More Digital, Not More Equal: The Hidden Gap in Smart City Healthcare

Cities are rapidly embedding artificial intelligence, telemedicine, connected sensors, mobile health platforms and real-time data systems into everyday urban life, but the key concern is whether these technologies can make them fairer. The review "Smart City Technologies and Health Equity: A Review of Urban Health Outcomes and Sustainable Development (2019–2026)," published in Sustainability by Mehdi Rezaei, Seungok An, Ehsan Heidarzadeh and Ladan Rokni., examines the concern across recent evidence on digital health and smart urban systems.

Smart city technologies have improved healthcare access for some underserved populations, but their overall contribution to health equity remains limited, uneven and heavily dependent on local conditions. Digital divides, socio-economic inequality, fragmented governance and weak institutional capacity repeatedly blunt the benefits of technological innovation, while people-centered design, participatory governance and inclusive digital infrastructure emerge as the factors most likely to improve outcomes.

More than 68 percent of the world's population is expected to live in urban areas by 2050, making cities central arenas for public health, digital transformation and inequality. As health services become more intertwined with digital infrastructure, poor design choices can widen existing disparities just as easily as good ones can reduce them.

Technology Can Expand Access, but It Does Not Automatically Reduce Inequality

The review examined literature published between November 2019 and May 2026 using PubMed and Scopus. From 357 screened records, 68 underwent full-text assessment and 22 studies were ultimately included in the qualitative synthesis. The authors evaluated both direct health-equity outcomes and the institutional, infrastructural and social conditions that enable or obstruct equitable implementation.

Across those studies, the evidence on direct equity gains remains thinner than the rhetoric surrounding smart cities might suggest. Many initiatives demonstrate improved access, efficiency or disease management, but relatively few directly measure whether inequalities between social or demographic groups actually decline. The review finds that equity considerations are often weakly incorporated into the design and evaluation of smart-city health interventions.

There are, nevertheless, important examples of practical benefit. Remote patient monitoring has helped reach geographically disadvantaged populations, mobile telemedicine clinics have expanded access in underserved urban communities, and digital platforms have supported treatment for chronic disease, HIV prevention and opioid use disorder. Yet increased access does not always translate into reduced disparities: one telehealth HIV-prevention programme expanded availability while failing to eliminate racial inequities.

The review challenges one of the most persistent assumptions in smart-city policy: that technological diffusion itself generates inclusion. Its evidence suggests the opposite. Without targeted interventions, technology tends to operate through the social structures already present, meaning pre-existing inequalities in income, education, infrastructure and institutional access shape who benefits first and most.

The Biggest Barrier Is Not the Technology but the System Around It

Smart health technologies do not operate in isolation; they sit within political, legal, financial and social systems that determine access, trust and accountability. Institutional barriers emerge as among the most widespread obstacles to equity, suggesting that the real bottleneck is often governance rather than innovation itself.

Infrastructure remains a major fault line. Reliable broadband, affordable devices, interoperable health systems and functioning digital services are basic prerequisites for equitable smart health. Where these are unevenly distributed, smart-city programmes can concentrate benefits in wealthier neighborhoods and better-connected populations. The review points particularly to African and Southeast Asian urban contexts where infrastructure is often concentrated in more affluent areas.

Digital literacy is equally important. Older adults, low-income households, migrants and linguistically diverse communities may be formally connected to a service but unable to navigate it effectively. Language, cultural factors and limited familiarity with digital tools can reduce actual utilization even when infrastructure exists. This means access must be measured in practical terms, whether people can understand, trust and use a system, not simply whether a digital platform is available.

Governance failures compound these barriers. The review warns against "pilot-project syndrome," in which promising interventions remain stuck in early-stage testing without robust evaluation or integration into public health systems. Top-down models can also marginalize community voices, producing technically sophisticated services that fail to address local priorities or real-world barriers.

For governments and development agencies, the implication is straightforward: investment in smart health cannot be separated from institutional capacity. Funding hardware or digital platforms without strengthening regulatory systems, workforce capacity, community participation and public accountability risks creating islands of innovation rather than durable improvements in health equity.

Privacy, Trust and Participation Could Decide Who Benefits

The review also places ethics and trust at the center of digital health equity. Health technologies increasingly rely on sensitive personal data, automated decision-making and monitoring systems. For marginalized groups, particularly informal workers and migrants, these tools can carry risks that go beyond conventional privacy concerns, including fear of surveillance, exclusion or punitive use of data.

Algorithmic bias adds another layer of risk. AI-driven systems may reproduce unequal outcomes if training data, design choices or governance structures fail to account for disadvantaged populations. The review notes that insufficient transparency in AI systems can deepen exclusion among groups already facing socio-economic disadvantage.

This is why participatory governance is more than a consultation exercise. The authors argue that communities, health professionals, urban planners and civil society actors should be involved in the design and implementation of smart-health systems. Co-creation can improve relevance, build trust and help ensure that technology reflects diverse needs rather than imposing standardized solutions from above.

The review notes that some smart-city initiatives present themselves as inclusive while offering residents little meaningful influence over decisions. Equity therefore depends not simply on whether participation occurs, but whether it has institutional weight and affects policy, resource allocation and system design.

For cities in the Global South, this point is particularly significant. Rapid digitization can offer opportunities to bypass legacy systems and extend services more efficiently, but it can also reproduce exclusion at scale if marginalized communities are treated as passive users rather than active stakeholders. The policy challenge is to ensure that smart-city governance evolves as quickly as the technologies it seeks to deploy.

The Next Smart City Agenda Must Link Health, Equity and Sustainability

The review broadens the debate beyond healthcare delivery by highlighting the connection between environmental sustainability and health equity. AI-driven systems that improve energy efficiency, reduce emissions or support environmental monitoring can indirectly improve health by reducing exposure to pollution, heat and other urban risks.

Health inequality is not produced only inside hospitals. Transport systems, air quality, housing, neighborhood design and exposure to climate risks all shape health outcomes. The review argues for a whole-of-system approach in which digital transformation, public health and environmental sustainability are treated as mutually reinforcing rather than separate policy domains.

The perspective creates a wider agenda for governments, investors and development institutions. Digital infrastructure investments should be assessed not only for efficiency gains, but for distributional impact: who gains better access, whose environmental conditions improve, and whether vulnerable groups face new forms of exclusion. Equity-sensitive metrics should therefore be built into monitoring from the beginning rather than added after implementation.

The study also notes that it includes English-language literature from a defined recent period, excludes some policy and grey literature, and does not apply a single formal quality-appraisal tool across all included studies because of their methodological diversity. Many underlying studies also lack rigorous equity-specific evaluation, while evidence on emerging technologies such as AI-enabled virtual health environments remains largely conceptual or early-stage.

The limitations point directly to the next research priority: cities need longitudinal, disaggregated evidence showing not simply whether digital health tools work, but for whom, under what conditions and over what period. Future research also needs stronger attention to recognitional and restorative justice, whether smart systems understand the distinct needs of marginalized populations and whether they address, rather than reproduce, historical disadvantage.

The larger lesson is that the future of healthy smart cities will not be decided by the sophistication of their technology stacks, but by whether institutions can convert technology into broad-based public value. A city can be hyper-connected, data-rich and AI-enabled while remaining deeply unequal.