Gaikhangduanliu M. Kamei

The COVID-19 Catalyst

India’s rural-urban healthcare divide is not simply a logistical or infrastructural issue, but a structural manifestation of caste, class, gender, and regional inequities embedded in its socio-political fabric. The COVID-19 pandemic exposed glaring inequalities in India’s healthcare system, most notably the persistent urban-rural divide. As the crisis unfolded, urban regions witnessed rapid infrastructural expansion. Hospitals were equipped with advanced diagnostic tools, intensive care units were scaled up, and digital health platforms, such as teleconsultation services, flourished. Both public and private healthcare institutions in cities adapted quickly, benefiting from stronger infrastructure and better coordination mechanisms.

Conversely, rural India, home to nearly two-thirds of the country’s population, struggled under the weight of an already fragile system. Primary health centers were often understaffed, ill-equipped, and lacked critical care capabilities. The shortage of trained medical personnel, such as doctors, nurses, and lab technicians, further strained these facilities. Patients in rural areas faced long travel times, limited testing access, and minimal COVID-19 care infrastructure. This disparity starkly revealed how deeply embedded inequalities in healthcare access and resource allocation had rendered rural populations significantly more vulnerable during public health emergencies.

The pandemic served as a global stress test for healthcare systems, revealing vulnerabilities and amplifying pre-existing deficiencies. In India, it highlighted long-standing challenges in healthcare infrastructure, including underfunded facilities, an overburdened workforce, and wide disparities in service delivery. These challenges did not emerge in isolation; they are rooted in systemic neglect and continue to persist in the post-pandemic period, calling for urgent reforms and a reevaluation of healthcare priorities. (Mishra, 2025, para.3)

Historical Roots of Rural Health Inequality

Importantly, the urban-rural healthcare divide did not emerge with the pandemic, it was merely intensified by it. The more pressing question, therefore, is not just how this divide became more visible during COVID-19, but why it exists in the first place. Why is there such a stark difference in the availability and quality of healthcare between rural and urban areas? Who contributes to the persistence of this disparity? And to what extent do factors such as education, awareness, and social inequality play a role in shaping these outcomes?

The roots of the divide lie in colonial legacies and post-independence development models that prioritized urban-industrial growth. Healthcare investments remained concentrated in cities, while rural health was relegated to underfunded schemes. Post-1990s neoliberal reforms intensified this neglect, promoting private healthcare expansion in profitable urban centers while primary care in villages languished. The long-standing rural neglect was aggravated by fragmented public health financing, insufficient local governance, and limited community participation in healthcare planning.

Structural Drivers: Caste, Gender, Geography, and Political Economy

Medical sociology, particularly theories of structural violence (Paul Farmer) and intersectionality (Kimberlé Crenshaw), provide critical lenses for analyzing health disparities. Caste remains a determining factor: Dalit and Adivasi communities are concentrated in remote regions, systematically deprived of quality care. Intersectional disadvantages are stark, rural Dalit women face cumulative burdens of caste, gender, and geographic exclusion. Political economy analysis highlights how health budgets favor tertiary care and urban-based insurance schemes over preventive, community-led primary health models.

Geography further shapes exclusion. While only 27% of the population resides in urban areas, they possess over 75% of health infrastructure. Rural India, housing nearly 72% of the population, suffers from under-resourced PHCs and CHCs. For instance, over 80% of Community Health Centres lack specialist doctors, and fewer than half of PHCs operate 24/7 (MoHFW, 2023).

Gendered exclusion is equally salient. Rural women experience higher maternal mortality, limited mobility, and lower health literacy. Cultural norms and unpaid domestic work limit their ability to seek timely care. The issue is not merely one of awareness but of agency and access shaped by structural patriarchy.

Localized Responses and National Imbalance

In response to the worsening doctor shortage, Punjab’s state government recently proposed merging rural medical officers with the health department, a move aimed at streamlining healthcare delivery and addressing staffing gaps. However, such measures are reactive and localized, lacking the comprehensive national vision needed for rural health transformation. Many rural doctors are on contractual terms with limited job security, which discourages long-term commitments to underserved areas.

