When the Comptroller and Auditor General tabled its audit of the Ex-Servicemen Contributory Health Scheme (ECHS) in Parliament on December 18, it did so without spectacle. There were no allegations of corruption, no dramatic losses to provoke outrage, no ready villains. The report passed almost unnoticed. Yet, read carefully, it offers a sobering account of how welfare schemes in India can survive politically while quietly faltering administratively.
Launched in 2003, ECHS was conceived as a moral assurance. After years of service, ex-servicemen and their families would not be left to navigate the uncertainties of civilian healthcare. Treatment would be comprehensive, cashless and capless, delivered through a nationwide network of polyclinics, service hospitals, government facilities and empanelled private hospitals. Over time, the scheme expanded with the growing number of veterans and came to symbolise the state's continuing obligation to those who had served it.
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What the audit makes clear, however, is that the scheme's ambition has steadily outpaced its administrative capacity.
One of the most persistent problems flagged by the CAG is uneven access. While ECHS formally spans the country, its actual reach varies sharply by region. In many areas, beneficiaries are compelled to travel long distances for referral treatment because empanelled hospitals are few or unevenly distributed. Even within the same regional centres, access can be skewed, leaving some pockets well served and others effectively excluded. The ministry has taken steps to simplify empanelment and expand the hospital network, but the audit underlines a deeper truth: a national welfare scheme cannot function reliably when access depends on geography.
Manpower shortages compound the problem. Despite a steady increase in the number of ex-servicemen, the categorisation of polyclinics, which determines their staffing levels, has not been revised since the scheme's inception. Authorised manpower at central offices, regional centres and polyclinics has remained largely unchanged for over two decades. Shortages were further aggravated when staff were diverted away from clinics to administrative offices. Recent approvals for additional manpower acknowledge the issue, but they also reveal how long the system has been operating on an outdated blueprint.
Infrastructure failures follow a familiar pattern. The audit documents shortages of medicines supplied by service hospitals, deficiencies in medical equipment, and the continued use of ambulances well beyond their economic life. Mobile Medical Units struggled to operate effectively. At the same time, capital budgets remained underutilised despite the availability of land to construct permanent polyclinic buildings. The contradiction is striking: resources were available, but execution lagged. Corrective approvals have now been issued, yet the audit suggests that delay, not scarcity-was the real obstacle.
The most damaging weakness, however, lies in financial management. Persistent shortfalls in allocations under Medical Treatment Related Expenditure led to recurring carried-forward liabilities year after year. Payments to hospitals were delayed, reimbursements to beneficiaries stalled, and private hospitals quietly opted out of the scheme. Veterans bore the consequences—either by paying out of pocket or discovering, often at the point of care, that coverage did not guarantee treatment.
A cashless healthcare scheme that regularly forces beneficiaries to advance money is not merely inefficient; it undermines the scheme's central promise. The ministry's proposal for a one-time infusion of funds to reduce liabilities is a necessary step. But the audit's message is unmistakable: predictable expenses were treated as annual contingencies, eroding trust along the way.
Beyond finance and infrastructure, the report flags softer but consequential gaps in oversight. Verification of emergency admissions remains inconsistent. Kiosks meant to ease processes at empanelled hospitals are unevenly installed. Station ECHS Vigilance Teams, designed to provide local oversight, function irregularly across the country. Individually, these appear procedural. Collectively, they determine whether a system learns from its failures or merely records them.
Read as a whole, the audit does not describe a scheme in crisis. It describes one worn down by neglect—expanded without redesign, digitised without integration, and corrected through piecemeal measures rather than structural reform. The ministry's responses show intent, but they also confirm how long these gaps were allowed to persist.
What gives the ECHS audit wider significance is how familiar its contours feel. Schemes grow, beneficiary numbers rise, but administrative frameworks remain frozen. Technology is layered on without rethinking workflows. Accountability weakens as complexity increases. In this sense, ECHS is not an exception but a mirror held up to India's welfare state.
The report does not ask moral questions outright. It does not need to. They hover between the lines: If the state struggles to deliver timely healthcare to those who once served it in uniform, what does that say about its ability to care for everyone else?
The absence of a scandal made this audit easy to overlook. That would be a mistake. Because what the CAG has documented—quietly and meticulously—is not just the story of one scheme, but a warning about what happens when governance begins to rely on endurance instead of reform.