RECOMMENDATONS/OBSERVATIONS- AT A GLANCE Budget Allocation for CGHS

 RECOMMENDATONS/OBSERVATIONS- AT A GLANCE Budget Allocation for CGHS- 

PARLIAMENT OF INDIA

RAJYA SABHA

DEPARTMENT-RELATED PARLIAMENTARY STANDING

COMMITTEE ON HEALTH AND FAMILY WELFARE

Rajya Sabha Secretariat, New Delhi

February, 2024/Magha, 1945 (Saka)

REPORT NO.

155

ONE HUNDRED FIFTY-FIFTH REPORT

ON

FUNCTIONING OF CENTRAL GOVERNMENT HEALTH

SCHEME (CGHS)

(Presented to the Rajya Sabha on 8th February, 2024)

(Laid on the Table of Lok Sabha on 8thFebruary, 2024

RECOMMENDATONS/OBSERVATIONS- AT A GLANCE

Budget Allocation for CGHS

The Committee recommends the Ministry implement measures aimed at maximising the utilisation of funds allocated to the CGHS. Furthermore, the Ministry should establish a robust mechanism to ensure optimal utilisation of these funds and curb any instances of wasteful expenditure. This proactive approach will ensure the judicious use of resources and enhance the overall efficiency of the CGHS.

(Para 1.4.3)

The Committee believes that there is a need to expand the coverage network of CGHS in existing and new cities, for which separate allocation needs to be made. These special funds may be utilised to open new wellness centres, polyclinics, and separate CGHS wings in government hospitals. The Committee feels that such a step will enable the Ministry to set a time-bound date and targets to complete the opening of new CGHS facilities.

(Para 1.4.4)

Need for Augmenting Wellness Centres

The Ministry informed that as of August 2023, the CGHS had a presence in 80 cities with 340 CGHS Allopathic wellness centres. The Committee has noted that out of these 340 allopathic wellness centres, 26% are concentrated in the Delhi NCR region. Further, only six states (excluding the Delhi NCR region) have more than 10 CGHS centres. This highlights that the distribution and accessibility of CGHS services across different regions of the country are not equitable and need to be addressed. The Committee noted that the state of Arunachal Pradesh and the UTs of Ladakh, A & N islands and Lakshadweep have no CGHS wellness centre.

(Para 2.2.1)

The Committee is aware that there are many cities and towns where there are a sizeable number of Central Government employees, pensioners, and their dependents, but no CGHS wellness centre exists there. As a result, the beneficiaries, particularly the retired beneficiaries, are required to travel long distances to get medical treatments, causing inconvenience to them. The Committee opines that this scenario, apart from being financially draining on the beneficiaries, also causes various other hardships to the beneficiaries.

(Para 2.2.2)

The Committee was informed that there are 18 CGHS polyclinics across the country. The Committee is of the view that 18 polyclinics against 43 lakh beneficiaries across the country are insufficient. The Committee would like the Ministry to take proactive steps for setting up new CGHS centres and consider exploring setting up wellness centres and 27

polyclinics at a rapid pace in underserved areas, especially the suburbs of large cities where a considerable population of serving and pensioner beneficiaries reside. The Ministry should ensure that all aspirational districts in the country have CGHS centres and empanelled hospitals. The number of CGHS centres and their geographical reach are the main facets. The Committee feels that the Government needs to consider relaxing existing norms or creating new norms for opening new wellness centres, particularly for beneficiaries of rural, hilly, remote, and Northeastern parts of the country.

(Para 2.2.3)

Infrastructure in a CGHS WC

The Committee has learned about the poor infrastructure of some wellness centres, viz. shabby buildings, lack of proper sitting arrangements, lack of proper lighting, cleanliness, availability of basic amenities, etc. The Committee is of the opinion that the Ministry should periodically review the condition of available infrastructure at wellness centres, and necessary renovation or maintenance work should be carried out in a planned manner. The Ministry should allocate separate and sufficient funds for periodic upkeep and up-gradation of the wellness centres.

(Para 2.3.1)

There is a lack of Ambulance service at many of the Wellness Centres. This is required in critical cases of referrals and emergencies. The Committee recommends that the Ministry also consider allocating separate funds for arranging at least one ambulance in each Wellness Centre so that the patient can be taken to the higher medical centre promptly for emergency treatment. The Ministry should also prepare a model list of essential services and equipments that all CGHS wellness centres should have available.

