Memorandum to 7th CPC on Medical Services to Central Govt. Employees

Memorandum on Medical Services to Central Govt. Employees

In our Country, even after 66 year of independence Public Sector Health Services is poor, insufficient and conventional in approach. There is significant expansion in Private Sector Health Services during last three decades. But their service is limited to big cities /towns and   these institutions are more business oriented than Missionary. Even the middle class citizen except under extreme emergency situation, cannot think of availing the services. Statistically it may be argued that at present more and more middle class people are receiving the services provided by Private players in Health Sector. Yes. But who are they?   They are persons either covered under Medical Insurance Scheme or under State-sector Health Scheme like, ESI CGHS, RLHS and Scheme introduced by the Public Sector for its employees and pensioners like BSNl, VSNl, ONGC, National Airport Authority etc.    

Central Govt. Employees and Pensioners

Prior to introduction of Central Govt. Health Scheme ,Central Govt. Employees were covered under C S (MA) Rules 1944.To meet the deficiencies in State Health sector, scheme of empanelment of Private Doctors was introduced in the year 1971.The empanelled Doctors are declared as Authorized Medical Attendant of the area where there is sizable concentration of Central Govt. Employees. The Scheme is still operative with limited scope of treatment and medical attendance for 10 days for same ailment. Subsequently, the patients have to consult MO of State Hospitals. The CS (MA) Rules are not applicable to retired Central Govt. employees.   

In the year 1954, Govt. of India introduced a supplementary medical attendance scheme viz. Central Govt. Health Scheme in phases exercising the authority vested under Rule 2 of CS (MA) Rules 1944. At present the Scheme covers 25 cities of 19 States viz. 1 Ahmedabad 2.Allahbad 3.Bengalaru 4.Bhopal 5, Bhubaneswar 6.Kolkata 7.Chandigarh 8.Chennai 9.DehraDun 10.Delhi &NCR 11.Guwahati 12.Hyderabad 13.Jabalpur 14. Jaipur 15. Jammu 16.Kanpur 17.Lucknow 18.Merrut 19.Mumbai 20.Nagpur 21. Patna 22.Pune 23.Ranchi 24.Shillong and 25.Thirruvanthapuram. Initially, only serving Central Govt. Employees other than Defence and Railways were covered under the Scheme. At present, the Scheme covers Central Govt. Pensioners, Work-Charged employees, MPs & ex-MPs, Freedom Fighters/Political Pensioners, Judges of Supreme Court & High Courts, both serving and retired, ex-Vice Presidents, ex-Governors & Lt. Governors, Journalists (accredited with PIB),Delhi Police personnel, Railway Board Employees and Autonomous Organizations of Central Govt. The Beneficiaries may consult MOs at Wellness Centre (Dispensaries) and Specialist Doctors of the CGHS /Govt. Hospitals/approved Private Hospitals for select diseases on reference and Diagnostics services at Laboratories of the Scheme/Govt. Hospitals/Private Diagnostic Clinics may be availed. Central Govt. Employees, on retirement are covered under the Scheme for hospital treatment irrespective of place of residence. The significant aspect of the Scheme is that even after existence for 60 years and expansion, technically, the Medical Officers of the concerned Dispensary are not Authorised Medical Attendants of the beneficiaries as required under Rule 2(a). It may be noted that the findings of Medical Officers attached to Dispensaries or Specialists of CGHS/approved Private Hospitals are required to be confirmed by State Hospitals for deciding the line of treatment.

Although CGHS was primarily introduced for providing services to its beneficiaries against payments of contribution, with the passage of time and inadequacies of medical services to the Central Govt. employees in general, the CGHS has acquired the central position of all the healthcare measures. At present, medical attendance /treatment /reimbursement of medical expenses of Central Govt. employees regulated under CS (MA) Rules 1944 is linked with comprehensive healthcare measures adopted by the CGHS for its beneficiaries. In this connection, following OM of Govt. of India, Min. of Health & Family Welfare is referred to:

a) S-14012/9/75-MC (MS) dated 18.06.1982.

b) S-14025/7/2000-MS dated 28.03.2000 and

c) S-14021/06/2005-MS dated 04.01.2007

Thus, any measures adopted by the CGHS to ensure comprehensive healthcare to the beneficiaries of CGHS provides same health care to the Central Govt. employees in general, as well.

