The Role of Pradhan Mantri Jan Arogya Yojana in Managing COVID-19 in India

About the Pradhan Mantri Jan Arogya Yojana

The Pradhan Mantri Jan Arogya Yojana or PM-JAY was launched by the Ministry of Health and Family Welfare (MoFHW), Government of India (GoI), under the larger umbrella of the Ayushman Bharat scheme, in September, 2018. Aimed at serving the poor, the scheme covers the lower 40% population of the country, accounting for approximately 50 crores or 0.5 billion beneficiaries. This makes PM-JAY the largest health assurance scheme, globally. A cover of INR 5 lakh (0.5 million) per annum can be availed for secondary and tertiary treatments by an eligible family. The scheme is financed entirely by the government with the Central and State governments sharing costs [6].

The scheme envisions to cover gaps of previous central and state-level publicly financed health insurance schemes. Most of the features of the scheme, such as choice of public-private providers, cashless and paperless benefits, online mode of operation, no cap on family size, portability of benefits for beneficiaries moving from one state to another — reflect this motive [6]. Since the scheme has become operational, it has been rapidly updated through a rigorous system of feedback and quality control [7]. Most of these updates can be studied on the official website of the scheme.

So far, the scheme has dealt with numerous issues including fraudulent activity, and fake websites [7], under the commendable foresight of the National Health Authority (NHA), the apex body that manages the scheme. The current pandemic however classifies as an unprecedented event. It is thus plausible to study the response of the scheme to the incumbent pandemic, that has tested the resilience of the health systems of some of the most developed countries in the world.

We conducted a review to document the role of Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana in the management of COVID-19 in India; in terms of 1) what has been the response of the scheme to the spread of COVID-19 in India?; and 2) how can the scheme be helpful in the current situation?. We searched the official website of the scheme, press-releases since January 2020 for content relevant to the objectives of the review.

Testing and Treatment of COVID-19

Since the advent of COVID-19 in India, the testing and treatment of COVID-19 was provided for free in public hospitals. Later, on the 4^th of April 2020, GoI took a decision to cover the testing and treatment for COVID-19 under PM-JAY [8]; by the time India had seen around 2000 cases [9]. This move provided the lowest 40% of the population with an opportunity for free testing in private labs and free treatment for the disease in hospitals (including private) empaneled under the scheme.

The vision behind this step was to - 1) reduce the burden of catastrophic illness among poor, 2) encourage the private sector to participate in the COVID response, and 3) enhance the testing and treatment capacity for the disease (by engaging the private sector) to prepare for the possibility of spike in cases [8].

A package for testing COVID-19 was made available under the scheme. The rates and type of the package were as per the Indian Council for Medical Research (ICMR). The empanelled centers were instructed to test beneficiaries for COVID-19 on prescription of a qualified physician as per ICMR criteria, in laboratories accredited by the National Accreditation Board for Testing and Calibration of Laboratories (NABL), having specified real time assay to test COVID-19 [8]. They were also instructed to follow protocols defined by the ICMR, MoFHW and State Governments regarding conduct of testing [10]. The criteria and its revised updates can be observed in the communications of the NHA to the empaneled providers [11].

Packages for treatment on the other hand were already present in the scheme under various heads - acute febrile illness, pyrexia of unknown origin, pneumonia, severe pneumonia, and respiratory failures. States were provided with the option to modify these package rates in the wake of infection control measures for COVID-19. Also, depending on the condition of the patient, packages other than those listed could be invoked by the treating hospital [10].

The decision of free COVID testing and treatment under the PM-JAY was hastened in the wake of the rising cases. Still, the NHA ensured that the quality of treatment is not affected. Firstly, the rates of pre-existing treatment packages suggested for treatment of COVID-19, were made open to revision of rates so as to account for optimal infection control, isolation of cases, and personal protective equipment (PPE) for healthcare workers. Individual states could thus customize the packages to ensure provision of optimal treatment and infection control based on the expected expenses and resources in their area. The transaction management system (TMS) under the scheme was thus made flexible to incorporate change in package rate [10, 12].

