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Field
Trial Status
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Before
in_development
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After
on_going
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Field
Abstract
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Before
Remote areas in low-income countries have poor access to quality healthcare. One challenge in developing state capacity in remote areas is the difficulty in attracting skilled workers (doctors and nurses), to which a common solution is to engage less skilled workers (community health workers). A new solution is to bring higher-skilled professionals to rural areas through digital technology. Telehealth, which connects patients to qualified healthcare professionals via phone, provides a new opportunity for governments to reach remote areas with high-quality healthcare services at relatively low costs. Although the popularity of telehealth has dramatically increased since the onset of the COVID-19 pandemic, there is to date no causal evidence of its impacts in low-income countries.
This project aims to provide the first experimental evidence on the impact of telehealth on healthcare utilization and health outcomes in low-income countries. The impact is ex-ante ambiguous: telehealth may expand access to healthcare in areas previously underserved by the health system, but it might also crowd out in-person care and lead to an overall drop in healthcare utilization by those most in need, who might be unable or unwilling to connect remotely with a health professional. The project will take place in 400 rural Indian villages that will be randomized into receiving telehealth or not, with or without a local facilitator, who will assist patients in connecting to the call and follow up with them after the visit. We will learn whether and under which conditions telehealth improves access and health outcomes for rural populations, and how it affects the divide in access by gender, income, and age.
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After
Remote areas in low-income countries have poor access to quality healthcare. One challenge in developing state capacity in remote areas is the difficulty in attracting skilled workers (like doctors or nurses), to which a common solution is to engage less skilled workers (community health workers). A new solution is to bring higher-skilled professionals to rural areas through digital technology. Telehealth, which connects patients to qualified healthcare professionals via phone, provides a new opportunity for governments to reach remote areas with high-quality healthcare services at relatively low cost. Although the popularity of telehealth has dramatically increased since the onset of the COVID-19 pandemic, there is to date no causal evidence of its impacts in low-income countries.
This project aims to provide the first experimental evidence on the impact of telehealth on healthcare utilization and health outcomes in low-income countries. The impact is ex-ante ambiguous: telehealth may expand access to healthcare in areas previously underserved by the health system, but it might also crowd out in-person care and lead to an overall drop in healthcare utilization by those most in need, who might be unable or unwilling to connect remotely with a health professional. The project will take place in 400 rural Indian villages that will be randomized into receiving telehealth or not, with or without a local facilitator, who will assist patients in connecting to the call and follow up with them after the visit. We will learn whether and under which conditions telehealth improves access and health outcomes for rural populations, and how it affects the divide in access by e.g. socioeconomic status and age.
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Field
Trial End Date
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Before
April 15, 2025
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After
December 15, 2026
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Field
Last Published
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Before
January 23, 2023 07:22 AM
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After
August 18, 2026 07:38 AM
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Field
Intervention (Public)
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Before
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?
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After
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, or 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. We will study the impact of the arrival of a new telehealth provider in a random subset of the 400 study villages in rural Bihar. The new health provider (Healing Fields Foundation, HFF) will introduce two (randomized) alternative versions of telehealth: with and without a facilitator, i.e., a community health worker that will help community members connect with a doctor remotely. We 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?
• Which types of patients are more likely to use telehealth with vs. without the facilitator? Does the impact differ across e.g. socioeconomic status and age groups?
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Intervention End Date
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Before
December 15, 2024
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After
December 15, 2026
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Field
Primary Outcomes (End Points)
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Before
Health service utilization, measured through a household survey and administrative data. This will encompass both telehealth utilization and in-person healthcare utilization. We will look at overall health service utilization as well as gaps in utilization by wealth, gender, and age.
We will also study whether telehealth crowds in or out in-person health services, and other telehealth programs (e.g. eSanjeevani), by looking at households’ interactions with each one of these service providers, as recorded in the household survey.
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After
1) Access to and utilization of healthcare. Measures will capture household contact with health actors; care-seeking in response to recent illness; the timing of care; referrals and follow-up; and use of telehealth, community health entrepreneurs (CHEs), and other public, private, informal, pharmacy, traditional, and government telehealth providers. We will examine both overall utilization and the composition of care in order to assess whether the study interventions expand access to healthcare or substitute for existing services.
2) Detection of chronic conditions and continuity of care for chronic conditions, particularly diabetes, hypertension, and anaemia. Measures will capture whether relevant health conditions are recognized or diagnosed and whether affected individuals are linked to appropriate providers and receive regular monitoring and follow-up.
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Field
Primary Outcomes (Explanation)
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Before
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After
We will summarize closely related measures within each primary outcome family in standardized domain-level indices, while substantively important component outcomes will also be reported separately. Provider-specific utilization measures will be used to distinguish changes in total healthcare use from substitution across types of care.
The main analyses will follow the randomized assignment of the telehealth and CHE components, separately and jointly. We will also examine whether treatment effects differ across relevant demographic and socioeconomic groups, including by gender (for questions where that is possible), age, socioeconomic status, baseline health needs, local availability of healthcare providers, and access to digital technology.
