REVIEW OF THE ECHS

REPORT ON PERIPATETIC CHECK AND REVIEW OF THE

ECHS

MAY- AUG 2008

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INDEX

VOLUME – I CHAPTER TITLE PAGE NO. CHAPTER I INTRODUCTION AND

BACKGROUND OF REVIEW

CHAPTER II ADM & FUND MANAGEMENT CHAPTER III MEDICAL COVER CHAPTER IV GENERAL RECOMMENDATIONS

AND CONCLUSION

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CHAPTER – I

INTRODUCTION AND

BACKGROUND OF REVIEW

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CHAPTER I - INTRODUCTION AND BACKGROUND OF REVIEW

Introduction 1. The Ex-Servicemen Contributory Health Scheme (ECHS) is a tri-Service Scheme sanctioned by the Government of India vide 22(1)/01/US(WE)/D(Res) dated 30 Dec 2002 (Appendix A) as a project organisation. The Scheme was implemented with effect from 01 Apr 03 and has completed five years since inception. 2. The Government has sanctioned 227 Polyclinics (106 Military and 121 Non-Military), 13 Regional Centres and a Central Organisation for implementation of the Scheme. The Scheme is being managed within the existing Command & Control infrastructure, existing medical setup under DGAFMS and existing infrastructure at the Station HQ besides the sanctioned Polyclinics, Regional Centres and Central Organisation. Background of Peripatetic Check 3. The financial powers stipulated vide GOI letter No. A/89591/FP-1/693 /2002(D(GS-I) dated 22 Apr 02 delegated to Army authorities as amended from time to time and equivalent powers in the Navy and Air Force were made applicable for ECHS. Additionally, financial powers were delegated to ECHS as new Organisations such as Regional Centres and Central Organisation were formed. Also, additional powers considering the peculiarity of the Scheme were also delegated to ECHS. The financial powers to ECHS was delegated vide GOI MoD letter No. 24(3)/03/US(WE) /D(Res) (i) dated 08 Sep 03 (Appendix B) and the financial procedures for ECHS expenditure was issued vide GOI MoD letter No. 24(3)/03/US(WE)/D (Res) (ii) dated 09 Sep 03 (Appendix C). 4. The financial powers of the Army authorities and equivalent powers in Navy and Air Force had been revised in May/ Jun 06 but the ECHS powers could not be revised. A case for revision of ECHS financial powers was forwarded to MoD after the approval of CGDA and Pr. IFA in Jul 2007 and is pending since then. The Government had stipulated that, “A peripatetic check of the mode and operation of the exercise of the delegated financial powers for the ECHS will be carried out by a team of officers from DG DC&W, MoD and MoD (Finance) once in two years or as and when required”.

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5. Regarding ECHS financial procedures, the Government had stipulated that, “A peripatetic check / review of the operation of these financial procedures for the ECHS at various ECHS stations as well as the Central Organisation and Regional Centres will be carried out by DG DC&W in consultation with CGDA once in two years or as and when required and the findings of such check / review will be communicated to MoD and MoD (Finance)”. However, no peripatetic check either for the review of ECHS financial powers or procedures could be carried as per stipulated guidelines. Constitution of Team 6. The Secretary (ESW) / MoD directed on 15 Feb 08 to constitute a team for the peripatetic check and review of the ECHS financial powers and procedures to include the following in the team:- (a) Dy MD ECHS - Presiding Officer

(b) MoD Representatives.

(c) Def (Fin) Representatives.

(d) CGDA Representatives.

(e) DG DC&W Representatives. 7. Accordingly, the following team was constituted:- (a) Presiding Officer -Brig Satish Malik Dy MD ECHS

(b) CGDA Reps -Shri Sanjeev Mittal IFA P-75 Shri Kanwaldeep Singh IDAS Dy CGDA (AT)

(c) MoD Reps -Shri MM Singh Deputy Secretary MoD Shri VK Jain Under Secretary MoD

(d) MoD (Fin) Rep -Shri KS Panchpal AFA (AG/PD) (e) DG DC&W Reps -Wg Cdr SK Agrawal, Jt Dir (P&FC) Lt Col AK Naik, Jt Dir (Med)

Note:- Shri Kanwaldeep Singh and Mr. VK Jain had not been available for the peripatetic checks as Shri Kanwaldeep Singh had not reported to Delhi

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on posting from Kochi till 3rd week of Jul 08 and Mr. VK Jain had been away on a course of instruction. The Scope of Peripatetic Check and Review

8. The financial procedures for ECHS vide GOI MoD letter No. 24(3)/03/ US(WE)/D(Res) (ii) dated 09 Sep 03 (Appendix C) stipulates that various procedures approved through separate Government letters will be followed such as procedures with respect to procurement of medicines, empanelment of civil hospitals, employment of contractual staff etc. 9. Accordingly, the scope for peripatetic check was stipulated as under:-

(a) Review of the GOI MoD letters No. 24(3)/03/US(WE)/D(Res)(i) dated 08 Sep 03 (Appendix B) on ECHS financial powers and 24(3)/03/US(WE)/D (Res) (ii) dated 09 Sep 03 (Appendix C) on ECHS financial procedures. (b) Examine all problem areas as brought out by the ECHS in the form of different proposals that are pending for the decisions of the MoD. (c) Examine all issues that the team may come across in the process of peripatetic check. (d) Make recommendations.

Programme for Peripatetic Check 10. Places of Visit. The constituted team deliberated at length on places to be visited for peripatetic check and the manner in which the checks should be carried out. It was decided that about 10% of the Polyclinics should be covered which should include all the zones of the country. Accordingly, a plan was prepared which included the period of visits and the places / formations to be visited. The plan is placed as Appendix ‘D’. 11. Guidelines for Check. A need was felt to identify all important areas related to functioning of the Scheme and accordingly, detailed guidelines / questionnaire for the conduct of the peripatetic check was prepared and is placed as Appendix ‘E’.

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Examination of ECHS Issues during Peripatetic Checks 12. All the 227 Polyclinics, 13 Regional Centres and the Central Organisation have been operationalised. The Polyclinics are functioning from the existing Government building in military stations and buildings constructed from ECHS funds or the hired buildings in non military areas. The existing infrastructure and resources have been utilised in operationalisation and functioning of the Polyclinics as the Scheme was sanctioned as an integral part of the three Services. 13. The peripatetic checks were carried as planned and each of the subjects brought out in Appendix E was examined in detail. Each of the issues listed in succeeding paras was examined in detail by the team and solutions to the problems observed in the process were deliberated at length by the team members. 14. The problem areas of ECHS can be classified into major and minor issues. While the minor issues relate to minor modification in procedures, the major issues comprise the following which were examined and appropriate recommendations have been made under relevant questions.

(a) Referral Policy and procedure for processing of hospital and individual bills.

(b) Inadequate authorisation of manpower for patient care. (c) Non-availability of scale of manpower for processing of medical claims leading to delay in payment to hospitals. (d) Inadequate delegation of financial powers on various issues especially for payment of medical bills. (e) Non-availability of medicines / delay in procurement of medicines including cancer medicines. (f) The authorised plinth area for Polyclinics does not commensurate the clientele load.

(g) Fees structure of the contractual staff.

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CHAPTER – II

ADMINISTRATION & FUND

MANAGEMENT

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CHAPTER II - ADMINISTRATION AND FUND MANAGEMENT

1. Question. Whether the Command & Control system of ECHS Polyclinics is functioning efficiently? 2. Brief. The existing Command & Control exercises the control on ECHS and has been utilised for the purpose of monitoring, exercise of financial powers, operationalisation and functioning of the Polyclinics. 3. Findings. The system is working efficiently. 4. Recommendations. It is recommended that the existing Command & Control system is appropriate and therefore may be allowed to continue. 5. Question. Whether Regional Centres are performing the tasks efficiently for which established? 6. Brief. 13 Regional Centres across the country have been authorised which exercise functional control over the Polyclinics within their region. The Regional Centres authorised and number of Polyclinics controlled by each one of them is given below:-

Regional Centre Number of Polyclinics

Regional Centre ECHS Chennai 22 Regional Centre ECHS Jaipur 22 Regional Centre ECHS Lucknow 27 Regional Centre ECHS Pune 38 Regional Centre ECHS Delhi Cantt 13 Regional Centre ECHS Chandimandir 21 Regional Centre ECHS Jammu 12 Regional Centre ECHS Patna 11 Regional Centre ECHS Kolkata 09 Regional Centre ECHS Jabalpur 15 Regional Centre ECHS Guwahati 09 Regional Centre ECHS Kochi (Navy) 11 Regional Centre ECHS Hyderabad (Air Force) 17

7. The Regional Centres function under the Command / Area / Sub Area with which they are co-located for administrative control and support and are responsible to Central Organisation for functioning of the Polyclinics within their region. The role of Regional Centres is placed at Appendix F.

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The Officers and PBORs authorised are posted against the offset vacancies of the three Services.

8. Findings. The current authorisation is satisfactory except for high pressure Regional Centres who may be provided additional contractual staff from the ‘Central Pool’ proposed in subsequent part of this report, considering their vast area of responsibility. The Regional Centres lack due authority for exercise of its functional control over the Polyclinics and also the Station HQ controlling the Polyclinics. Also, scope exists for improving its efficacy which can be improved by providing them additional resources.

9. Recommendation. It is recommended that the Regional Centres may be empowered more by the Central Organisation and the controlling Command HQ and provided additional contractual manpower and resources in effective discharge of its responsibilities.