Further, any Scheme with an object of providing comprehensive healthcare is not possible and the desired result cannot be achieved unless the ratio of Medical Officers and Para-medical Personnel per beneficiary is assessed scientifically. Experience of the beneficiaries should be the last word while reviewing the performance of any Scheme. Central Govt. Health Scheme is contributory and the amount of contribution is fixed taking into consideration all the relevant factor of health services. Rate of Contribution is revised periodically.

 2. Empanelled Hospitals/Diagnostic Centres

2.1 Earlier with a view to ensuring comprehensive health care to CGHS beneficiaries, CGHS has been, apart from the Govt. Hospitals, empanelling private Hospitals & Diagnostic Centres by floating tender periodically. However, subsequent review revealed that the number of Hospitals and Diagnostic Centres notified in some cities through the Tender Process is not adequate to provide a satisfactory level of health care to CGHS beneficiaries in all areas in these Cities. Also, there has been no or little response in certain other cities with the result that a situation has arisen where CGHS is not in a position to provide to its beneficiaries the requisite healthcare due to lack of adequate number of Hospitals & Diagnostics Centres in different cities. To overcome the situation Continuous Empanelment Scheme was introduced with effect from December 2012 (G.O.I. Min. of H&F.W, Dept. of H&FW OM. No 8-11011/23/2009-CGHS D-II/Hospital Cell (Part IX) dated 8.12.2011)

2.1.1 Effect of the change

a) For example. For more than 60000 Card holders under CGHS, Kolkata, the number of private empanelled Hospital for General Purposes and Diagnostic Centres at present is 5 and 8 only, respectively. Compared to number of beneficiaries, number of such Hospital/Diagnostics Centre are not adequate. Locations are disadvantageous. Beneficiaries residing at suburban areas of main cities where CGHS Wellness Centres are located, have to travel a long distance to avail services at empanelled Hospitals/ Diagnostic Centres. Difficulties of the Pensioners need not be emphasised further. There is no separate arrangement for CGHS beneficiaries in the empanelled Govt. Hospitals which are normally over burdened with patients of the concerned State, both outdoor and Indoor. Although Pensioners are eligible for Cashless treatment from empanelled Hospital, recognised and approved Govt. Hospitals do not extend the said benefits. Empanelled Private Hospitals, contrary to the Memorandum of Agreement are taking unsympathetic position and even denying admission on specious plea of No Vacancy. Some of such Hospitals, taking advantage of ignorance of the beneficiaries or persons accompanying them at the time of admission are refusing admission on the ground of –there is no vacancy in the Beds earmarked for CGHS Beneficiaries!

b) Moreover, under the Scheme for Continuous Empanelment, the empanelled Hospitals /Diagnostic Centres enjoy inherent continuous privilege to come out of the Agreement any time that suit them. Beneficiaries who are either not accustomed to INTERNET or do not/cannot keep regular touch with the Wellness Centres face an embarrassing situation when informed that said institution is no more empanelled while availing services from empanelled Hospitals / Diagnostic Centres. In case of emergency, the concerned beneficiary is compelled to get the services of the said institution as an ordinary patient.  Barring an insignificant number of such institutions, CGHS beneficiaries are looked upon with contempt.

d) So far there is no any empanelled Hospital / Diagnostic Centres outside the main cities/towns. Thus, Central Govt. employees working in District Towns have to get treatment in hospitals recognized by the concerned State Govt. for its own employees. However, the name etc. of empanelled Hospital / Diagnostic Centre approved by the concerned State Govt. is not circulated amongst the employees by the Central Govt. As a result, the Central Govt. employees or their Controlling Authorities for Medical re- imbursement purpose have no information of Hospitals recognized by the local Govt. Pensioners residing in the District are neither covered under CS (MA) Rules nor they can avail the scope extended under CGHS, for obvious reasons. Incidentally, it is stated that when response of private Hospitals /Diagnostic Centres located in main cities where there is sizable concentration of Central Govt. employees, both serving and retired, is not encouraging, it may not be expected that for few hundred Central Govt. employees working and residing in District Towns, private operators will be interested to sign Memorandum of Agreement.

