The Government of Odisha is going to establish digital dispensaries in the remote and inaccessible areas of Keonjhar, Nabarangpur and Ganjam to provide primary healthcare. These dispensaries will provide services to outpatients through online video consultation with the doctors. The digital dispensaries will have laboratories for basic pathological test and generic medicine dispensing centres. The pathological test reports will be uploaded by the pharmacist and after consulting with the doctor, pharmacists will dispense medicines to the patients. Given the severe lack of basic health facilities in remote areas of the state, this move can be seen as an out-of-box solution that harnesses the potentials of digitisation. However, this novel way of a digital solution to the provision of health services, unless seen as a complementary and limited measure for providing access to health care, is likely to result in a misguided attempt to underplay the structural inequalities that plague the healthcare system in Odisha.
As per the
World Development Report, 2016 ‘digital
technologies have
impacted only if
institutions are strong’
According to NFHS-4 report, infant mortality rate in rural areas of Odisha is 43 and the under-five mortality rate is 53 per thousand live births. Anaemia among children below five years and women in the age 15-49 age group is around 46 and 52 per cent respectively. In 2015, a study conducted by US-India Policy Institute and Centre for Research and Debates in Development Policy, New Delhi, has found that among all districts in Odisha, Malkangiri has the lowest human development index, followed by Nabarangpur, Rayagada and Nuapada in term of health indicators. Therefore, immediate action is required to address the issues of human development, including health and nutrition. Despite the improvements in some areas, there is a need to address the structural bottlenecks and a backlog of health infrastructure development in Odisha, particularly in the relatively less developed areas. This requires a sustained and long-term commitment to provide affordable healthcare for all. Solutions like digitisation might look innovative and novel at the first sight, but the real benefits of such programmes need to be evaluated carefully.
The quality and outreach of rural health infrastructure is a major concern for healthcare provisioning. Many remote rural areas in Odisha still do not have primary health centres (PHCs). Even for basic pathological tests, health centres need infrastructure, efficient pharmacists and technicians. According to Rural Health Statistics 2017, 1,280 PHCs in Odisha are functioning; of which, 1,239 PHCs are functioning without a lab technician and 134 without pharmacists. Also, 86 health centres are functioning without doctors. In the tribal-dominated areas, there is a shortfall of 90 doctors in PHCs as of 2017.
District-level Household and Facility Survey, 2012-13 indicates that 80 per cent of PHCs in Angul and 72 per cent in Malkangiri are functioning without any medical officer. Similarly, for maternal care services, the inclusion of lady medical officers in primary health centres is an advantage, as women feel comfortable with the doctors. It is surprising that 22 districts do not have single lady medical officers at the primary health centres. The absence of doctors in the remote areas deepens the problem further.
While advocating digital solutions to problems, the digital divide that has emerged among the citizens must be taken into account. There is evidence to suggest that the digital divide is closely associated with pre-existing social and economic inequalities. Even access to fast and steady Internet connectivity is a major problem in some of the proposed locations for online video calling. Census 2011 reveals that only 0.5 per cent of the households are having Internet connectivity in rural Odisha, against 6.4 per cent in urban areas. Of the total rural households, only 30.9 per cent of households are having mobile phones. Odisha has been observed to be one of the states with the lowest index in e-infrastructure (up to 0.26), as compared to Kerala and Punjab (more than 0.84) by the 2017 IAMAI report.
In Odisha, where the share of undernourishment and underweight children and anaemic women are so high that digitalisation of health service may work like a fast-aid box. Some diseases like prenatal and postnatal care for women, dehydration, malnourishment, diarrhoea cannot be treated by the pharmacists who will be in charge of the digital dispensaries. This will also give false assurance to the people that their treatment is going on. Very often generic life-saving drugs are also unavailable in the district hospitals. In the absence of availability of prescribed generic medicines for poor people in remote areas, digital access to doctor’s advice will have very limited meaning. Out-of-pocket health care expenditure has severe implications for the overall debt burden of the poor and vulnerable households. The impact of digitisation on health care expenditure needs to be examined.
The people in remote rural areas are vulnerable because of a number of reasons, including geographical isolation. Lack of basic facilities and physical access to doctors is a form of distributive injustice towards them. Digital dispensaries can be supplementary but not substitute to primary health centres in Odisha.
As per the World Development Report, 2016 ‘digital technologies have impacted only if institutions are strong’. Therefore, institutions for the betterment of health are necessitated along with digital dispensaries. While it may certainly work in certain circumstances, it should not be seen as a means to replace the long-term goal of providing affordable and quality health care to all people, including those living in less accessible areas.
Aparimita Mishra is an
independent researcher working on gender, environment and livelihoods issues.