10. Question. Whether the existing system for allocation of funds for management of ECHS is functioning satisfactorily?

11. Brief. The control of Polyclinics is through the existing Command & Control system. The technical control however, is exercised through the Regional Centres and Central Organisation. The funds are allotted by Central Organisation to Naval HQ, Air HQ and Army HQ Commands and are further sub allotted to 123 Station HQ handling ECHS funds through Command in the Army, Navy and Air Force. The existing financial powers delegated to the Army vide A/89591/FP-1/693/2002/D (GS-I) dated 22 Apr 02 as amended vide A/89591/FP-1/1974/2006/D(GS-I) dated 26 Jul 06 and equivalent powers delegated in Navy and Air Force are exercised for ECHS expenditure. Also, additional powers have been authorised to the newly formed formations on sanctioning of ECHS i.e. Regional Centres and Central Organisation.

12. Findings. The existing system of allocation of funds for management of ECHS is found satisfactory.

13. Recommendations. It is recommended that the existing system may be continued.

14. Question. Whether the Code Heads prescribed for ECHS expenditure are adequate and meet the functional requirement and whether sufficient budget have been provided to meet the expenditure in the preceding years?

15. Brief. The ECHS is budgeted under the Army Budget and funds are provided by the ADG FP to the Central Organisation, AG’s Branch, Army

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HQ. The Major Head for Capital budget is 4076 and Minor Head is 107 and for Revenue the Major Head is 2076 and Minor Head is 107. For ECHS receipts, the Major Head is 0076 and the Minor Head is 107. The receipts on account of Contribution from Membership are directly credited in the consolidated fund of India and are not available with ECHS for expenditure. 16. The Code Heads for ECHS Capital and Revenue expenditure and Receipts were issued vide Classification Hand Book Defence Services Receipt and Charges 1992 (Edition) No. 88/04 placed as Appendix ‘G’ and subsequently amended vide Classification Hand Book Defence Services Receipt and Charges 1992 (Edition) No. 116/2007 placed as Appendix ‘H’. 17. The major part of expenditure in ECHS is incurred through the Cash Assignment System subject to post audit and also by the Regional CsDA subject of pre-audit. However, the expenditure incurred for purchase of medicines by the DG AFMS and the SEMOs are subject to pre-audit and payment by Regional CsDA. 18. The data on monthly expenditure incurred by the spending agencies are compiled under the chain of Command and forwarded to Central Organisation for final compilation and submission to ADG FP. All periodical budgetary reports and returns are also prepared in similar manner. The post audit and booking of expenditure is carried out by the Regional CsDA after the accounts are received by them in the month following the expenditure. 19. Findings. The fund allotments and expenditure by the ECHS in the preceding three financial years in Revenue and Capital in broad expenditure categories are as under:- REVENUE

(Rs. in Cr)

Expenditure Category

Financial Year 2005-06 2006-07 2007-08

Allotment Expdr Allotment Expdr Allotment Expdr Salaries 16.35 15.80 23.39 23.51 25.91 26.08 Medicines 48.23 47.53 104.99 104.13 185.69 181.16 Medical Treatment 117.29 113.54 188.49 187.18 263.11 260.85 Others (IT, other stores, Misc etc)

06.19 04.91 07.27 05.98 15.20 14.12

Total 188.18 181.78 324.14 320.80 489.91 482.21

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CAPITAL (Rs. in Cr)

Expenditure Category

Financial Year 2005-06 2006-07 2007-08

Allotment Expdr Allotment Expdr Allotment Expdr Land 0.07 0.00 0.20 0.07 0.10 0.64 Construction 7.78 4.91 7.00 4.77 05.00 5.86 Medical Equipment 13.50 11.90 16.00 15.38 03.00 3.15 Total 21.35 16.81 23.20 20.22 08.10 9.65

20. The receipts on account of contribution in the preceding three years are as follows:-

(Rs. in Cr)

Financial Year

2005-06 2006-07 2007-08 Receipts 54.80 50.42 58.46

21. There is a delay in booking of expenditure by about one to two months for payments made through cash assignment due to post audit system. A policy for provisional booking by Regional CsDA has been introduced with effect from 13 Sep 07 wherein the Station HQ forward actual cash outgo data before the close of the month to the Regional CsDA for booking in the same month in which the expenditure is incurred. The provisional booking becomes final booking after the accounts are received and audited by the Regional CsDA. The system however has not settled down as yet. 22. The fund provided to ECHS in Revenue in the financial year 2008-09 amounts to Rs. 600.14 Cr and in Capital Rs. 60 Cr. It was found that the funds have been provided to ECHS as per the demand in the past and was sufficient to the requirement. The expenditure on purchase of medicines and medical treatment constitutes about 90 % of the total annual budget estimates. 23. It has also been observed that there is substantial increase in annual ECHS budget due to growth in membership / beneficiaries and it is expected that the fund requirement will continue to grow with membership. As against 60 Lakhs estimated eligible beneficiaries, 21 Lakh beneficiaries have joined the Scheme as on 31 Mar 2008 and about 60,000 annual retirees besides old eligible members would continue to join the Scheme in future. The progressive membership / beneficiaries data since inception of

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the Scheme is given below:-

Members as on Members (AFV) Total Beneficiaries 31 Mar 04 838 2933 31 Mar 05 78,999 3,63,261 31 Mar 06 2,60,876 9,82,654 31 Mar 07 3,39,875 14,22,464 31 Mar 08 6,33,596 21,02,891

24. The Code Heads provided to ECHS are adequate to meet the functional requirement. 25. Recommendations. The Code Heads provided are adequate and therefore may be allowed to continue. All out efforts should be made by the Station HQ and the Regional CsDA to put in place the system of provisional booking. Also, fund requirements as per growth in membership must be provided for smooth functioning of the Scheme. 26. Question. Whether the cash assignment system by Station HQ is functioning satisfactorily? 27. Brief. The expenditure on account of medical treatment, payment of contractual fees to Polyclinic staff and other office expenditure are affected through the Cash Assignment system. The procedure for release of cash assignment was stipulated by Central Organisation on concurrence by the CGDA vide B/49791/AG/ECHS dated 23 Jan 04 (Appendix J). Due to problems faced on release of cash assignment, the procedure was amended in consultation with the CGDA vide B/49797/AG/ECHS dated 13 Sep 07 (Appendix K). The requisition of cash assignment by stations to CDA was changed from monthly to quarterly and provisional booking was introduced. 28. The payment vouchers / accounts are forwarded to the Regional CsDA in the month following the expenditure for audit and booking. In order to monitor timely submission of accounts by the Station HQ and booking by the Regional CsDA, Central Organisation has devised a return in which the date of forwarding of accounts are compiled by the Regional Centres and forwarded to Central Organisation. 29. Findings. With the implementation of the revised Cash Assignment procedure, no major problems have been projected by the Station HQ. However, minor problems of inadequate / untimely release of cash

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assignment were experienced in respect of a few CsDA. The revised policy on procedure of release of cash assignment is considered appropriate. 30. Recommendations. The CGDA may resolve the minor problem by issue of appropriate directions to the Regional CsDA. 31. Question. Whether the financial procedures stipulated vide MoD letter No. 24(03)/03/US(WE)/D(Res) (ii) dated 09 Sep 03 is satisfactory from user as well as audit point of view? 32. Brief. The financial procedure for ECHS was issued vide GOI MoD letter No. 24(03)/03/US(WE)/D(Res) (ii) dated 09 Sep 03 (Appendix C) which was mostly based on the existing procedure of procurement wherein by and large the existing procurement agencies were tasked to make ECHS procurements such as procurement of medicines, payment of rental charges, procurement of medical equipment, procurement of land, construction of buildings, procurement of non-medical equipment like generators and vehicles. 33. Financial procedures issued vide 09 Sep 03 letter broadly includes the following:-

(a) General financial procedures for ECHS. (b) Financial management at Station HQ (c) Financial management at Polyclinics (d) Capital Expenditure (e) Revenue Expenditure (f) Allocation of funds and authority for financial powers.

34. Findings. The procedures outlined though found to be satisfactory by and large, a few areas needed clarity and modifications which are enumerated in succeeding paras alongwith recommendations for each issue. 35. Petty Cash by OIC Polyclinic. The petty cash authorised in Part-III of GOI MoD letter dated 09 Sep 03 (Appendix C) stipulates Rs. 1000/- as financial power of Officer IC Polyclinic with the following annual financial

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authorisation:-

Ser No

Stations Petty Expenditure (Annual)

1 Military Stations (a) Type A & B Rs 15,000/- (c) Type C & D Rs 10,000/-

2 Non Military Stations (a) Type A & B Rs 30,000/- (b) Type C & D Rs 20,000/-

36. Recommendation. For effective management of the Polyclinics in Military and Non-Military Stations, the financial power of OIC Polyclinic requires enhancement to Rs. 3000/- per transaction and the annual financial ceiling needs to be raised as follows considering the price escalation of the market and need of polyclinics:-

Polyclinics Petty Expenditure (Annual) Type A & B Rs 40,000/- Type C & D Rs 30,000/-

37. Hiring of CHT for Central Organisation, Regional Centres and Staff Officers ECHS. The Officers and PBORs of Central Organisation and Regional Centres besides Officers at the Station HQ discharging ECHS duties are posted against the offset vacancies of the three Services and their pay and allowances besides TA/DA and other entitlements are met through the existing budget of the three Services. Accordingly, it was found that CHT is being hired or service transport provided by the respective Services for ECHS requirements of Officers / PBORs of Central Organisation, Regional Centres and Station HQ. 38. Recommendation. The revised Govt letter on financial procedure needs to clearly mention the above provision to avoid ambiguity and ensure better management of the Scheme at all levels. 39. TA/DA on Temporary Move of Polyclinic Staff. The current policy stipulates that when a Polyclinic staff is detailed by Stn HQ for visit to any other Station for official work, the TA/DA will be applicable in accordance with the entitlement of service personnel of equivalent pay scale in the armed forces. A need has been felt to clearly specify the TA entitlements of Ex-Servicemen contractual staff and staff who are not Ex-Servicemen.