(Para 2.3.2)

The Committee further recommends the Ministry conduct a survey and collect data on the number of beneficiaries referred to higher centres and the reasons for such referrals. This would help in examining the lack of facility because of which the patient was required to be referred, and based on that report, the Ministry should consider developing infrastructure and facilities in the CGHS wellness centres and engaging specialist doctors and other allied staff.

(Para 2.3.3)

Staffing under CGHS

The Committee noted an additional requirement of about 20 to 30 % of the sanctioned strength of doctors, paramedical and administrative staff, over and above the sanctioned strength, in all CGHS set-ups across the country. The additional requirement for a Junior Health Administrative Assistant is around 70% of the present sanctioned strength. Further, during the deliberation, the Ministry informed the 28

Committee that a considerable percentage of the sanctioned strength of medical and administrative staff is also lying vacant. This leads to a poor doctor-to-beneficiary ratio, long waiting times for patients in CGHS dispensaries, and a decrease in the quality of patient care.

(Para 2.4.3)

The Committee is of the view that opening or operating CGHS centres without sufficient doctors and staff has no meaning and causes inconvenience to beneficiaries. The Committee, therefore, recommends that the Ministry expedite the recruitment process and fill up all vacant positions. To ensure an adequate doctor-to-patient ratio in all CGHS wellness centres, the recommendations of SIU may be implemented expeditiously. Based on the total number of beneficiaries being served by a Wellness centre, minimum criteria for doctors to see the patients per day may be fixed and strictly adhered to. On being enquired, the Ministry informed that around 500 contractual doctors have been engaged in addition to regular doctors to improve the doctor-to-beneficiary ratio.

(Para 2.4.4)

Availability and Quality of Medicines Supplied at Wellness Centres

The Ministry informed that after visiting the Medical Officer at the wellness centre, the beneficiaries are issued medicines at the pharmacy counter. If the medicines are available, they are issued right away. The medicines not readily available at the centre are indented and procured through an Authorized Local Chemist (ALC) within 48 hours. The beneficiary or the authorised representative can collect the medicines from the counter. It has come to the Committee’s notice that the medicines are often not procured promptly, causing inconvenience to the beneficiaries. In many cases, the bid/contract of the ALC is not renewed well in time, and the dispensary is not in a position to supply the medicines.

(Para 2.5.1)

The Committee recommends the Ministry investigate the issues of delay in procurement and subsequent distribution of medicines. The Ministry may bring necessary changes in the guidelines and simplify the procedure for the local purchase of medicines to ensure an uninterrupted supply of medicines. The Committee also recommends that the Ministry establish a mechanism to ensure the continuous availability of basic/essential medicines at CGHS dispensaries so that the need for local purchase does not arise. The Ministry should take necessary steps towards course correction, including making the required funds available for regular supply of medicines.

(Para 2.5.2)

The Committee is further of the view that the course of some of the medicines, like antibiotics, is required to be started by the patients on the same day or immediately, as prescribed by the medical officer of the dispensary or by the doctor of the empanelled HCOs 29

(visited after a referral from the dispensary). In case such medicine is not readily available in the dispensary, the same is indented. A patient cannot wait for two days to receive that indented medicine, and the procedure of buying directly from the ALC and getting the same reimbursed later causes inconvenience to the patient, who should rest to recover early instead of running from pillar to post. The Committee, therefore, feels that the turnaround time to receive indented medicine should be reduced to less than 24 hours. The Ministry should make necessary course corrections to ensure that the indented medicines are available by the very next day morning.

(Para 2.5.3)

The Committee has come to know that there are complaints regarding the quality of medicines disbursed at the pharmacy counter of the dispensary. Questions have been raised regarding the effectiveness of medicines procured through MSO and JAP. The quality of medicines is of paramount importance while providing healthcare services, and complaints regarding the quality should be taken seriously. This is also essential to ensure compliance with the Good Manufacturing Practice (GMP) standards of the World Health Organization (WHO). The Committee, therefore, recommends the Ministry establish a mechanism ensuring rigorous testing of medicines. The Ministry may inspect these laboratories and surprise test any random batch of medicines through any third independent NABL-accredited laboratory. The Ministry may also consider testing random batches of medicines from a reputed international laboratory.