(Above submission is based upon the experience of CGHS, Kolkata. Experience of others cities covered under CGHS will be more or less same)

2.2 Suggestions:  

(i)               Object being ensuring comprehensive health care to CGHS beneficiaries directly and indirectly to the Central Govt. Employees covered under CS (MA) Rules, when response of private operators in Health Sector both under the Tender Process or on- going Scheme of Continuous Empanelment of Hospitals / Diagnostic Centre, the Govt. through its monitoring machinery may undertake periodical review of the position of response to ongoing Scheme. In case of inadequacies or if it is found out that response is not covering the entire areas of the particular cities / towns CGHS may  approve /recognise Hospitals and  Diagnostic Centres through bilateral agreement outside the ongoing process. Previously, Hospitals /Diagnostic Centres were approved and recognised by the CGHS. At the same time terms and conditions of empanelment of private hospitals, diagnostic centres may be reviewed as the same is primarily identified as main cause of poor response of private hospital and diagnostic centres either under Tender Process or Continuous Empanelment Process.

(ii)                  Strengthen and improve the CGHS own Laboratories to provide   basic diagnostic services. This may be done by adopting the following measures: (a) opening of more Dispensary level Laboratory. (b) introduction of cost-effective and technologically advanced instruments.

(iii)           Engagement of Medical Specialists in all branches of treatment and empowering them with the power to decide the line of treatment. Till such time CGHS engages its own Medical Specialists, the beneficiaries may be allowed to consult Specialists attached to empanelled Private Hospitals of his/her choice. In case more than one Specialist of more than one empanelled Hospitals advises same line of treatment the present system of consulting State Govt. Hospitals for deciding line of treatment may be dispensed with. This may also help State Hospitals to ease the burden.

(iv)           In the District towns where there is Central Govt. Office including Post Office, Area Welfare Officer shall empanel Private Hospital/ Diagnostic Centre on the analogy of empanelling of Regd. Medical Practitioner as Authorised Medical Attendant relaxing the provision of G.I.M.H. OM No. S-14021/18/2005-MS dated 5^th Nov. 2007.

3. Expansion of CGHS

3.1. The previous Govt. as a matter of policy declared that the Central Govt. has no proposal to extend CGHS due to severe resource constrains, especially acute shortage of qualified medical and para-medical professionals, besides financial and logistics constrain.

3.2. In the first part of submission it is stated that the Central Govt. employees of 10 States out of 29 States are not covered under CGHS. Further, after retirement from service, the Central Govt. employees of these States are forced to remain outside the contemplated comprehensive healthcare scheme of the Govt. of India. Although, the serving Central Govt. employees of these States may avail the facilities of CS (MA) Rules, the Pensioners are deprived of any health services.

3.3. Even in cities covered under CGHS, there are Central Govt. employees who have to remain outside the comprehensive healthcare scheme as their residence is outside the jurisdiction of existing Wellness Centres. They are under CS (MA) Rules.

3.4. All over the Country, urbanisation is going on. Central Govt employees are moving to those places for residential purposes. These areas are not under the jurisdiction of the existing Wellness Clinics. There are areas where even Authorised Medical Attendants have not been appointed.

3.5. Consequent on recent decision, the Postal employees have become eligible to be member of CGHS.

   The Central Govt. Employees residing in non-CGHS areas including 10 (ten) States which are not yet covered under CGHS can be categorized as (i) where no Authorized Medical Attendant has been appointed in a Suburban area and (ii) where Authorized Medical Attendant has been appointed. As per extant instructions such Govt. servant may consult AMA and being advised by the AMA may consult Specialists in a Govt. / Recognized Hospital in adjoining City. Further, Central Govt. employees and members of their family may be permitted to avail of medical facilities in any of the Central Govt. /State Govt. Hospitals and the Hospitals recognized by the State Govt./CGHS Rules/CS(MA) Rules (Ref: G.I. M.H OM F. No S-14025/7/2000-MS dated 4.1.2007.

