Empowering echs polyclinics in healthcare domain of defence veterans

By Maj Gen Ashok Kumar , VSM (Retd) 

No comprehensive and institutionalised healthcare mechanism had existed for defence veterans and their dependants prior to the launch of ECHS which was launched on 01/04/2003 as a mandatory healthcare scheme for all the retirees on or after 01/04/2003 and optional for those retired upto 31/03/2003.

The scheme has Central Organisation, ECHS at the apex level comprising of serving personnel and headed by a serving Major General, 30 Regional Centres manned again by serving personnel and 427 ECHS polyclinics manned by 100% contractual staff spread across the country. These ECHS polyclinics functioning on OPD care basis not only constitute the first contact for defence veterans and their dependants but are also solely responsible for healthcare of veterans.

Covid-19 pandemic exposed challenges and difficulties of old age patients in unprecedented manner. Their sufferings were too intense and beyond description. Even vaccination was not given through these polyclinics at the initial stages adding to the suffering of people. While there has been substantial improvement in the functioning of ECHS in various domains but a lot is till left wanting.

A closer looks at Echs

Having studied healthcare of defence veterans in USA through VAHCS and that in UK through NHS, some important recommendations are contained in the succeeding paragraphs to ensure that we have vibrant ECHS polyclinics addressing healthcare of defence veterans.

These are currently staffed with 100% contractual staff with laid down percentages of reservation for ESM and is also being supported by station HQ, Subarea HQ and command HQ for manpower shortfall as there is huge deficiency in authorisation of staff. Salient aspects related to recommendations for ECHS Polyclinics are as under:

• Typecasting of ECHS Polyclinics is currently based on No of ESM and not on No of ECHS beneficiaries which needs to be corrected. The current categorisation of Type A to E needs to be accordingly re-worked out so that appropriate and correct classification emerges. This will also help address the manpower deficiencies to some extent.
• 100% contractual model is not an efficient model. A nucleus of one medical officer, one nursing assistant and one pharmacist should be part of all ECHS polyclinics from serving personnel. Even if there is some shortage in serving category of manpower authorisation, some contractual staff in lieu could be made available to service hospitals. Some practices pf CGHS should be adopted as exists for some wellness centres.
• Since there is manpower deficiency in No of ECHS Polyclinics, the adhoc support is provided by the Station HQs, Subarea HQs and Command HQs from their regimental funds besides CTS fund being allocated from AGs branch. There is an urgent need of doing away with these provisioning and ECHS should be able to provide requisite support of manpower itself.
• The current power delegated to MDECHS with respect to shifting of manpower, till suitable manpower is authorised, should be absolute and not restrictive as prevalent now to some extent. It will be more advantageous to bring out bi-annual manning document.
• There is a need to do away with Type E ECHS Polyclinic expected to function in mobile mode specially in those areas where ESM Population is less and/or there are remote areas. Instead, each Type A to Type D polyclinic should be able to take out this module on need basis so that ECHS Beneficiaries don’t have to travel long distances as age itself is a problem which needs to be factored. Instead, Type D Polyclinic should be authorised for 5000 or below with proviso to at least one such polyclinic in each district of the country. Recommended Categorisation is as under: 

Type A        –         20,000 and above

Type B        –         10000 to 20,000

Type C        –         5,000 to 10,000

Type D        –         Below 5000

Typecasting of ECHS Polyclinics is currently based on No of ESM and not on No of ECHS beneficiaries which needs to be corrected.

