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Digital Infrastructure As a Determinant of Health Equity: an Australian Case Study of the Implementation of the National Broadband Network

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Digital Infrastructure As a Determinant of Health Equity: an Australian Case Study of the Implementation of the National Broadband Network Australian Journal of Public Administration, vol. 77, no. 4, pp. 829–842 doi:10.1111/1467-8500.12323 Research and Evaluation Digital Infrastructure as a Determinant of Health Equity: An Australian Case Study of the Implementation of the National Broadband Network Ashley Schram and Sharon Friel The Australian National University Toby Freeman, Matthew Fisher, and Fran Baum Flinders University Patrick Harris University of Sydney Inequities in access to fast and reliable internet connections, essential for digital access to services and information that are important for health, can exacerbate social inequalities in health. We evaluated the social equity of the rollout of the National Broadband Network (NBN) in Australia based on the type of digital infrastructure delivered to areas of varying socioeconomic status. We found that areas of greater socioeconomic disadvantage were significantly less likely to receive the highest quality infrastructure, controlling for level of remoteness. These social inequities in provision of quality infrastructure will shape and possibly exacerbate inequities in health. In our discussion we consider how political decisions have obstructed equitable implementation of the policy. Lessons from the Australian case study may be valuable for other countries investing in public digital infrastructure who want to ensure equity of provision and can also inform Australian policy in the NBN’s remaining rollout. Key words: health inequalities, social inequity, social determinants of health, digital infrastructure, policy implementation Introduction Cave and Martin 2010; Willson et al. 2009). The US Broadband Opportunity Council de- Affordable quality broadband technology has clared in 2015 that broadband is ‘taking its been noted as a key component of effective place alongside water, sewer and electricity national telecommunication infrastructure. Ev- as essential infrastructure for communities’ idence has accumulated for its role as a vital en- (Middleton 2015). The growing acknowledge- abler of economic growth, social inclusion, and ment of broadband as a critical infrastructure environmental protection (Broadband Com- service is reflected in the increased prioriti- mission for Sustainable Development 2016; sation and investment from national govern- ments in telecommunication infrastructure, an area that has traditionally been the domain of No conflict of interest declared. private enterprise. A recent analysis found that Accepted for publication: March 26, 2018 151 out of 189 countries reviewed have adopted C 2018 Institute of Public Administration Australia 830 Digital Infrastructure and Health Equity December 2018 national broadband plans (Broadband Commis- inclusion by connecting friends, families and sion for Sustainable Development 2016). communities across the country and around the The shift to government investment in digital world through voice and video communication infrastructure provides an opportunity to alter services. Likewise, the internet provides un- underlying policies and strategies away from paralleled opportunities to deliver formal and commercially driven business models (Budde informal education through online degree pro- 2017). Under commercial models, higher in- grams or platforms such as TED Talks. Further- come neighbourhoods that are better able to more, it can support improved healthcare de- afford more expensive service packages have livery, such as patient engagement with online been more likely to receive higher quality in- personal health records, mobile health appli- frastructure that supports better digital access cations, telehealth tools and population health (Helsper et al. 2009). This has contributed to research initiatives, and the transfer of high res- a digital gradient (Parsons and Hick 2008) – olution medical images. wherein populations experiencing greater ad- Consequently, public investment in digital in- vantage have better access to digital technolo- frastructure may help support access to online gies, and associated opportunities, relative to health, education, and employment opportuni- populations experiencing greater disadvantage ties to improve health outcomes and reduce (Vinson et al. 2007). health inequities (Ahern et al. 2006; Latulippe et al. 2017; Shaw et al. 2006). However, re- National Broadband and Health Equity ducing inequities in access to the social deter- minants of health through online services will Much evidence shows that individual and popu- only be effective to the extent that enhanced lation health are determined in large part by the digital access is