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Experimental Design (Public)
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Before
The study will take place in 400 villages in the state of Bihar, India. The first part of the study will be based on a rich set of surveys administered to a representative set of households and to the universe of health providers located in these 400 study villages, as well as detailed administrative data from the existing telehealth provider eSanjeevani.
The second part of the study will be based on a 2x2 field experiment, which will be implemented after the initial data collection in collaboration with Healing Fields Foundation (HFF), an NGO which recently launched a telehealth program that relies on community health workers (CHWs) as “facilitators”. We will take advantage of the planned expansion of HFF activities in the study region, to randomly select the villages that will be reached first by the program. Each study village will be randomly assigned to one of four groups of equal size:
• Control (C): status quo (no HFF telehealth and no HFF CHW);
• Telehealth + CHW (T1): HFF will provide telehealth and will recruit and train a CHW, who will be in charge of facilitating it;
• Telehealth only (T2): HFF will provide telehealth services that community members can directly utilize, but won’t recruit any CHW;
• CHW only (T3): HFF will recruit and train a CHW, but there will be no HFF telehealth services.
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After
The study will take place in 400 villages in the state of Bihar, India. The study will be a 2x2 field experiment, which will be implemented after the baseline data collection, in collaboration with Healing Fields Foundation (HFF), an NGO which recently launched a telehealth program that relies on community health workers (CHWs) as “facilitators”. We will take advantage of the planned expansion of HFF activities in the study region, to randomly select the villages that will be reached first by the program. Each study village will be randomly assigned to one of four groups of equal size:
• Control (C): status quo (no HFF telehealth and no HFF CHW);
• Telehealth + CHW (T1): HFF will provide telehealth and will recruit and train a CHW, who will be in charge of facilitating it;
• Telehealth only (T2): HFF will provide telehealth services that community members can directly utilize, but won’t recruit any CHW;
• CHW only (T3): HFF will recruit and train a CHW, but there will be no HFF telehealth services.
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Field
Planned Number of Observations
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Before
18 households per village (~7,200 households in total) are the units of observation for the household outcomes, and 5 health providers per village (~2,000 in total) for the provider outcomes. These are spread across the clusters of 400 villages.
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After
15 households per village (~6000 households in total) are the units of observation for the household outcomes, and about 5 health providers per village (~2,000 in total) for the provider outcomes. These are spread across the 400 villages.
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Field
Sample size (or number of clusters) by treatment arms
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Before
100 villages in control group (~1800 households, ~500 health providers)
100 villages in T1 (~1800 households, ~500 health providers)
100 villages in T2 (~1800 households, ~500 health providers)
100 villages in T3 (~1800 households, ~500 health providers)
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After
100 villages in control group (~1500 households, ~500 health providers)
100 villages in T1 (~1500 households, ~500 health providers)
100 villages in T2 (~1500 households, ~500 health providers)
100 villages in T3 (~1500 households, ~500 health providers)
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Field
Secondary Outcomes (End Points)
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Before
Health outcomes (household survey). Trust and satisfaction with the official health system (household survey).
Changes in effort, motivation, earnings and activities of the health workers (health providers survey).
Changes in the types of patients different provides cater to and the health services provided across the different treatment arms (household and health provider survey). Effects on the government telehealth program from introducing a NGO program.
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After
Household-level:
1) physical health: Self-reported health and recovery from recent illness; ability to live well with chronic health conditions; health-related work disruption or loss;
2) psychological health: psychological wellbeing and access to psychological support;
3) health knowledge: knowledge of common illnesses, chronic conditions, and danger signs requiring referral;
4) preventive and treatment-related behaviours, including medication adherence, hygiene, diet, and care-seeking practices, including healthcare access during periods of extreme heat;
5) household decision-making over healthcare; costs and perceived affordability of care; perceived access to a trusted healthcare provider; trust in and satisfaction with available providers; understanding of health advice received;
6) awareness, experience, perceived barriers, preferences, and demand for telehealth. We will include unincentivized willingness to pay questions and hypothetical choices between telehealth and in-person providers.
CHE-level:
1) retention in the CHE role;
2) work effort and service activity: household outreach; health education, screening, vital-sign measurement, referrals, facilitated teleconsultations, and patient follow-up;
3) training and supervision;
4) availability and use of equipment and any digital tools;
5) earnings and pricing;
6) health knowledge and competence;
7) confidence, motivation, satisfaction, and perceived standing in the community.
Outcomes on the level of other healthcare providers:
1) provider entry and exit; staffing and availability;
2) service and activity: hours worked and patient volumes; home visits and remote-care provision; the range of services and tests offered; referrals;
3) fees, revenues, and earnings;
4) health knowledge and competence;
5) motivation and satisfaction.
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Field
Secondary Outcomes (Explanation)
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Before
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After
Secondary outcomes will be measured using the household, CHE, and healthcare-provider surveys and, where available, administrative data. Closely related outcomes will be combined into domain-level indices, with important individual outcomes also reported separately.
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