Sruthi Madhu explores how structures of exclusion are built into India’s increasingly digitised health care system.
Uneven roads in the village of Tadepalligudem in Andhra Pradesh, India, lead the way to one of the Government Area Hospitals in the district. To receive treatment at this hospital, patients are required to create an Ayushman Bharat Health Account (ABHA) ID at the registration desk, through which a token is generated that will allow the person to meet a doctor. Developed under India’s ‘Ayushman Bharat Digital Mission’, which aims to achieve integrated digital infrastructures in healthcare across the country, the Ayushman Bharat Health Account, better known as the ABHA ID, acts as a digital locker for the health journey of Indian citizens, allowing them to store and share medical records in a software application (ABDM 2025). The government aims to use this system to create a unified digital identity ensuring better treatment, less paperwork, accessibility, and an organised health experience (ABDM 2025).
Two long queues of men and women separately stand as they await to register their ABHA and receive treatment at the hospital. The eligibility to attain the ABHA card looks rather humble on paper, one must be a citizen or a resident of India, have an Aadhaar card (a 12-digit unique identification number issued by the Government as proof of identity) or a Driving Licence, and a mobile number linked with it. The 14-digit ABHA number can be generated with a One-Time Pass Code (OTP) to be received on one’s Aadhaar-registered mobile number. The Aadhaar database includes biometric data of the registered individuals and is often used for offline and online verification through the linked mobile number. With several medical institutes making the ABHA digital health record mandatory for Outpatient Departments (OPD), wherein patients receive treatment at the hospital without an overnight stay, the number of registrations has increased (PIB 2021). India’s ambitious effort to establish a complete digital health eco-system, however, has failed to foresee the barriers created through its mechanisms.
A woman in her late 60s in the long queue at the registration desk owns an old Nokia mobile phone, incompatible to download the ABHA application that requires an operating system of Android 7.0 and above. The woman on the other side of the registration desk has an Android device with the latest software, through which she opens the ABHA application. The woman seeking treatment provides her mobile number and asks for the OTP. The OTP is received on her son’s mobile number; he is working in a farm elsewhere. The woman’s treatment is further delayed as she waits for her son to call, so she can access the OTP and register on ABHA to obtain a token for treatment.
A study on the adoption of ABHA ID conducted with 425 outpatient department attendees in hospitals across the city of Agra in Uttar Pradesh, India, illustrated that overall digital health literacy amongst participants was moderate (Ranjan et al. 2026). Major barriers included preference for in-person healthcare (85.6%), high data plan costs (81.9%), difficulty using health apps (65.6%), language difficulties (64.0%) and hesitation to share OTPs (60.0%) (Ranjan et al. 2026). Notably, 88% expressed need for training and support, while 58.6% lacked adequate knowledge about the Ayushman Bharat Digital Mission despite visiting facilities that were participating in the programme (Ranjan et al. 2026).
Transdisciplinary scholar Ruha Benjamin introduced the concept of the “New Jim Code,” to explain the use of novel technological advancements that reinstate existing inequalities in the society, and which are often showcased as progressive in nature compared to the discriminatory practices of a previous time (Benjamin 2019, 16). She argues that, “tech fixes often hide, speed up, and even deepen discrimination, while appearing to be neutral or benevolent” (Benjamin 2019, 17). Benjamin further notes that the increasing gap between democratic philosophies and unequal actions are marked by “subtler forms of discrimination” that hide beneath a veil of progress (Benjamin 2019, 30). The implementation of ABHA illustrates Benjamin’s concern regarding a new form of discrimination, whereby technological solutions, though formulated to improve efficiency of a system, may dangerously reproduce social inequalities as they often fail to recognise unequal access to digital resources.
Healthcare access in India is deeply entrenched in social inequalities that are rooted in caste, class, and gender hierarchies. The caste system, a regressive form of social stratification, continues to influence everyday realities in India, and also shapes access to education, healthcare, occupation, and social status despite legal protection against caste-based discrimination (Areesh Kumar et al. 2025). The increasing privatisation of healthcare in the country, and the limited to no health insurance coverage, adds to the class inequalities resulting in higher out-of-pocket health expenditure for patients and families (Nagarajan 2026). Gendered inequalities also affect access to healthcare as women are often expected to provide unpaid care labour within families, often at the expense of their own health needs (Heise L, Greene M, Opper N et al. 2019). Nahia Hussain’s (2025) study on digital health inequities in India demonstrates that barriers to accessing digital health services are often a result of different infrastructural limitations, including connectivity and device access issues, alongside concerns of privacy and data security (Hussain 2025).
