Governing Care Through Inequality: Structural Violence, Political Economy, and Health Policy in Rural Jharkhand

This paper examines health policy and governance through the lens of structural violence and the political economy of care, drawing on ethnographic research conducted among rural and tribal communities in Jharkhand, India. It argues that everyday experiences of illness, care-seeking, and therapeutic mobility are shaped not only by individual choice or service availability, but by deeply political processes that allocate resources, distribute risk, and normalise unequal valuations of life. By situating health and healthcare within local governance structures and broader policy regimes, the paper contributes to political science debates on health as a contested arena of power, regulation, and public responsibility Empirically, the study is based on long-term fieldwork using ethnographic methods and Participatory Rural Appraisal (PRA), documenting how rural households navigate public and private health systems amid chronic underinvestment, fragmented regulation, and the growing influence of market-oriented health actors. The findings show that policy design and implementation, particularly in relation to primary healthcare, insurance-based schemes, and referral systems, produce patterned exclusions that compel marginalised populations to rely on informal providers, debt-financed care, and seasonal or distress-driven mobility. These dynamics are not solely policy failures, but rather reflect political choices embedded in health governance, where fiscal priorities, institutional fragmentation, and limited accountability mechanisms systematically disadvantage certain populations. The paper aligns most closely with conference themes on health reforms, politics and public opinion, as well as corporate political activity and health governance, while also addressing the open track. It demonstrates how corporate actors, intermediaries, and ancillary service providers shape rural health landscapes in subtle but consequential ways through diagnostics, pharmaceuticals, transport, and credit, often operating in regulatory grey zones that blur public–private boundaries. At the same time, it examines how rural citizens interpret, negotiate, and sometimes resist health policies, revealing a gap between policy narratives of “universal coverage” and lived experiences of care. Conceptually, the paper advances a political reading of structural violence by linking embodied suffering to governance arrangements, interest alignment, and policy priorities. Rather than treating health inequality as a technical problem of access or efficiency, it foregrounds the moral and political questions of “who gets what, when, and how” in health systems. In doing so, the paper contributes to the Health Policy, Politics and Governance agenda by bringing ethnographic evidence from the Global South into dialogue with debates on health policy, power, and the social contract underpinning contemporary welfare states.