sure that we also don't contribute to the digital divide because, after all, 49% of the world is still not connected to broadband. We do have also the responsibility to ensure that the gains of technology, processes, and people do not just benefit 51% of the world population. It should benefit 100% of the world population. In that ecosystem of digital health—between process, technologies, and people—we also have to think about the other side of the world that is still not connected.

Michael Krigsman: We have another question from Twitter, a very interesting question. Kanupriya Agarwal asks, "What is the role of academia, do you see, in moving forward with the intersection of public/private partnerships, especially when real-world evidence is needed, is required?"

Bernardo Mariano: The role of academia, which is very keen, the partnership model that is required for digital health should involve the private sector, academia, and the public sector. These three sectors normally don't operate in the same ecosystem. I have to say, WHO and the UN, we always say the private sector has a conflict of interest. I'm sure the private sector says the UN doesn't move at a pace that they move.

Academia is an interesting player to really glue these two sectors, but also to bring this, to pilot some of the concepts, to accelerate some innovation, to also operate in this space where evidence is not there. If you ask for evidence of AI for health today, we don't have scientific evidence to say AI will change the way and will improve, will largely impact the healthcare ecosystem.

We also have to make sure that we navigate across this hype that AI, for instance, has. The word itself, "artificial intelligence," is a hype. Academia, with the scientific knowledge and the research, has a very, very important role to strike the balance between the public sector reservation in relation to the interest of the private sector and the private sector reservation in relation to the public sector slowing down innovation to really bring the right balance to achieve those positive health outcomes.

What Role Should Government Policy Play in Healthcare Innovation?

Michael Krigsman: What about the role of government in terms of supporting healthcare innovation, as well as the availability, the broader availability of healthcare?

Bernardo Mariano: In the innovation space, there are three areas, at least within the World Health Organization, that we are operating. One is, of course, the innovation internally. These two areas are very important and one of them is more important than the other.

One is the incubation, right? The private sector and then a number of multinational and intergovernmental organizations plus NGOs are operating in incubation spaces for innovation. From our perspective, we want to make sure that if an innovation happens in Timbuktu in Mali, that innovation can actually have the opportunity to scale up; scaling up innovation for impact, especially health impact, that's where we want and we should put a lot of emphasis, at least from the global perspective, to ensure that if this innovation will address tuberculosis or resistance, antimicrobial resistance – we have a lot of examples on HIV AIDs. We need to join partnerships with both private sector academia and public sector governments, as well as UN agencies, to drive the scaling up of that innovation to make sure that the impact of that innovation that can save lives is accelerated.

Michael Krigsman: The role of WHO in this, as you said earlier, is in the ability, having the ability to convene multiple groups would not otherwise be so willing to come together.

Bernardo Mariano: Exactly. Then ensure that, for instance, governments and private sector academia, as those innovations take place, are tested, or go into trial and prototypes, the issues that we need to address, they are addressed at an early stage. We don't have an afterthought that, oh, these products or these innovations were supposed to improve health or improve diagnosis or improve management of aging. Then in the end, actually, it's harming people.

We want to strike the right balance. We can bring regulators, government agencies, private sector academia to really look at the different angles and bring the best out of each of these entities to ensure that the end product is one that delivers the good and positive health outcome.

Ethical Considerations of Healthcare Data

Michael Krigsman: Let's come back to this topic of data, which is so complex because, on the one hand, you have data as the source for machine learning and various techniques to uncover, and patterns that can teach us a variety of different things that will help improve health outcomes. At the same time, we have these various ethical considerations such as the ownership of that data. How do we start to navigate this data confusion?

Bernardo Mariano: That's where the role of the World Health Organization is key to ensure that we bring about some sort of international regulation on health data. The European Union has the GDPR that protects privacy. Each country has its own national privacy laws to protect their citizens' data.

More countries are actually bringing laws that forbid the cloud providers to take, for instance, data to the cloud. There are a number of examples of countries that health or national data, by regulation, should not leave national borders.

As these different interests and different perspectives come into play, and with the power of machine learning and artificial intelligence to really lean on big data to address some of the critical diagnoses or treatment of diseases, we want to strike that balance to ensure that privacy, ethical consideration is addressed to allow data sharing or sharing of data for global good to deliver those positive health outcomes, to deliver these gains, the acceleration to address diseases that otherwise we are challenged to address because of remote areas or to really bring primary healthcare or take primary healthcare to the next level because of digitalization.

The health data regulation is key and this is enshrined in our global strategy that is going to approval to our member states in May. We want to ensure that, as we go and get the approval from our 194 member states on this global digital health strategy, one of the deliverables of that strategy is international health data regulation to exactly address the issues we just talked about.

Michael Krigsman: We have another question from Twitter. Again, this is from Kanupriya Agarwal. It relates to trust. How do you see the public's role of trust in these digital health technologies evolving over time? Trust seems to be a key part of this.

Bernardo Mariano: Without that, the potential of digital health, we will not unleash the full potential. Some gains can be made, but the full potential will not be unleashed. The trust comes not by incidents such as data leakages or others that we see happening.

A people-centric approach and involvement of people at the earliest stage or at every stage are creating the capacity for dynamic consent. For instance, I think the European Union is leading on that, meaning that today I want to share my data for research and tomorrow I don't want to share my data. I should have the capacity to have dynamic consent.

Today, the consent is done in a way that I give consent and the consent is given for almost for life, kind of, in some respects. I think we need to move now from a blank consent to a dynamic consent. That requires technology and processes to be aligned.

One of the consequences of such a technology and process being aligned to a dynamic concept, it will start to bring about the trust because if I can trust that my data is safe and I have the power to give consent and not, to revoke it, I think that's where the ecosystem needs to move towards. Similar to today when I decided that I wanted to go and donate blood because I feel like it is part of my gesture as a global citizen is to donate blood to a blood bank, and tomorrow I don't want to do that, I have the power to decide whether I want to do it or not.

That dynamic consent is important and the platform providers, the technology, and the processes around it have to be enforced to ensure that that happens. That's the only way to start building trust in the system. The trust is key.

Michael Krigsman: What I find fascinating about this, if we think historically, healthcare advancement was about basic research, research into vaccines, antibiotics, and scientific research in the lab. Today, so much of healthcare research relies on data and, therefore, the set of issues around data privacy, security, consent, as you were just describing, is an almost equal partner as research in the lab. Is my point of view a naïve point of view that consent is almost an equal footing here?

Bernardo Mariano: You are right with all the trials and the consent for trials in the lab because the technology, the digital technology, is not just about supporting healthcare providers, but all healthcare practitioners. It's also supporting, accelerating the research. It will change the way companies, especially life science, do clinical trials and then assess the impact of those clinical trials and then report on them.

