Digitisation of primary care excludes those in greatest need

Digitisation of primary care excludes those in greatest needZhenyang Long hospital administrator Yip and Ge ask whether China can reorient a hospital-centric system towards primary care. 1 Payment reform, gatekeeping, and workforce investment are sensible starting points.But their editorial misses something: the speed of China's digital health transformation.Between 2018 and 2023, the number of internet hospitals grew from fewer than 100 to over 3000. 2 3 Telemedicine platforms route millions of consultations annually.The government has written remote diagnosis, AI assisted triage, and interoperable records into policy as pillars of strengthening primary care. 3 What policy documents do not discuss is who can use these tools.Zhang et al found digital health literacy to be low among older Chinese adults, with the steepest deficits among the rural, female, and less educated older people, a substantial share of whom cannot independently navigate online registration or access electronic records. 4Li et al studied 1207 rural older adults and found that lower digital literacy independently predicted worse health behaviours, with digital skills mediating whether health information translated into action. 5The pattern holds: digital health infrastructure is bypassing those with the greatest need.This matters for the reform that Yip and Ge describe.If patients are channelled towards online appointments, video consultations, and electronic referral pathways, all operational at scale, gatekeeping mechanisms function only for the digitally literate.A rural older adult without these skills defaults to the hospital outpatient departments that the reform is trying to depopulate.Digital exclusion reproduces hospital-centrism by default.The solution is not to slow digitisation but to make digital inclusion a budgeted, measured component of reform from day one.Three things would help: community based digital literacy programmes for older adults, drawing on peer education models tested in Chinese provinces; mandatory age friendly design standards for public health platforms, including voice navigation and offline fallbacks; and equity audits tracking who uses digital primary care tools and who is left out.Yip and Ge are right that China's primary care experiment carries lessons for health systems everywhere.One may be that digitising primary care without digitally including the population is not a shortcut to equity-it is a detour.