Clinical trials futures: reimagining health equity through a design and foresight approach

This paper proposes an approach to designing equitable decentralised clinical trials (DCTs) to address ongoing structural disparities in clinical research. Continuing historical legacies of exploitation in clinical trials, such as unethical medical experimentation on vulnerable populations, combined with global power asymmetries, has resulted in global access gaps where over two billion people lack essential medicines and vaccines often developed through these very trials. Guidelines such as International Council for Harmonisation of Good Clinical Practice uphold ethical compliance for the protection of the rights, safety and well-being of human participants involved in clinical trials. Despite this critical role, these guidelines remain inadequate for confronting the deeper legacies of structural harm. DCTs offer a potential paradigm shift to expand participation by integrating digital health technologies and local networks. However, without deliberate attention to a justice-oriented design, they risk reproducing the same inequities they seek to overcome. We, therefore, draw on futures thinking and design justice to propose three interdependent strategies: (1) anticipatory justice, (2) institutionalising reciprocity and (3) relational accountability. Such an approach invites a shift in how innovation is imagined and enacted in clinical research, one that anticipates future challenges, foregrounds local voices and offers a pathway toward more just and equitable global healthcare systems. When grounded in equity and co-creation, DCTs could evolve from methodological innovation into a moral infrastructure: one that redistributes power, protects against duress and reimagines clinical research as a practice of solidarity and shared flourishing.