Sayendri Panchadhyayi discusses the relationship between waiting, gender and marginalisation in Indian healthcare provision.
“The bathrooms are extremely unhygienic. The nurses do not arrive on time although patients are on the verge of death! The hospital staff do not miss any opportunity to harass (henostha in Bengali) family members— we were instructed to procure gloves and needles at 11 o’clock at night! Patients feel frustrated, but there is no sign of the doctor or nurses.”
Shanta, female, 30, from Kolkata in Eastern India
(Translated verbatim from the Bengali language)
In a recent conversation with Shanta (anonymized), with whom I share a decade-long friendship, she shared her exasperation around waiting for healthcare provision, prompting me to reflect on the interplay between waiting, time and inequality in access to healthcare.
Sociology of waiting and temporality in care
The social construction of time suggests centring one’s life around the clock and attuning the body clock to the capitalist model of time. The latter emphasizes the “utilization of time”, manufacturing guilt for “wasting time” and the interlinkage between productivity and time management. The term “chronic waiting” refers to indefinite waiting or waiting for lifetime (Jeffrey 2008).
For Jeffrey (2008), it is tied to the idea of institutionalization of chronological time, rather than adhering to seasonal rhythms, in the wake of modernity. With industrialization, time is construed as a scarce commodity, attaching an economic value to it (Waltz 2017). Being part of waiting lists, stranded in a “queue culture” and waiting for services are stitched into the tapestry of daily life in late modernity.
Waiting is an ambivalent time, a bridge between the present and the future, filled with expectations (Gasparini 1995). Social patterns govern the waiting that sketches out daily routines (Waltz 2017). Social time permeates every sphere of social life (Lewis and Wiegert 1981). Waiting predicates heightened suspense, a longing for solution or closure to malady. As family caregivers wait with their patients for consultation, diagnosis, operative procedures or collection of medicines and medical devices, they do so in anticipation of a favourable outcome.
However, there is an asymmetry between waiting for care and the outcome. The availability of public health services is undulating across different states in India due to low levels of investment in them – investment in Indian public health services is lower than in countries with the same level of income (Baru et al. 2010). This results in a weak public healthcare system, characterized by a “queue culture,” which quickly becomes a fertile ground for the proliferation of private hospitals, as an alternative. Unchecked and unregulated, these private hospitals in India are ignominious for charging high fees in exchange for healthcare. An average period of hospitalisation in a government hospital is likely to cost between 14,000 INR and 15,000 INR, whereas the same period of hospitalisation in a private hospital could cost up to 38,000 INR (Mondal 2022).
Gradation and limits of clinical waiting
Private hospitals have been found to have shorter waiting times compared to public hospitals. Clinical waiting can lead to hospital hesitancy, scepticism towards the medical system and delay in healthcare interventions. Waiting for doctors for an inordinate period, without knowing their exact time of arrival, is a recurrent issue at the hospital, which results in dissatisfaction for patients and their family members.
Clinical waiting is the most common form of waiting, especially with public or government-run hospitals struggling to attend to patients in a speedy manner. Understaffed and overburdened public hospitals in India have become a bastion of long-term waiting, which adds to public disillusionment with government hospitals (Arya 2013).
An article published a few years ago in The Guardian (Dhillon 2019) highlighted that, in the case of one government hospital in West Bengal, there were, on average, 250 people waiting in the outpatient ward of the psychiatric department for a consultation with one doctor. The same article states that longer waiting periods are the result of understaffed government hospitals. This finding is supported by the World Health Organization (2017), which reports that there are fewer than 2 mental health professionals for every 100,000 people in India.
Returning to Shanta, during our conversation she recounted an incident, in a public hospital, where she had to search for the doctor and the nurse to provide the necessary care for her grandfather, an emergency patient. This delay in the availability of healthcare staff not only exacerbated her ordeal, but sowed a negative attitude of mistrust towards the healthcare system.
The devaluation of the waiting individual’s time establishes a power differential (Schwartz 1974; Waltz 2017) between the clinical setting and the patients and their families. As stated by Schwartz (1974), the privileged are less likely to tolerate delays, since the costs of waiting are higher. This explains why people of ethnicity, with economic privilege, experience shorter waiting times (Sriram and Noochpoung 2018).
Waiting is a subaltern experience, as less powerful groups, with limited bargaining potential, endure longer waiting periods (Bayart 2007). For example, queueing up, a recurrent feature of waiting, underscores the fact that prompt access to healthcare is reserved for those who arrive first, whereas latecomers are distinctly disadvantaged (Mann 2017). The prerogative to make someone wait without accountability leads to another key area of gendered waiting: the social production of waiting. Making someone wait reveals privilege, as there is an intention to regulate the behaviour of those waiting. This reproduces and reinforces temporal domination and social inequalities. The correlation between waiting time and gender is consequential in a gendered social system.
