Echs Samvad

EX SERVICEMEN CONTRIBUTORY HEALTH SCHEME BY BRIG SC KUTHIALA (RETD) In the early Fifties when the Central Govt Health Scheme (CGHS) was first conceived the armed forces were asked to join. Gen Carriappa the C in C declined stating that the Armed Forces were quite capable of looking after their retirees/dependants. This was a very noble thought then and should continue to be the guiding principle even today. However, we are now dealing with an unresponsive civil administration that would be perfectly willing to absolve themselves of any responsibility towards Ex Servicemen (ESM) who do not contribute to a vote bank. Whereas the Armed Forces continued to care for their veterans for a considerable period the task became increasingly difficult because of the large gap between the AUTHORISED and ENTITLED persons availing medical facilities from Military Hospitals. Whereas the authorized manpower continued to remain static, person’s entitled treatment ie wives, children, dependant parents, ex servicemen, their wives/ dependants etc continued to increase. A study was done in 1996 (which I was privileged to head) wherein the ‘authorized to entitled’ ratio was found to be in the region of 1:16. That meant that for every one serving soldier on the authorized strength there were 16 entitled persons getting medical treatment for whom the Govt did not provide a budget. A hospital staffed and equipped for 100 serving personnel was actually providing medical services to1600 persons. The system was bound to collapse. This gap should have more than doubled since 1996.The study in 1996 also brought out very clearly that despite reservations by Ex Servicemen regarding the care provided to them in Military Hospitals NOT ONE respondent in the sample (which was very large) wanted to hand over this responsibility to the Central Govt. NOT ONE respondent wanted to join the CGHS. I am sure that a study today would only reconfirm our trust in the ECHS vis a vis the CGHS. This study was the first step towards creation of the ECHS. This article is not intended to be a critique but a sincere effort to correct matters before they get out of hand. We are all interested in setting an example in health care for veterans since each one of us is either already there or will reach there shortly. 3. Having said that, I am constrained to point out that because of shortsighted knee jerk reactions at numerous levels the basic ethos is being violated. The ECHS is for the benefit of Ex Servicemen; not for the staff at various HQ’s handling this subject, from polyclinics right up to the AG; not for the medical staff in polyclinics and not for the Military Hospitals or empanelled hospitals. Every time a Commander or staff officer somewhere passes an order he needs to ask himself a few questions. Firstly, does it benefit Ex Servicemen, Secondly,

can it be implemented by a widow in a remote village, Thirdly am I passing this order just to reduce my paperwork even if it increases the ground level problems faced by the lowest common denominator i.e. the jawan or his widow in a village, Fourthly will it be discriminatory in nature and Fifthly WILL IT STAND LEGAL SCRUTINY. The last question assumes importance because we in the Armed Forces are not trained to ask this question. The ECHS is NOT a Battalion Level institution where the Commanding Officers order is sacrosanct. Outside the Armed Forces discipline is not a “NOT TO REASON WHY” issue. You are not planning a military operation. ECHS is a Service and in the service industry discipline implies SERVICE TO THE CLIENT. A very difficult attitudinal change for any one in the Armed forces but something that will have to be learnt by the staff in the ECHS, otherwise, I suspect a whole range of RTI applications and litigation in the very near future. What I mean will be best understood by a perusal of para 7 on page (ii) of the brochure issued in Jan 2004. It says “IT SHALL REMAIN THE RESPONSIBILITY OF THE ECHS PATIENT TO ACQUAINT HIMSELF OR HERSELF OF THE LATEST ORDERS /INSTRUCTIONS-LACK OF KNOWLEDGE CANNOT BE CITED AS A REASON FOR WRONG ACTIONS OR MISUSE OF THE SCHEME” 5. The highlighted portion is familiar to all armed forces personnel. But passage of information within the Services and outside is a totally different matter. Would you be able to justify that Sep X in a village should know all orders pasted on the polyclinic notice board. Would you even be able to hold me guilty of not knowing the orders pasted on the polyclinic board in Noida. The above caveat is acceptable in the Army, nowhere else.

