Targeting ethical considerations tied to image-based mobile health diagnostic support specific to clinicians in low-resource settings: the Brocher proposition

Figures & data

Table 1. Distribution of the workshop participants by sector of activity and country.

	Country
Sector	South Africa	Africa Other^$	Sweden	Europe Other*	Canada, North America
Clinical	2	2			2
Research	1	1	4	3	2
Medical ethics	1		1
Health policy		2		4
Developers/business	1				1

*Finland, Germany, Switzerland ^$Mali, Tanzania, Uganda.

Figure 1. Overview of the process followed during the workshop to guide the discussions and generate agreed-upon views on how to tackle issues pertaining to each ethical principle covered (autonomy, safety, and justice).

Table 2. Synthesis of the priorities raised by the workshop participants related to respect of person and patient autonomy, split into the main lifecycle phases of mHealth applications.

Development	Implementation	Scale up/Follow up
Incorporate data security and patient privacy into the design process	Prioritise and always strive for consent that is informed, face-to-face, and individual	Establish clear rules of usage for informal mHealth systems that are consistent with the existing ethical and regulatory framework
Have a regulatory framework in place that safeguards data protection	Make use of existing local ethical guidelines	Ensure that continuous maintenance and updates of the system are in place
Use an open source data collection platform	Raise mHealth awareness among all stakeholders	Safeguard and maintain open source platforms
Build in secured mechanisms to facilitate efficient exchange of data into the existing health record system	Avoid perverse incentives that interfere with providers’ decision to use the system
	Foster local governance of digital applications within the country’s health care system
Engage all stakeholders throughout the whole process

Table 3. Synthesis of the priorities raised by the workshop participants related to patient safety, split into the main lifecycle phases of mHealth applications.

Development	Implementation	Scale up/Follow up
Proceed to development using a robust scientific process	Proceed to implementation following the principles of implementation science	Ensure ongoing, effective phone stewardship
Incorporate data security and patient privacy into the design process	Ensure mHealth literacy: all clinical users are trained in adequate device stewardship	Assure compliance of the system with a locally-agreed safety level
Incorporate a robust user authentication system into the design	Familiarise all clinical users with the overall process	With systems that employ artificial intelligence, ensure processes are in place to encourage the maintenance of clinical staff diagnostic skills
Make explicit the permissible (‘good enough’) standard-of-care being targeted, and ensure it has been set in a fair and transparent manner	Define clearly standards of clinical care that are desirable, permissible, and forbidden	Ensure continuous quality improvement mechanisms are in place
Avoid conflicts of interest or perverse incentives for developers
Engage all stakeholders throughout the whole process

Table 4. Synthesis of the priorities raised by the workshop participants related to justice, split into the main lifecycle phases of mHealth applications.

Development	Implementation	Scale up/Follow up
Assure the end product is accessible (i.e. affordable and robust)	Include a robust maintenance plan in the implementation strategy	Identify and prioritise target groups in a fair and transparent manner
Implement an open source data collection platform	Safeguard the engagement of all stakeholders throughout the implementation process	Ensure the system is equally accessible to the entire target group(s)
Incorporate interoperability of the final product into the existing health care system from inception		Assess the system’s ability to reach out to all segments of the population/population groups
Make explicit the permissible (‘good enough’) standard of care being targeted and ensure it has been set in a fair and transparent manner
Engage all stakeholders throughout the whole process
Develop apps in a transparent manner
Encourage ‘bottom up’, locally-relevant development that aligns with local health priorities
Balance use of existing resources with the need to drive innovation