Functioning of ECHS

Prologue

Health care in India is a daunting task for the Government due to the vast
population involved; almost one sixth of the world’s population. The Government is
seized with many other problems as well, to do with its citizens. Notwithstanding
it is a sacred duty for the nation to take good and exclusive care of the Ex-
Servicemen. These men have given the best part of their life to ensure that the
sovereignty of the nation is never threatened. It is unfortunate that most of the
people, notably the politicians and the bureaucrats, have no knowledge of the
severity of physical and mental strain a soldier has to undergo even during peace.
Hence, they underestimate the soldiers’ sense of patriotism, discipline, integrity
and willingness to help others. They consider the soldiering as just another job,
for performing which the soldiers are paid quite well.

Early retirement, which is an outdated concept, is still in vogue in Indian

defense services It takes a heavy toll on the Ex-Servicemen financially. Though
the Service Conditions promise healthcare even after retirement, due to paucity of
resources such care was restricted to few cities only. As most of the soldiers
live in small towns and the rural villages, they were deprived of healthcare,
prominently promised while enrolling them.

Introduction of ECHS

The introduction of ECHS is certainly a boon, and though quite late a step
towards living up to the promise of the Nation to the soldiers. No doubt, it
envisages widespread infrastructure given the size of our country and hence, we
have to show some patience giving adequate chance to the authorities in developing
the scheme to its full potential. However, the authorities must be sensitive to
the high expectations of the beneficiaries namely the Veterans who have been
feeling neglected for quite long in many counts, including the healthcare.

Functioning of ECHS

Reasonably good number of Polyclinics under ECHS has come up across the
country. The establishment and functioning of these polyclinics must be of the
nature of a role model for many more such polyclinics to come up in the near
future. However, I get the impression that all is not well from my interaction
with veterans at and near around Madurai and with friends at other places of
Tamilnadu. Hence, I am compelled to write this brief in an unbiased manner which I
feel might be of some help to the concerned. I am unbiased because I have not so
far had any personal experience with the Polyclinic at Madurai or at any other
place.

Setting Up of Polyclinics

Except in cosmopolitan cities, getting land and establishing Polyclinics

have been a bit of bother. In the local administration at state, district and
corporation levels, there is quite a bit of reluctance to allot land for
establishing ECHS polyclinics. They are inhibited by their narrow vision of the
future price the available land is likely to fetch. The Collector at Madurai makes
a public announcement that he has identified suitable piece of land and in two
months he shall ensure that the foundation stone for the clinic is laid. More than
nine months are gone. Still the poor OiC Polyclinic, Madurai is running from post
to pillar to find a suitable place.
 The point is obviously that there is no statute provision to bind the states
to allocate land as and when located by a board of officer for the purpose of
Polyclinic under ECHS. Here I want to quote two statements from an article by Dr
Harsh V Pant a professor teaching at King's College London. He says ‘A country
makes a sacred contract with its soldiers.’ …. ‘A country that refuses to respect
this contract with its armed forces will eventually end up getting forces that
will not respect the nations' aspirations.’ Can there be any justification for a
state in hesitating to allot a piece of land for building a hospital, that too for
the Ex-Servicemen? Tamilnadu is a state that boasts of highest ‘Flag Day Fund’
collections, year after year, crossing the ‘crore’ mark in the last couple of
years. Yet we find a very high degree of reluctance in the rehabilitation of Ex-
Servicemen in the state of Tamilnadu.

Staffing ECHS

It is sad when we compare ECHS polyclinics with the number of private

hospitals coming up and doing roaring business with profits at par with IT sector.
The staff in ECHS is paid pathetically low remunerations with the result that the
posts do not get filled up. There are doctors and nurses quite willing to offer
their services free or for an honorarium, as many hold the Services in high
esteem. They believe that their reward lies in the sense of pride in doing their
due bit to the soldiers who braved the rough weathers in the borders while they
were comfortably pursuing a lucrative career. It is time we are innovative in
motivating the country to do its bit. Shedding tears hearing Lata’s famous song
that moved Nehru is of no value. I am tempted to quote Dr Pant again. “This is a
nation that will cry with Lata Mangeshkar … when she sings ‘Aye Mere Watan Ke
Logon’ but will not make any effort to understand the real problems and concerns
of its soldiers.”

Empanelling of Hospitals

This is a big bugbear if I go by the cases at Madurai. The modus operandi

for empanelment of hospitals is so bureaucratic that reputed hospitals shy away
from seeking empanelment. The case of Arvind Eye Hospital Madurai, an
internationally renowned one suffices to prove the point. They were reluctant to
seek empanelment and acceded to the request of the ESL Madurai and of late Surgeon
Captain Christin in the interest of the welfare of Ex-Servicemen community. Now
this great hospital is taken off the empanelled list. ‘With no information to the
hospital’ claims the hospital, ‘proper notice terminating the MOA has not been
served … as required in terms clause 17 of the MOA’. Without taking sides, the
pertinent question that arises and that cannot be overlooked is ‘Can this kind of
relationship between the authorities and the hospital is conducive to provide the
necessary healthcare to the ex-servicemen community’.

The system of empanelling and removing from the list of empanelled hospitals
must be much more transparent than it is at present and must involve either local
representatives or the whole of the Ex-Servicemen community. It is possible simple
and reasonably quick with the technology available in the present days ruled by
electronic computing and communicating.