As we think about AI, how can we ensure that the AI that used data from one country and is sold in a different country or in a different part of the content, how can we ensure that that correlation or the local context is taken into consideration in that process? Data is an equal partner. Trust, it's important. Research, without data, today, will not deliver the results that we need.

Therefore, at the World Health Assembly, we have established a science division with research for health and digital health in part of the science division in addition to normative standards to really address and be at the forefront of these important topics, both digital health but as well as the research for health.

Michael Krigsman: There must be examples of positive cooperation. The reason I'm asking is that I work with many different technology companies and, in Silicon Valley, despite what we may say, the profit motive is king. Harnessing these companies to relinquish data or protect data in ways that interfere with profit-making seems an almost impossible task.

Bernardo Mariano: Not really because we are exploring partnership with some of the tech giants for them to relinquish data for research; depersonalize data to make sure that we can achieve some of the gains that depersonalized data can provide for research – some of the insights. It's true that there are some companies that are holding their data too close to their chest because they want to monetize it. It's true that that is happening, but some of the tech giants, they realize that free data can actually, one, address some of the key global challenges, but also create even new business avenues.

Think about the geo-positioning data. Satellites were launched and we have a GPS geo-positioning all over the world. It creates new insights. It creates new business. The fact that some of these depersonalized data for research are not made available to researchers actually might hinder those companies to actually find new business models. From our discussion with some of the companies in Silicon Valley—I was there a month ago with a number of my colleagues—they realize that, yes, we have to partner to ensure that data for research is freely available.

Business Models and Digital Health Innovation

Michael Krigsman: Changing business models become a very important part of this overall digital health landscape as well.

Bernardo Mariano: Yes, you cannot bring the physical ecosystem rules and procedures into the digital ecosystem because they don't work. Just to give you an example, we recently classified a gaming disorder as a disease. It is now part of the international classification of diseases, ICD-11.

In that classification, a gaming disorder as a disease happens in the digital ecosystem today. We're not talking about kids that go and play in the garden with their friends. We're talking about kids that spend hours in the digital ecosystem playing games in that ecosystem.

To ensure that we deal with that issue, we need to operate in the ecosystem itself and not outside. We shouldn't wait until the gamers get to the point of classifying that that gaming is a gaming disorder to say, "Look. Now go to the hospital to get treated." We have to start right inside that gaming ecosystem, so the digital ecosystem.

As part of our strategy, we have one of the outcomes or one of the products we want to have is guidance on virtual hospitals because a virtual hospital is about having hospitals in the digital ecosystem. Today, that might sound like science fiction, but that's what the world is moving towards in the way that the digital therapeutics or software apps can manage diseases, but also diseases that need to be managed from the digital ecosystem before you even reach the hospital.

Michael Krigsman: This coming together of partnerships, ecosystems, data, and new techniques such as machine learning, could we say that's the foundation, together with new business models? Is that the foundation of digital health and digital transformation of the healthcare system, I guess would be the right term?

Bernardo Mariano: Yes. In addition to that, the academy has to also change. Medical doctor curriculum has a very small percentage of the technology inside. Yet, we are moving to a digital ecosystem where a medical doctor is not just about the interaction between the professional, be it a nurse or a doctor, with a patient. It's also the interface with machine learning, with technology, robotics, and augmented reality. All that needs to be factored into an ecosystem.

The literacy is key. You can have the best product, well tested, but if the literacy is not there, the gains of that will not be realized. The academia has also a role to rethink and relook at the curriculum of medical doctors at the university, or nurses, or even how to train midwives to ensure that we really realize the gains and the potential of a digital health transformation.

Impact of Digital Transformation on Healthcare Providers

Michael Krigsman: What about the impact of all of this on healthcare providers, doctors and nurses maintaining their relevance as we're going through this change?

Bernardo Mariano: If you remember, in the '80s, there was the boom of robotics on, I think it was, the transport car industry where there was this perception that the computers or automation will make people lose jobs. I think, over and over, technology has proved that, actually, it's creating jobs.

It's true that the professions have to gain new skills. Reskilling doctors and repurpose some of the training of the doctors is key to make sure that we continue to achieve that coverage that we need, we continue to expand access of healthcare, we continue to actually reduce the cost. Perhaps, in the future, we'll have an artificial intelligence assistant to the doctor, or you will have, perhaps, a triage based on AI in the hospital that will reduce the queuing.

What is important, what we want to see is that a patient that should go to the secondary, tertiary care does not get stuck into the primary care. Meaning that if it's a patient that needs to see a specialist because he or she has Hepatitis C and live in a very remote village, she shouldn't or he shouldn't be stuck in the primary healthcare to the point where, when he or she reaches the specialist, the disease has developed beyond the stage that the person can be saved. Efficiencies in the hospitals, efficiencies in the healthcare practitioners, efficiencies of doctor/patient interaction have to be looked into as we move towards that digital transformation of healthcare.

Michael Krigsman: Don't we also run the risk, as we're attempting to make healthcare more widely available and more effective with these new digital techniques; aren't we running the risk of increasing the digital divide?

Bernardo Mariano: We will if we don't bring those low resourced communities into perspective. I challenge even the concept of low and middle-income countries because low resource communities exist everywhere, in countries that are high income, the countries that are middle income, and the countries that are low income.

The low resourced communities should not be forgotten. The issues, the challenges that they have vis-à-vis access, vis-à-vis cost of healthcare, vis-à-vis health insurance, vis-à-vis aging should not be underestimated. We need, as we move forward, to ensure that the inclusion is a key element of the digital health transformation. We need to make sure that accessibility is a key element of digital health transformation.

That's where we will see gains that will narrow that digital divide. We will see gains; we will see these low resourced communities getting great benefits with telehealth, telemedicine, and others.

We need also to set regulations that promote telemedicine to ensure that doctors can be remunerated as they practice telemedicine. We need, perhaps, new certifications on telemedicine to ensure that a doctor sitting in one country can practice telemedicine to a patient in another country.

Those are some of the rules that we have in the physical ecosystem where, as a medical professional, I have to be certified by a national authority in the country where the digital transformation now is challenging that because a medical professional can be sitting in one country and diagnosing a patient in another country. What are the rules and regulations and issues? We need to look into that to make sure that these achieve this universal health coverage, these support the access to health.

If a country in Europe has a deficit on nurses, how can we ensure telemedicine or remote telehealth allows that gap to be narrowed? Yes, there are lots of challenges, but also there are a lot of opportunities and we just need to strike the right balance to make sure that we achieve them.

Michael Krigsman: Another component of this equation then is supporting new technologies, new business models, and new innovations by government policies that make them possible.