(Para 2.5.5)

Clearance of bills of empanelled hospitals

The Committee appreciates the efforts of the Ministry to ensure timely settlement of bills despite functioning under different kinds of constraints. However, the Committee observed that many bills due for payment are carried over to the next financial year owing to various reasons, which is affecting the credibility of CGHS. It is one of the major reasons for refusal of treatment to CGHS beneficiaries by some of the empanelled hospitals. The Committee simultaneously observes that the empanelled hospitals are in financial distress because of outstanding dues from CGHS. The Committee, therefore, recommends that the Ministry establishes a mechanism for daily review of pending bills to ensure that the processing of bills gets smoother and disbursements are made seamlessly. The Ministry should fix a turnaround time for the settlement of bills.

(Para 2.6.3)

The Ministry may consider periodic meetings of CGHS authorities with the HCOs at the regional level to deliberate upon the regularly raised objections, which HCOs can correct in future. The Government may also consider payment to HCOs using predictive statistical analysis/tools about the cost of treatment. This can enable the system to determine the percentage of the amount to be deducted and thereafter, release the balance amount automatically. Such a step will be in the interest of both the 30

beneficiaries and HCOs and will also, to some extent, address the grievances related to denial of treatment by hospitals.

(Para 2.6.4)

Consultation and Diagnostic Rates

As part of the revision of rates, the Committee recommends the Ministry review the rates of all the remaining procedures and diagnoses in CGHS in a time-bound manner. While revising the rates, the Ministry should consult the HCOs and other stakeholders extensively. The Ministry may also get the rates audited by a professional agency and should clearly state the basis on which the rates of different procedures are revised. The Committee further recommends the Ministry put in place a mechanism to review the rates of procedures/diagnosis under CGHS every third year periodically and to keep the rates reasonable enough to attract the interest of a large number of HCOs.

(Para 2.7.3)

The Committee observed that some procedures related to physiotherapy, mental disorders, psychological counselling, therapies, etc., are either not covered under CGHS or their categorisation is not well defined. This area needs the attention of the Ministry. Particularly after the COVID-19 pandemic, mental health issues are on the rise and should be seriously taken by the Ministry. In view of the serious concerns expressed by the Committee in its 148th Report on Mental Health Care and its Management in Contemporary Times, the Committee would recommend the Government to review and expand the coverage of mental health ailments and treatment procedures.

(Para 2.7.4)

Integrative Medicine

The Committee appreciates the Ministry‘s initiative to integrate the Indian system of medicine with the network of CGHS wellness centres. However, from the information received from the Ministry, it is evident that the number of AYUSH centres expanded to 107 in August 2023 from 85 in March 2014, which translates to about a 25% increase over nine years. The Committee is of the view that such a meagre increase in the number of AYUSH centres does not align with the Government‘s vision to popularise the indigenous system of healthcare in the country. The Committee, therefore, recommends that the Ministry consider setting up more AYUSH centres across the country and taking initiatives to popularise the Indian system of medicine among the beneficiaries of the CGHS.

(Para 2.8.2) 31

The Committee also observes that out of the 107 AYUSH units, 84% of the units pertain to Ayurveda and homoeopathy. The Committee, therefore, recommends that the Ministry consider setting up more AYUSH centres pertaining to Yoga, Siddha, and Unani alternative systems of medicine across the country

(Para 2.8.3)

The Committee has learned that about 36% of CGHS AYUSH centres are in the Delhi-NCR region. Further, about 60% of AYUSH centres are located in the cities of Delhi-NCR, Bengaluru, Mumbai, Chennai, Hyderabad and Kolkata. The Committee has seen that the distribution of AYUSH centres is concentrated in these six major cities. The Committee, therefore, recommends that the Ministry should take proactive steps to set up more AYUSH centres in newer cities.

(Para 2.8.4)

Separate facility for CGHS beneficiaries at Government Hospitals

The Committee appreciates the efforts of the Ministry in extending cashless treatment (including secondary and tertiary treatment) to the beneficiaries of CGHS. The Ministry should enter into agreements with more AIIMS, Institutes of National Importance and eminent Government and Autonomous hospitals across the country to extend cashless facilities to CGHS beneficiaries. The Committee also feels that the proposal to collaborate with partner health organisations like Railways, ESIC, and ECHS should be pursued generously. The Ministry should also consider collaborating with State Government health centres and hospitals. Such collaborations would encourage the sharing of infrastructure and interoperability. This would also help increase the accessibility of health care services to remote areas across the country with less burden on the government exchequer.

