Intervention(s)
Telehealth connects patients to qualified health care professionals via phone. Although its popularity dramatically increased since the onset of the COVID-19 pandemic, there is limited rigorous evidence of its impact. In particular, the impact of telehealth on health access and healthcare inequality in low-income countries is ex-ante ambiguous. On the one hand, telehealth could allow individuals currently out of reach of the official health system -- e.g., because of their remote location or because of prevailing norms -- to access quality healthcare providers, thus improving the quality of care and equalizing access. On the other hand, telehealth might crowd out in-person care, with potential negative consequences on health outcomes for those individuals who do not engage with technology, who are not e-literate, and who have little trust in modern medicine to start with (e.g., women, the elderly, the poor). This may result in telehealth excluding individuals who might need care most, exacerbating inequality in healthcare.
Given the potential barriers to the utilization of telehealth in low-income settings, the presence of local “facilitators” may be crucial to its success. First, local facilitators may attenuate the digital divide by allowing marginalized individuals, including women with low power in the household, to contact the doctor and nurse through a smartphone that has access to the internet. Second, local facilitators may allow for more “continuity of care”, an aspect which is often lacking in telehealth programs that prioritize the “speed of care” (i.e., patients meeting with the first available provider even if that provider is unknown to them) and which might matter especially in contexts with low trust in modern medicine. Finally, local facilitators may complement telehealth services by monitoring the evolution of health conditions of patients that require frequent follow-ups (e.g., noncommunicable diseases).
India provides an ideal study setting, both because of the vast potential user base in need of telehealth services and because recent years have seen a rapid diffusion of telehealth providers. The Indian government has pioneered this technological revolution, by launching and promoting its platform, called eSanjeevani, and has been rapidly followed by other telehealth providers, in an attempt to reach even the most remote areas of the country. However, while millions of people have already used these services, their reach seems so far to be below expectations.
The project will develop in two phases. In the first phase, we will study the current diffusion of telehealth services in rural Bihar, with a particular focus on the government program eSanjeevani. Through a rich data collection that will span 400 villages, our objectives are to study:
• How popular are telehealth services in rural Bihar? In particular, how familiar are people with the government eSanjeevani program? What are the main challenges to telehealth diffusion?
• Which types of patients are more likely to use telehealth? In particular, does telehealth reduce gender inequality in access to healthcare?
In the second phase, we will then study the impact of the arrival of a new telehealth provider in the study location. The new health provider (Healing Fields Foundation, HFF) will introduce two alternative versions of telehealth: with and without a facilitator, i.e. a community health worker that will help community members connect through telehealth. In this second phase we will aim to study:
• What is the causal impact of telehealth on access to health services and health outcomes among people in rural areas?
• Does the presence of a facilitator increase the spreading and utilization of telehealth?
• Does telehealth reduce gender inequality in access to healthcare typically observed in many low-income countries?
• Which types of patients are more likely to use telehealth with vs. without the facilitator? Does the impact differ across gender, income, and age groups?