Bernardo Mariano: The role of governments to ensure that the innovation for health is supported, it's important. The role of government to ensure that as innovators and has the private sector accelerates that innovation for health. We need to ensure that the governments and the public sector are not a part of a roadblock or not part of hampering that innovation.

We need to transform within to allow this transformation to happen. At the World Health Organization, one of our targets and one of the outcomes is really to promote innovation for health and that's what we want to do with a number of partners. We are currently working within and also with bringing some partnerships. We are preparing also our innovation strategy to make sure that the innovators that have information for high impact on the healthcare sector, they have a pathway to scale up. They have a pathway to really realize those potentials.

Yes, it is important. I think it's important that we also recognize our own biases, as we talk about innovation and to ensure that innovation is not just in Silicon Valley, but it's also in Mozambique. It can be in Mozambique. It can be in Timbuktu in Mali. It can be in Angola. It can be anywhere in this world, and we need to make sure that, as innovation happens, regardless of the country or location of that innovator, there's a pathway to scale up, especially if it's a good innovation that really has the high impact.

What is the Role of VC Funding on Innovation in Digital Healthcare?

Michael Krigsman: We have another couple of questions from Kanupriya Agarwal. She's really on a roll today. Let me ask you these and then I think it's going to be time to finish up. Number one, she asks about the funding. What is the evolving role of venture financing for digital health innovation for the global good?

Bernardo Mariano: This touches that area of scaling up. Venture capital, development banks have a key role to scale up or to support innovation scaling up, especially innovation that has a high impact. At WHO, this is a key element in our strategy to ensure that health innovation for impact is scaled up; finds a pathway to scale up.

Think about the Ebola crisis in West Africa, DRC, and other countries. There, to achieve or to succeed in managing that or contain and control the disease, we need innovators. Innovation needed to be very fast to bring about the vaccine, to bring about the treatment, to enhance care, and to ensure that the patients and the risks of those diseases are mitigated early enough. That's a good example of a partnership between the private sector and public sector academia to really bring about innovation that has a very good impact on health.

The role of venture capital, the role of development banks, the role of commercial banks to scale up, it's key. In the role of WHO, within that process is to contribute or to at least acknowledge those innovations that have a high impact that will support the achievement or accelerate the achievement of sustainable development goal number three, health for all, and ensure that health gains are realized through innovation.

Michael Krigsman: A very important question and topic. She has another great question. Kanupriya Agarwal, you should be sitting here in my chair asking these questions. The issues you're raising are fantastic. She says, "Have we studied and drawn any parallels from other industries using digital and undergoing digital transformation? What conclusions or lessons could be applied to healthcare?"

Bernardo Mariano: We have some good examples of other industries. I think the financial sector is perhaps closely related to health. One, because it's highly regulated. Two, privacy and security are key. Three, it impacts everyone in that ecosystem that uses that.

If you roll back 15 years ago, we used to call it digital banking, digital financing. Today, it's banks. It's no longer digital. The digital word disappeared.

The digital health that we call it today, ten years from now I think we'll just call health because it will be part of the new normal. We want to do better than the financial sector. We want to do better than any other sector because it impacts health.

At the end of the line, there's somebody's life and somebody's health at stake. The life or the health, wellbeing of that person is more important than anything. Therefore, it is key that we do it right. We do it better than the financial sector. We do it better than social media. We do it better than any other sector because we can't negotiate health.

Health is a human right and we want to make sure that products, systems, and solutions in digital technology delivers better health outcomes and not bad ones and do not do harm. We want to make sure that the quality of health is enhanced, increased, and the coverage is increased as we go through that digital transformation.

Michael Krigsman: We have another question from Twitter, again from Arsalan Khan. You guys are asking great questions. Thank you for that. He is asking, "Are there any examples of countries that have adopted digital health on a very large, wide-scale? What has the result been?"

Bernardo Mariano: With the risk of being so undiplomatic, normally in the U.N., we try not to mention one country because the other countries will think that they have a better system. Let me perhaps start by saying that the digital health maturity level needs to be assessed in different countries because the prioritization of digital health investments should be aligned to the maturity level of the country on digital health. Some countries are way advanced that perhaps the challenge is different than the countries that are still quite behind, vis-à-vis electronic health records, perhaps, and so on and so forth.

One country that we all use as an example is Estonia. If you look at Estonia, digital, how the whole country moved to e-government and the whole system into a digital ecosystem, including health, I think it's an interesting country to look into.

We have also countries that are quite advanced in Europe, in Australia, and other countries that are moving quite, quite, quite, quite strongly towards that. The one problem that every country has now, with no exception, is the interoperability of information systems. The interoperability is an issue that no matter which maturity level the country is on digital health, that issue is a key issue that, at the World Health Organization, we want to support because it's a global issue.

In this globalized world, without interoperability, we will not really achieve all the gains that technology or digital health technology could support. Therefore, yes, while at the national level and sub-national level we have a number of very good examples in many developed countries, we still have the issue of interoperability.

Michael Krigsman: Kanupriya Agarwal makes the comment. I invited her; she should be the interviewer today. She says, actually, she's an elected member of the WHO digital health roster of experts.

Bernardo Mariano: Yes, that's very good. The roster of experts and also the technical advisory group are a group of experts that we are leaning into as we navigate this journey of digital transformation to ensure that the expertise that is out there is used for global good. Thank you for having expressed interest in the digital health roster, but also the technical advisory group.

Advice on Digital Health for Healthcare Policymakers

Michael Krigsman: Bernardo, as we've been speaking, we've covered a great many sets of issues. What advice do you have for policymakers to navigate this very difficult set of challenges and conflicting set of goals among the various partners and players?

Bernardo Mariano: I think that policymakers have – I mean talking to the Minister of Health of Mozambique who is a good childhood friend, one of the challenges, and a number of them came to ask in a number of meetings that we had, especially in the last World Health Assembly, is really the prioritization of the investment and sustainability of that investment. I mentioned to you that the digital health maturity, I don't want to call it an index, but the maturity level is important, that the countries understand what is their maturity level. We can support them on that front. Then create a roadmap on investment priorities because investment priorities will define how well and how solid is that investment and how sustainable is that investment.

If a country does not have electronic health records and it goes and implements a system for delivery or even on artificial intelligence, that investment might actually not yield the benefits that the country is trying to achieve.

Depending on the maturity level, the advice for policymakers is, look at your maturity level. Look at your investment priorities and address the areas or diseases that are more prevalent in your country where digital health can support. If it's diabetics, how can digital health support a reduction and better management of the diabetics?

There are one billion people suffering from uncontrolled hypertension. If hypertension is an issue, how can countries and how can that particular country look at the digital health technologies to address that particular disease?