6. We are all aware that the ECHS was created to reduce the load on Military hospitals. Page 1 para 3 of the Brochure says “This in turn will reduce the load on Military Hospitals, since the exclusive Polyclinic facility will be located in nominated districts………………….” Page 2 para 5 lays down the Aim. “To provide comprehensive, quality and timely medical care………………………………………” through “out-patient” facilities at 227 all India Polyclinics, and “in patient” treatment through service hospitals and empanelled civil hospitals/facilities. 7. I have gone to some extent in elaborating that the whole purpose of the ECHS was to reduce the load on Service hospitals. The very inception of this scheme was to “enable the organization to commence sending ECHS members to empanelled diagnostic facilities, specialists and private hospitals” CHAPTER 3 PAGE 7 PARA 1 OF THE BROCHURE. And yet nearly all-good hospitals in the NCR are opting out of the Scheme. Apollo and Ganga Ram which were earlier on the panel opted out because they had no time to chase

ECHS staff for clearance of their bills (running in to crores for very long periods) and Escorts has been removed for reasons and in a method that at best can be termed suspicious. 8. Now for the specifics. Since I am no longer in Service my views are obviously determined by my personal experiences in NOIDA. 9. ECHS members in NOIDA cannot be referred to hospitals in Delhi. On what basis has this demarcation been done? Is it for administrative control by the Station HQ or the convenience of patients? If it is okay for a Noida patient to travel to the RR then why the demarcation for empanelled hospitals? Is the intention to reduce the load on the better hospitals in Delhi or are ECHS members in Delhi a superior breed? Does this not amount to discrimination? Are you not violating your own rules? Page 45 answer to question 44 in the Brochure. “In case bed space is not available in the Service Hospital (in this case RR) the patient ONLY will decide the civil empanelled hospital of his choice, any where in India- cost of transportation of going there to be borne by him.” Why is a Noida ESM not referred to a hospital of his choice in Delhi? Annexure 1A to MOD/GOI letter No. 22D (14)/07/US (WE)/D (Res) of 18th September 2007 very clearly gives a common list of EMPANELLED HOSPITALS AND NURSING HOME FOR ECHS in DELHI/GURGAON/NOIDA. Further the Regional Centre for these three regions of the NCR is also common. The inter formation boundary is obviously for staff convenience. A recent letter issued by Stn HQs Delhi Cantt (245/Accts/Gen/ECHS of 25 Jun 2008) which is on the Noida polyclinic notice board states that the Station Commander is not happy with the fact that a very large proportion of patients are being referred to Batra Hospital as against a few others also in Delhi. He desires that this imbalance be evened out by referring patients equally to all hospitals. Does the Station Commander realize what he is saying? Is it his job to influence such decisions? Page 14 para15 k of the Brochure states “The ECHS member alone will have the right to make the selection of desired civil empanelled hospital and will NOT be influenced by any doctor” Another instance of mindless arbitrary decision-making is the recent case of disempanellment of Escorts. It is obvious that there is or are some disputed bills between Escorts and ECHS. The Authority concerned in this case presumably the Station Commander has decided to “sort out” Escorts (in standard military fashion) and has therefore arbitrarily shut off referral to Escorts by issuing a departmental order, in violation of Govt norms. To ensure that the action is adequately covered Station HQ has conveniently not renewed the MOA, which had become due for renewal. By this method they have skirted the issue of disempanellment, which would have created legal complications. Who suffers because of such shortsighted actions? Obviously not the ECHS. Escorts is a big successful

