Marcelo Dagostino

Artificial intelligence (AI) is rapidly reshaping the landscape of health care, from clinical diagnostics and disease surveillance to the prediction of individual health risks. Yet, its immense promise will only materialize if the tools we deploy work for everyone. Algorithms trained on incomplete or biased datasets risk embedding historical health disparities and can replicate patterns of uneven data representation, thereby limiting accuracy and generalizability across population groups. Addressing algorithmic bias should be treated as a core health quality standard, comparable in importance to safety and efficacy evaluations, to ensure consistent performance across all segments of the population. This paper aims to frame algorithmic bias in health-related AI as a quality, safety, and governance challenge for health systems rather than solely a technical problem for developers. It aims to inform policymakers, regulators, health system leaders, and developers by translating existing scientific evidence and regulatory guidance into operational governance considerations, with particular attention to the realities of low- and middle-income settings in the region of the Americas. This paper synthesizes existing knowledge and institutional experience into a practical, regionally grounded policy perspective. To operationalize this perspective, this paper first outlines the main forms of algorithmic bias relevant to health systems—including representation, measurement, aggregation, and deployment biases—and illustrates how each can emerge across the AI lifecycle. It then situates these technical challenges within the broader digital health context, where structural, commercial, and social dynamics may amplify inequities. This paper discusses the implications of biased data for emerging areas such as precision medicine before proposing a governance-oriented framework for bias mitigation that spans design, validation, deployment, and postmarket monitoring. It concludes with priority governance actions for policymakers, regulators, and health system leaders to embed fairness as a measurable component of health system performance.

UNSTRUCTURED Artificial intelligence (AI) is rapidly reshaping the landscape of health, from clinical diagnostics and disease surveillance to the prediction of individual health risks. Yet, its immense promise will only materialize if the tools we deploy work for everyone. When algorithms are trained on incomplete or biased datasets, they risk embedding historical health disparities and can replicate patterns of uneven data representation that limit accuracy and generalizability across population groups (1). Addressing algorithmic bias should be treated as a health quality standard, comparable in importance to safety and efficacy evaluations, ensuring consistent performance across all segments of the population. This editorial aims to inform both policymakers and technical experts, offering a framework that bridges scientific rigor with practical, regionally grounded governance models.

This article analyzes the evolution of telehealth regulation in Brazil, with emphasis on its integration into public policies through the SUS Digital Program, an initiative coordinated by the Secretariat of Information and Digital Health of the Ministry of Health. It is a narrative review based on normative analysis of legal and regulator y instruments, including laws, decrees, ministerial ordinances, and resolutions issued by professional health councils. The study organizes the trajectory of telehealth into three major phases: pilot initiatives and initial legal frameworks; progressive institutionalization supported by ministerial programs; and regulatory consolidation with Law No. 14,510/2022, which authorizes the permanent practice of telehealth. It argues that the COVID-19 pandemic acted as a catalyst for normative and operational changes, enabling the expanded use of telehealth across all levels of care. The findings align with previous research highlighting the role of telehealth in expanding access and improving quality of care, particularly in remote regions. The creation of the Secretariat of Information and Digital Health and the launch of the SUS Digital Program mark a new phase in which telehealth is embedded within a broader strategy for the digital transformation of the Brazilian Public Health System. The data support studies that emphasize the need for coordinated actions, ongoing investment in infrastructure, professional training, and digital governance. The evidence suggests that the advancement of telehealth legislation is consistent with international guidelines and may contribute to greater equity in healthcare delivery.

Practice and training in geriatrics and healthy aging across the Americas. As Chief of the Healthy Life Course Unit at the Pan American Health Organization (PAHO), Dr. Vega García played a central role in shaping discussions and advancing policies on healthy aging and health systems through a life-course approach. His passing leaves a significant absence in the global health community. Yet his groundbreaking work continues to guide reforms in public health, particularly those addressing the pressing challenges of an aging population. His legacy transcends the traditional boundaries of public health and geriatrics. He was not only a scientist, policy-maker and mentor but also a visionary whose work reshaped how we understand aging in modern society. He championed a new and inclusive vision of healthy aging: understood as the process of developing and maintaining the functional ability that enables well-being in older age. This perspective, which he promoted assiduously, shifted the conversation from care and decline to independence, autonomy, participation and well-being. His contributions-scientific, institutional and deeply human-remain enduring and profound. He also oversaw programs related to child and adolescent health, promoting integrated and equitable health across all stages of life. His high spirits, warmth and unwavering optimism infused energy into his work every day and inspired all who knew him. Gifted with an extraordinary ability to build positive relationships, he connected fluidly with people from all walks of life, propelling initiatives forward and ensuring implementation of public policies for older adults across the Region.