Whereas, Chandigarh, for example, is set to receive a new state-of-the-art multispecialty hospital, underscoring the widening chasm between urban expansion and rural stagnation, making the gap even more obvious. Similarly, the upcoming Sarma–Neotia Centre for Excellence in Healthcare in Assam’s capital city aims to benefit the entire Northeast region, but its urban-centric location raises questions about actual accessibility for remote tribal and rural populations who remain underserved (Times of India, 2024). While such facilities boost regional pride and urban infrastructure, they rarely address the root causes of rural health exclusion.

COVID-19 as Amplifier of Inequity

The pandemic did not create disparities, it made them unignorable. Urban hospitals expanded ICU capacity, while rural PHCs struggled for PPEs (Personal Protective Equipment Kit). Migrant workers returning home carried the virus into poorly equipped villages, yet public discourse largely blamed communities rather than state neglect. Essential services like immunization and antenatal care were disrupted. Frontline workers, mostly women, worked without pay or protection. Reports from Bihar and Uttar Pradesh show mortality from preventable diseases rose sharply during lockdowns, revealing the pandemic’s indirect toll.

Furthermore, state responses were urban-centric. Telemedicine initiatives and insurance coverage under Ayushman Bharat were largely inaccessible due to digital divides and geographic inaccessibility. The state’s focus on biomedical interventions ignored socio-economic determinants and community-based care, reinforcing health as a commodity rather than a right.

The rural healthcare crisis is not uniform; it is deeply intersectional. The lockdown strategy, while meant to curb spread, had cascading consequences for rural India. Job losses among migrant workers disrupted entire rural economies. The absence of public transportation and accessible healthcare further deterred timely medical intervention. For women, children, and the elderly, who already faced barriers to care, the pandemic’s restrictions became doubly punishing.

Additionally, caste and class dynamics continue to influence access to care. Marginalized communities often reside in the most remote, underserved regions, where both public and private medical options are limited. For them, the promise of healthcare remains abstract, a luxury instead of a right.

Policy Critique: Ayushman Bharat’s promise and shortfalls

India’s step toward Universal Health Coverage (UHC) took form in 2018 with the launch of the Ayushman Bharat Scheme, also known as the Pradhan Mantri Jan Arogya Yojana (PMJAY). While ambitious in scope, it illustrates policy urbanism. Despite targeting 500 million people, only a fraction of rural households have been effectively enrolled. The scheme’s insurance-driven model prioritizes hospitalization over primary care. It benefits empaneled urban hospitals more than under-resourced rural centers. Middle-income rural families, excluded from eligibility, remain vulnerable. Moreover, there is little oversight on private hospitals denying claims or charging hidden fees.

Rather than bolstering grassroots public health, such schemes risk deepening privatization. Scholars like R.V. Baru and K.R. Nayar critiques this model for sidelining social medicine and comprehensive primary care. An overemphasis on digital health, without addressing structural inequities, renders these solutions inaccessible to those most in need.

Recommendations: Toward Equity and Structural Reform

1. Reinvest in Primary Care: Allocate larger portions of the health budget to rural PHCs and CHCs, ensuring round-the-clock services and staff training.
2. Adopt an Intersectional Health Policy: Integrate caste, gender, and spatial justice into health planning, with participatory inputs from marginalized communities.
3. Redesign Insurance Schemes: Shift focus from tertiary care to preventive and promotive care, and include middle-income rural families.
4. Strengthen Data Systems: Collect disaggregated data on caste, gender, and geography to guide equitable resource allocation.
5. Localize Health Governance: Empower Panchayati Raj Institutions and Accredited Social Health Activist (ASHA) workers with resources, training, and decision-making authority.

Conclusion: A Window for Reform

India’s rural healthcare crisis is not an aberration, it is the outcome of decades of structural neglect and policy design rooted in urban bias. COVID-19 offers a unique policy window to reimagine healthcare not as a reactive mechanism but as a proactive, inclusive, and justice-oriented public good. Transforming rural health requires more than infrastructure; it demands political will to center equity, empower communities, and dismantle systemic barriers.

Importantly, service planning must move beyond a “one-size-fits-all” framework. Defining clear frames of reference for “rural” and “urban” is crucial to ensure that models of care reflect the diversity of India’s rural landscape. The rural community is deeply interconnected and structurally complex; therefore, health services must be designed to enhance realized access, ensuring they are not only available but also acceptable, culturally resonant, and effectively utilized. (Gupta, 2024, para. 21).

There can be no public health without social justice. Bridging the urban-rural divide will require confronting the deeper hierarchies that shape who lives and who dies, not just during pandemics, but every day.

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References

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