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40. Recommendations. The following TA entitlements of Polyclinic staff are recommended:-

(a) Officers - AC-II Tier / AC Deluxe Bus (b) Para- Medical staff - AC-III Tier / AC Bus (c) Non-Medical staff - Sleeper class / Ordinary Bus

41. Daily Allowance may be made applicable in accordance with the pay scales stipulated in Travelling Regulations (TR) for the armed forces. 42. Procurement of Furniture & Air Conditioners. The scale of Furnitures and Airconditioners for Polyclinics has been stipulated separately by the Govt. The procurement procedure is through the MES. It was observed that acquisition of Furnitures and Airconditioners and their maintenance through MES in Non-military areas have been difficult and also expensive. 43. Recommendations. It is recommended that furniture and Airconditioners be procured and maintained from the open market as the same is also permitted in the Armed Forces for procurement through office contingency Code Head. This will increase efficiency due to speedy acquisition and will also be more cost-effective. 44. Advertisements through Newspapers. Considering the difficulties faced by the Station HQ in placing of advertisements in the print media for ECHS requirements through DAVP and also the change in the DAVP policy allowing placing of advertisement directly with the newspaper agencies, the Govt permitted direct placement of advertisement with the newspaper vide GOI MoD letter No 22D(04)/08/US(WE)/D(Res) dated 15 Apr 2008 (Appendix L). Though the permission brought relief to the Scheme, it was observed that the existing financial powers on publicity issued vide GOI MoD letter dated 08 Sep 03 (Appendix B) would require enhancement. It is pertinent to mention that financial powers are not required for placing advertisements through the DAVP as per Schedule XXII of GOI MoD letter No. A/89591/FP-1/1974/2006/D(GS-I) dated 26 Jul 06 (Extract at Appendix M). 45. Recommendations. Since expenditure on advertisements forms integral part of Misc Code Head 366/00 of ECHS, it is recommended that

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financial powers be authorised as follows:-

Authority Financial limits for each insertion per Newspaper

Stn Cdr Schedule I of Govt of India letter No. A/89591/ FP-1/1974/2006/D(GS-I) dated 26 Jul 06, as amended from time to time.

Dir, Regional Centre As per powers delegated for Misc & Contingency expenditure.

MD ECHS DG DC&W AG

46. Insurance of Vehicles and Ambulances. As per Para 31 of Part -VI of GOI MoD letter No. 09 Sep 03 (Appendix C), insurance of ambulances and vehicles are to be made by cheque by Station Cdr. ECHS vehicles and ambulances are Govt vehicles with BA numbers from the Army and therefore are not required to be insured as per the Govt rules. 47. Recommendation. The revised Govt letter on financial procedures should be amended and insurance of vehicles be discontinued in order to save public money. 48. Revenue Works. The Govt has authorised construction of ECHS Polyclinics, maintenance of buildings, payment of property tax and water & electricity charges as per GOI MoD letter No. 22(1)/01/US(WE)/D(Res) dated 30 Dec 2002 (Appendix A). The construction of Polyclinic is authorised from the Capital budget and expenditure on maintenance of buildings, payment of property tax and water & electricity charges from the Revenue budget. The buildings are constructed by the MES and are taken over by the Station HQ. 49. Due to insufficiency of the authorised space in ECHS, additional works at a few places have been carried out from regular allotments (not ECHS) of Army, Navy and Air Force. Also, expenditure on external services is being catered through the regular works fund. Expansion of the Polyclinic buildings may be required in future considering the growth in patient load. 50. Recommendations. It is recommended that expenditure on one time construction of Polyclinics be made out of ECHS Capital budget. Also, the expenditure towards water and electricity charges in Non-military Stations should be made out of ECHS revenue budget considering the administrative inconvenience in timely payment of bills. The expenditure towards further

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enhancements in the buildings and maintenance be however, catered through the regular funds of the Services for administrative convenience. The buildings are as such constructed by the MES and taken over by Stn Cdrs as per the Defence Works Procedure (DWP). 51. General Observations. It was observed that the existing GOI letter dated 09 Sep 03 (Appendix C) has discrepancies at various places. For example in Part-VII, in the column, authority of financial powers for revenue works for expenditure on hiring of buildings, property tax, water & electricity charges and maintenance of buildings, the financial powers quoted is GOI MoD letter No. 24(3)/03/US(WE)/D(Res) (i) dated 08 Sep 03 (Appendix B) whereas the quoted letter does not indicate any such powers. 52. Recommendations. The revised procedure should be so re-structured and drafted that the procedure for expenditure with respect to Polyclinics, Regional Centres and Central Organisation are clearly indicated along with the procedure for allocation of funds and the authority to exercise the financial powers for all types of Revenue and Capital expenditure. Due care should be exercised to avoid discrepancies. Ambiguity should be avoided. 53. Question. Whether the stipulated manner of exercising financial powers for each item of expenditure is being followed? Examine the basis for delegation of existing financial powers vide GOI MoD letter No. 24(03)/03/US(WE)/D(Res) (i) dated 08 Sep 03 and establish problems, if any, faced due to its insufficiency? 54. Brief. The conditions for exercise of financial powers in ECHS are the same as being followed in the Services except for payment to civil empanelled facilities which is guided by a separate Govt letter issued for the purpose. The stipulated manner of exercising financial powers without consultation and in consultation with the IFAs at various levels was examined and found satisfactory. 55. The ECHS being an integrated Scheme of the Services, the financial powers delegated to the Army authorities vide GOI MoD letter No. A/89591 /FP-I /693 / 2002 / D (GS-I) dated 22 Apr 02 as amended vide GOI MoD letter No. A/89591/FP-1/1974 /2006/D(GS-I) dated 26 Jul 06 and equivalent powers in Navy and Air Force is applicable as also the existing Command & Control system is to administer the Scheme. The ECHS was also delegated additional powers with the creation of new ECHS formations i.e. the Regional Centres and the Central Organisation. The financial powers to ECHS authorities was delegated vide GOI MoD letter No.

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24(03)/03/US(WE)/D(Res) (i) dated 08 Sep 03 (Appendix B). The powers delegated vide 08 Sep 03 letter was stipulated considering the powers delegated in the rank structure to the Army authorities. As per the hierarchy of ECHS, the financial powers of MD ECHS was equated with GOC Div, DG DC&W with Corps Commander and AG with GOC-in-C and the financial powers of Regional Director was equated with the powers of head of the establishment of the rank of Colonel. 56. The financial powers for medical re-imbursement is a new area of expenditure for the Army and therefore the proposed enhancement is based on the practical difficulties faced in the preceding years. The proposed enhancement is expected to reduce the delay in payment to civil empanelled facilities which will also require contractual manpower at the lower levels. 57. Findings. The financial powers to the Army authorities stipulated vide GOI MoD letter No. A/89591/FP-I/693/2002/D (GS-I) dated 22 Apr 02 has been amended vide GOI MoD letter No. A/89591/FP-1/1974 /2006/D(GS-I) dated 26 Jul 06. The ECHS also felt the need for enhancement of financial powers and proposed enhancements to the MoD on the similar lines as per the norms followed in the past. Case File No. B/49782/1/AG/ECHS was forwarded to the MoD on 25 Jul 07 after obtaining concurrence of the Pr. IFA / CGDA. The proposed enhancement is placed at Appendix N. The proposal is considered just and reasonable. It is learnt that the proposal is under active consideration by MoD / Def (Fin) and is likely to be approved shortly. 58. Recommendation. It is recommended that the proposal for enhancement in financial powers delegated to ECHS functionaries forwarded vide Central Org case file No. B/49782/1/AG/ECHS dated 25 Jul 07 should be approved by the Govt expeditiously. 59. Question. Whether the required auditable documents are being maintained and audited by Regional CsDA and LAOs regularly and whether the system of post audit of payments effective? 60. Brief. The audit procedure in ECHS has been stipulated in Paras 19 to 21 of the Part-I of GOI MoD letter dated 09 Sep 03 (Appendix C). 61. Findings. The required documents are being maintained as specified and post-audit is being carried out as per the stipulated periodicity by the LAOs/ RAOs of the Regional / Navy / Air Force PCsDA/ CsDA under whose

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geographical jurisdiction the Polyclinic falls. The objections are being raised and attended to by the concerned authorities. 62. Recommendation. The present system of post-audit is effective and is recommended for further continuation. 63. Question. Whether the procedure for hiring buildings for ECHS Polyclinics in Non-Military Stations stipulated vide GOI MoD letter No. 24(5)/03/US(WE)/D(Res) dated 08 Sep 03 is satisfactory? 64. Brief. The procedure for hiring of building for Polyclinics in Non-military Stations have been stipulated vide GOI MoD letter No. 24(5)/03/US(WE)/D(Res) dated 08 Sep 03 (Appendix O) and the limits for powers of hiring of immovable properties for ECHS Policlinics at Non-Military Station have been issued vide GOI MoD letter No. 24(15)/03/US(WE)/D(Res) dated 20 Feb 04 (Appendix P). 65. Findings. The procedure stipulated vide letter dated 08 Sep 03 has been implemented and no problems have been faced by the Scheme. The special powers delegated for hiring of ECHS Polyclinics at Non-Military Stations stipulates that the powers will be applicable for the period of two years or till the new Polyclinics have been constructed in the Station (which ever is earlier). Consequently, the time limit for exercise of the powers has been extended thrice and is now valid upto 31 Mar 2011, depending upon the status of construction of new Polyclinics. 66. The maximum delegated special power to GOC-in-C is Rs. 2.00 Lakhs per annum and the minimum is Rs. 0.75 Lakhs per annum to Commander of a Bde, Bde Area or Sub Area. Presently, no problems have been faced on the adequacy of the power delegated. 67. Recommendation. The existing procedure and the financial powers may be allowed to continue. 68. Question. Whether the system provided for payment of contractual fees to the Polyclinic staff / service provider is effective and procedure for tax deduction at source and deduction with respect to current Labour laws from contractual fees exist and is functioning satisfactory? 69. Brief. The procedure for payment of contractual staff has been enumerated in Paras 2 to 8 of Part-VI of GOI letter dated 09 Sep 03 (Appendix C). While no problems are faced towards disbursement of

