The Pitfalls in India's Vaccination Policy
Anushca Thomas - Guest Author
Picture Credit: The Hindustan Times
The task of vaccinating an entire population of 1.4 billion can be met only with efficient and equitable strategic planning. Alas, the Indian programme has been nowhere near these two agendas. The follies of Indian vaccination programme have been countless. Right from procuring the vaccines to deploying them, the policy followed has been thoughtless and chaotic. India still lags behind most other countries with less than 3.5% of the population fully vaccinated until now (as on 25th May, 2021). This stands in stark contrast to countries like the US, UK, Israel that have already achieved more than 40% vaccine coverage. It seems that amidst the raging second wave when dead bodies are floating in Ganga waters, the centre has absolved its responsibility of vaccinating people by transferring the major share of workload to the states and the private sector.
India’s population density was highly conducive to a breakout regardless of any actions that the government could or should have taken. This is especially applicable to the rural areas of India; notorious for its meagre health facilities and dense population. The rural population came through the first wave of the virus relatively unscathed. Our hon' health minister even praised this delusive victory by proudly declaring that we were entering ‘the endgame of the pandemic’. This false sense of security crept in at a time when ICMR sero-survey had proved that only 1/5th of the Indians had antibodies to resist the virus and the majority were still susceptible to the virus.
The Don’t Rush Challenge
It is this complacency in the system that curbed us from making advance vaccine purchases, at a time when countries like Israel, UK, Hungary were placing advance orders 4-5 times their entire population, already in 2020. The Bill & Melinda Gates foundation risk-funded about 300 million dollars to SII as early as September 2020 for the vaccination development. As opposed to this, India invested 4500 crores in the two Indian manufacturers SII and BB, only by April, 2021 when the death toll was at its apogee. India has been a laggard in its assessment of the gravity of the situation as can be proved in the piecemeal strategy adopted by us for procuring vaccines. This slow-moving policy gave the vaccine manufacturers zero incentive to produce more as has been pointed out by Adar Poonawalla. He retorted “There were no orders, we did not think we needed to make more than 1 billion doses a year.” Policy-makers underestimated the deadly virus and ordered only about 15 million vaccines initially without realising the benefits of mass vaccination.
Government was keen on undertaking a ‘don't rush’ challenge by ordering meagre amounts of vaccines over hugely spaced intervals rather than having a bulk order which would have helped in increasing the capacity of vaccine manufacturers. India requires 1932 million doses to provide 100% coverage against the virus to individuals above 18, and at least 1160 million doses for 60% coverage. As 100% vaccination coverage seems too ambitious to be true, we need at least 3.8 million doses a day to achieve 60% coverage by January 2022. But as of reports from May 1st, India is struggling to administer 2.4 million doses daily when the deaths are close to 4000 on an average. Thus, at this slow pace, India will be a welcome home for the virus for a third wave as well.
Flaunting ‘Make in India’ amidst a pandemic was not nationalism but an arrogant display of jingoistic nationalism that has placed us in this conundrum. Techniques that lacked rationale and scientific thinking were blindly followed by the government. While countries like UK, Hungary, Israel were approving multiple vaccines, we limited the official approvals to two vaccines- Covishield and Covaxin, warding away other vaccine manufacturers from the market. We committed a logical fallacy by not pre-ordering potential vaccine candidates (J&J, Sputnik, Novavax) from around the world. The conservative policy of Atmanirbhar is backlashing upon us in the form of severe vaccine crunches today. India with its magnanimous population size and dismal health system could have pre-ordered vaccines for all its citizens with just 0.36% of its GDP (Ind-Ra). This would have trickled down in the form of herd immunity helping the country to possibly dismiss the second wave and thereby saving 2-3% of the GDP. India warded interested vaccine manufacturers like Pfizer away from the market by parading a slew of licensing requirements. What an irony that within a few months we are begging them to sign contracts with us.
‘Divide and Give’ Policy.
The government has failed to realise that the COWIN app has only been a ‘win’ for the privileged. The rat-race to book slots through the app within the stipulated time is a luxury for many Indians because they are in the race to fill their plates for a day’s dinner. The use of digital technologies to avail the health services that people are entitled to has been nothing but a sheer automation of inequalities that persisted in the society. The essentials of booking a vaccine slot are not limited to having a smart-phone alone, but also the availability of stable connectivity and technical know-how. The uncertainty regarding when the booking will begin, has closed the doors of vaccine registration to many daily-wage employers in India. The employment of English language by COWIN without translations to native languages has exacerbated exclusionary politics further. The tech savvy has been reserving all the elusive appointments to themselves by hacking into the system. With all these limitations, the marginalised and disadvantaged groups don't stand a chance to procure the vaccine.