Suggestion:

a)    Central Govt. employees residing in cities covered under CGHS and adjacent township areas which are, at present not within the jurisdiction of either of the existing Dispensaries may be given an option to be a member of the Scheme and got registered in a nearby Wellness Centre. As, under present dispensation, CGHS beneficiaries may consult any Dispensary even other than the Dispensary where he/she is registered, above section of Central Govt. employees may get proper coverage under CGHS without opening new dispensary. Residence clause may be relaxed, if necessary. (G.O.I, Min. of Health & Family Welfare Circular No Misc. 6024 /2007 /CGHS/ (HQ) CGHS (P) dated 17.12.2012)

4.1. It is universally accepted principle that any health care service cannot be comprehensive minus the personnel who are providing the same, managing the same from different position. What should be the basic norms of such health care? In the case of CGHS, norms were laid down in Govt. of India, Ministry of Finance, Department of Expenditure, Staff Inspection Unit’s letter to the Secretary, Min. of Health and Family Welfare no. 25/1/97-SIU dated 2.11.1999.

a)    Average Attendance: The single workload parameter determining the workload of a CGHS dispensary is the average daily attendance of patients which, in turn is related to factors namely: the number of card holders and the number of beneficiaries attached to the dispensaries. The CGHS generally projects the number of beneficiaries at the rate of 4 t0 5 beneficiaries per card.

b)    Per Unit Time- Doctors: Number of patients per day per doctor 75 patients. The administrative work at the level of dispensary-in-Charge takes about 3/4 hrs a day.

c)     Per Unit Time- Pharmacists: Number of patients per day per Pharmacists: 180 patients.

d)    Clerks: No of patients per clerk per day (a) for registration:270 and (b) for all items of work including registration:200

e)   Staff Nurses: One for each dispensary on functional basis

f)     Dresser/Female Attendant/Nursing Orderly/Peon: Total of 5 Group D Posts for each dispensary

g)    Sweeper: One for each dispensary

h)   Chowkidar: One for each dispensary

i)      Polyclinic Facilities: Where Poly-Clinic facility is available under the CGHS, cases for laboratory tests are required to be referred to such Poly-clinics.

j)       Patients Care: One of the most common complaints against the CGHS dispensaries is that the MOs do not pay adequate attention to the patients. In fact most of the beneficiaries reported that Doctors take only a minute or two for examination of the patients.

k)    Complement of staff for a new CGHS dispensary for a minimum  2000 card holders:

1.    Medical Officers                            2

2.    Pharmacists                                   2

3.    Clerk                                                1     

4.    Staff Nurse                                     1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

5.    Group D other than

Sweeper & Chowkidar                4 

6.    Sweeper                                        1

7.    Chowkidar                                    1

4. Conclusion:

4.1. While introducing Scheme of Continuous Empanelment of Hospitals /Diagnostic Centres replacing Tender Process it is stated that as the response was not encouraging so far as the object is concerned, CGHS replaced the periodical Tender Process by continuous empanelment with a view to ensuring comprehensive healthcare to CGHS beneficiaries. CGHS has been, apart from the Govt. Hospitals, empanelling private Hospitals/ Diagnostic Centres by floating tender periodically.

 The hardship caused to the patients due to delay in issuing medicines get further compounded when they get medicines which do not give the desired level of relief. The main reasons for the declining attendance at dispensaries are the casual manner of examination of patients, delay in dispensing medicines in time and the poor quality of medicines issued. These practices at the CGHS dispensaries are against the very right and interest of the beneficiaries. (Para 5.6 of Chapter V Report on the Staffing Norms for CGHS (Allopathic) Dispensaries)

Thus, mere bringing in some changes in the process of empanelling private hospital/diagnostic centre or empanelling more and more private hospitals etc., the desired objective of ensuring comprehensive health care to CGHS beneficiaries may not be achieved. Health care can only be comprehensive when it reaches the beneficiaries in all respect. Due to unscientific norms, the Medical Officers prefer to remain untouchable to the patients. Patients are deprived of the warm touch of the DOCTOR which has a psychological effect on treatment. The Medical Officers prescribe medicines with eyes fixed on computer on his table. His whole attention is divided between the patients and the computer. Further, due to acute shortage of Para-medical Staff in dispensary, the Medical Officers have to discharge duties of vacant posts. These factors are required to be addressed administratively to ensure comprehensive health care.