achieved equitably. social and economic conditions in which peo- ple live, the social determinants of health. Po- Australia’s National Broadband Network litically structured socioeconomic inequalities contribute to inequalities in access to social de- The roots of government investment in a Na- terminants of health and in health outcomes be- tional Broadband Network (NBN) in Australia tween groups of differing socioeconomic status began in 1994, when under an Australian La- (WHO Commission on Social Determinants of bor Party1 government concerns were raised Health 2008). These inequalities have been de- in the senate about monopoly power in Aus- fined as health inequities on the grounds that tralia’stelecommunications infrastructure (Ag- they are largely avoidable and unfair (White- ius 2013). On releasing the Networking Aus- head 1991); a normative stance which we en- tralia’sFuture report in 1995, then Prime Minis- dorse and adopt in this paper. ter Paul Keating noted ‘ . that access to the na- Thus the digital gradient is increasingly prob- tional information infrastructure will be no less lematic for health equity, as the internet has a general right than access to water, or public evolved into an essential determinant of health, transport or electricity’ (Keating 1995). How- supporting full participation in economic, so- ever, before any Labor initiatives commenced, cial, educational, political, and cultural life a Coalition government was formed in 1996 un- (Baum et al. 2012; Kvasny et al. 2006; Vin- der the Prime Ministership of John Howard.2 It son et al. 2007). This can include new ways has been argued that this marked the beginning to access or participate in the economy by of an 11-year period of a national broadband means of the internet as a comprehensive tool strategy that prioritised subsidies for market to search for new employment, as a method actors to support development in regional and to work remotely, as a source of employment remote areas (Agius 2013). in and of itself, and as a way for businesses By failing to address initial concerns about and entrepreneurs to engage with global mar- monopoly power, in the mid-2000s Australian ket opportunities. Fast, reliable and affordable telecommunications company, Telstra, held the broadband connections can also enhance social single largest telecommunications monopoly in C 2018 Institute of Public Administration Australia Schram et al. 831 any developed economy (Budde 2017). Gre- as the fixed wireless, and satellite being rolled gory (2017) contends that Telstra’s market out in regional and remote areas are all inferior dominance allowed it to delay broadband up- toFttPintermsof‘...speed and capacity de- grades and prevent other companies from hav- livery, maintenance costs, reliability, longevity ing access to its broadband networks (Gregory and upgrade costs’ (Quigley 2016, p. 32) (see 2017). When the Coalition announced in 2007 Figure 1 for overview). Significant differences that it would allocate 1 billion dollars in fund- in cost, data allowance, and speed between the ing to telecommunication providers Optus and various NBN services (FttP, FttN, HFC, fixed Elders to bring faster internet access to regional wireless, and satellite) may be putting some and remote Australia, Telstra launched a law- populations at a significant disadvantage in ac- suit, which Aguis (2013) claims contributed to cessing health opportunities (Australian Medi- a rapidly deteriorating situation in Australian cal Association 2017) as well as other key social telecommunications. The federal election in determinants of health such as employment, November 2007 saw a return of a Labor gov- education, and social inclusion. The Coalition ernment and the move to the development of an is now facing heavy criticism itself (see, e.g. NBN. Coyne 2016; Kenny 2016) as the NBN remains After one false start, in 2009 the Labor gov- behind schedule and over budget, while de- ernment announced plans to invest 43 billion livering an inferior product. As of mid-2017 dollars in a fibre-to-the-premises (FttP) net- the NBN had been rolled out to just over 50% work – widely believed to be the gold standard of premises in Australia with completion pro- of broadband infrastructure (Ellis et al. 2015; jected in 2020 (NBN Co Ltd 2017). Ross 2012) – to 93% of homes and businesses In this paper we examine the implementation and fixed wireless or satellite to the remaining of a national digital infrastructure policy, the premises in remote and rural Australia. That NBN in Australia, as it relates to its capacity to same year the government established the NBN mitigate or exacerbate inequities in digital ac- Co to design, build, and operate the wholesale- cess. Specifically, we explore the deployment only, open-access broadband network. It was of various broadband technologies across the framed as a nation-building investment that socioeconomic gradient and level of
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