The struggle for digital inclusion : phones, healthcare, and marginalisation in rural India

The gains from digital technology diffusion are deemed essential for international development, but they are also distributed unevenly. Does the uneven distribution mean that not everyone benefits from new technologies to the same extent, or do some people experience an absolute disadvantage during this process? I explore this question through the case study of curative healthcare access in the context of rapid mobile phone uptake in rural India, contributing thus to an important yet surprisingly under-researched aspect of the social implications of (mobile) technology diffusion. Inspired by a previous analysis of cross-sectional data from rural India, I hypothesise that health systems increasingly adapt to mobile phone users where phones have diffused widely. This adaptation will leave poor non-adopters worse off than before and increases healthcare inequities. I use a panel of 12,003 rural households with an illness in 2005 and 2012 from the Indian Human Development Survey to test this hypothesis. Based on village-cluster robust fixed-effects linear probability models, I find that (a) mobile phone diffusion is significantly and negatively linked to various forms of rural healthcare access, suggesting that health systems increasingly adapt to phone use and discriminate against non-users; that (b) poor rural households without mobile phones experience more adverse effects compared to more affluent households, which indicates a struggle and competition for healthcare access among marginalised groups; and that (c) no effects emerge for access to public doctors, which implies that some healthcare providers are less responsive to mobile phone use than others. Overall, my findings indicate that the rural Indian healthcare system gradually adapts to increasing mobile phone use at the expense of non-users. I conclude that rapid mobile phone diffusion creates an opportunity to improve people’s access to healthcare in rural India, but it also creates new forms of marginalisation among poor rural households

New impulses from international development for more comprehensive and balanced public engagement evaluation

Public engagement in health research has gained popularity because of its potential to co-create knowledge, generate dialogue, and ground research in the priorities and realities of the target groups. However, public engagement that achieves these objectives could still entail unforeseen negative consequences or a wasteful use of resources. Although the evaluation of public engagement has evolved in recent years, project-specific idiosyncrasies prevent systematic and transparent assessments of success and failure. This article introduces standard evaluation criteria from the field of development aid evaluation (effectiveness, efficiency, impact, relevance, sustainability) to promote more systematic and comprehensive evaluation practice. I apply these criteria to the public engagement component of a recent research project into antimicrobial resistance, antibiotic use, and health behaviour in Thailand and Laos. Considering village-level engagement workshops, international exhibitions of photo narratives of traditional healing in northern Thailand, and social media communication, I demonstrate that activities that seem to achieve their objectives can still have problematic characteristics in other dimensions. I conclude that these five generic evaluation criteria can broaden our understanding of public engagement. Their more widespread use in evaluations can help build a more comprehensive and balanced evidence base, even if only a sample of public engagement projects and programmes can be evaluated systematically

Exploring the mismatch between mobile phone adoption and use through survey data from rural India and China

Persistent disciplinary and methodological divides between technology diffusion and adoption studies and the study of use and engagement with technology raise obstacles to understanding the development implications of mobile technology diffusion, for example in the area of healthcare access. As quantitative assessments in the area of health and technology almost exclusively rely on binary indicators of mobile phone adoption, it is not clear whether this is indeed a reasonable proxy that does not obscure the distributional implications of mobile phone use. This paper therefore compares patterns of mobile phone adoption and utilisation using original survey data from rural India and China. "Utilisation" here is assessed through a simple yet novel multidimensional index. The paper further assesses the role of these concepts as determinants of locally emerging forms of mobile-phone-aided healthcare-seeking behavior ("health action"). The investigation uses descriptive statistical analysis and multilevel logistic regression analysis, which provide evidence in support of the claims that (a) patterns of mobile phone diffusion and utilisation are related yet incongruent, that (b) mobile phones facilitate health action in both field sites to a notable extent, and that (c) the mobile phone utilisation index is a better predictor for phone-aided health action than mobile phone adoption. In light of the superiority of the utilisation index vis-à-vis binary measures of mobile phone adoption, other researchers can apply the survey instrument and technology utilisation concept developed in this paper to support the analysis of the social implications of technology diffusion

Review of After access : inclusion, development, and a more mobile internet by Donner, J.

The subject of Jonathan Donner’s latest book After Access […] documents and analyses the current state of mobile internet usage around the world. His global scope, analysis of the implications of internet use for livelihoods and participation, and interest in digital divides speak to the broader development community as well as to the specific disciplines of mobile communication studies, and information and communication technologies and development (or “ICTD”)

The social implications of technology diffusion : uncovering the unintended consequences of people’s health-related mobile phone use in rural India and China

After three decades of mobile phone diffusion, thousands of mobile-phone-based health projects worldwide (“mHealth”), and hundreds of thousands of smartphone health applications, fundamental questions about the effect of phone diffusion on people’s healthcare behavior continue to remain unanswered. This study investigated whether, in the absence of specific mHealth interventions, people make different healthcare decisions if they use mobile phones during an illness. Following mainstream narratives, we hypothesized that phone use during an illness (a) increases and (b) accelerates healthcare access. Our study was based on original survey data from 800 respondents in rural Rajasthan (India) and Gansu (China), sampled from the general adult population in 2014 in a three-stage stratified cluster random sampling design. We analyzed single- and multi-level logistic, Poisson, and negative binomial regression models with cluster-robust standard errors. Contrary to other research at the intersection of mobile phones and healthcare, we captured actual health-related mobile phone use during people’s illnesses irrespective of whether they own a phone. Our analysis produced the first quantitative micro-evidence that patients’ personal mobile phone use is correlated with their healthcare decisions. Despite a positive association between phone use and healthcare access, health-related phone use was also linked to delayed access to public doctors and nurses. We considered theoretical explanations for the observed patterns by augmenting transaction cost and information deficit arguments with the prevailing health system configuration and with notions of heuristic decision-making during the healthcare-seeking process. Our study was a first step toward understanding the implications of mobile technology diffusion on health behavior in low- and middle-income countries in the absence of specific mHealth interventions. Future research will have to explore the causal relationships underlying these statistical associations. Such a link could potentially mean that development interventions aimed at improving access to healthcare continue to require conventional solutions to sustain healthcare equity