Then you start; we also start seeing evidence of maturity level versus investment priorities and the impact of on the specific diseases of that country to really have that large impact. Also, we have countries that even have access issues, so that's the other. In most countries, primary healthcare is key, so having digital health to support primary healthcare is another advice that I would say a country really needs to make sure that is part of their strategy.

With a global digital health strategy that is going to be approved by our member states in May, we want to make sure that we support countries in that particular journey. But we want to work, and we will work, with a number of partners that either support these countries or fund these countries to ensure that the investment priority is aligned to the maturity level and delivers the positive outcome to ensure that there's a sustainable model, but also there's a very high impact on the health of the population of that country.

Advice for Healthcare Practitioners on Digital Transformation?

Michael Krigsman: What advice do you have to healthcare providers, hospitals, and hospital administrators on managing their own transformation so that they can keep up?

Bernardo Mariano: For hospitals and healthcare providers, the status quo is no longer a possibility, meaning that digitalization or digital transformation of healthcare providers should be part of a strategy of any hospital. I see, at least in some of the hospitals in the developed world, that has already taken place.

What is even more important is literacy, as I mentioned before. We want the midwives, nurses, doctors to really maximize the potential of digital health and, therefore, investment in literacy from hospital providers or hospitals and healthcare providers is important.

The other element that I want to make sure that the healthcare providers are aware of is, who is going to buy who? Are the tech giants buying healthcare or healthcare will continue to use technology as they've been using before? That has to be very, very close to the mindset of healthcare providers. If they don't pay attention, actually, the tech giants will buy healthcare providers.

I think we want to ensure that the delivery of care and the quality of that delivery does not go down. No matter where that hospital is, be it in a developing world, in the developed world, the quality has to increase as we digitalize health, as we go health in the digital ecosystem.

At WHO, also we have a drive to digitalize WHO content, products, and services. That is an internal drive to ensure that the guidelines, products of WHO, they are available in the digital ecosystem.

Hospitals need to ensure that, to look at the issues such as digital hospitals, issues such as a virtual assistant to medical doctors, the issues as triage that happens that increases efficiency of queues at hospitals. It is important that the hospitals embrace the journey and do it ensuring that the quality of healthcare, the real deliverable is not penalized.

Michael Krigsman: Okay. What a very fast and important set of topics we've been discussing. We've been speaking with Bernardo Mariano. He is the chief information officer and responsible for the digital health initiative at the World Health Organization. Bernardo, thank you again for taking your time to be with us today.

Bernardo Mariano: My pleasure. Thank you for having me here today.

Michael Krigsman: Everybody, thank you for watching. Before you go, please subscribe on YouTube and hit the subscribe button at the top of our website. We will send you great information about upcoming shows.

Thanks so much. I hope you have a great day and we'll see you again. Take care. Bye-bye.

This transcript has been lightly edited.

Introduction

Michael Krigsman: We're exploring digital health, the digital transformation of healthcare with a senior leader of the World Health Organization. Bernardo Mariano is Chief Information Officer and Director of Digital Health and Innovation at WHO.

Bernardo Mariano: The World Health Organization, which I will refer to as WHO, is a 194-member-state organization with over 150 offices around the world. Our main strategic targets for the next 4 years, up until 2023, are centered around what we call the triple billion target.

The triple billion target basically is the aspiration and our strategy to make sure that, by 2023, one billion more people enjoy better health coverage and health services; one billion more people enjoy better health emergencies and one billion more people have better health and wellbeing. Around this triple billion target, there are 46 outcomes, result outcomes that drive the work of the organization.

Michael Krigsman: What is your role?

Bernardo Mariano: My role as a chief information officer and director for digital health and innovation is really to ensure that the digital WHO supports the digital transformation, the digital healthcare transformation, to ensure that as the world goes digital and healthcare goes digital, the quality of healthcare deliverables, the quality of health services, the expansion, the accessibility of health services is enhanced. The achievements of our sustainable development goals by 2030 are accelerated with the digital transformation, so my role is to cut across all areas of WHO and within the triple billion targets to make sure that digital health and digital transformation accelerate the achievement of the triple billion targets but also of the (United Nations) sustainable development goals.

Michael Krigsman: How does digital health achieve these goals or support the achievement of these goals?

Bernardo Mariano: The digital healthcare sector is quite behind compared to other sectors that have gone already to digital transformation. We have some that have gone smoothly, but also we have some that have gone through that transformation with some unintended consequences.

As a normative agency and a scientific organization, we want to make sure that the global issues such as interoperability, the health data regulations, how AI is used to offer technologies, how we ensure that, as the world goes and transforms into this digital ecosystem, all the gains that we achieved on elimination of diseases, all the gains that we want to achieve to eliminate the existing diseases, we do it better, we achieve it quicker, and we really meet our targets, the triple billion target, but also this SDG targets.

Partnership and Ecosystems in Digital Health

Michael Krigsman: One of the key issues is this notion of partnership and ecosystem. When we talk about the digital transformation of healthcare, there are now many parties that are involved. I know that this is something that you've given quite a bit of thought to.

Bernardo Mariano: Partnership is key because the ecosystem is composed of companies, people, government, things that are connected through a platform to share an outcome. If these different parts of an ecosystem—be it infrastructure, be it regulation, be it the people—are not connected, then they are not delivering the best in that particular area of the ecosystem they are responsible for. Then we will have not so good outcomes. We might have, actually, unintended consequences.

I could give you an example of an ecosystem that somehow was created to bring benefit, but we had a negative, unintended consequence. For instance, the reappearance of measles in countries that the measles was already eliminated. The antivaccine movement used platforms such as Facebook, Google, and Amazon, the tech giants, to really campaign against vaccines, which resulted in the reappearance of measles in countries that had eliminated it.

An unintended consequence of the ecosystem, if the ecosystem's different entities of the ecosystem do not work together, then we will have problems. Therefore, in my view, I think if we don't look at the digital health through a whole ecosystem and the partnership of the players of that ecosystem is not addressed correctly, we will not achieve the gains or the promises of the gains such as AI, blockchain, precision medicine, or even genomics can bring. We really need the best partnership to look at all angles of the ecosystem.

Michael Krigsman: Bernardo, you've just raised two distinct issues. Number one is technology. You mentioned AI, machine learning, and blockchain. At the same time, you've just been describing, could we say, what are really social dimensions, these dimensions of use of social media, sharing information, and the use of these ecosystem platform companies who are not healthcare providers but they are playing this crucial role.

Bernardo Mariano: We see the two sectors, the tech giant or the technology sector and the life sciences and pharmaceuticals coming together. Those two sectors have different cultures. The tech giants, the technology is a culture of fast-paced, minimal viable product delivered. The life science and pharmaceuticals are highly regulated because they do no harm, ensure tests, and tests and trials.

