Experiencing medical desertification: A care-seeker-centered qualitative comparison across rural and urban sites in France and Slovenia.

"Medical desert," referring to conditions of unequal access to medical care, remains contested in its definition and measurement. Predominantly supply-focused, most studies rely on quantitative indicators and few examine how care-seekers perceive and navigate shortages, nor do they address desertification as a dynamic, policy-driven process. None, to our knowledge, compare these experiences across rural and urban settings or countries. We conducted a qualitative comparative investigation during the COVID-19 pandemic among people experiencing health and social vulnerabilities in France and Slovenia, employing the WHO Availability, Accessibility, Acceptability, and Quality (AAAQ) framework. From January to July 2021, we interviewed 156 participants in one urban (Paris-Seine-Saint-Dénis) and one rural (Vendôme territory) site in France and 214 participants in one urban (Ljubljana) and one rural (Pomurje) site in Slovenia. Thematic analysis revealed shared patterns across sites and countries. Participants in all sites reported insufficient availability of services and personnel; urban residents experienced shortages despite nominally abundant resources. Accessibility barriers extended beyond spatial distance to encompass cost, time poverty, informational gaps, digital exclusion, language barriers, and clientelism. Dissatisfaction with care quality (claims of dismissive providers, absent holistic diagnosis, eroded trust) was pervasive although invisible to standard medical desert metrics. Social vulnerabilities compounded these barriers, producing uneven experiences of desertification. These findings demonstrate that care-seeker-centered approaches can foreground processes of medical desertification that transcend the rural-urban divide. By illuminating perceived shortages that supply-side indicators miss, they suggest that desertification may reflect a broader austerity-driven erosion of public healthcare whose consequences surfaced during the pandemic.