Universal Platforms, Unequal Access: Public Digital Health Initiatives in Developing Economies

Abstract

Problem definition: Developing economies face significant challenges in distributing scarce resources to ensure equitable population healthcare access. Digital health initiatives are often promoted by policymakers and NGOs as a way to improve healthcare access, yet evidence regarding their efficacy in resource-constrained environments remains mixed. We examine how the rollout of a public digital health ecosystem impacts access to care, using the launch of India's Ayushman Bharat Digital Mission (ABDM) program. We then explore whether this impact is distributed equitably between groups. 

Methodology/results: Using a single-difference approach, we find that, after ABDM was fully launched in September 2021, monthly outpatient care volume increased by 22.9%. Further, a continuous difference-in-differences analysis examining the role of regional wealth in shaping the initiative's effectiveness indicates that wealthier sub-districts experienced larger increases in care volume than poorer regions. This gap in healthcare access after the initiative remains robust to alternative model specifications, alternate measures of wealth, aggregation across specific types of care, a falsification test, and the removal of outlier sub-districts. Finally, we investigate how this gap can be mitigated through infrastructure investments. We find that the gap in healthcare access after the initiative is lower in sub-districts with higher information access, physical infrastructure, and social support capacity. 

Managerial implications: This work provides evidence that implementing public digital health ecosystems can be effective in impacting the healthcare access of the general populace. However, our findings also highlight these access improvements can be distributed unequally between wealthy and poor regions. For policymakers and NGOs, our paper shows that digital health initiatives can systemically impact access to care, but proper considerations towards improving localized and allied infrastructure should be made to ensure equitable impacts for disadvantaged groups.