Purpose:
Digital health has been widely heralded as a transformative solution for improving healthcare access and quality, yet evidence from low- and middle-income contexts suggests adoption is uneven and contingent on multiple socio-technical factors, cultural, and infrastructural factors. Karachi presents a critical case to examine these dynamics and their implications for patient safety and equity.

Design/methodology/approach:
A mixed methods design was employed, integrating a structured narrative review of literature published between 2020 and 2024 with qualitative interviews conducted among 31 healthcare practitioners in Karachi. The literature synthesis draws on peer reviewed studies and institutional reports to map global trends, while semi-structured interviews provide context specific insights into real world implementation. Interviews explored experiences with digital health tool adoption, patient engagement, and perceived barriers to sustainable implementation. Data were analysed using thematic synthesis and thematic analysis, followed by side-by-side integration to identify convergence and divergence between global evidence and practitioner experience.

Findings:
The findings reveal that digital health adoption is shaped by interdependent socio-technical constraints rather than purely technological factors. The findings reveal that digital health adoption is shaped by a complex interplay of socio technical factors rather than technological availability alone. Five interrelated themes define this landscape: technical instability of digital systems, persistent gaps in patient digital skills, cultural and linguistic misalignment, context dependent trust dynamics, and weak policy and system integration. While the pandemic accelerated digital uptake, this expansion was often rapid and uneven, producing short term familiarity without sustained competence. In certain cases, digital health interventions reproduced existing inequalities, disproportionately benefiting populations with higher digital capacity. Importantly, these limitations are not only barriers to adoption but also sources of clinical risk, as unreliable systems, misinterpretation of information, and exclusion from digital pathways can compromise patient safety and continuity of care.

Research limitations:
The study is contextually grounded in a single megacity, which may limit direct generalisation, although the patterns identified resonate with broader low resource settings. Future research would benefit from longitudinal designs to assess whether post pandemic digital health gains are sustained, and from intersectional analyses that capture how digital exclusion interacts with gender, age, and socio economic status. There is also a clear need for stronger integration of patient safety metrics within digital health evaluation frameworks.

Practical implications:
Effective digital health implementation requires more than technological deployment. Policy frameworks must prioritise digital inclusion through investments in infrastructure, targeted digital literacy interventions, culturally and linguistically adapted platforms, and trust building mechanisms. Health systems must also embed patient safety principles into digital design and governance, ensuring reliability, usability, and error prevention across care pathways.

Social implications:
The study highlights that digital health is not inherently democratizing. Without deliberate attention to equity, it risks reproducing and amplifying existing social inequalities in healthcare access and outcomes. Digital exclusion functions as a structural determinant of health, influencing not only who can access services but also who can do so safely. Addressing these inequities is therefore central to both public health resilience and social justice, particularly in contexts where healthcare systems are already unevenly distributed.

Originality/value:
This study advances digital health scholarship in three ways. It integrates post-pandemic global evidence with practitioner perspectives from a low and middle income megacity, offering a grounded account of implementation realities often absent from policy level analyses. It reframes digital health as a socio-technical system rather than a technological intervention, emphasising the centrality of contextual alignment. Most importantly, it introduces patient safety as a core analytical lens, demonstrating that the success of digital health initiatives must be evaluated not only in terms of access or efficiency but in their capacity to deliver safe, reliable, and equitable care. In other words, study argues that meaningful digital health transformation must balance technical innovation with commitment to patient and societal well-being.

Statement of public interest:
Digital health grew rapidly during the COVID-19 pandemic and has often been promoted as a way to address gaps in healthcare access. This study demonstrates that its benefits depend on whether people can use these technologies effectively and trust them. When digital systems are unreliable, hard to navigate, or poorly suited to local contexts, they can delay care and create new risks. Making digital health work for diverse populations requires ongoing investment in skills, infrastructure, and inclusive design. These findings highlight the need to build health systems that are not only technologically advanced but also safe, equitable, and responsive to the needs of real people.

Keywords

Digital health adoption; digital literacy; patient safety; socio-technical framework; health equity; participatory design; low- and middle-income countries; digital inclusion; culturally tailored healthcare technology; health system governance.