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 mala-
fide 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 visit-
Appointment 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.
• 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.