Centre’s New ‘Ill- Conceived’ Strategy
Hitherto, the central government as the wholesale buyer of vaccines could drive down the prices to affordable rates. But the new policy of fragmenting and tiering the market between centre, state and private hospitals has opened the Pandora’s box. The centre has neatly absolved their responsibility of procuring vaccines for the nation by transferring the onus to the states and private organisations. This was done on the pretext that markets could allocate vaccines more efficiently and also helps in beefing up the production. This will lead to an unhealthy competition between the states and the private hospitals making the situation more chaotic. Larger private hospitals with better networking can procure vaccines from SII and BB in bulk leaving the rural and smaller hospitals at a disadvantage. This is the perfect recipe to poison the benefits of a universal immunisation programme by indirectly allocating all the vaccines to the rich in metropolitan cities.
The new strategy has abandoned the centre’s power to channel diplomatic connections into vaccine procurement by transferring the burden to the states. States are ill-placed to deal and network with international manufacturers because of diplomatic constraints. Given the disproportionate financial and diplomatic resources among states, there will be an unequal distribution of vaccines amongst states. With poor resources states are given the task of vaccinating 600 million 18+ individuals while the centre is managing free vaccination only to the 300 million 45+ adults. This ill-conceived strategy doesn't take into consideration the very fact that the centre has a constitutional obligation to stop the inter-state transfer of infectious diseases under the concurrent list.
Given the fact that Bharat Biotech had ICMR and NIV as its knowledge partner in the development of Covaxin, Indian government could have leveraged the advantage by licensing production agreements in January itself. This could have helped India, dubbed as the ‘pharmacy of the world’ to get out of the vaccine crisis by ramping up production in the country. Although this has been recently licensed to three domestic manufacturers including Haffkine, it has become too late to begin. We will have to wait 3-4 months for them to scale up production and solve the vaccine shortage. Besides the folly of not opening the vaccination for 45+ in early March, we have now placed the cart before the horse by opening up vaccination to citizens above 18+. This demands us to open the market up for multiple vaccines and ramp up production through licensing multiple manufacturers.
Way Forward and the Kerala Model
To save the country from a pandemonium it is time to own up mistakes and rectify them. This is neither the time to hoist the nationalistic flag nor to play blame-game amongst political parties. However late, now is the time to invest in capacity augmentation to achieve expanded vaccination hastily. Centre cannot and should not abdicate its responsibility by providing free vaccination to 45+ alone. They should take an active part in procuring vaccines for the states and deploying them transparently. To provide accountability, a daily dashboard of vaccine deployment should be provided at the centre, state and distinct level. Moreover, the centre should not be hung upon the exclusionary COWIN app that serves the tech savvy and literate alone. We have to diversify the efforts to vaccination by actively employing ASHA workers, primary health centres and Polio vaccination infrastructure to register people under the vaccination drive. It's high time that we move away from unfair market fragmenting practises of pricing and earmarking, so as to enable equitable vaccination for all.
The states could emulate from the ‘Kerala Model’ wherein vaccines are rolled out more equitably on a transparent canvas. A daily dashboard of doses administered and stock left in each district is communicated to the people through the Covid Control Room. Moreover, in the 18-45 group, vaccine slots are neatly divided amongst the priority category without leaving it to the fate of ‘fastest fingers’. This system could be adopted at the central level as well, as vaccines shortage is at its peak for the 18-45 category.
Lastly, it has been time and again proven that our immediate focus should be not on revisioning the public-sector healthcare but the public health care, whereby we can envision a system that can ensure the health of the public- population. For guaranteeing maximum participation in this universal vaccination programme, our government should think about initiating a ‘voucher system’ whereby the government provides the disadvantaged sections vouchers for vaccination. We should leave it up to the population to choose between the private or public healthcare to receive their vaccination.
All the views, thoughts, and opinions expressed in the article solely belong to the author and do not necessarily reflect the official policy or position of C.R.R.S.S, as an organization or to other groups of individuals belonging to C.R.R.S.S. Assumptions made in the analysis are not reflective of the position of any other entity other than the author(s) - and, since we are critically-thinking human beings, these views are subject to change, revision, and rethinking at any time. Please do not hold them in perpetuity.
About the Author:
Anushca Thomas is an undergraduate student of History Honours at St Stephen’s College, University of Delhi. She is an ardent reader and research enthusiast, interested in SDGs, health, and environment policies.