Time to Reform the Central Government Health Scheme: Economic & Political Weekly

The Central Government Health Scheme provides health services to three million government employees, pensioners and their dependents with the second being the fastest growing segment. However, a scheme that started with a lot of promise has got bogged down with medical and administrative problems that need to be dealt with if it has to fulfil its aim of reducing medical expenditure costs and maintaining healthy lifestyles. – Article by Manoj Grover on Economic & Political Weekly

[The views expressed are personal and do not necessarily reflect the official position of the Planning Commission.]

Started in 1954, the Central Government Health Scheme (CGHS) currently provides healthcare services to more than three million central government employees, pensioners and their dependents across 25 cities covered under it. The package of services is generous and covers inpatient and outpatient care, including preventive care and the ayurveda, yoga, naturopathy, unani, siddha and homoeopathy (AYUSH) system of medicine. There are no exclusions for pre-existing diseases or any cap or limit on the coverage (La Forgia and Nagpal 2012).

Regardless of the fast-growing expenditures of this health benefit package, there is widespread dissatisfaction among beneficiaries. A comprehensive reform is needed in the orientation, service delivery and quality management systems of the scheme.

The CGHS wellness clinic functions as a mere channel for referrals to private hospitals and claim reimbursement. Experts have questioned the attitude of the CGHS medical officers. There is improper adherence to the drug list, and irrational drug combinations are commonly prescribed. Many patients enamoured of the expensive medicines commonly prescribed by private practitioners demand the same from the CGHS doctor or else seek referrals to fancy private hospitals (Bhat 2006). Most patients are treated or referred without a proper clinical examination or in-house laboratory investigations. The doctors on their part say that this happens because they can devote very little time to each one due to the excessive load of patients (Sharma, Kataria and Gandhi 1979). This often leads to a vicious cycle with the medical officers of the CGHS eager to refer patients elsewhere than take the responsibility themselves and the patients in turn, sensing the indifference of the medical officers, feel less confident about consulting them again. Moreover, the cumulative records are not maintained properly and lead to missed opportunities for better case management and epidemiological interventions to improve population health (Bhat 2006).

There are several reasons why the CGHS has reached such a situation. Since there is no cap/co-payment, there is a double-sided moral hazard. The beneficiaries may tend to overuse expensive curative care as they have no financial incentive to seek care early or follow a healthy lifestyle (demand side moral hazard). Empanelled hospitals may also provide unnecessary care to maximise their profits (supply side moral hazard). Short service hours worsen this problem, as the CGHS medical officers can refer patients so as to reduce their workload (Haldar et al 2008). Due to the poor delivery of services at the CGHS clinics, the healthcare practitioners lose touch with the basic skills and medical advancements. Though the providers are reimbursed at higher prices, there is no other mechanism to monitor or enforce quality of treatment outcomes. The CGHS covers the cost of alternative systems of medicine and even import of recently developed expensive medicines, which may be least cost effective.

Prescription of Solutions

Despite the poor range and quality of services provided at the CGHS clinics, the beneficiary community tends to trust the integrity and fairness of the system (Haldar et al 2008). It would be a pity if this trust is eroded due to management failure. The level of services provided by the CGHS wellness clinics must be upgraded so that it is well above that of the primary health centres situated in the remote rural areas. Proximity to some of the best medical and public health institutions must be exploited through collaborations. The best areas for such partnerships are for continuing medical, nursing and paramedical education for the CGHS staff and monitoring of quality of service delivery in CGHS clinics and empanelled hospitals. Another mechanism worth replicating is the Andhra Pradesh Government Employees Health Scheme, which puts the onus on the network hospitals in case of any related complication. The network hospital is obliged to treat it within the package price. This helps them simultaneously improve quality and control costs.

