In the rapidly evolving landscape of healthcare innovation, the promise of new technologies and approaches often carries with it an implicit assumption: that these advancements will benefit all segments of society equally. However, recent qualitative research challenges this notion, shedding light on a more troubling reality—that health and social care innovations are frequently designed in ways that exclude marginalized populations, exacerbating existing inequalities rather than alleviating them. The study, conducted by Tooman, Frost, Adams, and colleagues, provides a critical examination of how systemic biases and structural barriers shape the trajectory of health innovation, effectively sidelining those who arguably stand to gain the most from improved care.
At the heart of this investigation is the concept of “exclusion by design,” a phenomenon where the frameworks, priorities, and mechanisms through which innovations are developed inherently limit their accessibility or relevance to certain groups. Unlike exclusion stemming from incidental oversights or resource limitations, exclusion by design reflects deeper, embedded patterns within the innovation ecosystem. Such patterns often arise from normative assumptions held by developers, funders, and policymakers about who the “typical” user is, what kinds of needs should be prioritized, and which outcomes are most valued. These assumptions can inadvertently replicate social hierarchies, privileging already well-served populations and marginalizing others along axes of race, socioeconomic status, geographic location, disability, and more.
The methodological strength of the study lies in its qualitative design, which centers the lived experiences and perspectives of multiple stakeholders involved in health innovation—from innovators themselves to patients, caregivers, and frontline healthcare workers. Through interviews, focus groups, and ethnographic observations, the researchers unearthed detailed narratives that reveal how exclusion manifests at various stages of the innovation lifecycle. For instance, early ideation phases often lack input from marginalized communities, leading to the development of solutions that fail to address their unique challenges. Subsequently, the clinical trials or pilot testing phases sometimes exclude participants who do not meet narrow eligibility criteria, further limiting the relevance and applicability of findings.
Delving into the technical dimensions, the study highlights that health innovations—from digital health apps and telemedicine platforms to new pharmaceuticals and care models—are frequently built on certain technological standards and infrastructures that are not universally accessible. Digital innovations, in particular, can exacerbate the “digital divide,” where individuals lacking reliable internet access, digital literacy, or compatible devices find themselves unable to benefit from new services. This suggests that innovations premised on high-tech solutions must consider and integrate strategies to bridge infrastructural gaps, such as offline functionality, multilingual interfaces, or supportive training programs tailored to diverse user demographics.
Another salient point discussed in the study relates to the funding environment governing health innovation. The allocation of resources, often driven by market incentives or the priorities of dominant funding bodies, tends to favor innovations with commercialization potential or scalability within affluent populations. As a result, projects addressing more complex, intersectional social determinants of health—such as housing instability, food insecurity, or systemic racism—may receive less attention or be considered too challenging to “scale.” This funding bias indirectly channels innovation toward already privileged groups, leaving systemic inequities unaddressed.
Furthermore, regulatory and policy frameworks shape the contours of inclusion in innovation in profound ways. The study identifies that current regulatory approval pathways often lack flexibility to accommodate diverse populations, imposing strict evidence requirements that do not easily capture social context or long-term equity impacts. There is a compelling argument for regulators to adopt equity-focused criteria, including mandating the involvement of representative populations in trial designs and prioritizing innovations that demonstrably reduce health disparities.
A key technical insight from the research involves the use of data in driving innovation. Health data collected from electronic health records, wearable sensors, and patient-reported outcomes serve as foundational inputs for developing and validating innovations. However, the skewed representativeness of these data sources—frequently underrepresenting racial minorities, the elderly, or those experiencing homelessness—may bias algorithmic models, leading to suboptimal or harmful outcomes for these groups. This underlines the urgent need for methodological advances in data collection and analysis, incorporating fairness metrics and ensuring transparency.
The implications of exclusion by design extend beyond principle to practice, as they bear directly on health outcomes. Innovations that fail to accommodate or include marginalized groups can perpetuate a cycle of poor health and social disadvantage, undermining trust in healthcare systems and deepening social fragmentation. This has serious consequences for public health, particularly when innovations play a central role in addressing pressing challenges such as chronic disease management, mental health support, and pandemic response.
Addressing these entrenched inequities requires a paradigm shift in how health and social care innovations are conceptualized, developed, and implemented. The study posits that a more inclusive innovation ecosystem demands intentional co-design processes where marginalized communities are authentic partners rather than passive recipients. Such co-creation mobilizes local knowledge, fosters culturally relevant solutions, and builds trust and engagement, enhancing both the effectiveness and equity of innovations.
Capacity building among innovators, funders, and regulators is also paramount. Training programs that emphasize equity literacy, cultural competence, and participatory methods can equip stakeholders with the skills to identify and counteract exclusionary dynamics. This extends to the adoption of innovation metrics that go beyond traditional measures like cost-effectiveness or adoption rates, incorporating equity impact assessments as a standard evaluative criterion.
The researchers also underscore the importance of interdisciplinary collaboration, bringing together expertise from public health, social sciences, engineering, and ethics to address the multifaceted nature of inequality in innovation. Such collaborations can foster novel approaches that integrate technical rigor with social justice orientation, challenging siloed thinking.
Critically, empowering marginalized populations through policy reforms is necessary to sustain equitable innovation. This includes enhancing data sovereignty for underrepresented groups, ensuring equitable representation in decision-making bodies, and enshrining equity mandates in funding and regulatory processes. Without systemic reform, the risk remains that exclusion by design will persist, confirming rather than disrupting patterns of disadvantage.
In reflecting on the broader ecosystem, the study calls attention to the role of power dynamics in shaping innovation trajectories. Those who design, fund, and regulate innovations often represent dominant social groups, with implicit biases influencing priorities and perceptions of “value.” Transforming innovation culture to embrace humility, reflexivity, and equity requires not only technical adjustments but also deep institutional change.
The research conducted by Tooman and colleagues constitutes a wake-up call for the health innovation community. It reveals that technology alone is insufficient to achieve health equity; rather, the social, political, and economic contexts in which innovation occurs must be interrogated and transformed. The findings propel a critical dialogue on how to build a future where innovations are not only revolutionary but just, ensuring no one is left behind by design.
This work is particularly timely as the global health system grapples with growing disparities exacerbated by pandemics, aging populations, and climate change. Health innovations hold immense promise to alleviate these pressures, but unless equity is embedded from conception through implementation, such promise risks being hollow for communities most in need.
Moving forward, research agendas must prioritize the generation of evidence on what works to promote inclusion in innovation. This encompasses experimental designs evaluating inclusive innovation strategies and policy interventions. Furthermore, disseminating best practices widely can foster a cumulative knowledge base, encouraging replication and scaling of successful models.
Ultimately, restructuring health and social care innovation to dismantle exclusion by design is not merely a technical challenge; it is a moral imperative. By embracing equity as a foundational principle, the innovation ecosystem can unlock transformative potential to improve health outcomes and social well-being for all, advancing a vision of justice that technology alone cannot achieve.
Subject of Research: Inequalities in health and social care innovation
Article Title: Excluded by design: a qualitative study of inequalities in health and social care innovation
Article References:
Tooman, T.R., Frost, H., Adams, R. et al. Excluded by design: a qualitative study of inequalities in health and social care innovation. Int J Equity Health (2026). https://doi.org/10.1186/s12939-025-02751-5
Image Credits: AI Generated
