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Vaccine Equity: Making Tech Work for the Digitally Disconnected Kanimozhi Udhayakumar & Sarayu Natarajan August 2021 Acknowledgements In addition to contributions from the wider Aapti team, this report also draws from the experiences of the interviewees. We are grateful for their inputs. Editor: Sujay Pan, Chandana S, Anushree Choudhury & Rujuta Naik Report design: Meher Rajpal | Cover illustration: Inika Charles C O NT ENTS 01 Executive Summary 5 02 Introduction India launched its COVID-19 vaccination drive on 16th January 2021. A technology platform to facilitate this vaccination drive, CoWin, was launched by the Government of India. CoWIN is a digital platform that helps Indian citizens discover and register for vaccine slots. The nationally digitised platform was helpful to rollout and effectively organise the vaccine distribution system at a large scale. CoWIN helps citizens to track their vaccination doses, the type of vaccine given, and the timeline through digital certification. A centralised digital certificate is issued across the country that can be universally authenticated. CoWIN further enables vaccine providers to publish their schedule of vaccination based on availability, and verify citizens at point of vaccination, while recording the event of vaccination. Though CoWin has advantages in creating authentic data trails, create an accountable mechanism for documentation, it is important to ensure the digital interface does not inhibit the access for those across the digital divide. Our research explores the barriers experienced, and the ways they intersect with the digital divide, the health infrastructure and pre existing structural inequities. 7 Indian Government opened up registrations for vaccination through its vaccine booking portal- CoWin in April, 2021. Close to ten million people signed up in the first 8 hours, causing the interface to crash.. This resulted in multiple problems ranging from inability to book slots, perpetually full slots, not getting text alerts or OTP, among others. Given challenges of accessing CoWin, it led to the emergence of new digital intermediaries such as platforms like Under45.in, getjab.in etc. Prominent big tech companies and small startups also launched their own slot notifications apps and mechanisms. They were helpful for the digitally savvy population to keep track of slot opening times and make the booking process faster and efficient for them. These digital intermediaries enabled the users to sign up, several of these at the time of writing this report had more than 1 lakh subscribers. 8 03 Approach This study focuses on examining breakdowns in access in the context of digital solutions for vaccination. We used mixed methods combining quantitative and qualitative tools. This ensures methodological robustness, by gleaning insights from broader trends and exploring them through empirical evidence from the field. The research was carried out in 2 steps: 1 First, we undertook qualitative tele-fieldwork among the marginalised sections of the society to understand key challenges with digital, and consequent vaccine access breakdowns on the ground. 2 Simultaneously, we conducted a quantitative analysis by using a digital survey to glean the broad trends of cowin usage. The survey was circulated among the close networks of the researchers via Whatsapp. (Questionnaire in Appendix) The study does not attempt to prove causal links between predictors and their impact, nor does it prove the quantum or direction of impact of a specific solution. We hope to use this research as a generative process to inform technological development and solution development towards wider and deeper access. We aimed for diversity; however, the lockdown and the pandemic constrained respondent availability and responsiveness. 10 Variables in the graphs followed are explained for ease of understanding We were limited by the unavailability of respondents due to time constraints (eg: people working from home, daily wage labourers), and limited participation because of remote locations of the respondents and lack of clarity on virtual communication. Our digital survey sample was representative and seemed elite. Aapti researchers’ positionality as people from elite backgrounds should be considered in accordance with the networks we reached out. 11 We circulated the survey in several social media platforms with a general exhortation to share further. This resulted in wide distribution across several groups. We attained a gender balanced sample. However, the mode of distribution and the response suggest that the survey primarily accessed those who could access digital means and navigate an English survey. 12 13 04 Learnings UNPACKING PROBLEMS Across sections of the society, digitally mediated vaccination process has been more of a struggle than ease. However, elites had different experiences compared to the marginalised sections of the society Elites had the access and ability to navigate CoWin. The problems appeared related to the vaccine distribution process, policy volatility, and technical glitches. Most commonly highlighted issues were inadequate vaccine supply, lack of nearby vaccine infrastructure and changing vaccine norms from the government. Elite sections of the society faced several issues issues while trying to get vaccinated. 15 Responses from qualitative questions in the survey pointed us towards other barriers. As a result of this, elite sections of the society used their network of friends and social network to get vaccinated, without having to go through CoWin. They also booked slots away from the city since the slots were unavailable in the city’s urban pockets. This also further thwarted access to vaccines for the vulnerable population. Marginalised sections of the society needed to overcome the digital divide - lack of digital access, lack of digital ability - while accessing CoWin. This ended up alienating vulnerable sections of the society from vaccination. Over and above this, given that vaccines required payments at that time, poor people experienced further inhibitions. 16 While a few of our respondents managed to obtain slots and get vaccinated, several experienced difficulty. In the process of qualitative coding, few other reasons mentioned by the respondents for not using CoWin. 17 Women and the economically weak are the most disadvantaged people because of this. In addition to various types of access problems, they also face agency issues where they do not feel empowered to get vaccinated even when they are clear that they need it and realise the advantages of it. Digitally savvy younger sections of the society and elite sections of the society have been helpful for these sections of the society for them to access vaccines. 18 UNPACKING SOLUTIONS Offline intermediaries enable the marginalised to access vaccines Offline intermediation is fundamental to access in conditions of marginality, especially for women, economically disadvantaged etc. 19 20 Qualitative coding from tele-fieldwork and qualitative responses from the survey gave us the insight that people prefer to reach out to local neighbourhood based community associations. The digital survey had multiple categories of community based organisations 21 22 From our tele-fieldwork, non elite sections of the society depended on their younger sections of the family and friends networks to book slots for them using CoWin. Tele fieldwork also suggested that there were local drives happening in government schools, PHCs etc, and respondents were aware of it. However, in addition to the issues with information about the said camps/drives, respondents also said they were hesitant to seek the vaccine due to uncertainty about its side effects. Emerging digital intermediaries assist elites in seeking vaccine The structure of CoWin amplified underlying issues in supply and health infrastructures, especially in areas where they were weak. This gave rise to a new category of digital intermediaries who helped to ease the process thereby solving some architectural backend problems with CoWin. 23 Exponential growth of digitally mediated tools facilitating slot booking in the CoWin in the past few months. 24 Digital intermediaries have utility, but they also end up mirroring the digital divide. With the possibilities of them becoming prominent in the near future, it is important to think of their governance, regulation and accountability mechanisms. These private enterprises collect vast amounts of data, and do not have clearly established governance and transparency mechanisms. Digital intermediaries, by its nature, have embedded inequality exacerbating mechanisms in them. Most of the digital survey respondents have registered for these slot finding applications while most of the tele-fieldwork respondents were unaware of it. 25 26 05 Recommendations Vaccines remain a critical element in any country’s arsenal to fight Covid. Digital mechanisms to manage certification and supply can have significant impact. However, given the findings from our research, and the existing scenario about digital divide, it is critical to build approaches that are inclusive of those that struggle to navigate state systems, particularly when mediated by digital.It also becomes imperative in the near future with the new variants of COVID coming up in narrowing time spans raising the demand need for booster shots. 28 aapti institute 2021 Aapti is a public research institute that works at the intersection of technology and society. It examines the ways in which people interact and negotiate with technology both offline and online. -www.aapti.in | www.thedataeconomylab.com This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 2.5 India License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/2.5/in/