Other mechanisms have been suggested to develop the managerial and technical capacity of the CGHS medical officers (Bhat 2006). In-service administrative training course within one year of selection is a must since most of them are not aware of the manner in which government machinery functions and this leads to lack of confidence and a feeling of inadequacy in dealing with the office staff and in handling disciplinary matters. A compulsory transfer, preferably at the time of each promotion as is followed for officers in nationalised banks, or at least on promotion to the chief medical officer (CMO) grade and additional director grade, is a must to broaden their outlook. Even if the Medical Council of India (MCI) does not make it compulsory for doctors to attend refresher courses periodically to renew their registration as is being suggested, it should be made compulsory for CGHS medical officers.

Though the CGHS covers outpatient primary care, the focus is limited to secondary prevention and opportunities of primary prevention are missed. A reorientation is required to shift the focus towards prevention throughout the CGHS system. Behaviour change communication to promote healthy lifestyle should be given a major thrust at the CGHS captive wellness centres. Under the Affordable Care Act, the US Preventive Services Task Force recommends several interventions which have been proven to be effective in improving health outcomes US Preventive Services Task Force 2014). Many of them are relevant to the Indian context especially those targeting anaemia, obesity and tobacco consumption and hence should be the focus of the CGHS. To enforce this, incentive systems should also be developed so that both providers and beneficiaries comply with the primary prevention measures. Maintenance of healthy lifestyle can be rewarded by reducing the premiums just like insurance companies reward car owners for non-claim of insurance.

Under the proposed Central Government Insurance Scheme (La Forgia and Nagpal 2012), the cap of Rs 5 lakh per annum per family may do very little to control moral hazard because it will target only the extremely expensive procedures. Rather cost sharing measures/co-insurance mechanisms can be introduced where the insured will share a certain percentage of costs with the CGHS for the outsourced services, especially those with poor cost-effectiveness. In any case, the decision to include experimental forms of treatment must be based on the sound evidence demonstrating their effectiveness. Cost should also be a factor in this consideration and procedures, and drugs with doubtful effectiveness may not be reimbursed. Preventive healthcare services should be kept fully free for the beneficiaries so that they stay healthier and the demand for curative services is reduced. Active employees currently have to pay the expenses of treatment to the hospital, which are reimbursed by the government later. This could be troublesome in case of expensive inpatient treatment and cashless facility should be extended to active employees, just as it is done for pensioners. However, this may be challenging due to the complaints by empanelled hospitals of long delays in payments by the CGHS. Therefore, the scheme must simultaneously ensure timely payment to providers.

Pensioners

The fastest growing segment in terms of expenditure is that of the pensioners (La Forgia and Nagpal 2012). This is due to greater burden of disease and longer recovery periods in this segment of the population. Moreover, the scheme is not proactive enough to control this potential crisis. A majority of the elderly suffer from multiple disorders. It has been reported by many beneficiaries that they are dispensed with surplus medicines, most of which are not consumed due to poor tolerance or partial relief or may be due to lack of counseling from the health providers about the importance of compliance of treatment, especially the antibiotics, anti-hypertensives or oral hypoglycaemics, etc. Many of these patients would respond better to lifestyle modification, with the added benefit of fewer side effects. Apart from resulting in incomplete cure, there is a risk of development of antibiotic resistance if they are not consumed as advised. Such unnecessary expenditure is not justified in a country where the majority of the population suffers from poor financial protection from catastrophic health expenditure. Cities with large number of pensioners (>20,000) should have dedicated programmes for geriatric care focused on prevention. This will lead to reduction in the expenditures due to rational evidence-based care, proper compliance and preventive focus leading to improvement in health and longevity.

In short, to remain sustainable the CGHS must immediately focus on quality of service delivery in its wellness clinics as well as empanelled hospitals. One of the best ways to do so is to collaborate with premier medical and public health institutions, especially in areas of continuing technical education for CGHS staff and quality monitoring. There is also a need to reorient the focus of the CGHS from expensive curative care to cost-effective preventive care through evidence-based interventions. This is needed most urgently for the pensioners who are also increasingly claiming the most resources from the CGHS treasury. With these reforms, we can strengthen the CGHS and build upon it to progress towards our dream of universal health coverage.

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