A sociological imagination (Mills 2006) predicates that private troubles are part of the wider social issues. Following that logic, a brief survey of studies on gender and waiting suggests that medical waiting rooms import the unequal gender relations existing in the everyday social matrix. This is illustrated by the fact that female relatives accompanying patients are more likely to act as care workers and provide active care compared to men (Waltz 2017).
In our conversation, Shanta, my childhood friend, recounted that she waited for 5 hours (from 12:30 pm to 5:30 pm) for a nephrologist, due to an instruction from the hospital management that all the patients had to be present from 12:30pm, without verifying the availability of the doctor. She felt that this amounted to a time penalty, foisted on her for being a woman within the medical setting. Her role, as an active family caregiver, was underplayed. The delayed response from the hospital staff corroborated her view of a longer waiting window resulting in inequitable access to care.
Indefinite waiting or prolonged waiting hints at the barriers in access to healthcare. Payal Mehra (2016) writes that the median waiting time in a public hospital in Kolkata is 30 minutes and waiting time is strongly related to outpatient satisfaction. The same study found that 64 per cent wait for more than 3 hours for a cardiac consultation.
This is not a problem exclusive to India, rather it is a prevalent issue worldwide. In hospital emergency rooms in the USA, women are likely to experience a longer waiting period than men, usually by an average of 12 minutes (Dunleavy 2022); however, Mehra (2016) found that male patients were more affected by extended waiting periods. As a corollary, waiting for a longer time appears to be understood as a “waste of time” for men. This could be due to the “active” role expected from men in many societies, deeming their time as more economically valuable.
Further findings evince that women of all races and colours have longer waiting periods than white men, with women performing their care responsibilities and doing gender through waiting (Waltz 2017). Mehra (2016) points out that more than waiting time, it is the experience of the consultation that is correlated with patient satisfaction. This resonates with Salisbury et al. (2023) who suggest that the tolerability of waiting is less about the quantity of time and more about the quality of the outcome.
Elsewhere in our conversation, Shanta expressed her disappointment at the squalid state of the toilets in government-run hospitals and the dearth of seating arrangements for patients and their families. These impinge upon the experience of family members, especially women. A menstruating woman writhing from cramps, women with osteoarthritis or a woman carrying her child are some of the women she observes in the waiting room, attesting to the ordeals faced by women, based on their physical condition, life course and the nature of their ailments. Infrastructural gaps in appropriate needs-based services cause hesitancy in hospital visits, delayed healthcare, progression of ailments and, eventually, intensification of suffering.
Intervention and implementation
Proactive intervention and policy innovation, which includes reducing the pressure on government hospitals by increasing their number, recruiting qualified healthcare professionals at district (primary healthcare) level, to facilitate access to quality healthcare, and increasing the preparedness of clinical staff to aim at a gender-sensitive approach, could result in greater equity in access to healthcare. Patient and family caregiver satisfaction is the cornerstone of establishing trust and faith in the healthcare system – and it is this trust that helps generate more positive outcomes, while ensuring repeat value and wellbeing for family caregivers.
Moreover, informing patients and their families, in advance, of likely waiting times can enable better planning. Mail alerts or text notifications regarding delay or cancellation can save time. Improved seating arrangements, an in-built library or a room for relaxation are measures that could make the waiting experience less exasperating. Ambient elements including temperature, lighting, music and spatial layout (Baker and Cameron 1996), together with gender-sensitive requirements, will foster social justice and inclusivity for people waiting for care.
In a setting of high medical surveillance and medicalization of health, to guarantee a positive outcome for patients and their families, these issues of indefinite waiting and delayed care can become opportunities to address fault lines in healthcare, develop a feedback loop and update patients on adopted measures, in order to improve the healthcare system. Never forget that public healthcare is the primary organ of a country’s growth and delayed care is denial of care!
About the author
Sayendri Panchadhyayi holds a PhD in Sociology and is currently a research fellow at IIM Calcutta, working on a research project titled: “Healthcare Inequalities in India: Mapping Actors, Logics and Care Practices.” Her interests encompass medical anthropology, cultural gerontology, death and bereavement, sociology of care and policy research. Her doctoral research focused on ideas of wellbeing, the notion of intimate belonging and illness and care narratives specific to the cultures of South Asia, seeking to offer perspectives on embodiment, resilience, suffering and healing in those specific cultural contexts. She won the award for best research paper at the Second Global South Students’ Conference, organized by George Mason University, USA, and she has been invited to deliver a talk (virtually) on her doctoral research at “The Ayah and Amah International Research Network,” London School of Economics. She has also had an abstract selected for a special issue on “Innovation at the End of Life” to be published in Mortality (Taylor and Francis) in 2024.
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