Every day, by 6 A.M., patients start lining up at the registration counter of the government hospital I work in. Similar to most government hospitals, OPD tokens here are issued only during a 4-hour window—7 A.M. to 11 A.M. This ensures that OPD, which is officially supposed to run until 4 P.M., shuts down by noon, giving consultants the freedom to leave, often so that they can run their private practice.
After that, patients with everyday complaints—fever, cough, cold, diarrhea, abdominal pain—flood the casualty department, turning what is supposed to be an emergency service into a second OPD.
In my six-hour shift, where I sit as a lone doctor in the casualty, I often see 70–100 patients. However, 80-90% of these people do not present with conditions requiring emergency care but come seeking care for illnesses that otherwise could have been treated in the OPD. Emergencies—actual emergencies—compete for attention and resources in the middle of this mess.
The worst part? When I tell these patients to come to the OPD the next day, they either return frustrated or don’t come at all. The reason is apparent: OPD timings don’t match the lives of the people it serves.
Rigid timings for a flexible problem
Most patients in government hospitals come from low-income, working-class backgrounds. They’re daily wage workers, shopkeepers, and office employees who cannot afford to lose a day’s wages. These patients don't have the privilege of sick leave. They’re free only in the evenings after their work or on Sundays—times when the OPD is conveniently closed. Casualty then becomes their only point of contact for accessing formal healthcare.
When asked, “Aap log OPD subah me kyu nahi aate (Why don’t you come to the OPD in the morning?),” there is one standard reply, “Sir, hum din bhar duty pe rahte hai. Abhi free hue toh socha dawa le le (Sir, we are on duty all day. Now that we're free, we thought we'd get some medicine).”
The most common group of patients that show up at the casualty are sick children, who either have school in the morning or their parents at work, turning the emergency pediatric room (EPR) into a 24-hour OPD.
This is where even quacks (informal healthcare providers) come into the picture, who can provide services at a low cost and also suit patients' timings. Whenever I ask a patient their reason for delay in seeking care, the typical answer is, “Pass ke private dawakhana se dawa kar rahe the, abhi zada badh gaya toh socha sarkari aspatal me dikhate hai (We were getting treatment from a nearby private clinic, but now that it has worsened, we thought of visiting the government hospital).”
The neglect of chronic wounds
Casualty is meant to handle only fresh or old wounds with life-threatening infections. Old wounds that need only dressings are restricted to the Surgical OPD from 9–11 a.m. This rigid system creates a significant problem—why would a patient, especially one with limited mobility or financial resources, stand in line for hours to get a routine dressing change? Many don’t, and as a result, their wounds worsen.
The worst affected are people from a poor socioeconomic background belonging to the marginalized communities. They arrive at casualty with foul-smelling, maggot-infested wounds, hoping for care. Instead, they are turned away or even thrown out by hospital helpers and dressers apathetically, stating the casualty dressing room rules and OPD timings.
The consequence? Neglected wounds turn into severe infections that often require an amputation of the limb. The suffering is immense, and it’s entirely avoidable.
Lack of patient-centric diagnostic services
The lack of round-the-clock diagnostic facilities in public hospitals makes timely and accurate diagnosis impossible. For OPD patients, blood investigations are only available until noon. After that, anyone requiring lab tests—whether for fever, infection markers, or any other condition—must get them done at private diagnostic centers. In casualty, routine investigations are not an option unless the patient is admitted.
“Come tomorrow morning for the blood test, or get it done at a private center—it's closed here,” the hospital staff tells patients who come in the evening with high fever. Their options? Spend money, when available, on unaffordable tests or accept empirical treatment—meaning broad-spectrum antibiotics, anti-malarials, antivirals, and painkillers all at once—because a diagnosis can not be confirmed without tests by the treating doctor. Often, for those who can’t afford private diagnostics, the waiting game means their illness progresses unchecked.