By having these two industries coming together, it's important that the quality of the healthcare delivered is not affected. It's important that the positive health outcome is enhanced. It's important that the costs of healthcare are reduced because the global problems right now that we have include half of the world population that has no access to healthcare. It includes 100 million people per year that go out of pocket because of health expenses.

We want digital health and the transformation of digital health to ensure that the global issues that we are facing today, the challenges we have are addressed by the support of the technology. Therefore, organizations such as WHO, we are there to really strive to make sure that we find that TechQuilibrium between tradition and technology, digital transformation, to achieve the positive health outcomes, to really get the best out of technology, to really deliver the best value for healthcare. Health is important for all of us.

How do we Align Interests of Healthcare Ecosystem Partners?

Michael Krigsman: How do we accomplish this goal and align the interests? When you have any type of ecosystem such as you're describing, there must be some harmony among those ecosystem partners and the incentives. As you said, medical professionals have the goal of health and wellness, whereas platform companies have the goal of profitmaking. This seems like a tough bridge to overcome, or am I not correct in that?

Bernardo Mariano: It is. Today, I donate blood. People donate organs. As we go in the life science and healthcare sector, contribution to global health is enshrined in the culture of the health sector.

We have the tech giants that monetize on data: Google, Amazon, Facebook, and the others. How can we strike the right balance to ensure that, as data is seen as the new blood and is monetized by some while the academia needs research data to really bring about evidence of some of the gains that we need to make in some of the rare diseases? A right balance is important?

When I go to a conference where most government officials are there and they say, "Data should be demonetized," and everybody raises their hands and say, "Yes." If I go to the private sector meeting and say, "Data should be demonetized," they look at me as, where am I coming from?

We need to strike the balance between demonetization of data for research and monetization of data to ensure that we have an equitable share of that monetization. Currently, platform owners own and they basically take the biggest share. Now, to do that, we need to bring some sort of international standards on data regulations to ensure that, as we monetize the health data, we ensure that it also helps reduce health costs or health insurance costs of the people that will donate or will give data that is monetized.

We should not shy away and leave the principle of free data or free data flows for research to achieve health gains is important. We should not shy away from that. We need to strike the right balance. It's not an easy balance but, to do that, the partnership within the sectors is important.

What is the Role of WHO in Bringing Together Healthcare Ecosystem Players?

Michael Krigsman: What's the role of WHO, the World Health Organization, in helping bring these multiple parties together to strike this balance and align the incentives so that the ultimate benefactor is positive health outcomes?

Bernardo Mariano: We have a convening power to bring different stakeholders with different interests to the table to try to achieve that balance, no matter how difficult the balance is to achieve. To achieve the balance, to ensure that the interests of the different stakeholders are taken into consideration as we develop tools, systems, and solutions that improve health, improve health coverage, and improve healthcare services.

The power, the convening power of WHO is something that we believe all sectors should leverage and we are very much aware of and our member states actually ask us to ensure some of the key issues such as interoperability, such as minimum health records or minimum patient health records, as well as other issues around genomics and the ethical issues. Those are some very difficult issues that if we just leave them unattended, unintended consequences on health will make us move backward in time of the diseases that we already tackled.

Is Digital Transformation in Healthcare Mostly Technology or Process?

Michael Krigsman: We do have a question from Twitter. Arsalan Khan is asking. He says that digital transformation requires process optimization first and then technology implementation second. How does WHO look at these two things, the processes and then the implementation of technology?

Bernardo Mariano: In addition to processes and technology, we have people. The tech giants are currently reaching the consumer base; basically, reaching the people. The processes that the technology, the companies use is basically minimal viable product and adoption by the user.

On the other hand, if the World Health Organization does not operate in that space and we continue to say, "Look, we will just provide our guidelines, the recommendations, and normative standards for policymakers," we will miss a large set of population.

In the end, between technology and processes, we have a person at the end of the line. We have somebody who is worried about their health and wellbeing. We have somebody that has health issues.

We want to make sure that process, technology, and people strike the right balance to achieve the wellbeing or to achieve a better diagnosis, to achieve that better outcome, health outcome, and to make sure that we also don't contribute to the digital divide because, after all, 49% of the world is still not connected to broadband. We do have also the responsibility to ensure that the gains of technology, processes, and people do not just benefit 51% of the world population. It should benefit 100% of the world population. In that ecosystem of digital health—between process, technologies, and people—we also have to think about the other side of the world that is still not connected.

Michael Krigsman: We have another question from Twitter, a very interesting question. Kanupriya Agarwal asks, "What is the role of academia, do you see, in moving forward with the intersection of public/private partnerships, especially when real-world evidence is needed, is required?"

Bernardo Mariano: The role of academia, which is very keen, the partnership model that is required for digital health should involve the private sector, academia, and the public sector. These three sectors normally don't operate in the same ecosystem. I have to say, WHO and the UN, we always say the private sector has a conflict of interest. I'm sure the private sector says the UN doesn't move at a pace that they move.

Academia is an interesting player to really glue these two sectors, but also to bring this, to pilot some of the concepts, to accelerate some innovation, to also operate in this space where evidence is not there. If you ask for evidence of AI for health today, we don't have scientific evidence to say AI will change the way and will improve, will largely impact the healthcare ecosystem.

We also have to make sure that we navigate across this hype that AI, for instance, has. The word itself, "artificial intelligence," is a hype. Academia, with the scientific knowledge and the research, has a very, very important role to strike the balance between the public sector reservation in relation to the interest of the private sector and the private sector reservation in relation to the public sector slowing down innovation to really bring the right balance to achieve those positive health outcomes.

What Role Should Government Policy Play in Healthcare Innovation?

Michael Krigsman: What about the role of government in terms of supporting healthcare innovation, as well as the availability, the broader availability of healthcare?

Bernardo Mariano: In the innovation space, there are three areas, at least within the World Health Organization, that we are operating. One is, of course, the innovation internally. These two areas are very important and one of them is more important than the other.

One is the incubation, right? The private sector and then a number of multinational and intergovernmental organizations plus NGOs are operating in incubation spaces for innovation. From our perspective, we want to make sure that if an innovation happens in Timbuktu in Mali, that innovation can actually have the opportunity to scale up; scaling up innovation for impact, especially health impact, that's where we want and we should put a lot of emphasis, at least from the global perspective, to ensure that if this innovation will address tuberculosis or resistance, antimicrobial resistance – we have a lot of examples on HIV AIDs. We need to join partnerships with both private sector academia and public sector governments, as well as UN agencies, to drive the scaling up of that innovation to make sure that the impact of that innovation that can save lives is accelerated.

Michael Krigsman: The role of WHO in this, as you said earlier, is in the ability, having the ability to convene multiple groups would not otherwise be so willing to come together.