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remuneration to contracted staff, the procedure does not cater to procedure for tax deduction at source and actions to be taken for compliance of various labour laws by the Drawing and Disbursing Officers (DDOs). 70. Findings. No tax has been recovered at source and deductions made towards compliance of labour laws from the contractual fees paid to the Polyclinic staff by the DDOs till date. A case file has been forwarded by Central Organisation to the MoD vide B/49793-TDS/AG/ECHS dated 25 Mar 08 for consideration and involvement of the CGDA in resolving the issue. 71. Recommendation. The task of tax deduction at source and compliance of labour laws does not appear feasible by ECHS due to non authorisation of trained manpower for the purpose. If the task is performed by employing and training contractual staff or by employing tax consultants at 227 Polyclinics, the proposal may not be cost effective. Since the task of providing accounting services to the Army is carried out by the Defence Accounts Department, a procedure may be evolved by the CGDA in which the Defence Accounts Department perform the task of the DDOs and carry out the required actions for tax deduction at source and compliance of labour laws, if applicable. 72. Question. Whether the staff employed contractually by the ECHS vide GOI MoD letter No. 24(6)/03/US(WE)/D(Res) dated 22 Sep 03 is adequate? 73. Brief. The procedure for employment of contractual staff / service provider for Polyclinics was issued vide GOI MoD letter No. 24(6)/03/US(WE)/D(Res) dated 22 Sep 03 (Appendix Q). The reservations for ESM, QRs and monthly contractual fees were also stipulated in the same letter. 74. The authorisation of various types of Polyclinics is based on the anticipated patient load are as follows:-

Type Population of eligible ESM A > 20000 B 10000- 20000 C 5000-10000 D 2500-5000

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75. The four types have been further classified into military and non-military. With the premise that military support (Military Stations and Hospitals) will be provided to the Polyclinics in military Stations, the authorisation of manpower has been less to military Polyclinics as compared to the non-military Polyclinics. The authorisation of Polyclinics is as follows:-

Type Mil Non-Mil Total

A 10 08 18 B 17 20 37 C 28 42 70 D 51 51 102

Total 106 121 227 76. The authorisation of manpower for patient care at Polyclinics is as follows:-

Details Type A & B Type C & D

Mil Non-Mil Mil Non-Mil

Medical Officer 02 02 01 02

Medical Specialist 01 02 - 01

Dental Officer 01 02 01 01

OIC (Non Medical) 01 01 01 01

Gynaecologist - 01 - -

Nursing Asst/Nurse 03 03 01 02

Lab Asst 02 02 01 01

Dental Hygienist 01 01 - -

Receptionist - 01 - -

Driver 01 03 01 01

Peon 01 01 01 01

Safaiwala 01 01 01 01

Female Attendant 01 01 01 01

Total 15 21 09 12

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77. Findings. It was observed that the criteria of ESM concentration for deriving types of Polyclinics and the authorisation of manpower accordingly has not been realistic as the load of two similar types of Polyclinics is not the same. Even the authorised manpower which is the maximum at Type ‘A’ Polyclinics at various locations is not adequate. Dehradun, Amritsar, Chandigarh, Delhi are a few examples. The load is also related to the availability of Service and civil medical infrastructure in a Station. Considering this factor, large numbers of referrals to these Stations are being made which increases the work load. These places can be classified as high pressure Stations. It appears difficult to stipulate the type of Polyclinics vis-à-vis the authorisation of manpower for a Station as the situation is dynamic and the workload is continuously increasing with the increasing membership. It is further mentioned that on an average, every member has about 2.5 dependents which increases the dependency on the Polyclinics by 250 %. It is considered that the type of Polyclinics authorised should have been based on the total clientele load including dependents and outside referrals. 78. The morbidity data depicting the increase in workload of the Scheme and the trend of referrals to Service and civil empanelled facilities is given below:-

Year Total no. of Patients Seen

Patients referred to Service Hospitals

Patients referred to empanelled facilities

No. % No. % 2003-04 60,298 6253 10.37 2979 4.94 2004-05 7,18,907 1,10,320 15.34 29,672 4.12 2005-06 13,81,979 1,91,200 13.83 74,024 5.35 2006-07 32,29,544 2,06,370 6.39 1,84,603 5.71 2007-08 48,23,766 2,39,453 4.97 2,80,821 5.82

79. It is estimated that the referrals to civil empanelled facilities in the coming years will continue to grow substantially as the facilities in Service hospitals are fixed and limited. Major expenditure of the Scheme is towards the referral to civil empanelled facilities. About 54.09 % (Rs. 260.85 Cr) of the ECHS budget of FY 2007-08 was expended only towards civil empanelled facilities and 37.57 % (Rs181.16 Cr) towards procurement of drugs and consumables, making a total of 91.66 % (Rs. 442.01 Cr) of the total budget.

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80. It has been felt that efforts should be made to control the growing expenditure on civil empanelled facilities and procurement of drugs. To control the rising ECHS expenditure, the following are recommended:-

(a) Create infrastructure and institute measures for closer scrutiny of the hospital and individual medical bills by authorising manpower for processing of medical claims.

(b) Reduce referrals to civil empanelled facilities by augmenting Polyclinic / Service Hospital facilities by providing specialist cover within the authorised medical equipment.

(c) Improve the system of drugs procurement and management by improving the policy for drugs procurement by DG AFMS and Polyclinics and by authorising contractual manpower for better drugs management.

81. There are about 26 high pressure Stations managing 77 Polyclinics (Appendix R) where the referrals are maximum leading to heavy expenditure on medical treatment and drugs. The numbers of such Stations/Polyclinics is likely to increase by about 10 % annually as the dependency on the Scheme grows. Major portion of ECHS budget is being expended at these high pressure Stations on medical treatment, drugs and consumables. Thus, there is a need to improve the quality of checks in the processing of medical bills and other expenses to achieve savings. In sample check of bills at a few Stations, it was found that the bills from civil hospitals are being inflated and in large number of cases the inflated amounts are being disallowed while processing such claims by the ECHS. While care is being exercised to properly scrutinise the bills to the extent possible within the available manpower at the Polyclinics, Station HQ and Service Hospitals, it is felt that scope still exists for strengthening the scrutiny which can be possible by strengthening the system by authorising manpower for the purpose. It is estimated that the savings achieved on improved scrutiny will be much higher and will easily set off the cost of additional manpower, if authorised. This measure will also strengthen the Scheme and discourage hospitals from unnecessary inflation of the bills in future as well. Authorisation of contractual manpower(MO and clerical staff) to SEMO, especially at high pressure stations will result into better scrutiny of bills and drug management.

82. It is essential that the high pressure Stations have to be treated differently as compared to others. In case specialists cover is increased at the required Polyclinics and Service Hospitals, the cost of referral to civil empanelled facilities will drop sizably. Thus, there is a need to augment

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specialist facilities within the scaled medical equipment at the Polyclinics and the Service hospitals at high pressure Stations. The flexibility should be given to Central Organisation ECHS to decide the type of specialist and their location of augmentation in order to achieve best output and value for money. 83. Presently, there is no authorisation of manpower towards the heavy ECHS workload of Station HQ and SEMO. Even Officers and PBORs posted at Central Organisation and Regional Centres are against offset vacancies of the three Services who are finding difficult to cope with the growing ECHS workload. Considering the present workload at all levels, there is a need to augment the system with contractual manpower for accounting and other clerical jobs.

84. As of now, the accounting and clerical task is being handled by employing manpower from the welfare funds of the Army, Navy and Air Force. Additional manpower for medical care considering the growing load has also been employed. About Rs. 1.40 Cr per annum is being spent from the AG’s welfare fund and almost the similar amount is being expended from various Command and Station welfare funds. The staff employed is grossly inadequate and are being paid nominal salary which compels them to leave the job within short periods. In other words, the arrangement is totally adhoc and undesirable. In order to make the Scheme effective and viable in the long run, there exists a requirement of meeting this expenditure from public fund by employment of contractual manpower at a reasonable remuneration.