Second, of the total private facilities empaneled under the PM-JAY, only those facilities that were optimally equipped to deal with the novel coronavirus cases were considered for roll-out of the free COVID testing and treatment plan [12]. This would help in controlling the spread of disease by restricting un-prepared facilities from rendering treatment for the highly infectious disease.

Thirdly, the State Health Agencies (state level counterparts of the NHA) were instructed to hasten the process of empanelment of additional hospitals based on their requirement [10]. To strengthen this commitment, the NHA launched the ‘Hospital Empanelment Module Lite’ in order to fast-track the empanelment of well-equipped hospitals under the PM-JAY. Additionally, these hospitals were given an option to either render ‘non-COVID’ services to patients suffering from cancers, cardiac or other ailments that require continuous medical support or to convert in to dedicated ‘COVID-only’ hospitals. This strategy aimed at controlling cross-infection among hospitals catering both COVID-19 and non-COVID patients [13, 14].

Furthermore, shortly after the roll-out of the free testing of COVID-19, the NHA found limited use of the package. It therefore instructed the State Health Agencies to support empaneled hospitals by linking them to private labs for testing, and also to ensure protocols of COVID-19 as mandated by the ICMR and MoHFW [15].

The importance of the PM-JAY in COVID-19 treatment was also highlighted at national level in a recent incident. The Supreme Court of India (SCI, the apex court in India) took the Ayushman Bharat (PM-JAY) scheme rates in consideration while addressing a plea. The plea sought regulation of COVID-19 treatment costs at private facilities to prevent over-charging patients in this crucial time. In this on-going hearing, the SCI has sought to ascertain the willingness of private hospitals to cap the rates for COVID-19 treatment for public based on Ayushman Bharat package rates [16, 17].

Transport facility for healthcare workers

The NHA declared its partnership with Uber India, a ride-hailing service provider in the beginning of April 2020. The partnership aimed at providing a credible transport option to India’s frontline healthcare workers serving in the pandemic. For a head start, a total of 150 cabs were promised free of cost under the ‘Ubermedic’ initiative to ease the to-and-fro movement of COVID workforce in hospitals in the national capital region and some other cities in northern India. Besides free rides, the service aimed to ensure sealed separation between the driver-passenger compartments, and disinfection of the car after each ride, to prevent transmission of the disease [18].

General Preparedness of the Scheme

Apart from the free testing, treatment and transport initiatives, certain pre-existing features and past efforts of the scheme are promising in terms of managing the current outbreak. These have been documented below.

The PM-JAY boasts a robust health benefit package that covers close to 1400 secondary and tertiary care procedures [6]. Even before the case load of COVID-19 became pronounced, the PM-JAY was pre-equipped with comprehensive packages to deal with such a disease [10]. The same were thus recommunicated when the NHA declared free treatment for COVID. Also, the resilience of the scheme in dealing with unprecedented situation is demonstrated in the mode of the operation. This can be appreciated in terms of flexibility given to states for modifying health care packages and updating the TMS that handles service delivery under the scheme; as noted above under Testing and Treatment of COVID-19.

As the PM-JAY offers portability of the services [6], beneficiaries can avail treatment in any of the participating states throughout the country apart from their state of residence or registration. This feature is particularly significant with regard to people who migrate to other states for work. For these reasons, the portability feature was recently noted as one of the biggest features of the scheme by the Hon’ble Prime Minister of India [19]. In India, the densely populated major cities are at a higher risk of COVID-19 transmission. Migrant workers serve as the backbone of such cities. Ensuring tests and treatment at place (city/state) of work can thus impact the course of the outbreak by halting undue movement of the migrant workers to native states to seek treatment. Furthermore, this would ensure trust in the health-care system in these sensitive times.

Other promising features of the PM-JAY are the cashless, paperless transactions and online mode of operation [6]. These features may play a positive role in the controlling disease transmission by reducing excessive movement and physical exchange, especially with surge in number of COVID care sought under the scheme in the near future.

As the novel coronavirus is highly infectious, instances with multiple members of same families being infected are expected. A maximum claim amount of INR 5 lakh or 0.5 million, with no cap on family size [6], can play a pivotal role in saving poor families from catastrophic expenditures on testing and treatment.