corporate house and can handle such issues. The sufferer is quite clearly the ESM. Did whoever ordered non-referral ask himself the questions recommended in para 3 above? The relevant para of Govt of India Ministry of Defence New Delhi letter No. 24(9)/03/US (WE)/D (Res) dated 16 Jun 2004 reads as follows: “In case of unsatisfactory performance, unethical practices or medical negligence by any empanelled Hospital, Nursing home and Diagnostic Centre, a show cause notice will be issued to concerned empanelled facility by the Station Commander. Agreement/contract of empanelment will be terminated if charges are established, on approval from Ministry of Defence i.e. the appointing authority. Empanelled hospitals provide emergency treatment to ESM on production of the ECHS card. Thereafter “Empanelled hospital will inform the nearest ECHS Polyclinic. On learning about admission OIC Polyclinic will make arrangements for verification of the facts. The onus of informing the OIC Polyclinic within 48 hrs lies with the Empanelled Hospital and not with the ECHS member/patient. However, the ECHS member may also convey the information on his own to ensure action. Thereafter, the OIC Polyclinic will initiate an emergency referral after verifying the emergency. He will also ensure that the Emergency referral reaches the Empanelled Hospital in time and that the Empanelled Hospital does not charge the patient, inadvertently or otherwise.” Central Organisation (ECHS) letter No B/49774/AG/ECHS/Referral dated 01 Sep 04 A number of us have gone to empanelled hospitals in an emergency and recollect vividly the running around we have had to do on our own to get the referral from the Noida polyclinic. To resolve this issue all you have to see is the procedure followed by Third Party Administrators (TPA) of good insurance companies. The details are faxed by the empanelled hospital to the TPA who does a quick verification and faxes back an interim approval followed by a detailed approval later. Incidentally all good hospitals have a front desk dealing with corporate clients and TPAs. The Noida polyclinic does not even have a FAX machine. This also requires a change in mindset. But what happens when an empanelled hospital is taken off the list without the Hospital or patients being informed and the Station Commander and OIC Polyclinic resort to Unit level modus operandii to place a shop out of bounds by a simple diktat. We need to be aware that it is just these sort of actions that give rise to suspicions of malafide intentions on the part of ECHS staff involved with passage of Hospital and individual bills. One way of responding to this would be to state that it is just “loose talk” It may however be better to collect data on pending bills of hospitals in Noida and Delhi with amounts and periods thereof and carrying out a comparative study to determine which Hospitals are promptly paid and those whose bills are pending inordinately.

We have all been referred to RR on numerous occasions. We all know the number of visits a single referral means. First visit – Get Appointment, Second visit -Consultation, Third visitAppointment for ordered investigation, Fourth visit- Collect investigation Reports etc etc. Now see the rules. “In Military Stations, ECHS members and their authorised dependents requiring hospital admission will, if the ECHS member desires, be referred to the Service hospital in the station. The Officer in Charge (OIC) Polyclinic will telephonically ascertain the availability of beds/facilities in the Service Hospital so as not to inconvenience the patients. When beds/facilities are NOT available in the Service hospital, this fact will be endorsed on the referral form, and the patient will be outsourced to an empanelled hospital of patients’ choice for admission. The patient shall have full freedom to decide on which empanelled hospital he/she desires to go – ECHS staff will only act in an advisory capacity”. Central Organisation (ECHS) letter No B/49774/AG/ECHS/Referral dated 01 Sep 04.

Polyclinics provide only “outpatient” treatment. But they also have very comfortable working hours. Authority: Central Org, ECHS letter No B/49760/AG/ECHS(R) dated 04 Jun 2007. Broad guidelines for timings of ECHS Polyclinics have been laid in the referred letter. It states “It is reiterated that OPD registration in all polyclinics be stopped at 1430h daily. This would enable referrals to be generated up to 1500h. Thereafter the polyclinic would have one hour (i.e. from 1500h to 1600h) dedicated for its interior economy, which includes data entry, and processing of reimbursement bills submitted by hospitals and individuals. However all emergency cases will be handled till 1600h or till the polyclinic closes, whichever is later”. Under the circumstances after 1600 hrs “outpatient treatment” is NOT POSSIBLE under the rules since Polyclinics are closed and empanelled hospitals are not permitted to provide ‘out patient’ treatment. ESM can only proceed without reference to an empanelled hospital under MEDICALLY DEFINED emergencies. Just one example from the list of emergencies is - (c) Cerebro-Vascular Accidents including Strokes, Neurological Emergencies including coma, cerebro meningeal infections, convulsions, acute paralysis, acute visual loss. If I were to twist my ankle after 4 PM I cannot go to even an empanelled hospital because I must have a “Life threatening Injuries including Road traffic accidents, Head Injuries, Multiple Injuries, Crush Injuries and thermal injuries.” or “Any other condition in which delay could result in loss of life or limb.” Since at the NDA I was given first aid training “ In all cases of emergency the onus of proof (of the emergency) lies with the ECHS member.” If however I did go to an empanelled hospital the Dr would not give me “out patient” treatment since that cannot be claimed. If he were wise he would admit me, order an X-ray followed by a CAT scan, followed by xxxxxxxxxx, and present a bill for “inpatient” treatment under emergency. This I am sure is happening all the time. Inflation of hospital bills, which is a recognised malaise of the system, is actually the fallout of hare brained rules. As I said at the outset the purpose here is to suggest improvements and not just make irresponsible criticism.