85. The flexibility to the Scheme has been provided by allowing MD ECHS to shift the vacancies as per situation on ground for maximum utility of the authorised contractual manpower. The orders to this effect was issued GOI MoD letter No. 22(84)/06/US(WE)/D (Res) dated 27 Jun 07 (Appendix S). Issuance of such an order means that the total sanctioned contractual manpower for Polyclinics have been placed under a “Central Pool” which can be shifted from one place to another considering the changing workload of the Polyclinics. This is a welcome step towards addressing ECHS problems. The total authorisation of contractual manpower in various categories is as under:-

Sl No. Staff Auth 1 OIC + Med Officers 1061 2 Para Medical Staff 767 3 Non Medical Staff 992

Total 2820

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86. In the opinion of the team, the “Central Pool” may be augmented with the following contractual manpower who would be employed under the existing procedure:-

(a) 227 Accounts / GD Clerk @ 01 Clerk per Polyclinic

(b) 123 Accounts / GD Clerk @ 01 Clerk per Station HQ

(c) 100 Medical Officers (14 for drug management)

(d) 35 Specialist, as required to meet the growing requirement. (e) 43 Pharmacist / SKT (f) 37 Clerks For drugs Management (g) 19 Peons / Amb Asst

87. It is estimated that authorisation of the proposed additional manpower to ECHS in the Central Pool under the control of Central Organisation will provide ECHS the flexibility to meet growing workload for the next five years at least. The Central Organisation will have the discretion to employ the above mentioned contractual vacancies at the Polyclinics, Station HQ, Service Hospital, Regional Centres and Central Organisation as per the changing workload. The situation can be reviewed after five years in order to ascertain changes.

88. It is anticipated that atleast 10% of savings will be achieved on medical treatment and procurement of drugs amounting to Rs. 53.10 Cr as the annual sanctioned budget on Treatment and Medicines in the current financial year 2008-09 is Rs 531 Cr. The savings will further grow with the increase in budget in the forthcoming years. The cost of the proposed manpower will be as follows:- Vacancies Proposed

Monthly Remuneration

Total Annual cost

227 Accounts / Clerk @ per Polyclinic

8,000 2,17,92,000

123 Accounts / Clerk @ per Station HQ

8,000 1,18,08,000

100 Med Offrs (MBBS) 25,000 3,00,00,000 35 Specialists (in required speciality)

40,000 1,68,00,000

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43 Pharmacist / SKT 10,000 51,60,000 37 Clerks for drug management

8,000 35,52,000

19 Peons / Amb Asst 6,500 14,82,000

Total 9,05,94,000 (Say Rs. 9.06 Cr)

Note:- The initial fixation of contractual fees for the newly proposed Accounts Clerks / GD Clerks is Rs. 8,000/- per month. Proposed monthly remuneration for MOs and Med Splst is explained in the Para 98 below pertaining to enhancement in contractual fees.

89. A case file for authorisation of additional para-medical and non-medical manpower was initiated by Central Organisation vide B/49760/AG/ECHS dated 02 Sep 05 in order to achieve proper utilisation of the authorised equipment for which the manpower was not originally sanctioned. This will also arrest the referrals to civil empanelled facilities besides improving the services of the Polyclinics. Non utilisation of these equipment and referral to civil empanelled facilities inspite of availability of equipment at polyclinics may be objectionable and therefore needs consideration. The proposal for authorisation of Chowkidars in Non-military Polyclinics and additional Receptionists also would need to be addressed in due course as the non military polyclinics get constructed. 90. With the inclusion of cost of 732 additional para-medical staff proposed as referred above, the total cost at the proposed remuneration will be as follows:-

Vacancies Proposed Monthly Remuneration

Total Annual cost

732 Para Medical Staff 10,000 8,78,40,000 Total (Say Rs. 8.78 Cr)

91. The total savings achieved against an improved infrastructure and medicare is estimated as under:- Total Savings estimated : Rs. 53.10 Cr Less total liaibility on addl

Contractual manpower (Rs. 9.06 Cr + Rs. 8.78 Cr) : Rs. 17.84 Cr Net Savings estimated : Rs. 35.26 Cr

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92. Recommendation. In order to strengthen the Scheme and improve the medicare of ECHS dependents, the following are recommended:-

(a) The proposals for additional contractual manpower as suggested in Para 86 and 90 above are recommended considering the likely savings on improved management of the Scheme. (b) The situation should be re-assessed after five years to ascertain the changes with the change of time.

93. Question. Examine the adequacy of contractual fees for all categories of staff and suggest revision in contractual fees, if any. Also, examine the QRs and the retirement age of contractual staff.

94. Brief. The authorisation of contractual staff and fees has been stipulated vide GOI letter No. 24(6)/03/US(WE)/D(Res) dated 22 Sep 03 (Appendix P). The Policy also provides employment of service provider for employment of non-medical staff. The remuneration for Specialists was enhanced from Rs. 20,000 pm to Rs. 25,000 pm in the year Jun 2005.

95. Findings. The contractual fees for all categories of contractual staff except Specialists have not been enhanced since the issue of the initial authorisation. The revision in the contractual fees of Specialists in Jun 05 has also not been able to address the problem. The 6th Pay Commission of the Central Government is in its final stage of sanction wherein a minimum increase of 20 % is expected.

96. The following have been the constituting factors and justifications for proposing increase in remunerations of the contractual staff since Sep 2003:-

(a) Increase in Dearness Allowance from Jan 03 (the month of initiation of case for remuneration of ECHS contractual staff) to Jan 2008.

(b) Merger of 50 % of DA with basic pay with effect from 01 Apr 04.

(c) A minimum of 20% enhancement is expected in salaries of Central/State Govt employees in the 6th Pay Commission.

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97. A tabulation of increase of Rs. 100 to Rs. 244 from Jan 03 to Jan 08 is given below:-

Month Basic Salary Rs. 100/-

Existing DA (%)

Enhancement (%)

Increase in Salary from Rs. 100/-

30 Dec 02 100 52 Nil 100 01Jan 03 100 55 3 103 01 Jan 04 100 61 6 109.00 01 Apr 04 (50 % DA merged)

150 11 - 166.50

01 Jan 08 150 47 36 204.00 Note:- By including minimum expected enhancement in 6th Pay Commission by 20 %, Rs. 100/- will get raised to Rs. 244/- in Jan 2008 (an increase by 144%)

98. Considering the increase since Sep 03 due to increase in DA, merger of 50 % of DA on 01 Apr 2004 and the anticipated increase by the 6th Pay Commission, the corresponding increase in contractual staff vis-à-vis the proposed enhancement is as follows:-

Category Staff Existing Enhancement @ 144 %

Total Proposed

Officers

OIC 15,000/- 21,600/- 36,600/- 25,000/- Med Offr 15,000/- 21,600/- 36,600/- 25,000/- Med Splst 20,000/-* 36,000/- 61,000/- 40,000/- Gynaecologist 20,000/-* 36,000/- 61,000/- 40,000/- Dental Offr 15,000/- 21,600/- 36,600/- 25,000/-

Para Medical Staff

Nursing Asst (General)

7000/- 10,080/- 17,080/- 9500/-

Nursing Asst (Nurse)

7,500/- 10,800/- 18,300/- 10,000/-

Lab Assistant 7500/- 10,800/- 18,300/- 10,000/- Dental Hygienist 7500/- 10,800/- 18,300/- 10,000/-

Non Medical Staff

Receptionist 7500/- 10,800/- 18,300/- 10,000/- Driver 4500/- 6480/- 10,980/- 7000/- Peon 3500/- 5040/- 8540/- 6500/- Safaiwala 3500/- 5040/- 8540/- 6500/- Female Attendant

3500/- 5040/- 8540/- 6500/-

* Increase to Rs. 25,000 in Jun 2005

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99. The proposed enhancements in contractual staff are based on the problems faced in employment of quality manpower and the feedback from various ECHS formations during the peripatetic checks. The proposed enhancements are confirming to prevalent market rates. The same should be re-examined for further escalation after five years or before depending upon the rise in market value. The total financial implication of enhancement of contractual fees is as follows:-

FINANCIAL IMPLICATION OF CONTRACTUAL FEES ENHANCEMENT

Appt

Auth

Existing Proposed Fees pm

Annual Cost

Total cost (In Cr)

Fees pm

Annual Cost

Total Cost (In Cr)

OIC 227 15000 180000 4.086 25000 300000 6.810 Med Splst 176 25000 300000 5.280 40000 480000 8.448 Gynaecologist 28 25000 300000 0.840 40000 480000 1.344 Med Offr 375 15000 180000 6.750 25000 300000 11.250 Dental Offr 255 15000 180000 4.590 25000 300000 7.650 Nur Asst, Lab Asst and Dental Hygienist

767 7500 90000 6.903 10000 120000 9.204

Receptionist 28 7500 90000 0.252 10000 120000 0.336 Driver 283 4500 54000 1.528 7500 84000 2.377 Other non-medical staff

681 3500 42000 2.860 6500 78000 5.312

Total 2820 33.089 52.731 Note:- Total additional liaibility of Rs. 19.642 Cr. 100. With the proposed increase in remunerations of the contractual staff and the proposal for additional contractual staff, the total liaibility on payment on remuneration will be as follows:-

(a) Cost of contractual pay of the authorised staff - Rs. 52.73 Cr

(b) Cost of additional contractual staff - Rs. 17.84 Cr Total - Rs. 70.57 Cr

Note:- The total liability will be 11.76 % of the annual revenue budget of Rs. 600.14 Cr in FY 2008-09.