Administration of ECHS

In management circles it is a popular belief that while decentralization

increases efficiency and effectiveness considerably, the scope for corruption also
increases. Opting for centralization has the opposite effect. Decentralization
with effective reasonable performance audit is the golden middle path that will
ensure the best result. I came to know that advisory committees have been set up
to help the ECHS. The manner in which the advisors are appointed is not known. At
Madurai, of the two advisors one, Col Simon is an active member of both the
Associations for the Ex-Service Officers and the Ex-Servicemen, whereas the other
one claimed to be too busy to get involved in these associations and hence refused
to join any of these associations when invited. You can draw your own conclusions
on the effectiveness of such an advisor in the committee. By virtue of being a
member of the associations Col Simon interacts with the veterans and the OiC ECHS
and projects their mutual problems objectively. What has the other member been
doing so far is a mystery.

Treatment

At present the system of treatment is that a patient has to report to the

polyclinic wherein necessary treatment if possible is rendered. If facilities at
the polyclinic are not adequate, the patient is referred to the empanelled
hospital that is equipped suitably. Transportation is not provided and the patient
has to report to the referred hospital on his own. Propriety and necessity of this
procedure needs study and suitable modification by way of charging a nominal
transportation fee, if a must, can be considered. I was informed of a case where a
heart patient with angina was asked to report to the empanelled hospital and it
took two full days for him to get admitted.

Issue of medicine is yet another issue that needs to be radically

rationalized. Those in medical profession vouch for the miracles that can happen
in recovering from even very serious illness with faith, faith the patient has on
the hospital, the doctor and the medicine prescribed. Almost every patient is
critical of the poorly packed medicines issued at polyclinics. There is an element
of suspicion whether such medicines are potent and clinically safe enough to cure
the illness. Can a patient with such a lack of faith in the system of healthcare
ever be benefited? True, faith has to be inherent in a patient and equally true is
that a sound system of healthcare instills faith.

Distribution of medicine in cases of prolonging treatment also needs

addressing. Periodic piecemeal distribution is being observed at present due to
obvious reasons of economy. This is a short-sighted approach that causes a lot of
inconvenience to the patients and infructuos workload for the hospital staff. I do
not see any scope for dispute or malpractice in adopting to reimburse purchase of
medicine at the contract rate. It is convenient and economical, as well.

Treatment of minor ailment is practically denied to the veterans. Before the

introduction of the ECHS a medical allowance of about Rs 100/= was being paid, I
believe. The continuation of this meager sum for those who are resident at say
beyond 3 Km radius from the clinic or those desirous of availing this allowance
can be considered. The smartcard can be encrypted with suitable information. A
point that has to be borne in mind is that at present there is no provision for
periodic medical check which the medical fraternity considers as an inescapable
requirement in the case of people above say 50 years of age. Sanctioning this sum
may take care of this requirement.

Malpractices

It is prudent for any concern to take due note of the possibility of some
kind of malpractice that is bound to occur, howsoever noble the cause is and
committed the management is. Therefore, adequate measures need to be planned and
implemented to eliminate completely if possible, and if not, minimize the chances
of malpractice to the extent possible.

The bonafides of the beneficiary is established by the use of smartcard.

However, in addition to the verification by the staff at ECHS polyclinic,
provision for proper verification at the hospital responsible for the treatment of
the patient is one such measure that will eliminate the remote but quite likely
impersonation. It is quite practicable by providing swiping machines to the
hospitals and providing access to the database on the patient. It is as simple and
similar to the use of credit/ debit cards. Such a measure shall go a long way in
helping the patients seeking medical help with the empanelled hospitals directly
in emergent situations.

Extensive Billing is another area that needs to be tackled. This has been a
bone of contention between the polyclinic management and the hospitals. Even
within the ECHS conflict between the Administrator of the polyclinic and the
doctors has been brought to my notice. The decision with regard to the kind of
treatment, testing and medication is obviously the prerogative of the doctors. But
doctors tend to play safe by prescribing elaborate and highly sophisticated
testing which is not absolutely necessary in some cases. Such testing is a big
drain on the meager resources at the disposal of the polyclinic and hence the
administrator is compelled to use whatever means available to him to curtail this
practice. This aspect needs careful analysis.

First case pertains to that of emergent situation. I do not think that there
can be any difference of opinion that in emergency it is the word of the doctor
that is final. The bills preferred by the hospital in emergent cases have to be
honored without any hesitation by the administrator of the polyclinic. In spite,
the need to monitor if the hospital is unscrupulously taking advantage of the
emergency and of the fact that the government is footing the bill, cannot be ruled
out.

The second case is of routine nature. It is quite common to seek a second

opinion when a patient has to foot the bill or if he is doubtful of the competency
of the doctor. Unfortunately, in the cases where government doctors are involved,
the doubt factor is quite common. If time is not at premium, the patient can be
permitted to seek a second opinion and cost reimbursed as and when the patient’s
stand has been found correct.

Concept of Medical Board It may be worthwhile to study to what extent and to

what advantage constituting Medical Review Boards will help to study such disputes
and to render their considered opinion. Perhaps some compromise can be arrived at
through prompt payment of bills and subsequent recovery, if the billing has been
very opportunistic. In a country as vast as India, there is ample scope for
disputes whether justifiable or not, and therefore, it is inevitable for setting
up means for conflict resolution.