Digital inequality- Health and Educational sector

Introduction

• Virginia Eubanks’ widely acclaimed book, Automating Inequality, alerted us to the ways that automated decision-making tools exacerbated inequalities, especially by raising the barrier for people to receiving services they are entitled to.
• The novel coronavirus pandemic has accelerated the use of digital technologies in India, even for essential services such as health and education, where access to them might be poor.

Economic inequality

• People whose jobs and salaries are protected, face no economic fallout.
• The super-rich have even become richer (the net worth of Adani has increased).
• The bulk of the Indian population, however, is suffering a huge economic setback.
• Several surveys conducted over the past 12 months suggest widespread job losses and income shocks among those who did not lose jobs.

Inequality in Digital Education

• For a few, the switch to online education has been seamless.
• According to National Sample Survey data from 2017:
  • only 6% of rural households and 25% of urban households have a computer.
  • Access to Internet facilities is not universal either: 17% in rural areas and 42% in urban areas.
• Sure, smartphones with data will have improved access over the past four years, yet a significant number of the most vulnerable are struggling.
• Surveys by the National Council of Educational Research and Training (NCERT), the Azim Premji Foundation, ASER and Oxfam suggest that between 27% and 60% could not access online classes for a range of reasons:
  • lack of devices,
  • shared devices,
  • inability to buy “data packs”, etc.
• Further, lack of stable connectivity jeopardises their evaluations (imagine the Internet going off for two minutes during a timed exam).
• Besides this, many lack a learning environment at home: a quiet space to study is a luxury for many.
  • For instance, 25% of Indians lived in single-room dwellings in 2017-19.
• Peer learning has also suffered.
• While we have kept a semblance of uninterrupted education, the fact is that the privileged are getting ahead not necessarily because they are smarter, but because of the privileges, they enjoy.

Inequality in digital health services

• India’s abysmally low public spending on health (barely 1% of GDP) bears repetition.
• Partly as a result, the share ‘of pocket (OOP) health expenditure (of total health spending) in India was over 60% in 2018.
  • Even in a highly privatised health system such as the United States, OOP was merely 10%.
• Right now, the focus is on the shortage of essentials: drugs, hospital beds, oxygen, and vaccines.
• In several instances, developing an app is being seen as a solution for the allocation of various health services.
  • It is assumed that these will work because of people’s experience with platforms such as Zomato/Swiggy and Uber/Ola.
  • We forget that those work reasonably well because restaurants/food and taxis/drivers are available for these platforms to allocate effectively.
• Patients are being charged whatever hospitals like, and a black market has developed for scarce services (such as oxygen).
• Digital “solutions” create additional bureaucracy for all sick persons in search of these services without disciplining the culprits.
• Along with the paperwork, patients will have to navigate digi-work.
• Platform- and app-based solutions can exclude the poor entirely, or squeeze their access to scarce health services further.
• In other spheres (e.g., vaccination) too, digital technologies are creating extra hurdles.
• The use of Cowin to book a slot makes it that much harder for those without phones, computers and the Internet.
• The website is only available in English.

Online sharks

• It is also alarming if the pandemic is being used to create an infrastructure for future exploitation of people’s data.
• The digital health ID project is being pushed during the pandemic when its merits cannot be adequately debated.
  • Electronic and interoperable health records are the purported benefits.
  • For patients, interoperability (i.e., you do not have to lug your x-rays, past medication and investigations) can be achieved by decentralising digital storage (say, on smart cards) as France and Taiwan have done.
  • Yet, the Indian government is intent on creating a centralised database.
• Given that we lack a data privacy law in India, it is very likely that our health records will end up with private entities without our consent, even weaponised against us (e.g., private insurance companies may use it to deny poor people an insurance policy or charge a higher premium).
• There are worries that the government is using the vaccination drive to populate the digital health ID database (for instance, when people use Aadhaar to register on Cowin).

Way forward

• The point is simple: unless health expenditure on basic health services (ward staff, nurses, doctors, laboratory technicians, medicines, beds, oxygen, ventilators) is increased, apps such as Aarogya Setu, Aadhaar and digital health IDs can improve little.
• Unless laws against medical malpractices are enforced strictly, digital solutions will obfuscate and distract us from the real problem.
• We need political, not technocratic, solutions.