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101. Temporary Employment on Unannounced Vacation of Posts. It had been observed that due to higher remunerations being paid to private sector, the contractual staff is very often vacating their posts without giving any prior notice. This leads to mounting of pressures at the Polyclinics as the authorised staff at the Polyclinics is minimal. The minimum time involved in refilling the vacancies is about two months under the existing procedure. There needs to be a provision for temporary employment of contractual staff until formal employment is carried out. 102. Enhancement of Age Limit of Para-Med Staff. The retirement age of contractually employed Officers is 65 years whereas the retirement age of para-medical and non-medical staff is 55 years. While the retirement age of Officers is considered adequate, the retirement age of non-medical staff can be raised to 60 years to improve employability. 103. Contact Period of Staff. The existing policy authorises employment of contractual staff for one year which can be extended every year till superannuation subject to review of their conduct and performance. It was found that due to insecurity of extension of service, applicants are hesitant to apply for the post. Also, an employee starts looking for employment outside Polyclinic no sooner he finishes eight to nine months of service and is able to succeed in getting another employment causing frequent vacancy of posts. Therefore, it is proposed that the initial employment could be raised from one year to three years and extension upto a maximum of five years subject to satisfactory performance and attainment of retirement age. 104. Employment Service Providers on Minimum Bid. It was observed that instead of employing service providers for services, they have been employed as manpower providers while the provision exists for outsourcing of services. The existing contractual fees to female attendant, Driver, peon and Safaiwala are less than the monthly remuneration stipulated in the Minimum Wages Act of the States. The payments to the service providers is to the extent of authorised contractual fees in the policy wherein the service providers are required to adhere to all conditions stipulated under the labour laws. Over and above, the profit margin of the service providers ranges from 10 to 15 %. With the result, the salary in the hands of non-medical staff is almost 25 to 30 % less than the stipulated contractual fee, which is far below the stipulated ceilings of Minimum Wages Act of the concerned States. The payment to the service provider should be made on minimum bid basis rather than the rates stipulated in the policy. This will enable better services from the non-medical staff besides raising satisfaction for the employed staff through the service provider.

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105. The case file forwarded by Central Organisation to the MoD for revision of contractual fees vide file case No. B/49782-Salary/AG/ECHS dated 11 Nov 07 has been examined and it is felt that the same needs to be amended accordingly. 106. Recommendations. The recommendations are:-

(a) The contractual fees of various categories of manpower may be enhanced as suggested in Para 98 above. (b) Provision may be created for temporary employment of contractual staff on occasions of unannounced vacation of posts. (c) The age limit for Para-medical staff and non-medical staff be raised from 55 years to 60 years as per proposal in Para 102 above. (d) The initial employment be raised from one year to three years and extension upto a maximum of five years subject to satisfactory performance and attainment of retirement age of contractual Staff. (e) The employment of service provider should be for the services and not for individuals on lowest bid basis and should not be limited to contractual fees proposed in Para 98 above.

107. Question. Whether the procedure for procurement of land in non-military Station for ECHS Polyclinics stipulated vide GOI MoD letter No. 24(1)/01/ US(WE) /D(Res) dated 31 Jan 05 and the progress on acquisition of land is satisfactory? 108. Brief. In military Stations, defence land is required to be used for Polyclinics. However, in non-military Stations where 121 Polyclinics are to be constructed, land is to be acquired. The procedure for procurement of land in Non-military Stations for ECHS was stipulated on 31 Jan 05 (Appendix T) and was valid for a period of three years. The GOC-in-C of a Command was delegated special powers for procurement of land to the extent of Rs. 5.00 Lakhs from the Capital budget. The procedure and current status of procurement of land in non-military Stations was examined in the light of the existing policies.

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109. The authorisation of land for Polyclinics in non-military areas stipulated vide GOI MoD letter dated 30 Dec 2002 is as follows:-

Type of Polyclinic A B C D Area of Land (in sq yards) 1200 1200 700 700

110. Findings. The current status is placed at Appendix U. The reasons for slow progress are as follows:-

(a) Non-availability of Suitable Land. As per Appendix A to GOI MoD letter No. 24(14)/03/US(WE)/D (Res) dated 31 Jan 05, “If defence land is not available or found un-suitable then simultaneous efforts will be made to look for land belonging to any other Central Government Department / State Government / Local Housing Body / Development Authority etc”. The Centre / State Governments etc. are not coming forward to provide suitable land for Polyclinics. The honourable Raksha Mantri himself wrote a letter to Chief Ministers of States requesting them to provide land but the situation has not improved to a satisfactory level.

(b) Limited Financial Powers. The financial powers for purchase of land by Army Cdrs from open market sanctioned vide Appendix A to GOI MoD letter No. 24(14)/03/US(WE)/D (Res) dated 31 Jan 05 is Rs. 5.00 Lakh only, which is very low and unrealistic.

(c) Lengthy procedure for Acquisition of land.

111. A file case initiated by Central Organisation and forwarded to MoD for enhancement of financial powers of the Army Commanders vide B/49705-Land Policy/AG/ECHS dated 30 Jul 07 was examined. The ECHS has proposed an enhancement in financial powers of GOC-in-C from Rs. 5.00 Lakhs to Rs. 50.00 Lakhs to make the delegation more realistic. 112. Recommendations. It is recommended that the procedure may be allowed to continue till the task of acquisition of land is completed. In order to make the delegated financial powers more realistic, the following enhancement is recommended for GOC-in-C for acquisition of land either from private parties or from any Govt agency:-

Class of City Proposed Financial powers

Type A &B Type C & D A 30,00,000 20,00,000 B 20,00,000 15,00,000 C 15,00,000 10,00,000

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113. The cost effect of enhancement has not been made as it may substantially vary from place to place as also can be procured at minimal cost from Central / State Government. 114. Question. Whether the procedure for construction of ECHS Polyclinics stipulated vide GOI MoD letter No. 24(7)/03/US(WE)/D(Res) dated 17 Sep 03 and the design of Polyclinics approved vide GOI MoD letter No. 24(4)/03/US(WE)/D(Res) dated 01 Aug 03 is satisfactory? Comment on the progress on construction. 115. Brief. The procedure for construction of ECHS Polyclinics stipulated vide GOI MoD letter No. 24(7)/03/US(WE)/D(Res) dated 17 Sep 03 (Appendix V) and the design of Polyclinics approved vide GOI MoD letter No. 24(4)/03/US(WE)/D(Res) dated 01 Aug 03 (Appendix W). Govt. of India, MOD letter No. 22(1)/01/US(WE)/D(Res) dated 30 Dec 02 (Appendix A) accorded approval for Construction of ECHS Polyclinics in Military and Non Military Stations as follows:

Type of Polyclinic A B C D Built up Area (in Sq Feet) 5000 4000 2500 2000

116. Findings. It was observed that the authorised plinth area is insufficient and there is huge congestion at a large number of Polyclinics. The waiting areas were insufficient besides other facilities and the members were found to be facing a lot of inconvenience. The rooms authorised are small and its sizes vary depending on the type of Polyclinic. The authorised construction is a single storey building and lacks scope for further expansion on the first floor. The Polyclinics which have already been constructed in military as well as non military stations do not cater to the load of the first floor. However, space is available for expansion on the ground floor itself. 117. It is considered that the design of the Polyclinic should be left at the discretion of ECHS for construction of Polyclinics which should be based on the shape of the land and the available space within the Military and Non-military areas. Guidelines can be taken from design of MI Rooms and Station Sick Quarters. The Govt must however, prescribe the total authorised plinth area to have the cost assessment and control. Considering the growth of the Scheme and ample scope should be left for future expansion of the building and ground floor should be constructed accordingly. There is a possibility of shifting the stores and waiting areas for relatively younger and physically fit beneficiaries on the first floor. While

35

the waiting rooms for the senior citizens and handicapped and treatment / diagnostic facilities may be kept at the ground floor. 118. The Central Organisation in consultation with the E-in-C Branch has stipulated a ceiling of Rs. 765/- per Sq Ft to control the cost. Wherever difficulty is faced in carrying construction in the stipulated ceiling due to local conditions, additional cost sanctions are accorded by Central Organisation in consultation by the E in C branch. This process is delaying the progress in construction at large number of places where land has already been acquired for construction of Polyclinics. This ceiling limit must be raised immediately considering the rise in cost of construction in the recent times in order to expedite the process of construction. The current status of construction is placed at Appendix X. Since a sizeable number of Polyclinics are yet to be constructed, the above proposal may be incorporated while constructing them. 119. The authorised size of the Polyclinics is too less to accommodate the current clientele load and therefore, there is a need to increase the size considerably. It is considered that the present authorised size of land will be able to accommodate the increase in plinth area in military as well non military stations. A one time cost of construction from Capital budget for the Polyclinics which are yet to be constructed at a reasonable cost of Rs. 900 per Sq Ft in double storey configuration is as follows. :-

Polyclinics yet to be constructed

Auth Plinth Area

Cost (in Lakhs)

Proposed Plinth Area

Cost (in Lakhs)

Difference

Type No. A 6 5000 270.00 10000 540.00 270.00 B 21 4000 756.00 8000 1512.00 756.00 C 43 2500 967.50 5000 1935.00 967.50 D 64 2000 1152.00 4000 2304.00 1152.00

Total 134 3145.50 6291.00 3145.50 (Say 31.50 Cr)

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120. The additional cost of construction of the constructed /under construction Polyclinics at the same cost of construction will be as follows:-

Polyclinics constructed/ under construction

Auth Plinth Area

Proposed Addl Plinth Area

Addl Cost (in Lakhs)

Type No. A 12 5000 5000 540.00 B 16 4000 4000 576.00 C 27 2500 2500 607.50 D 38 2000 2000 684.00

Total 93 2407.50 Say Rs. 24.00 Cr

121. Recommendations. The following are recommended:-

(a) The design of the Polyclinic should be left to the discretion of the ECHS which must consider future expansion. (b) The existing authorised plinth area may be increased as proposed in Para 119 above.

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CHAPTER – III

MEDICAL COVER

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CHAPTER IV- MEDICAL COVER 1. Question. Comment on the quality of medicare at the Polyclinics. Suggest measures for improvement, if any? 2. Brief & Findings. It was observed from interaction with the beneficiaries across the country ranging from 45 years to 95 years that the clientele is very satisfied with the Scheme and considers it to be a boon from the Govt which was long awaited. It is considered that the Scheme would not have been so successful until the three Services had not supported with the following:- (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.