To my mind there is a very basic structural flaw in the concept. ECHS has been designed to use the existing structure of the armed forces by augmentation of the Central organisation, Regional centres and 227 Polyclinics including 106 Military Polyclinics (Augmented Armed Forces Clinics). Entire manpower authorised to ECHS is contractual. Additional resources have NOT been authorised for ECHS purposes at MH (all types), Station HQs, Area HQs and Command HQs. Similarly additional resources for ECHS purposes have not been authorised for medical procurements including medicine at all levels of the logistics chain. The Scheme is running through essential supplements courtesy Army Welfare Funds and attachments/ postings of serving soldiers. Army, Navy and Air Force are providing manpower and funds for these administrative organisations from within their existing resources. Without going into too many details what this implies in a nutshell is as follows: MD ECHS is responsible for the functioning of the Polyclinics through the Regional centres; however the Regional Centres function under the Command/Area/Sub Area with which they are co located. Administrative control of funds, accounting/audit/passage of bills etc is through Station HQs, Area HQs etc WITHOUT ADDITIONAL MANPOWER AND IN ADDITION TO THEIR BASIC TASK. Medical cover is in the first instance through existing Services Hospitals without augmentation. Similarly additional resources for ECHS purposes have not been authorised for medical procurements including medicine at all levels of logistics chain. Our Babus have again taken the gullible Services hierarchy for a ride. Our serving soldiers who are ever so keen to do good for their respected Veterans have accepted in true military style to continue to look after us from within their own resources including their welfare funds. A recent report on ‘Peripatetic Check and Review of the ECHS-May-Aug 2008 has this amazing Finding: “Xxxxxxxxx the clientele is very satisfied with the Scheme and considers it to be a boon from the Govt, which was long awaited. IT IS CONSIDEREDTHAT THE SCHEME WOULD NOT HAVE BEEN SO SUCCESSFUL UNTIL THE THREE SERVICES HAD NOT SUPPORTED WITH THE FOLLOWING”: - (SIC) (a) Additional Medical Officers and Specialists from welfare funds. (b) Huge clinical manpower which includes both the serving doctors and hired manpower from Regimental funds. (c) Patient comfort by providing amenities from its regimental funds and creation of additional space at the Polyclinics. Does all this sound even remotely like a sincere effort to reduce the load on the Services medical facilities???? Just one small example of how expecting the Armed Forces to

provide ECHS cover from within existing resources man power and funds affects the system will be enough. Currently, after a reimbursement bill has been passed the cheque has to be collected by the ESM personally from Station HQs Delhi Cantt. Reason. The Station HQs are not authorised funds and therefore service labels to stick on the envelopes forwarding the cheques to the individuals, which have to be sent through the mail. Whereas we have generally got used to being taken for a ride by our worthy politicians and babus the question that needs an answer is - how was the existing structure of the ECHS conceived? It does not take a genius to comprehend that such multiple channels of command will be a non-starter. Is it any surprise that no matter how hard the MD ECHS tries he will not be able to push Station HQs Area HQS etc who neither report to him nor have dedicated staff for ECHS purposes. The MD ECHS and the Regional Centres lack authority for exercise of functional controls over the Polyclinics and also the Station HQS controlling the polyclinics. No wonder good hospitals refuse to waste their time chasing their claims and we are left with poor quality health care. The Army has adequate experience in such Schemes in the shape of AGIF, AWES and AWHO. Though these schemes are pure Army schemes without Government resources did we need to make a hash of the Command and Control structure of the ECHS. Unified Command is a well-known and recognised tenet of management within the Armed forces. MD AGIF manages all AGIF functions, MD AWHO manages all AWHO functions, then why the mess in the ECHS. Is it any surprise that things are not settling down even five years after inception of the Scheme? As I said at the beginning the purpose of the ECHS was to reduce the Ex Servicemen load on Services hospitals and resources. Somewhere along the line this main thought has been lost sight of and the ECHS has fallen prey to the standard “building of its own empire” syndrome. We therefore have a recommendation from the Review Committee, which states: (a) Reduce referrals to civil empanelled facilities by augmenting Polyclinic/Service