Bernardo Mariano: Exactly. Then ensure that, for instance, governments and private sector academia, as those innovations take place, are tested, or go into trial and prototypes, the issues that we need to address, they are addressed at an early stage. We don't have an afterthought that, oh, these products or these innovations were supposed to improve health or improve diagnosis or improve management of aging. Then in the end, actually, it's harming people.

We want to strike the right balance. We can bring regulators, government agencies, private sector academia to really look at the different angles and bring the best out of each of these entities to ensure that the end product is one that delivers the good and positive health outcome.

Ethical Considerations of Healthcare Data

Michael Krigsman: Let's come back to this topic of data, which is so complex because, on the one hand, you have data as the source for machine learning and various techniques to uncover, and patterns that can teach us a variety of different things that will help improve health outcomes. At the same time, we have these various ethical considerations such as the ownership of that data. How do we start to navigate this data confusion?

Bernardo Mariano: That's where the role of the World Health Organization is key to ensure that we bring about some sort of international regulation on health data. The European Union has the GDPR that protects privacy. Each country has its own national privacy laws to protect their citizens' data.

More countries are actually bringing laws that forbid the cloud providers to take, for instance, data to the cloud. There are a number of examples of countries that health or national data, by regulation, should not leave national borders.

As these different interests and different perspectives come into play, and with the power of machine learning and artificial intelligence to really lean on big data to address some of the critical diagnoses or treatment of diseases, we want to strike that balance to ensure that privacy, ethical consideration is addressed to allow data sharing or sharing of data for global good to deliver those positive health outcomes, to deliver these gains, the acceleration to address diseases that otherwise we are challenged to address because of remote areas or to really bring primary healthcare or take primary healthcare to the next level because of digitalization.

The health data regulation is key and this is enshrined in our global strategy that is going to approval to our member states in May. We want to ensure that, as we go and get the approval from our 194 member states on this global digital health strategy, one of the deliverables of that strategy is international health data regulation to exactly address the issues we just talked about.

Michael Krigsman: We have another question from Twitter. Again, this is from Kanupriya Agarwal. It relates to trust. How do you see the public's role of trust in these digital health technologies evolving over time? Trust seems to be a key part of this.

Bernardo Mariano: Without that, the potential of digital health, we will not unleash the full potential. Some gains can be made, but the full potential will not be unleashed. The trust comes not by incidents such as data leakages or others that we see happening.

A people-centric approach and involvement of people at the earliest stage or at every stage are creating the capacity for dynamic consent. For instance, I think the European Union is leading on that, meaning that today I want to share my data for research and tomorrow I don't want to share my data. I should have the capacity to have dynamic consent.

Today, the consent is done in a way that I give consent and the consent is given for almost for life, kind of, in some respects. I think we need to move now from a blank consent to a dynamic consent. That requires technology and processes to be aligned.

One of the consequences of such a technology and process being aligned to a dynamic concept, it will start to bring about the trust because if I can trust that my data is safe and I have the power to give consent and not, to revoke it, I think that's where the ecosystem needs to move towards. Similar to today when I decided that I wanted to go and donate blood because I feel like it is part of my gesture as a global citizen is to donate blood to a blood bank, and tomorrow I don't want to do that, I have the power to decide whether I want to do it or not.

That dynamic consent is important and the platform providers, the technology, and the processes around it have to be enforced to ensure that that happens. That's the only way to start building trust in the system. The trust is key.

Michael Krigsman: What I find fascinating about this, if we think historically, healthcare advancement was about basic research, research into vaccines, antibiotics, and scientific research in the lab. Today, so much of healthcare research relies on data and, therefore, the set of issues around data privacy, security, consent, as you were just describing, is an almost equal partner as research in the lab. Is my point of view a naïve point of view that consent is almost an equal footing here?

Bernardo Mariano: You are right with all the trials and the consent for trials in the lab because the technology, the digital technology, is not just about supporting healthcare providers, but all healthcare practitioners. It's also supporting, accelerating the research. It will change the way companies, especially life science, do clinical trials and then assess the impact of those clinical trials and then report on them.

As we think about AI, how can we ensure that the AI that used data from one country and is sold in a different country or in a different part of the content, how can we ensure that that correlation or the local context is taken into consideration in that process? Data is an equal partner. Trust, it's important. Research, without data, today, will not deliver the results that we need.

Therefore, at the World Health Assembly, we have established a science division with research for health and digital health in part of the science division in addition to normative standards to really address and be at the forefront of these important topics, both digital health but as well as the research for health.

Michael Krigsman: There must be examples of positive cooperation. The reason I'm asking is that I work with many different technology companies and, in Silicon Valley, despite what we may say, the profit motive is king. Harnessing these companies to relinquish data or protect data in ways that interfere with profit-making seems an almost impossible task.

Bernardo Mariano: Not really because we are exploring partnership with some of the tech giants for them to relinquish data for research; depersonalize data to make sure that we can achieve some of the gains that depersonalized data can provide for research – some of the insights. It's true that there are some companies that are holding their data too close to their chest because they want to monetize it. It's true that that is happening, but some of the tech giants, they realize that free data can actually, one, address some of the key global challenges, but also create even new business avenues.

Think about the geo-positioning data. Satellites were launched and we have a GPS geo-positioning all over the world. It creates new insights. It creates new business. The fact that some of these depersonalized data for research are not made available to researchers actually might hinder those companies to actually find new business models. From our discussion with some of the companies in Silicon Valley—I was there a month ago with a number of my colleagues—they realize that, yes, we have to partner to ensure that data for research is freely available.

Business Models and Digital Health Innovation

Michael Krigsman: Changing business models become a very important part of this overall digital health landscape as well.

Bernardo Mariano: Yes, you cannot bring the physical ecosystem rules and procedures into the digital ecosystem because they don't work. Just to give you an example, we recently classified a gaming disorder as a disease. It is now part of the international classification of diseases, ICD-11.

In that classification, a gaming disorder as a disease happens in the digital ecosystem today. We're not talking about kids that go and play in the garden with their friends. We're talking about kids that spend hours in the digital ecosystem playing games in that ecosystem.

To ensure that we deal with that issue, we need to operate in the ecosystem itself and not outside. We shouldn't wait until the gamers get to the point of classifying that that gaming is a gaming disorder to say, "Look. Now go to the hospital to get treated." We have to start right inside that gaming ecosystem, so the digital ecosystem.

As part of our strategy, we have one of the outcomes or one of the products we want to have is guidance on virtual hospitals because a virtual hospital is about having hospitals in the digital ecosystem. Today, that might sound like science fiction, but that's what the world is moving towards in the way that the digital therapeutics or software apps can manage diseases, but also diseases that need to be managed from the digital ecosystem before you even reach the hospital.