The place of technology in the Capability Approach

Increasing scholarly attention has focussed on how to integrate technology within the Capability Approach (CA), yet without a consistent solution. Some describe technology as a special kind of capability input, but others consider the concept of technology to be fundamentally different from that of an ordinary input. We aim to contribute to the theoretical development of the CA by offering a consistent justification for the explicit inclusion of technology in this framework. We propose that technical objects have a ‘generative’ and a ‘transformative’ dimension through which they enable capabilities directly and affect other inputs in the attainment of valued capabilities. The objects acquire the transformative dimension from the broader technological context, which we propose as a new class of conversion factors. Using the example of mobile phones and their role in healthcare access, we demonstrate that our proposal helps to frame the analysis of the development impact of technology

Healthcare access : a sequence-sensitive approach

It is widely accepted that healthcare-seeking behaviour is neither limited to nor terminated by access to one single healthcare provider. Yet the sequential conceptualisation of healthcare-seeking processes has not diffused into quantitative research, which continues to analyse healthcare access as a “one-off” event. The ensuing lack of understanding healthcare behaviour is problematic in light of the immense burden of premature death especially in low- and middle-income countries. This paper presents an alternative approach. Based on a novel survey instrument, we analyse original survey data from rural India and China that contain 119 unique healthcare pathways among 637 respondents. We offer three applications of how such sequential data can be analysed to enhance our understanding of people's health behaviour. First, descriptive analysis of sequential data enables more a comprehensive representation of people's health behaviours, for example the time spent in various healthcare activities, common healthcare pathways across different groups, or shifts in healthcare provider access during a typical illness. Second, by analysing the effect of mobile technology on healthcare-seeking process characteristics, we demonstrate that conventional, sequence-insensitive indicators are potentially inconsistent and misleading approximations when compared to a more precise, sequence-sensitive measure. Third, we describe how sequential data enable transparent and flexible evaluations of people's healthcare behaviour. The example of a sequence-insensitive evaluation suggests that household wealth has no statistical link to an illustrative “ideal” form of public healthcare utilisation. In contrast, sequence-sensitive evaluations demonstrate that household wealth is associated with an increased likelihood of bypassing referral processes and approaching unregulated and costly informal and private practitioners before accessing a public clinic. Sequential data therefore do not only reveal otherwise neglected locational idiosyncrasies, but they also yield deeper insights into the drivers of people's health behaviours compared to a conventional approach to “access to healthcare.

Manifestations, drivers, and frictions of mobile phone use in low- and middle-income settings : a mixed methods analysis of rural India and China

Against the backdrop of alleged mobile phone ubiquity and the enthusiasm about the developmental value of mobile technology, this paper examines the manifestations, drivers, and frictions of mobile phone use in two low- and middle-income settings where mobile technology has diffused rapidly. Qualitative data from 231 participants and survey data from 800 adults in rural Rajasthan and Gansu provide consistent and strong support for the claim that the notion of ‘ubiquity’ can mislead development practice because it obscures persistent non-use, under-utilisation, and heterogeneous engagement with mobile technology despite its apparently wide accessibility in rural field sites. The paper suggests avenues for further work on the indicators of technology adoption, and it cautions that phone-based development interventions (and their benefits) may diffuse unevenly if the assumption of ubiquitous technology use is violated

Impact of high-intensity polio eradication activities on children’s routine immunization status in Northern India

The objective of this article is to analyse and quantify the side effects of the Polio Eradication Initiative on routine immunization performance in India. Past studies have faced methodological challenges in assessing these side effects. This article offers a methodological alternative for health policy analysts. The research uses secondary household survey data from the Indian District-Level Household and Facility Survey (DLHS), focusing on children aged 10–30 months in the Northern Indian states of Uttar Pradesh (n = 34 327) and Bihar (n = 20 525). Covering the years 2002–08, this is the latest large-scale data from India that enables the matching technique used in this article. District-level programme intensity data of the Polio Eradication Initiative in India were reconstructed using publicly available resources. The methodological innovation compared with previous studies consists of matching each child in the DLHS data set with a child-specific value of programme exposure depending on its district of residence, its birth date, and the date of the survey interview. Average and age-specific associations between polio programme exposure and children’s full immunization status were assessed using logistic regression, controlling for other determinants of immunization. The regression results show that the link is negative in Uttar Pradesh and positive in Bihar. Age-specific analysis shows that the positive association diminishes for older children in Bihar and that a negative association emerges and becomes increasingly pronounced for older children in Uttar Pradesh. This indicates that heterogeneous results emerge across two neighbouring states with similar programme intensity and suggests that the catch-up of unvaccinated older children may be a channel through which negative effects accrue. The method described in this article, based on an analytical focus on individual-level programme exposure, can therefore help health policy implementers and evaluators to illuminate positive or negative interactions between a health intervention and a health system

It is time to give social research a voice to tackle antimicrobial resistance?

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