• Since Ortho and eye related problems are very predominant in ECHS beneficiaries due to old age factor, each Type A and Type B Polyclinic should be authorised an orthopaedic and eye specialist. Based on the patient load, employment could be planned on part time as well.
• OIC Polyclinic plays an important role in efficient running of ECHS Polyclinics. Currently this appointment has certain restrictions wherein it is not open to medical officers besides those officers who are not graduates specially SL officers. This needs to be corrected. It is recommended that all defence officers should be eligible for appointment and educational restriction should be done away with. It should also be open to medical officers specially in those Type D Polyclinic where DASR (Daily Average Sick Report) is 25 or below. This will not only optimise the expenditures besides providing quality treatment wherein dual role medical officer can handle patients preferably on forenoon and can handle administrative functions in the afternoon. Some financial incentive could be planned for such dual tasks.
• Timing of ECHS Polyclinic also needs to be looked at wherein maximum staff is needed between 0830 hr to 1430 hr and nominal thereafter. Based on statistical analysis, suitable staffing and payment norms should be adopted.
• There are certain remote and hilly areas where local doctors are not keen to work full eight hours and patient load is also minimal (say less than DASR of 25), in such cases, employment could be done merely for four hours as this will assist in equipping such polyclinic with suitable manpower.
• Input for majority veterans indicates that there should be an ECHS Polyclinic within an area of less than 20 km in cities and less than 30 km in other areas while distances have not been given that importance till the time there is an ECHS Polyclinic in each district. While it may be pretty difficult to achieve, empanelment of doctors should be started in ECHS as against only hospitals & diagnostic centres on the lines of General Practitioners as prevalent in NHS of UK. Once empanelment of doctors is done, OPD service will reach doorstep of ECHS and it will bring qualitative and convenient change in healthcare.
• Detailed Government orders and CO ECHS guidelines exist related to selection of staff giving primacy of ECHS staff selection to station commanders, GOC Sub Areas and Command HQs. Total overhaul in this system is needed. The following should be factored:
• No ECHS staff should be exclusively posted to these HQs. Any support needed to ECHS echo system should be provided by Colonel (Veteran) where posted else by those officers looking after ‘A’ Branch subjects. Medical Branch could be co-opted where needed.
  • The current selection should also be revamped as in No of cases, the selection gets delayed in addition to pulls and pressures which should be avoided. The responsibility should be entrusted to veterans so that they are directly accountable for the quality of their healthcare. VHA in USA has accorded enhanced role to veterans. Once the QR is decided, selection as well as other HR related aspects can also be outsourced to a professional organization in this particular field. Challenges if any, beyond recruiting by outsourced agency should be handled by ECHS ecosystem under DGAFMS set up and its chain as against the current dependence on  local commanders in chain. This will free stake holders  to concentrate on healthcare rather than administrative functions.
  • ECHS staff except officers is being given nerrick rates as applicable to central Government rates as against those applicable in concerned states and union territories. Without going into the merit, it is recommended that nerrick rate of the state/UT should be applicable if the same is higher. The current system relates to adoption of rate by CGHS based on revision of rates of central Government and thereafter same is applied in ECHS. This relates to procedural delay and unnecessary paperwork. It will be more prudent that ECHS adopts these changes immediately on notification in the CGHS to simplify the process and changes can be promulgated by CO ECHS. It is also important to have a formal arrangement wherein all notifications and circulars are also addressed to CO ECHS for which the latter should be included in the distribution list of CGHS. 
  • In Case of absence of medical officer specially in case of single MO, RC ECHS should be empowered to detail another MO from the polyclinic having more than one MO with appropriate provisioning of TA & DA. DA is essential to be factored in the entitlement to make it workable. 
  • HR needs to be cared for appropriately and is required to be skilled upwards from time to time. Their entitlements are also required to be factored appropriately. The following aspects are recommended: 
  • Initial selection should be for five years. Annual reporting should be related to adverse performance/unsatisfactory performance. If not initiated, it should be deemed appropriate for extension. 
  • In addition to provident fund contribution (EPF) limited to mandatory threshold of 15000 per month or as amended from time to time, it must be extended to entire ECHS staff irrespective of amount of contractual pay.
  • Gratuity should be also applicable to entire ECHS staff. 
  • Insurance cover of at least 20 times the monthly pay should be provided in case of death whereas 10 times for major disability for all ECHS employees who don’t have such care. 
  • Suitable uniform allowance to facilitate atleast two pairs of dresses should also be authorised.
  • There should be 100 percent reservation for ECHS beneficiaries and their dependants as against the current norm but there should not be any dilution in the QR for such purposes. Staffing should look at quality healthcare first wherein employment facilitation for ECHS beneficiaries should be secondary. Unfilled vacancies should be filled by NCC qualified persons as well as those who have been SPARSH Volunteers, an AWWA initiative for helping ECHS beneficiaries and open to all citizens of the country. 
  • While there is a substantial provision for caregivers in USA, in ECHS even OPD facility is not provided to non ECHS beneficiary staff. There is a definite need to provide basic OPD care to entire ECHS staff for their own well being. 

It is felt if these recommendations are adopted, there will be substantial changes in echo system and ECHS beneficiaries will be genuinely benefitted.