While prevailing inequalities rooted in hierarchies of caste, class, age, and literacy, continue to permeate various dynamics in healthcare in India, the digitalisation of healthcare services brings forth a new form of exclusion that conjoin existing disparities. The absence of supportive digital infrastructure within the healthcare institutions reflects these inequalities and amplifies them. Hospitals often lack public Wi-Fi facilities, dedicated registration kiosks, or other mechanisms that can provide support in generating ABHA IDs and in turn, navigate digital health systems. The registration process and its related burden is largely transferred to individual patients who are forced to traverse an unfamiliar digital space. Digital systems like ABHA presume access to smartphones, internet connectivity, and digital literacy, constructing an image of the self-sufficient digital citizen. While ABHA supports 13 Indian languages, it still remains quite limited within a country that has extraordinary linguistic diversity including 122 major languages (Mohanty 2010). The application also fails to account for the varying literacy levels in states across the country and unresolved digital connectivity challenges in rural India (Koratagere Anantha Kumar et al. 2022). The difficult reality of Indian healthcare includes aging patients, ill bodies, limited or no technological access, and higher dependency on kinship networks.
Rural areas in India particularly rely on kinship networks to navigate everyday life and accessing public services. Digital health systems such as ABHA are premised and designed on the idea of the autonomous digital citizen who possesses a particular technological device, documentation, and skills required for registration and further use. The son receiving an OTP for his mother on his mobile phone, or another family member assisting a patient in the hospital space, are common sights in hospitals in India. Family members and friends often play an important role in healthcare access through accompanying patients to hospitals, providing transportation, financial assistance, filling in medical records, purchasing medicines, and other health procedures. Elderly patients, often with limited literacy and declining physical strength, who are navigating hospital spaces are highly vulnerable and this is intensified when they are forced into unfamiliar digital spaces as their ill bodies await treatment. Access to mobile phones and internet connectivity is also unevenly distributed in Indian households, wherein smartphones are sometimes shared by family members and a few may not possess individual devices. Frameworks like ABHA reduce this wide network of relationships and overlook the relational nature of healthcare access. The reality of interdependence in the face of bureaucratic delays can render primary healthcare inaccessible within a system that claims to have been designed to save time, but often increases it: for example, through delaying access to out-patient desks at hospitals where previously access to doctors were immediate and treatment was quickly provided.
The ‘digital divide’- as defined by Jan van Dijk- demonstrates that digital exclusion is rarely absolute (Dijk 2019, 15). Van Dijk elucidates that digital division points towards a fracture in the society, or a “social split,” wherein access and use of digital media differentiates between groups (Dijk 2019, 15). Dijk, however, clarifies that modern society is multifaceted and complex and cannot be divided into a binary population. Thus, digital access, according to him, sits on a spectrum between an “information elite” and the “fully excluded” wherein, most people fall between, possessing access and knowledge to technology to a certain extent, but not fully (Dijk 2019, 15-16). This concern is reflected in Ruqaiijah Yearby’s healthcare justice framework, which acts a guiding principle in understanding the need for a movement towards equal health access where laws, policies, institutions must provide a renewed attention towards the goal of health equity (Wiley et al. 2022). Health justice underscores collective effort, inclusive government policies, and equitable distribution of healthcare resources through public investment Wiley et al. 2022).
The increasing digital health infrastructure showcase the adaptation to growing technological tools, including digital health IDs, and online portals across the Global South- such as Brazil’s Conecte SUS, a similar application that is connected to the Ministry of Health (Conrado et al. 2025). Comparable concerns surrounding digital exclusion and access have emerged across nations, indicating a broader landscape of digital health transformation across the world. The implementation of ABHA cannot be analysed merely as a move towards digital efficiency or technological development, but rather, it demands an assessment of constrains to equitable access to healthcare among populations often already marginalised and digitally excluded.