From our roles within international public health organizations, we have collectively witnessed the global challenges presented by outdated health information systems, platforms, and applications. The COVID-19 pandemic has clearly exposed the limitations of our current paper-based vaccine certification methods and highlighted the deficiencies of outdated technological platforms that lack interoperability standards, a situation that underscores the critical need for a digital transformation in how we manage and verify immunization records. Digital vaccination certificates are understood to be secure, electronically stored, and easily accessible records that provide verifiable proof of a person’s immunization status. The Pan American Health Organization (PAHO) envisions leveraging digital technologies to strengthen health systems, enhance data-driven decision-making, and improve health outcomes. The organization’s vision emphasizes the integration of innovative technologies to build resilient and responsive health systems capable of addressing modern public health challenges. In an era of unprecedented technological advancement, our continued reliance on paper-based vaccine certificates is not just anachronistic—it is a significant liability for global public health that impacts the efficiency and effectiveness of our health systems on multiple fronts, limiting our ability to respond to public health crises effectively. With the strategic guidance from its Member States, PAHO has agreed to move toward the digital transformation of the health sector across the entire continent with an initiative that aims to improve health outcomes, ensure equitable access to health services, and enhance the overall efficiency of health systems in the Americas. The roadmap for this digital transformation outlines strategic actions and goals to achieve a connected, efficient, and resilient health sector.

UNSTRUCTURED Information Systems for Health (IS4H) are essential for achieving universal health coverage and reducing healthcare inequities. In the post-COVID-19 era, investing in the digital transformation of the health sector is crucial to optimize resource use, make informed decisions, and ensure cost-effective healthcare delivery. The Americas face a growing need for interconnected and interoperable information systems to improve data collection, strategic public health planning, and epidemiological surveillance, among others. Historically, there was a lack of standardized metrics and tools for assessing health information systems (HIS). To address this, the IS4H (Information Systems for Health) initiative was launched in 2016, aiming to Implementing universal access to health and universal health coverage in the region through interconnected and interoperable health-related information systems that assure effective and efficient access to quality data, strategic information and digital health tools for decision making and wellbeing. The IS4H initiative, led by the Pan American Health Organization (PAHO) and endorsed by Member States and strategic partners, focuses on implementing a better decision and policy making mechanism through health-related information systems and digital solutions that ensure universal, free and timely access to data and strategic information using the most cost-effective digital health tools. Implemented in the Americas Region, IS4H provides a framework for evaluating and improving health information systems through comprehensive maturity assessments. This article reviews the progress made from 2016 to 2023, highlighting key advancements in governance, data, information and knowledge management, digital transformation and innovation. It also addresses the challenges faced and provides recommendations for future improvements. The findings emphasize the importance of continued investment in digital health infrastructure, the adoption of international data standards, and the enhancement of digital literacy among health workers.

UNSTRUCTURED From our roles within international public health organizations, we have collectively witnessed the global challenges presented by outdated health information systems, platforms and applications. The COVID-19 pandemic has clearly exposed the limitations of our current paper-based vaccine certification methods and highlighted the deficiencies of outdated technological platforms that lack interoperability standards, a situation that underscores the critical need for a digital transformation in how we manage and verify immunization records. Digital vaccination certificates are understood to be secure, electronically stored, and easily accessible records that provide verifiable proof of a person's immunization status. PAHO's Director, Dr. Jarbas Barbosa, envisions leveraging digital technologies to strengthen health systems, enhance data-driven decision-making, and improve health outcomes. His vision emphasizes the integration of innovative technologies to build resilient and responsive health systems capable of addressing modern public health challenges (1). In an era of unprecedented technological advancement, our continued reliance on paper-based vaccine certificates is not just anachronistic—it’s a significant liability for global public health that impacts the efficiency and effectiveness of our health systems on multiple fronts, limiting our ability to respond to public health crises effectively (2). With the strategic guidance from its Member States, PAHO has agreed to move towards the digital transformation of the health sector across the entire continent with an initiative that aims to improve health outcomes, ensure equitable access to health services, and enhance the overall efficiency of health systems in the Americas. The roadmap for this digital transformation outlines strategic actions and goals to achieve a connected, efficient, and resilient health sector (3).