Michael Krigsman: This coming together of partnerships, ecosystems, data, and new techniques such as machine learning, could we say that's the foundation, together with new business models? Is that the foundation of digital health and digital transformation of the healthcare system, I guess would be the right term?

Bernardo Mariano: Yes. In addition to that, the academy has to also change. Medical doctor curriculum has a very small percentage of the technology inside. Yet, we are moving to a digital ecosystem where a medical doctor is not just about the interaction between the professional, be it a nurse or a doctor, with a patient. It's also the interface with machine learning, with technology, robotics, and augmented reality. All that needs to be factored into an ecosystem.

The literacy is key. You can have the best product, well tested, but if the literacy is not there, the gains of that will not be realized. The academia has also a role to rethink and relook at the curriculum of medical doctors at the university, or nurses, or even how to train midwives to ensure that we really realize the gains and the potential of a digital health transformation.

Impact of Digital Transformation on Healthcare Providers

Michael Krigsman: What about the impact of all of this on healthcare providers, doctors and nurses maintaining their relevance as we're going through this change?

Bernardo Mariano: If you remember, in the '80s, there was the boom of robotics on, I think it was, the transport car industry where there was this perception that the computers or automation will make people lose jobs. I think, over and over, technology has proved that, actually, it's creating jobs.

It's true that the professions have to gain new skills. Reskilling doctors and repurpose some of the training of the doctors is key to make sure that we continue to achieve that coverage that we need, we continue to expand access of healthcare, we continue to actually reduce the cost. Perhaps, in the future, we'll have an artificial intelligence assistant to the doctor, or you will have, perhaps, a triage based on AI in the hospital that will reduce the queuing.

What is important, what we want to see is that a patient that should go to the secondary, tertiary care does not get stuck into the primary care. Meaning that if it's a patient that needs to see a specialist because he or she has Hepatitis C and live in a very remote village, she shouldn't or he shouldn't be stuck in the primary healthcare to the point where, when he or she reaches the specialist, the disease has developed beyond the stage that the person can be saved. Efficiencies in the hospitals, efficiencies in the healthcare practitioners, efficiencies of doctor/patient interaction have to be looked into as we move towards that digital transformation of healthcare.

Michael Krigsman: Don't we also run the risk, as we're attempting to make healthcare more widely available and more effective with these new digital techniques; aren't we running the risk of increasing the digital divide?

Bernardo Mariano: We will if we don't bring those low resourced communities into perspective. I challenge even the concept of low and middle-income countries because low resource communities exist everywhere, in countries that are high income, the countries that are middle income, and the countries that are low income.

The low resourced communities should not be forgotten. The issues, the challenges that they have vis-à-vis access, vis-à-vis cost of healthcare, vis-à-vis health insurance, vis-à-vis aging should not be underestimated. We need, as we move forward, to ensure that the inclusion is a key element of the digital health transformation. We need to make sure that accessibility is a key element of digital health transformation.

That's where we will see gains that will narrow that digital divide. We will see gains; we will see these low resourced communities getting great benefits with telehealth, telemedicine, and others.

We need also to set regulations that promote telemedicine to ensure that doctors can be remunerated as they practice telemedicine. We need, perhaps, new certifications on telemedicine to ensure that a doctor sitting in one country can practice telemedicine to a patient in another country.

Those are some of the rules that we have in the physical ecosystem where, as a medical professional, I have to be certified by a national authority in the country where the digital transformation now is challenging that because a medical professional can be sitting in one country and diagnosing a patient in another country. What are the rules and regulations and issues? We need to look into that to make sure that these achieve this universal health coverage, these support the access to health.

If a country in Europe has a deficit on nurses, how can we ensure telemedicine or remote telehealth allows that gap to be narrowed? Yes, there are lots of challenges, but also there are a lot of opportunities and we just need to strike the right balance to make sure that we achieve them.

Michael Krigsman: Another component of this equation then is supporting new technologies, new business models, and new innovations by government policies that make them possible.

Bernardo Mariano: The role of governments to ensure that the innovation for health is supported, it's important. The role of government to ensure that as innovators and has the private sector accelerates that innovation for health. We need to ensure that the governments and the public sector are not a part of a roadblock or not part of hampering that innovation.

We need to transform within to allow this transformation to happen. At the World Health Organization, one of our targets and one of the outcomes is really to promote innovation for health and that's what we want to do with a number of partners. We are currently working within and also with bringing some partnerships. We are preparing also our innovation strategy to make sure that the innovators that have information for high impact on the healthcare sector, they have a pathway to scale up. They have a pathway to really realize those potentials.

Yes, it is important. I think it's important that we also recognize our own biases, as we talk about innovation and to ensure that innovation is not just in Silicon Valley, but it's also in Mozambique. It can be in Mozambique. It can be in Timbuktu in Mali. It can be in Angola. It can be anywhere in this world, and we need to make sure that, as innovation happens, regardless of the country or location of that innovator, there's a pathway to scale up, especially if it's a good innovation that really has the high impact.

What is the Role of VC Funding on Innovation in Digital Healthcare?

Michael Krigsman: We have another couple of questions from Kanupriya Agarwal. She's really on a roll today. Let me ask you these and then I think it's going to be time to finish up. Number one, she asks about the funding. What is the evolving role of venture financing for digital health innovation for the global good?

Bernardo Mariano: This touches that area of scaling up. Venture capital, development banks have a key role to scale up or to support innovation scaling up, especially innovation that has a high impact. At WHO, this is a key element in our strategy to ensure that health innovation for impact is scaled up; finds a pathway to scale up.

Think about the Ebola crisis in West Africa, DRC, and other countries. There, to achieve or to succeed in managing that or contain and control the disease, we need innovators. Innovation needed to be very fast to bring about the vaccine, to bring about the treatment, to enhance care, and to ensure that the patients and the risks of those diseases are mitigated early enough. That's a good example of a partnership between the private sector and public sector academia to really bring about innovation that has a very good impact on health.

The role of venture capital, the role of development banks, the role of commercial banks to scale up, it's key. In the role of WHO, within that process is to contribute or to at least acknowledge those innovations that have a high impact that will support the achievement or accelerate the achievement of sustainable development goal number three, health for all, and ensure that health gains are realized through innovation.

Michael Krigsman: A very important question and topic. She has another great question. Kanupriya Agarwal, you should be sitting here in my chair asking these questions. The issues you're raising are fantastic. She says, "Have we studied and drawn any parallels from other industries using digital and undergoing digital transformation? What conclusions or lessons could be applied to healthcare?"

Bernardo Mariano: We have some good examples of other industries. I think the financial sector is perhaps closely related to health. One, because it's highly regulated. Two, privacy and security are key. Three, it impacts everyone in that ecosystem that uses that.