Hospital facilities by providing specialist cover within the authorised medical establishment (b) Improve the system of drugs procurement and management by improving the policy for drug procurements by DGAFMS and Polyclinics and by authorising contractual manpower for better drug management. The ECHS in the absence of clarity of a strategic vision, which envisaged outsourcing of ESM patients to existing civil facilities, has embarked on a course of creating more polyclinics, more dependence on Armed Forces infrastructure and funds without insisting

that the Govt ensure the desired standards. The report on Peripatetic Check and Review of The ECHS says it all in just one sentence “IT IS CONSIDERED THAT THE SCHEME WOULD NOT HAVE BEEN SO SUCCESSFUL UNTIL THE THREE SERVICES HAD NOT SUPPORTED WITH THE FOLLOWING.”

This is the philosophy that has prompted the ECHS to propose a shift of the Noida Polyclinic from its present location to Sector 52 in land owned by the Coast Guard (Defence Land) so as to raise a more spacious Polyclinic. The comfort and convenience of ESM “Comes Last Always and Every Time”. I am strongly of the opinion that in Noida where there is such a large concentration of ESM the Arun Vihar RWA must get actively involved in all ECHS matters not as an authority but in a supportive role. Improvement in the functioning of the ECHS is a continuing subject. This article is intended to make ESM aware so that they can demand what is justifiably theirs by right; and to make the ECHS more responsive to ESM requirements. To summarise what is required is as follows: • Refer patients to empanelled hospitals of the patient’s choice anywhere in the NCR. • Permit empanelled hospitals to undertake “out patient” treatment in emergencies to be determined by the Dr at the empanelled hospital. • Appointments in RR to be arranged by the OIC Polyclinic. A methodology can quite easily be worked out. • After investigation reports to be collected by OIC Polyclinic from the RR. • All paperwork required after emergency “in patient” and “outpatient treatment” at empanelled hospitals to be handled between OIC Polyclinic and the empanelled hospital. • OIC Polyclinic should keep a track of all individual reimbursement claims generated after emergency treatment at non-empanelled facilities, which should be cleared at various levels in a set time frame. Presently the ESM has to do the chasing of the claim after it leaves the Polyclinic. • Reimbursement claims of individuals be sent to the Noida polyclinic from where they can be collected. • The Polyclinic must continue in ArunVihar with the RWA getting more actively involved in its day-to-day problems without becoming a hindrance. • The Polyclinic should be the one point contact for ESM. There should be no need for him to contact anybody else in the ECHS chain. • Make arrangements despite staffing problems to ensure early clearance of pending bills of empanelled hospitals. This is the reason why all the good hospitals have delinked from the Scheme. An all out effort needs to be made to get the best hospitals on the ECHS panel. • Reference to empanelled hospitals should be the norm. More and more dependence on Army Hospitals is violative of the very basis on which the ECHS was created.

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FINALLY AND MOST IMPORTANTLY THE ORGANISATIONAL STRUCTURE REQURES A VERY SERIOUS RELOOK. UNITY OF COMMAND IS A MUST. THE PRESENT FRAGMENTED AND FRACTURED STRUCTURE WILL COLLAPSE. IT IS ALREADY BEING CORRUPTED SINCE ARMY PERSONNEL AT STATION –SUBAREA –AREA AND COMMAND HQS ARE NOW DEALING WITH CIVIL HOSPITALS AND NUMEROUS CIVIL AGENCIES FOR EMPANELLMENT/ PASSAGE OF BILLS/PROCUREMENT OF MEDICAL EQUIPMENT AND STORES ON A DAY-TO-DAY BASIS. IN ANY CASE THEY ARE DOING ECHS WORK IN ADDITION TO THEIR OWN CHARTER WITHOUT ADDITIONAL MANPOWER AND WITHOUT ANY INCENTIVE. THE MD ECHS IS NOT IN THEIR CHAIN OF COMMAND AND HAS NO CONTROL ON THEIR FUNCTIONING.