    As there will be considerable addition to the existing number of Beneficiaries due to extension of Scheme to all categories of Postal Employees including Pensioners and for allowing un-covered Central Govt. employees to enrol as beneficiaries two Shifts may be introduced. Personnel manning the Second Shift, number of such personnel being less than the General Shift for obvious reasons, grant of Split Duty Allowance on the line of existing instruction may be considered after suitable modification.(G.I M.F. OM. No. 9(11)/2008-E-II (B) dated 29.05.08) 

Some of the existing Wellness Centres may be relocated rationally keeping in view the extension of city limits and shifting of middle class people including Central Govt. employees both serving and retired in the areas outside the main city limits on economic grounds. 

Similarly Scheme of annual review of number of beneficiaries attending the Wellness Centres, programme of revision of territorial jurisdictions of Wellness Centres may be incorporated.

Medical Advance

The Heads of Department of Min. & Dept. are stationed at Delhi/New Delhi. The Central Govt. employees working in the offices located outside Delhi, New Delhi are deprived of the Medical Advances as the Application for grant of Advance can only be considered by the Heads of the Departments. In the process, the urgency of financial assistance in the form of Medical Advance is overlooked.

Desirability of empowering the Heads of Offices to grant Medical Advance following the provision of Rule 1 of Chapter 2 of Swamy’s Compilation of Medical Attendance Rules may be considered. According to above provision, the Heads of Offices were empowered to grant Medical Advances to Central Govt. employees.

Serving employees—Treatment obtained in emergency

Where in emergencies, treatment is obtained in Hospitals recognised under the CGHS or under CS (MA) Rules,1944 without following the prescribed procedure, the reimbursement may be allowed in full in accordance with the rates as approved under the CS (MA) Rules or under the CGHS. In case of empanelled private Hospital, a serving Central Govt. employee pay at the rate charged by the Hospital but get reimbursement at the lower rate. It is noticed that a serving CGHS beneficiary is discriminated against a beneficiary of CGHS entitled to cashless treatment from the same empanelled hospital. Rectification of this sort of discriminatory arrangement merits review and remedial measures recommended.     .

However, suggestions given above are not alternative to opening of more Wellness Centre, Poly Clinic, engaging more Medical Specialists covering all major areas of Treatment and rationalisation of functioning of CGHS, the only solution to achieve the object of ensuring comprehensive healthcare to the beneficiaries. Large number of retired Central Govt. employees not covered under the C S (MA) Rules or deprived of the Dispensary service as beneficiary of CGHS for the reasons narrated above are worst sufferers. They have to remain satisfied with Medical Allowance of Rs 300/- a month when even treatment of common ailment cost more than that. In most of the Wellness Clinic the sitting arrangement is insufficient forcing aged and physically challenged to wait for their turn in standing position, particularly at the peak hour. There is no arrangement of drinking water. Circulars etc are displayed in a routine manner without taking into account the   inconveniences of the aged beneficiaries. To avail the facilities of the empanelled hospitals/diagnostic centres, they have to travel a long distance from residence, at their cost. For example, for the beneficiaries attached to 3 Wellness Centres located in the Salt Lake area of Kolkata, there is only one private empanelled Diagnostic Centre for routine pathological test. All empanelled Govt Hospitals are located at places which are more than 8/10 km away from Salt Lake and other adjacent areas of Kolkata. Considering their age, natural infirmities to move independently, the problems of ex-employees need to be addressed humanely. Ex- employees residing at vast areas not covered under CGHS, should have an opportunity to opt for medical benefits under C S (MA) Rules or Medical Allowance. C S (MA) Rules may be amended/ modified accordingly.