3. It is considered that even the additional manpower proposed will not be able to completely set off the load on the welfare funds, but will provide relief besides causing improvement in services. 4. The present support is inadequate as at large number of high pressure Polyclinics, the daily sick reports are continuously increasing ranging from 300 to about 650 with which the existing MOs, Splst and para-medical staff is not able to cope up. Also, there is a long waiting at these Polyclinics inspite of the staff working beyond the call of their duties. 5. About 60 to 70 patients per Doctor / Specialist is considered a reasonable load, whereas at high pressure Polyclinics about 100 or more patients are being seen by one Doctor in a day making it impossible to do justice with the patients. The patients were also found complaining and expressing dissatisfaction on this aspect. 6. Recommendation. The additional MOs, Specialists and para-medical staff recommended shall be sanctioned.

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7. Question. What is the status of supply of medical equipment to be procured from ECHS funds? 8. Brief. The procedure for procurement of medical equipment has been issued vide GOI MoD letter No. 24(4)(b)/03/US(WE)/D(Res) dated 11 Aug 03 (Appendix Y). The medical equipments for ECHS Polyclinics were procured in 03 (Three) phases in line with evolution of ECHS Polyclinics which came up in phases I, II & III. The procurement action of ECHS authorised equipment has been done through the DGAFMS and all efforts were made to have timely action so that equipment are delivered in time. 9. Finding. It was however, observed that at some non-military locations where the Polyclinic has been functioning on rented accommodation and some military Stations where Polyclinic is functioning in temporary accommodation before being shifted to permanent KLP, there is space crunch to keep the medical equipment authorised. 10. This has led to non-opening of the packages at same places where the equipments are lying packed and unutilised. 11. Recommendation: At Station HQ level, concerted efforts should be made to expedite the construction of Polyclinics so that medical equipment can properly be placed and utilised. In the interim period, these should be kept at the nearest Service Hospital. The equipment must be functionally tested and made operational for its optimal utilisation towards medical care of Armed Forces Veterans. 12. Question. Whether the procedure for procurement of medical equipment for ECHS stipulated vide GOI MoD letter No. 24(4)(b)/03/US(WE)/D(Res) dated 11 Aug 2003 is satisfactory ? 13. Brief. The medical equipment for the ECHS Polyclinics were procured as per the guidelines in GOI MOD letter No. 24(4)(b)/03/US(WE)/D(Res) dated 11 Aug 2003 (Appendix Y). The procurement action has been undertaken by the DGAFMS. An Empowered Committee of MoD has been constituted for processing the procurement of equipment where the total cost exceeds Rs. 3 Crores. AFMSD Delhi was assigned the task to procure minor medical equipment for all the 227 Polyclinics 14. The placement of supply orders was done in 03 (Three) phases as per the operationalisation of ECHS Polyclinics.

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15. Finding. After a period of 05 years, on analysis of the utilization pattern of these equipment, it is found that utility of following equipment is minimal. Hence, these items should be deleted from the present scale:- (a) Portable Ultrasound machine

(b) One Steam Sterilizer Table Top from Type ‘A’ and ‘B’ Polyclinics (c) Surgical Micrometer 16. The following items should be added to the list as the requirement has been projected for the equipment:- (a) Lead protector with Screen (b) Patient exam couch/table (c) Pulse oximeter (d) Proctoscope (e) O2 Cylinder 623 Ltr with complete fitting (f) Manual Cell counter for DLC (g) Micro-pipette adjustable 1000 micro litre & 100 micro litre (h) Digital Photo Calorimeter 17. The physiotherapy equipment already scaled as follows must be procured as the aged clientele of ECHS require physiotherapy facility at the Polyclinics:-

(a) Wax Bath (b) Interferential Therapy Unit.

(c) Apparatus Short Wave Diathermy.

(d) Ultrasound therapy Unit

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18. Recommendations. It is recommended to revise the scale of medical equipment for ECHS Polyclinics. The physiotherapy equipment for the procurement of which Technical Evaluation has already been completed procurement action should be undertaken on fast track and the equipment should be placed at the Polyclinics. 19. Question. Whether the procedure for procurement of drugs and consumables for ECHS stipulated vide GOI MoD letter No. 24 (10)/03/US(WE)/D(Res) dated 25 Nov 03 is satisfactory? Also, whether there is a problem in availability and supply of medicines to the ECHS members? 20. Brief. The procedure for procurement of drugs and consumables for ECHS stipulated vide GOI MoD letter No. 24 (10)/03/US(WE)/D(Res) dated 25 Nov 03 (Appendix Z). The procurement of drugs and provisioning is done through 03 (Three) sources:- (a) Bulk supply through AFMSDs. (b) DGLP through SEMOs. (c) LP from empanelled Chemist through LP powers of OIC

Polyclinics in non-military Station. 21. Finding. It was found that there is a problem in issue of high cost medicines like anti-cancer drugs. It becomes difficult to maintain continuity of anticancer therapy by the patients after being discharged from the empanelled hospitals. It was suggested that the anti-cancer medicines may be issued from the empanelled hospitals for the prescribed duration or for 30 days. 22. Cancer drugs are expensive with limited life and are provisioned only by a few Service hospitals where cancer is treated. Whereas, the cancer drugs may be required for ECHS beneficiaries through out the country. The delay in procurement of cancer drugs may be detrimental to the life of the patient. The expensive cancer drugs cannot be procured under the powers of SEMOs without IFA consultation and procuring them with IFA concurrence will delay the supply of drugs. 23. The DGLP procedure is quite lengthy and thus it takes almost six to eight weeks before the supplies materialise. Thus, at many occasions, DGLP medicines are not made available for issue to the ECHS beneficiaries and the patients are compelled to buy from their own resources.

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24. The review committee is of the view that the position of supply of DG LP funds can considerably improved in case the SEMOs are permitted to enter into rate contract every year with the local vendors, as being followed in the Air Force. 25. The local purchase power should be given to the OIC Polyclinic of military Station as well as existing in non-military Station. 26. Since the existing financial ceilings of Rs 50,000/- pm for A & B types Polyclinics and Rs 30,000/- pm for C & D Polyclinics for purchase of emergent drugs by the OIC Polyclinic is not adequate, the ceilings may be enhanced to Rs 100,000/- pm & Rs 60,000/- pm respectively. The provision should also be made applicable for Polyclinics in Military Stations to improve the situation in Polyclinics in military Stations as well. 27. Recommendations. The following are recommended:-

(a) The cancer drugs may be procured by the SEMOs from DGLP funds subject to ex-post facto sanction of the CFA or special powers may be delegated to SEMOs without IFA consultation for speedy procurement.

(b) Whenever the medication needs to be continued post-discharge from an empanelled hospital, it should be issued from the hospital at the time of discharge for 30 days and billed in the consolidated final hospital bill.

(c) The financial ceiling of OIC Polyclinics in non-military Station for

emergent purchase of drugs should be enhanced to Rs 1,00,000/- & Rs 60,000/- for A,B & C,D Polyclinics respectively. Similar provisioning should also be made for military Station Polyclinics.

(d) DGLP procedures which requires a long time should be simplified to include system of rate contract with the local vendors. Emphasis should be given on central procurement of drugs to achieve utmost economy.

28. Question. Whether the procedure for payment and re-imbursement of medical expense under ECHS vide GOI MoD letter No. 24 (8)/03/US(WE)/D(Res) dated 19 Dec 2003 is satisfactory?

29. Brief. The procedure for payment and re-imbursement of medical expenses under ECHS has been stipulated vide GOI MoD letter No. 24 (8)/03/US(WE)/D(Res) dated 19 Dec 2003 (Appendix AA).

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30. Finding. It was projected by the SEMOs and Station HQ of high pressure Station that the clearance of bills gets delayed because of lack of manpower. The clerical staff was found employed at these places from existing Station resources which was found to be inadequate compared to the heavy workload. 31. Hospitals have complained on many occasions regarding delay in their payments and some of the reputed hospitals have already opted out from ECHS due to this reason. 32. Even for minor expenditure such as consultation and minor investigation, the procedure to be followed is same as for major bills. The workload with SEMOs increase substantially as even minor bills have to be perused and recommended by the SEMO for payment.

33. All the individual claims of treatment in non-empanelled hospitals have to be sent to Central Organisation ECHS for sanction. It was pointed out that this takes a long time for the individual to be re-imbursed. Since all these claims are already examined by the SEMO and CFA sanction is accorded, Central Organisation ECHS makes no value addition in any case except for repeat checking. In case these claims are sanctioned at the CFA level, It would reduce the time gap between preference of claim and re-imbursement to the member. 34. Under the existing policy, there is a provision to pay 80 % of the estimated cost of treatment at Medical Institutes of national repute when a member decides to take treatment. It was observed that the advance is being sanctioned at the CFA level depending upon the estimated cost. This causes delay in treatment as CFAs are mostly not available locally. In a clarification sought by Central Organisation vide B/49791/AG/ECHS dated 01 Nov 06 from the CGDA (Appendix AB), CGDA vide AT/IV/4807/ECHS/VI dated 26 Mar 07 expressed no objection provided the Govt orders are accordingly changed (Appendix AC). 35. Recommendations.

(a) Additional MOs and contractual manpower should be sanctioned for the SEMOs and Station HQs at High pressure Station for processing of bills.

(b) The minor bills amounting to Rs. 5,000/- or less may not be scrutinised by the SEMO himself and he should authorise a staff

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medical officer to recommend such bills for payment. This will ensure quality checks by the SEMOs of higher value bills which may result into large savings.