(Para 2.9.3)

Apart from agreeing with eminent public medical institutions, the Committee feels that the Ministry should also consider constructing secondary and tertiary CGHS hospitals (at least ten hospitals across the country) with cutting-edge facilities and research on which the beneficiaries can have the belief, particularly for the treatment of some serious diseases like cancer, cardiovascular, renal failure, etc.

(Para 2.9.4)

Grievance Redressal

The Committee was apprised that as of August 2023, in the financial year 2023-24 (including the carried forward from the financial year 2022-23), a total of 1526 grievances had been received on CPGRAMS, out of which 1271 (about 83%) had been disposed of with total 255 grievances pending. The Committee appreciates the actions of the Ministry to redress the grievances of the CGHS beneficiaries. However, the Committee would like to see 100% redressal of beneficiaries’ grievances. This 32

would enhance the trust of beneficiaries and the credibility of the institution. The Ministry should further strengthen the grievance redressal mechanism to deal with grievances proactively and fix the timeline to redress them with regular monitoring at the Joint Secretary level. The Committee also believes that the complaint registration mechanism should be as simple as possible, particularly for senior citizens and beneficiaries who are not techno-savvy.

(Para 2.10.2)

During the meeting with the Committee, the Ministry presented a pie chart providing the distribution of different kinds of grievances that come across different CGHS wellness centres and zones. The Committee noted that most of the grievances were related to medicine and the wellness centre. The Committee recommends that the Ministry thoroughly study the grievances about these two areas and take proactive measures rather than reactive actions to reduce these grievances.

(Para 2.10.3)

The Committee has also been informed of the unsympathetic and indifferent approach towards patients by the doctors and other staff of the CGHS dispensaries. There are also complaints regarding the difference in treatment given to the serving and retired beneficiaries. The Committee expresses its dismay over such a state of affairs and recommends that the Ministry implement communication skills and sensitisation workshops to instill soft skills and professionalism in the CGHS workforce and improve their attitude towards patients, particularly the senior citizens.

(Para 2.10.4)

The Committee is aware of the complaints of the beneficiaries on the denial of empanelled private hospitals to admit CGHS beneficiaries for in-patient treatment because of the non-availability of beds. There are also instances of some empanelled hospitals/diagnostic centres charging exorbitantly and collecting more fees than CGHS rates. The Committee impresses upon the Ministry to deal with such grievances in a deterrent manner and initiate prompt penal action against the erring hospital if any irregularity is observed.

(Para 2.10.5)

The Committee observes that patient satisfaction is essential for measuring healthcare quality. The Committee, therefore, recommends the Ministry put in place a mechanism measuring and evaluating CGHS beneficiaries’ experiences in CGHS wellness centres and the empanelled private hospitals. Such an exercise may help the Ministry determine critical drivers of beneficiaries’ dissatisfaction with health care delivery. This would also help to develop and implement improvement strategies across the healthcare sector under CGHS.

(Para 2.10.6) 33

Referral System under CGHS

The Committee has, however, learnt that as per present practice, even after obtaining a referral in the first instance, if the consultant in the private hospital prescribes any tests/investigation/treatment, the beneficiary is required to report back to the dispensary and get that prescribed tests/investigation/treatment endorsed from the CGHS doctor. The Committee feels that the present referral system is cumbersome, which only inconveniences the beneficiaries and adds to the woes of a patient with poor health. The Committee recommends the Ministry devise appropriate solutions to simplify the referral system so that a beneficiary is not required to visit the CGHS dispensary multiple times just to get the prescribed tests done following a referral in the first instance.

(Para 2.11.2)

The Committee appreciates the existing guidelines of direct consultation for beneficiaries aged 75 years and above. It would further recommend the Ministry review the guidelines to bring all CGHS pensioners/beneficiaries aged 60 years and above into the ambit of direct private consultation from empanelled hospitals. This would align with the existing set-up as pensioners/beneficiaries aged 60 years and above receive cashless treatment from private empanelled hospitals.

