The Digital Divide in Health: Who's Left Behind in India's Digital Health Push

With nearly 690 million ABHA IDs generated, over 276 million telemedicine consultations completed, and ambitious targets to bring every citizen into the fold of connected healthcare, the Ayushman Bharat Digital Mission (ABDM) and eSanjeevani represent one of the world's most ambitious attempts to digitize health at scale.

While India now boasts 886 million active internet users, approximately 630 million people, 41% of the population, remain offline. The majority of these disconnected citizens are rural, female, and low-income, the very populations that depend most heavily on public health systems. As digital platforms become increasingly integral to healthcare delivery, we risk creating a scenario where those who need care the most have the least access to it.

The Numbers Tell a Story of Uneven Progress

According to the National Family Health Survey, only 33% of women have ever used the internet, compared to roughly 57% of men. Among women in the lowest wealth quintile, internet usage drops to a mere 9%.

When a rural woman needs to access her health records, book a teleconsultation, or track her pregnancy through a digital platform, she faces multiple barriers that her urban, male, or wealthier counterparts don't encounter. She may not own a phone at all; only 54% of women report having a phone they can use. Even if she does, it's likely shared with family members, creating privacy concerns for sensitive health matters. The National Sample Survey Office found that only 52% of Indian households have internet access, with rural access remaining below 35%.

Moreover, rural India now accounts for 54-55% of all internet users in the country, approximately 488 million people. However, the rural users often contend with intermittent connections, shared devices, and low-speed networks that make using health applications frustrating at best and impossible at worst.

When Infrastructure Meets Reality

The ABDM dashboard tells us that 152,000 healthcare facilities are now using ABDM-enabled software. Of these, 131,000 are government facilities, while only 21,479 are private. Given that private clinics provide a substantial portion of outpatient care in India, this represents a critical gap in the digital health ecosystem. Small private practitioners cite costs, lack of interoperability, and unclear incentives as barriers to adoption.

The success of the "Scan & Share" QR-code service offers a glimpse of what works when digital health tools are implemented thoughtfully. Active in 17,481 facilities across 35 states and union territories, this service has generated 66.4 million tokens, saving an estimated 33 million person-hours by reducing waiting times from 30-40 minutes to just 5-10 minutes. This is the kind of tangible benefit that builds trust and adoption. However, registrations remain concentrated in Maharashtra, Karnataka, and Tamil Nadu, while northeastern and central states lag behind.

eSanjeevani's journey from 397 hubs and 6,868 spokes in 2020 to 14,036 hubs and 108,610 spokes in 2023 demonstrates rapid scale-up. The platform now covers approximately 78% of Health and Wellness Centres, with over 108,000 facilities equipped to provide teleconsultations. Women make up 57-60% of users in the provider-assisted model and 58-70% in the direct-to-patient model, suggesting that when the barriers are lowered, women do engage with digital health services. The largest user group falls between ages 25-45, representing people in their prime working and family-building years.

But again, five states- Tamil Nadu, Uttar Pradesh, Madhya Pradesh, Karnataka, and Andhra Pradesh- account for 70.6% of all consultations. Andhra Pradesh leads with 43.5 million consultations, and Telangana has achieved over 98% coverage of Health and Wellness Centres. This clustering suggests that existing digital readiness and infrastructure, rather than population health needs, are driving adoption patterns.

The Five Barriers Keeping Millions Offline

When we examine why 630 million Indians remain disconnected from the internet, five key barriers emerge, each contributing roughly equally to the problem. About 25% cite lack of awareness; they simply don't know what the internet is or why it might be useful. Another 16% point to affordability; data costs and device prices remain prohibitive for families living on tight budgets. Seventeen per cent lack devices altogether, while 20% face social restrictions, particularly women and girls whose internet use may be controlled or discouraged by family members. Finally, 20% cite low digital skills, the inability to navigate apps, websites, or digital interfaces effectively.

These barriers compound each other. A woman who faces social restrictions on phone use is unlikely to develop digital skills. Someone who lacks awareness of the internet's benefits won't prioritize saving for a device. And even those who overcome these hurdles often encounter a final barrier: language. While 98% of Indian internet users now access content in Indic languages, and 15% use voice commands, many health applications remain available primarily in English or require text-based navigation that assumes literacy levels many users don't possess.

State-level variations illustrate how geography intersects with these barriers. Kerala leads with 72% internet penetration, followed by Goa at 71% and Maharashtra at 70%. At the other end, Bihar sits at 43%, Uttar Pradesh at 46%, and Jharkhand at 50%. These gaps reflect not just infrastructure differences but also variations in literacy rates, economic development, and government commitment to digital inclusion.

