Khem Karan, Punjab - Gurmej Singh shivered as he sat on a cement bench in an almost deserted clinic enduring a fever that had grown progressively worse over two weeks.
The gaunt construction worker had journeyed 24km through wheat fields on an early bus, hoping to be the first patient seen that day at the only public hospital in Khem Karan, a remote border town in the northern Indian state of Punjab.
But 45 minutes after the doors had opened at 8am just one doctor out of the five who were supposed to be on duty, was present - a surgeon waiting to end his night shift. The door to the laboratory, where Singh was to receive a tuberculosis test, was padlocked.
Absenteeism within hospitals in rural India, home to 70 percent of the country's population, reflects a disturbing trend in the country's health system. A study by Harvard University in 2011 found that nearly 40 percent of doctors and other medical staff are absent on a typical day.
And the impact on patients is clear: high rates of maternal death, preventable illness and chronic diseases persist.
"An absentee doctor destroys everything," said Poonam Muttreja, director of the Population Foundation of India, an independent think-tank.
"There is a cultural of indiscipline. Where there is doctor absenteeism there is absenteeism of other workers also."
An absentee doctor destroys everything. There is a cultural of indiscipline. Where there is doctor absenteeism there is absenteeism of other workers also.
Government doctors in India hold a coveted position in the medical profession, enjoying a monthly salary, regular hours, benefits, and a generous retirement pension.
But this status does not translate into high productivity in states like Punjab, which ranks among the worst for doctor absenteeism with 44.5 percent of government physicians missing on any given day. Remote areas such as Khem Karan bear the heaviest burden.
Dr Mulkh Raj, a senior medical officer who oversees hospital administration and attendance in Khem Karan, blames irregular bus services and the hospital's location for the absence of health workers, who are meant to be on duty from 8am to 2pm.
He insisted that the absence of the majority of his staff that morning was not routine, even as the clock ticked past 9am.
"This is a far away place on the border - it's hard for some people [to come on time]," he said, adding that few doctors wanted to relocate from major cities to rural areas.
Raj said there is a strict code of conduct at his facility, including surprise inspections, with those violating the rules facing "stiff action". But he admitted that political pressure by district administrators rendered his actions ineffective - even after reprimands, disciplined staff were soon restored to their positions.
The Harvard study showed that 42.4 percent of all medical service providers in Punjab were absent when unannounced visits were conducted.
Patients suffer the consequences. Singh, who lay in the waiting area of the one-storey building, said he was accustomed to waiting at least an hour for a doctor.
Other people waiting complained that government hospitals offered the lowest quality of care, even if they were affordable.
The doctor left early. If there is no doctor, sometimes the pharmacist comes to examine the patients. If anyone is [seriously] sick, he calls the doctor to see where he is if he is not in the clinic.
About five hours away in the village of Dagh - a cluster of concrete homes and small tracts of cultivated land - the area's sole clinic is a neglected, two-room structure.
Safe motherhood pamphlets are piled on an empty doctor's chair and a metal bed with a dusty mattress sits beside a rusting table, refrigerator, and messy medicine cabinet.
Every day, about 70 people from the mostly working-class community visit this sleepy clinic less than a mile from the Pakistan border.
But the trickle of patients coming to the door are told by a listless assistant that both doctor and pharmacist are out.
"The doctor left early," said Jagdeep Singh, 24. "If there is no doctor, sometimes the pharmacist comes to examine the patients. If anyone is [seriously] sick, he calls the doctor to see where he is if he is not in the clinic."
Disgruntled patients in Punjab have developed a negative attitude towards ramshackle clinics and unreliable public servants, and many believe a secure salary and separate, if illegal, private practices make government doctors apathetic.
"Everyone has a duty but they don't come," said Indira Rani, a 60-year-old woman from Preet Nagar, an hour from Amritsar. "I go to the private hospitals because of this."
Unable to receive timely treatment from a rarely available government ophthalmologist, Rani turned to a private doctor, despite the high cost.
She is among 80 percent of Punjab's residents who opt for private care, according to a 2014 report published under the auspices of the Woodrow Wilson Center and Princeton University.
Muttreja of the Population Foundation believes private practices highlight a lack of investment in health: India spends up to 2 percent of its GDP on public healthcare, compared with 5.1 percent in China or 9 percent in Brazil.
"We should have never allowed private practice, we should have given higher salaries and better infrastructure to government doctors," she said.
Opportunities for change
Across India, there are signs that innovative approaches are now being developed to deal with absenteeism.
Muttreja, who has served on a committee reviewing the government's National Rural Health Mission, believes there is ample opportunity for change.
In Udaipur, Rajasthan, her team came across a chief medical officer who had combined different government health funds to pay for the installation of hidden cameras in clinics that allow the quality of services and staff attendance to be monitored.
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The state government of Karnataka has linked up with partners, including Harvard University, to test a mobile messaging system enabling communities to report doctor absences and other health data.
Punjab's government has launched a helpline to report problems, said Vini Mahajan from the state's Department of Health and Family Welfare, who insists the problem of doctor absenteeism is declining and will continue to improve as they tackle complaints that are reported "in real time".
"The problem, we believe, is not as serious as it used to be in the past, and on the whole doctors are performing their duties fairly diligently," Mahajan said.
But Muttreja said poor governance will still limit progress in states like Punjab where many private and public clinics remain unkempt, underserviced, and ignored by officials.
Unless that changes, patients like Gurmej Singh and Indira Rani will have no choice but to find other care - or simply remain in the waiting room.
"They don't care much about the patients," Rani said, surrounded by her family in Preet Nagar. "Patients will die but the doctors will be nowhere in sight."
Follow Ankita Rao and Bibek Bhandari on Twitter: @anrao and @bibekbhandari