(Para 2.11.3)

Increase in the empanelment of big hospitals under CGHS

The Committee has come to know that on the one side, many small hospitals approach the authorities for empanelment under CGHS, but the beneficiaries do not want to visit these hospitals due to lack of facilities whereas, on the other side, some good hospitals, where the beneficiaries would like to visit, are not willing to get empanelled under CGHS. The Committee acknowledges the efforts of the Ministry to persuade big hospitals to empanelment under CGHS by improving the processing system, like taking steps to make the bill settlement quick and raising the rates of consultation and procedures under CGHS. The Committee recommends that the Ministry examine the grading system by NABH and, if required, may suggest a more efficient grading system based on a point system. Such grading of NABH may be used for grading the hospitals like Grade ‘A’, ‘B’, etc. and fix the CGHS rates for hospitals as per the grading of the hospitals. Even now, the Ministry is doing the same for NABH and non-NABH hospitals. This may be extended further as per the grading of NABH-accredited hospitals. The Ministry may also study the NQAS scoring of public sector hospitals to make changes in NABH grading.

(Para 2.12.1)

Further, to increase the empanelment of better hospitals under CGHS, the Committee recommends that the Ministry ask the CGHS authorities at a zonal level to search for hospitals doing good in their areas and make result-oriented efforts to bring them under 34

CGHS empanelment. The Committee feels that the empanelment process needs to be simplified for non-CGHS-covered cities and brought at par, like that for CGHS-covered cities. Many of these cities also have considerable CGHS beneficiaries.

(Para 2.12.2)

The Committee recommends that the Ministry may also consider enforcing mandatory empanelment of healthcare facilities in the private sector falling under the following categories:

i) health facilities availing tax benefits.

ii) those receiving land grants/ concessions from the Centre/ State Governments for their establishment.

iii) facilities affiliated with medical colleges; and

iv) any other category deemed fit by the Government.

(Para 2.12.3)

Need to improve the functioning of LAC and ZAC

The Committee was apprised of the Local Advisory Committee (LAC) constitution at the Wellness Centre level and Zonal Advisory Committee (ZAC) in each of the Zone of Additional Directors in CGHS wellness centres. The Committee underlines the need for regular interaction between public representatives and government organisations/departments with regard to monitoring and effectively delivering public services. The LAC and ZAC are effective platforms for interaction between the CGHS officials and local Members of Parliament (MPs) of the area. The Committee feels that such platforms help strengthen the services delivered by CGHS, as Members of Parliament, apart from being public representatives, are also beneficiaries themselves. Hence, their feedback in such interactions will greatly benefit CGHS. However, the Committee has come to know that many MPs have never received a call from anybody regarding the schedule of such Committee meetings. The Committee, therefore, recommends the Ministry to take up this issue and give necessary directions to CGHS authorities to ensure that the local MPs in the area of CGHS dispensary are informed well in time about the conduct of LAC and ZAC meetings. The Ministry should also monitor the compliance of such directions by the CGHS authorities.

(Para 2.13.1)

Expansion of coverage of cashless treatment

The Committee has been informed that certain categories of beneficiaries are provided treatment on a cashless basis. The Committee feels that it is not appropriate that the CGHS services are cashless for some people and others have to take reimbursement. It is informed that the processing and payment of hospital bills pertaining to CGHS are being completed on the IT platform of NHA. The Committee, therefore, recommends 35

the Ministry consider expanding the ambit of cashless treatment to all beneficiaries. The Ministry may consider using NHA’s IT platform or explore the possibility of developing new software for the common use of all Ministries and Departments to streamline the process for payment/reimbursement of cashless treatment.

(Para 2.14.1)

Employees of Jawahar Navodaya Vidyalayas (JNVs) and Kendriya Vidyalayas (KVs) under CGHS

The Committee is of the view that the participation of autonomous bodies with CGHS is abysmal. Out of about 450 such bodies, only 60 are covered under CGHS. Most autonomous bodies, particularly the KVs and JNVs, have employees with all India transfer liability. The coverage under CGHS would benefit the employees of these organisations in providing health care facilities across the country. The Committee, therefore, recommends the Ministry to take up this issue with the Ministries and Departments concerned.

(Para 2.15.2)