What Gets Measured Gets Addressed

Perhaps the most concerning aspect of India's digital health push is what we're not measuring. The ABDM dashboard tracks impressive aggregate numbers but offers limited visibility into who is actually benefiting. Without equity indicators built into our monitoring frameworks, we risk celebrating coverage while missing exclusion.

When marginalized populations are underrepresented in national health datasets, program design and evaluation become skewed toward the needs and experiences of those who are already connected. Policy decisions get made based on incomplete pictures of population health needs. Resources flow toward areas with high digital adoption rather than high health burdens.

The voluntary nature of ABDM enrollment compounds this issue. In regions with low awareness, people don't sign up simply because they don't know the system exists or understand its benefits. Without proactive outreach and enrollment drives, particularly in underserved areas, digital health infrastructure risks becoming yet another service that the well-informed and well-connected access first and most completely.

Building Bridges, Not Walls

Some states offer promising models for more equitable digital health adoption. Kerala and Tamil Nadu have integrated ABDM with primary healthcare outreach programs like Makkalai Thedi Maruthuvam, bringing digital health records directly to doorsteps rather than waiting for patients to navigate the system themselves.

Gujarat has piloted automatic ABHA enrollment at the time of registration in public hospitals, removing the burden of separate sign-up processes.

Uttar Pradesh has linked ABDM with hospitals empanelled under Ayushman Bharat-PMJAY for real-time claims reporting and monitoring, creating immediate value for both providers and patients.

These innovations share a common thread: they meet people where they are rather than requiring them to meet the technology on its terms. This principle should guide broader implementation. Digital literacy programs need to target community health workers who can become trusted intermediaries, helping patients navigate digital tools while respecting privacy and building confidence.

Investment in digital infrastructure must prioritize underserved blocks and Aspirational Districts, expanding broadband connectivity and making devices more affordable through the Digital India program.

Hybrid Models for Inclusive Care

Perhaps most importantly, we need to embrace hybrid models that blend digital and in-person care. Digital health should enhance access, not replace human connection or create new barriers. For populations with limited digital access, whether due to connectivity, literacy, or choice, in-person services must remain robust and well-funded. The goal isn't universal digitization; it's universal access to quality healthcare, delivered through whatever means work best for each community and individual.

Consent literacy and data governance deserve special attention. As health records become digitised and data flows increase, patients require clear and understandable information about their rights. Who can access their health data? How is it protected? What happens if there's a breach?

Given that many users rely on shared devices and have limited digital literacy, building this trust requires sustained education and robust privacy protections that go beyond policy documents to practical, enforceable safeguards.

The ABDM's "Privacy-by-Design" framework and federated architecture, aligned with the Digital Personal Data Protection Act 2023, provide a foundation. But frameworks matter only if they translate into user experiences that feel safe and respectful. This involves testing consent processes with diverse user groups, establishing transparent and accessible audit mechanisms, and developing accountability systems that respond promptly to emerging issues.

The Path Forward

India's digital health revolution represents an extraordinary opportunity. The technical infrastructure being built, the policy frameworks being established, and the partnerships being forged could genuinely transform healthcare access for hundreds of millions of people. But transformation requires deliberate, sustained attention to who benefits and who gets left behind.

The digital divide in health isn't inevitable. It's a product of choices, about where to invest, whom to design for, what to measure, and how to implement. Every decision about digital health infrastructure is also a decision about equity. When we choose to prioritize urban over rural rollout, we're making an equity choice. When we design apps that require high literacy and continuous internet, we're making an equity choice. When we measure success by aggregate numbers rather than distribution across populations, we're making an equity choice.

The question is whether we can achieve scale with equity, building systems that serve those who need them most, not just those who can access them most easily. The answer will determine whether India's digital health revolution ultimately narrows or widens the health disparities that have long plagued our healthcare system.

For digital health professionals, entrepreneurs, innovators, and policymakers, this presents both a challenge and an opportunity. We have the opportunity to build something truly inclusive, demonstrating that digital health can be a tool for equity rather than a new mechanism for exclusion. But realizing that potential requires moving beyond impressive aggregate numbers to ask harder questions about distribution, access, and outcomes. It requires designing with and for marginalized communities, not just deploying solutions built elsewhere. And it requires measuring not just how many people we reach, but who we're missing and why.

The infrastructure we're building today will shape Indian healthcare for decades to come.

Let's ensure it's infrastructure that serves everyone.

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