(c) The procedure as followed for re-imbursement of bills from empanelled facilities should be followed for individual claims also for medical treatment undertaken at non-empanelled hospitals / Diagnostic Centres. Henceforth, the emergency individual claims less than 4 lakhs should be cleared at the concerned CFA level. Only bills above 4 lakhs should be sent to Central Organisation, ECHS for sanction of VCOAS/ MoD. (d) It is recommended that 80 % advance for treatment in hospitals of national repute may be paid by the Station Commander without cost limitation since such hospitals are limited and are of national repute.

36. Question. Whether sufficient checks and balances exist for ECHS payments especially for payment of hospital bills and re-imbursement of individual bills? 37. Brief & Findings. It was found that sufficient checks and balances exist for ECHS payments. These are as follows:-

(a) Verification of emergency while issuing Emergency information report.

(b) Prior approval in cases as follows:-

(i) When the anticipated expenditure for medical treatment for a single hospitalization/ procedure/ test is beyond Rs. 5.00 Lakhs. (ii) For procedures/ treatment modalities/ tests not listed in the approved CGHS/ ECHS rate list.

(iii) Certain cardiology procedures where prior approval is required.

(c) Obtaining concurrence and comments of concerned Specialist & Senior Advisor of Army Hospital R&R in high cost treatment alongwith perusal by Sr. Consultant, O/O DGAFMS.

(d) Admittance of package rates as per CGHS/ AIIMS rates only.

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38. Recommendation. It was recommended that while maintaining appropriate measures for check & balances, it must be ensured that there is no delay in medical treatment to the patient or any kind of inconvenience to the ECHS members. 39. Question. Whether the system of referral in military and non-military stations is functioning satisfactorily? 40. Brief & Findings. It was found that the procedure of referral is being followed as per the laid down guidelines by the Central Organisation ECHS. In the current provisions, the OIC Polyclinics are only authorised to issue referrals which is causing problems for old aged patients to move to and fro more than twice from Service hospitals to the Polyclinics. There is a need to also authorise the SEMOs to allow direct referrals for which an updated list of empanelled facilities should be made available by the OIC Polyclinics. Central Organisation may devise procedure to simplify referrals to empanelled facilities. 41. Under the present policy, in case empanelled facilities do not exist within the Station for a specific speciality / diagnosis, the Polyclinics are to refer such patients to the nearest Govt / Service / Empanelled Hospital / Diagnostic Centre. This is causing problems for aged Ex-Servicemen to travel long distances where they have to make their own arrangements for outstation stay. The problem is acute in the Northern and North-Eastern regions. Since the Govt liability is limited to the CGHS rates, re-imbursement of treatment in non-empanelled facilities is such cases should be authorised. The Ex-Servicemen should be allowed to go to Hospitals / Diagnostic Centres of their choice where local empanelment of the facility does not exist, where the ESM would need to pay on their own and claim re-imbursement at CGHS rates. 42. A few important medical institutions / hospitals have declined to offer credit facilities and have opted out of ECHS. Similar problem had been felt by the CGHS. For the purpose of cancer treatment, special permission has been accorded by Govt of India, Ministry of Health & Family Welfare vide REC-1-2004/JD/(Gr.)/CGHS/Delhi/CGHS (P) dated 01 Oct 07 (Appendix AD) in respect of four hospitals wherein the beneficiaries can initially pay and claim subsequently reimbursement at CGHS rates. In ECHS, such important hospitals may be identified where re-imbursement as per the above procedure may be permitted.

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43. Instances have been reported from the Northern and the North-Eastern regions that due to inadequate medical facilities in the region, hardships are being faced in treating emergency cases. Presently, patients are not authorised for air evacuation through civil airlines and also the policy is silent about traveling allowances for places not connected by rail. The existing provisions allow entitled class of rail fare as applicable at the time of retirement by shortest route. It is proposed that air evacuation through civil airlines may be permitted for remote areas on specific recommendations of the Specialists to the nearest medical facility connected by Air. Also, Road Mileage Allowance for outstation referrals may be permitted for places not connected by rail. 44. Recommendations. The following are recommended:-

(a) Central Organisation may devise procedure to simplify referrals to empanelled facilities causing minimum inconvenience for the patients by allowing SEMOs to also raise referrals. (b) The Ex-Servicemen should be allowed to go to Hospitals / Diagnostic Centres of their choice where local empanelment of the facility does not exist, where the ESM would need to pay on their own and claim re-imbursement at CGHS rates.

(c) The referral facility may be extended to the ECHS identified reputed hospitals where the beneficiaries can be allowed to claim reimbursement at CGHS rates for cancer and other treatment as well, since the financial liability of the Govt remain unaltered. (d) Air evacuation of patients through civil airlines may be permitted for remote areas on specific recommendation of the Specialists to the nearest medical facility connected by Air. (e) Road Mileage Allowance for outstation referrals may be permitted for places not connected by rail.

45. Question. Whether there is a delay in processing of Hospitals bills and individual reimbursement claims? Also, examine whether the stipulated period for payment is practical under the given infrastructure and financial powers? 46. Brief & Finding. The delay in processing of Hospital bills and individual re-imbursement claims is there because of lack of man power. It was projected by the Polyclinics in high pressure stations that unless the

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manpower is augmented, bills may not be cleared within stipulated time span. 47. It was brought out that once the cost of bill/claims is above Rs. 5.00 Lakhs where the CFA is MoD, the time for sanction takes almost more than one (01) year. 48. Recommendation. The review committee recommended that the existing financial power of CFAs at different level should be revised. The CFA power of VCOAS should be Rs 08 Lakhs so that bills above this are only sent to the MoD.

49. Question. Whether the procedure for empanelment of Hospitals, Nursing Homes and Diagnostic Centres and the procedure for its renewal stipulated vide GOI MoD letter No. 24(9)/03/US(WE)/D(Res) dated 16 Jun 04 is satisfactory? 50. Brief. The procedure for empanelment of Hospitals, Nursing Homes and Diagnostic Centres and the procedure for its renewal is stipulated in GOI MoD letter No. 24(9)/03/US(WE)/D(Res) dated 16 Jun 04 (Appendix AE). 51. Findings. It was projected at most of the stations that the time taken for empanelment is too long. This acts as deterrence to the civil medical facilities for getting empanelled with ECHS. At some smaller towns, the available civil medical facilities do not meet the qualitative requirements (QRs) as laid down by ECHS for getting empanelled. Due to this, there are about 75 Stations still uncovered. Also at many Stations, some of the specialities are not yet covered. 52. It was brought out that the case for renewal also has to be projected to the Empowered Committee of MoD for approval as per the GOI MoD letter No. 24(9)/03/US(WE)/D(Res) dated 16 Jun 04. Since it is practically not possible, the approval is being accorded by Central Organisation, ECHS based on satisfactory evaluation report by a Board of Officers. However, it takes a long time to accord approval for extension. 53. Recommendation. The following are recommended:-

(a) Expeditious processing of application from the civil medical facilities.

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(b) To have flexibility to relax the qualitative requirements (QRs) at smaller towns so that the available medical facilities can be empanelled.

(c) The Station Commander should be delegated authority to sanction renewal of MoA subject to satisfactory performance.

54. Question. Whether the present empanelment of Hospitals, Nursing Homes and Diagnostic Centres for various specialities throughout the country is satisfactory? 55. Brief & Findings. The empanelment procedure that is being followed was projected to be too cumbersome. The empanelment application form is too exhaustive. It was also brought out that it takes a long time for the Govt. letter/ final approval to come through recommendation. 56. Recommendations. The following are recommended:-

(a) To have separate application form for empanelment of Hospitals, Diagnostic Centre and Dental Centres.

(b) To prioritise action for getting civil medical facilities from uncovered areas.

(c) To simplify the policy on empanelment.

(d) Delegation of authority to Central Organisation ECHS for empanelment of civil medical facilities.

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CHAPTER – IV

GENERAL RECOMMENDATIONS

& CONCLUSION

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CHAPTER IV- GENERAL RECOMMENDATIONS & CONCLUSION 1. Question. Examine all other issues that the team may come across during peripatetic check and suggest remedial measures, if problems observed. 2. Periodic Review of the Scheme. It was observed that a large number of proposals had been raised by the Central Organisation and forwarded to the MoD but decisions had been forthcoming considering the clause that the Scheme was overdue for its review. The Scheme is growing at a fast pace and will take some more time to stabilise as a definite pattern has not emerged towards its future dependency and budgetary implications. Thus, the bottlenecks observed from time to need to be periodically reviewed and resolved. 3. Recommendations. The problems which require structural changes and do not have immediate adverse impact on the Scheme shall be reviewed every two years till the Scheme fully stabilises. However, issues which effect the day-to-day functioning or have immediate adverse impact or may tarnish the image of the Scheme should be dealt with due priority. If considered essential, the matter should be examined by visiting the location of the problem by the ECHS functionaries in the MoD/Def (Fin). 4. At the initial stages of implementation of the Scheme, the policy letters on subjects which are purely administrative were also issued by the Govt. Since the Scheme is now having an experience of more than five years, administrative matters which do not have financial implications should be directly dealt by the Army Headquarters. This will facilitate immediate course corrections as the Scheme grows further. 5. Management Information System (MIS). It was observed that the desired data base is not available with the Organisation. Presently the data is being mostly compiled by the Central Organisation through the reports and returns generated by lower formations in the material form (hard copies). The data forwarded on the WAN through telephone lines connected between Polyclinics, Regional Centres and Central Organisation suffers appropriateness of software, sufficiency and consistency in supply. This is particularly for the reasons that adequate infrastructure for data entry and data mai