The Employees’ State Insurance Corporation (ESIC) is stepping up its efforts to provide medical care to its beneficiaries, especially in non-implemented, partially implemented districts, and unserved areas. With an aim to strengthen healthcare access for insured persons (IPs) and their families, ESIC has devised a policy for the provision of medical services through Primary Health Centres (PHCs) and Community Health Centres (CHCs) in these areas.
The ESI Act’s Mandate
As outlined in Section 58(1) of the ESI Act, 1948, State Governments are required to ensure access to necessary medical services for insured persons and their families. This includes medical, surgical, and obstetric care. Following consultations and deliberations with various stakeholders, ESIC has developed a framework to extend primary and secondary healthcare services in underserved areas, leveraging existing infrastructure in State-run PHCs and CHCs.
Current Healthcare Infrastructure Norms
The existing norms for setting up healthcare centres across rural and urban areas provide a foundation for the new policy:
- PHCs are mandated to serve populations of 20,000 in hilly and tribal areas, and 30,000 in plains.
- UPHCs in urban areas cater to populations of 50,000, often situated near urban slums.
- CHCs are designed for larger rural populations—80,000 in hilly and tribal areas and 120,000 in plains. Urban CHCs serve as secondary care referral centers in larger cities.
- FRU and non-FRU CHCs offer essential and specialized services, respectively.
However, disparities exist in the quality and availability of services across these centers, particularly in areas with fewer resources or staff shortages.
A Comprehensive Approach to Healthcare Delivery
To bridge the gap, the new policy outlines that ESIC beneficiaries can access both primary and secondary healthcare services at the notified PHCs and CHCs. This includes:
- Primary Care: Outpatient consultations, diagnostic services, pharmacies, and medical certification for cash benefits.
- Secondary Care: Diagnostic services, medicines, and regulation certificates, with referrals to nearest ESIC/ESIS hospitals or PMJAY/CGHS empanelled hospitals if required.
Implementation Modalities
The ESIC is working closely with regional offices and state governments to assess the healthcare infrastructure and ensure that the centres meet the needs of ESIC beneficiaries. The process involves:
Assessment and Mapping: Identifying and evaluating existing PHCs and CHCs to determine their capacity for service delivery and certification of beneficiaries.
Collaboration with State Governments: The policy emphasizes the importance of coordination between ESIC and state governments. The concerned Regional Director will engage with state authorities to establish the necessary agreements (Memorandum of Understanding, MoU) for providing services.
Expansion of Resources: States will be asked to allocate additional staff, such as doctors, and provide adequate infrastructure if patient load exceeds norms.
The Role of ESIC Mitra
To facilitate seamless service delivery, ESIC will appoint ESIC Mitra—a contractual, third-party service provider—at notified PHCs and CHCs. These personnel will help manage the registration and certification processes, ensuring a smooth experience for beneficiaries. ESIC Mitras will be trained on ESIC guidelines, the Dhanwantri module, and certification processes.
Accessing Services and Certification
To streamline the process and ensure easy access for beneficiaries, dedicated registration counters and queues will be established at notified PHCs and CHCs. Services will be provided on a cashless basis, and regulation certificates for cash benefits will be issued through the Dhanwantri Module. If shortages of prescribed medicines or diagnostic services occur, ESIC will compensate beneficiaries for out-of-pocket expenses.
Special Considerations for Hilly and Remote Areas
Recognizing the unique challenges faced by beneficiaries in hilly and difficult-to-access areas, the policy allows flexibility in the number of insured persons required for establishing dispensaries in such regions. The Regional Director will assess these specific needs on a case-by-case basis and propose adjustments to the policy as necessary.