About the author
Sruthi Madhu is a doctoral researcher in English at the National Institute of Technology Andhra Pradesh, India whose work focuses on health, illness, and caregiving. Her research examines the intersections of healthcare, theatre, and health justice. She can be found on LinkedIn.
References
Areesh Kumar, Karamala, T V Prajwal, Edberg D. Cheeran, and Abdul Rehman. 2025. “Locating Caste in SDGs: A Critical Analysis of Caste Discrimination and Its Implications for India’s Development Agenda.” Asian Bioethics Review 18: 433–48. https://doi.org/10.1007/s41649-025-00377-x.
Benjamin, Ruha. 2019. Race after Technology. John Wiley & Sons.
Conrado, Luiz Felipe, Milena Estanislau Diniz Mansur dos Reis, Jackeline Franco Couto, Luis Enrique Valdiviezo Viera, Nicolas Rodrigues Lima, Ana Carolina Sanches Zeferino, Edmilson Suassuna da Silva, and Robisom Damasceno Calado. 2025. “Digital Health: Context and Challenges in Brazil with Focus on Public Health.” In 2025 16Th IEEE International Conference on Industry Applications (INDUSCON), 1153–60. https://doi.org/10.1109/INDUSCON66435.2025.11241578.
Create Ayushman Bharat Health Account – ABHA Number. 2025. Review of ABHA | ABDM. Abdm.Gov.In. 2025. https://abha.abdm.gov.in/abha/v3.
Heise, Lori, Margaret E Greene, Neisha Opper, Maria Stavropoulou, Caroline Harper, Marcos Nascimento, and Debrework Zewdie. 2019. “Gender Inequality and Restrictive Gender Norms: Framing the Challenges to Health.” The Lancet 393 (10189): 2440–54. https://doi.org/10.1016/s0140-6736(19)30652-x.
Hussain, Nahia. 2025. “Digital Health Inequities: Analysing Barriers to Access across Demographic Groups in India.” Journal of Development Policy and Practice 11 (1). https://doi.org/10.1177/24551333251382726.
Jan Van Dijk. 2019. Digital Divide. S.L.: Polity Press.
Koratagere Anantha Kumar, Shruthi, Ihita Gangavarapu Vigneswara, Sachin Chaudhari, and Paventhan Arumugam. 2022. “A Survey on Rural Internet Connectivity in India.” Strathprints.strath.ac.uk. IND. January 8, 2022. https://doi.org/10.1109/COMSNETS53615.2022.9668358.
Mohanty, Ajit K. 2010. “Languages, Inequality and Marginalization: Implications of the Double Divide in Indian Multilingualism.” International Journal of the Sociology of Language 2010 (205). https://doi.org/10.1515/ijsl.2010.042.
Nagarajan, Rema. 2026. “NSO: Out-of-Pocket Spending Still Drives Hospitalisation Costs.” The Times of India. The Times of India. April 27, 2026. https://timesofindia.indiatimes.com/business/india-business/nso-out-of-pocket-spending-still-drives-hospitalisation-costs/articleshow/130541583.cms
PIB. 2021. Review of Ayushman Bharat Digital Mission Crosses Landmark Milestone of 90 Crore ABHA Accounts. Pib.Gov.In. 2021. https://www.pib.gov.in/PressReleasePage.aspx?PRID=2266979®=3&lang=1.
2025. Review of ABHA | ABDM. Abdm.Gov.In. 2025. https://abha.abdm.gov.in/abha/v3.
Ranjan, Ayushi, Geetu Singh, Himalaya Singh, and Mohit Singh. 2026. “Adoption, Digital Health Literacy, and Patient Satisfaction of Ayushman Bharat Digital Mission: An Analytical Cross-Sectional Study among Outpatient Department Attendees.” BMC Health Services Research, March. https://doi.org/10.1186/s12913-026-14314-7.
Wiley, Lindsay F., Ruqaiijah Yearby, Brietta R. Clark, and Seema Mohapatra. 2022. “INTRODUCTION: What Is Health Justice?” Journal of Law, Medicine & Ethics 50 (4): 636–40. https://doi.org/10.1017/jme.2023.2.