If you roll back 15 years ago, we used to call it digital banking, digital financing. Today, it's banks. It's no longer digital. The digital word disappeared.

The digital health that we call it today, ten years from now I think we'll just call health because it will be part of the new normal. We want to do better than the financial sector. We want to do better than any other sector because it impacts health.

At the end of the line, there's somebody's life and somebody's health at stake. The life or the health, wellbeing of that person is more important than anything. Therefore, it is key that we do it right. We do it better than the financial sector. We do it better than social media. We do it better than any other sector because we can't negotiate health.

Health is a human right and we want to make sure that products, systems, and solutions in digital technology delivers better health outcomes and not bad ones and do not do harm. We want to make sure that the quality of health is enhanced, increased, and the coverage is increased as we go through that digital transformation.

Michael Krigsman: We have another question from Twitter, again from Arsalan Khan. You guys are asking great questions. Thank you for that. He is asking, "Are there any examples of countries that have adopted digital health on a very large, wide-scale? What has the result been?"

Bernardo Mariano: With the risk of being so undiplomatic, normally in the U.N., we try not to mention one country because the other countries will think that they have a better system. Let me perhaps start by saying that the digital health maturity level needs to be assessed in different countries because the prioritization of digital health investments should be aligned to the maturity level of the country on digital health. Some countries are way advanced that perhaps the challenge is different than the countries that are still quite behind, vis-à-vis electronic health records, perhaps, and so on and so forth.

One country that we all use as an example is Estonia. If you look at Estonia, digital, how the whole country moved to e-government and the whole system into a digital ecosystem, including health, I think it's an interesting country to look into.

We have also countries that are quite advanced in Europe, in Australia, and other countries that are moving quite, quite, quite, quite strongly towards that. The one problem that every country has now, with no exception, is the interoperability of information systems. The interoperability is an issue that no matter which maturity level the country is on digital health, that issue is a key issue that, at the World Health Organization, we want to support because it's a global issue.

In this globalized world, without interoperability, we will not really achieve all the gains that technology or digital health technology could support. Therefore, yes, while at the national level and sub-national level we have a number of very good examples in many developed countries, we still have the issue of interoperability.

Michael Krigsman: Kanupriya Agarwal makes the comment. I invited her; she should be the interviewer today. She says, actually, she's an elected member of the WHO digital health roster of experts.

Bernardo Mariano: Yes, that's very good. The roster of experts and also the technical advisory group are a group of experts that we are leaning into as we navigate this journey of digital transformation to ensure that the expertise that is out there is used for global good. Thank you for having expressed interest in the digital health roster, but also the technical advisory group.

Advice on Digital Health for Healthcare Policymakers

Michael Krigsman: Bernardo, as we've been speaking, we've covered a great many sets of issues. What advice do you have for policymakers to navigate this very difficult set of challenges and conflicting set of goals among the various partners and players?

Bernardo Mariano: I think that policymakers have – I mean talking to the Minister of Health of Mozambique who is a good childhood friend, one of the challenges, and a number of them came to ask in a number of meetings that we had, especially in the last World Health Assembly, is really the prioritization of the investment and sustainability of that investment. I mentioned to you that the digital health maturity, I don't want to call it an index, but the maturity level is important, that the countries understand what is their maturity level. We can support them on that front. Then create a roadmap on investment priorities because investment priorities will define how well and how solid is that investment and how sustainable is that investment.

If a country does not have electronic health records and it goes and implements a system for delivery or even on artificial intelligence, that investment might actually not yield the benefits that the country is trying to achieve.

Depending on the maturity level, the advice for policymakers is, look at your maturity level. Look at your investment priorities and address the areas or diseases that are more prevalent in your country where digital health can support. If it's diabetics, how can digital health support a reduction and better management of the diabetics?

There are one billion people suffering from uncontrolled hypertension. If hypertension is an issue, how can countries and how can that particular country look at the digital health technologies to address that particular disease?

Then you start; we also start seeing evidence of maturity level versus investment priorities and the impact of on the specific diseases of that country to really have that large impact. Also, we have countries that even have access issues, so that's the other. In most countries, primary healthcare is key, so having digital health to support primary healthcare is another advice that I would say a country really needs to make sure that is part of their strategy.

With a global digital health strategy that is going to be approved by our member states in May, we want to make sure that we support countries in that particular journey. But we want to work, and we will work, with a number of partners that either support these countries or fund these countries to ensure that the investment priority is aligned to the maturity level and delivers the positive outcome to ensure that there's a sustainable model, but also there's a very high impact on the health of the population of that country.

Advice for Healthcare Practitioners on Digital Transformation?

Michael Krigsman: What advice do you have to healthcare providers, hospitals, and hospital administrators on managing their own transformation so that they can keep up?

Bernardo Mariano: For hospitals and healthcare providers, the status quo is no longer a possibility, meaning that digitalization or digital transformation of healthcare providers should be part of a strategy of any hospital. I see, at least in some of the hospitals in the developed world, that has already taken place.

What is even more important is literacy, as I mentioned before. We want the midwives, nurses, doctors to really maximize the potential of digital health and, therefore, investment in literacy from hospital providers or hospitals and healthcare providers is important.

The other element that I want to make sure that the healthcare providers are aware of is, who is going to buy who? Are the tech giants buying healthcare or healthcare will continue to use technology as they've been using before? That has to be very, very close to the mindset of healthcare providers. If they don't pay attention, actually, the tech giants will buy healthcare providers.

I think we want to ensure that the delivery of care and the quality of that delivery does not go down. No matter where that hospital is, be it in a developing world, in the developed world, the quality has to increase as we digitalize health, as we go health in the digital ecosystem.

At WHO, also we have a drive to digitalize WHO content, products, and services. That is an internal drive to ensure that the guidelines, products of WHO, they are available in the digital ecosystem.

Hospitals need to ensure that, to look at the issues such as digital hospitals, issues such as a virtual assistant to medical doctors, the issues as triage that happens that increases efficiency of queues at hospitals. It is important that the hospitals embrace the journey and do it ensuring that the quality of healthcare, the real deliverable is not penalized.

Michael Krigsman: Okay. What a very fast and important set of topics we've been discussing. We've been speaking with Bernardo Mariano. He is the chief information officer and responsible for the digital health initiative at the World Health Organization. Bernardo, thank you again for taking your time to be with us today.

Bernardo Mariano: My pleasure. Thank you for having me here today.

Michael Krigsman: Everybody, thank you for watching. Before you go, please subscribe on YouTube and hit the subscribe button at the top of our website. We will send you great information about upcoming shows.

Thanks so much. I hope you have a great day and we'll see you again. Take care. Bye-bye.