"Doctor, kal bola tha test karne ko, appointment next week ka mila. Tab tak dawa kaise chalu kare? (Doctor, you told us to get the test done yesterday, but we got an appointment for next week. How do we start the medication until then?),” one patient asked me. The absurdity is real—diagnostics often are the backbone of treatment, yet patients are requested to wait indefinitely, sometimes worsening their condition in the meantime.
The unaccountable referral system
Another issue is wrong referrals to the government hospital from private practitioners. "Humein Nalasopara se bheja hai, sir. Waha bola yeh hospital bada hai, yaha sahi se dawa jaanch ho jayega (Sir, we were sent from Nalasopara. They said this hospital is more equipped, and the treatment and tests will be done correctly here),” patients tell me, having traveled 40-50 km for non-emergency issues.
They often come from far-off places where either government hospitals are unavailable or are still 10-15 km away. Even if they show up during the OPD hours, many of them are referred on the wrong day when the consultant they were referred to doesn't have a clinic.
The situation is worse for patients referred to a tertiary care centre who end up at our secondary care centre, where their required investigations and treatment aren't available.
Once, a patient who had undergone emergency neurosurgery at a private hospital was brought unconscious on oxygen support by relatives who said, “Private me admit rakne ke paise nahi the to sarkari me jaane bola. Kisi ne bataya pass me apka aspatal hai toh hum le aaye (We couldn’t afford admission in a private hospital, so they told us to go to a government hospital. Someone mentioned that your hospital is nearby, so we brought the patient here).”
Victims in an apathetic system
An effective referral system would ensure that a patient admitted to a secondary care hospital needing higher care is transferred to a tertiary care public hospital in the region and provided appropriate care. However, not just the health system but also individuals and groups working in these public hospitals often fail to ensure the transfer of patients to the right hospital. This, coupled with the lack of practical referral guidelines, means that the patients are left alone to figure out where and how they will go to the “higher centres” they are referred to.
However, apathy is not limited to the public health system. Poorly thought-out urban planning also creates a glaring issue in healthcare accessibility.
In the northern part of Mumbai, where most secondary hospitals are located, patients rely heavily on rickshaws for transportation for their healthcare needs. However, these rickshaws are not permitted to enter South Bombay, where all four tertiary care centers are situated—they are accessible only by taxis. The sheer illogicality of this situation is mind-boggling! How can we expect anyone in a critical state, who ideally should have been in an ambulance, to switch transportation from an auto to a taxi mid-journey?
A call for change
We do not need to invent new models or look too far away for solutions. The Telangana government has worked to improve access to healthcare by introducing evening OPDs since 2022. Under this system, doctors are assigned rotational shifts in the morning or evening, with weekly changes. This eliminates concerns about extending regular working hours while significantly improving access to healthcare. With this model, patients are no longer restricted to morning OPD hours.
Government hospitals can offer outpatient services from 9 AM to 2 PM and 4 PM to 6 PM. In the morning, patients can consult a doctor and undergo diagnostic tests, which are processed and made available within a few hours. In the evening, they can return with their results and receive a final diagnosis and treatment plan, ensuring a more seamless and efficient process. This system would also help decongest casualty departments where emergency cases could be prioritized.
A structured wound care unit that operates alongside the OPDs and not just for two hours in the morning is also needed. This could prevent thousands of patients from unnecessary pain, disability, and life-threatening complications. Similarly, diagnostics for OPD and casualty patients must be made more accessible to improve access to quality healthcare.
Public hospitals are supposed to be the backbone of accessible healthcare. Yet, their practices are failing both patients and healthcare workers. Private clinics and hospitals, on the other hand, get it right. Their OPDs function in the evening, catering to people after work hours. Private setups understand that healthcare is a service industry, and their flexibility ensures accessibility.
It’s time that the people managing the public healthcare system realized that healthcare is a service that needs to be structured to meet people's needs. Until then, the cycle of inefficiency, neglect, and frustration will continue.
Edited by Parth Sharma
Image by Gayatri
