India had opened up Covid-19 vaccination for the 18-44 years category starting May 1, 2021. This was done under the ‘Liberalised Pricing and Accelerated National Covid-19 Vaccination Strategy’, which resulted in the target population being increased three-fold (while vaccine supply remained nearly the same); three different market prices for the same vaccine (for three groups - Union, state and private sector); and shifting responsibility to the state and private sector, by making them directly purchase vaccines from manufacturers. A quota system of 50-25-25 for manufacturers, to supply vaccines to the Centre, state and private sector, respectively, was developed.
The strategy received heavy criticism from subject experts. There were many technical and operational arguments against the new strategy. To start with, for all government vaccination programmes and campaigns i.e. polio elimination, in India, the Central government would procure vaccines while the states were involved in delivery. The states do not have prior experience of vaccine procurement in India and were pushed into uncharted territory. The differential price for states meant that overall government spending on vaccines (though responsibility was shifted to the states) would be far higher than had the Central government done the procurement. The independent experts had one common suggestion: in the pandemic, vaccines should be free for all citizens and Centrally procured, at a single rate (countries across the world are doing so).
New strategy stalled drive
From Day 1 of the implementation of the new strategy, the vaccination drive nearly derailed. There was a shortage of vaccines and the vaccination for all age groups slowed down and was halted by many states for the 18-44 age group. The vaccines being produced by Indian manufacturers were not enough to meet the increased demand. To surmount this challenge, nearly a dozen of Indian states floated global tenders, only to be told that international manufacturers would deal only with the federal government. Thereafter, the chief ministers of many Indian states wrote to the Union government to procure vaccines on their behalf and provide them either at a common rate or free to the states. Alongside, with the new vaccine-sharing formula, there were more than sufficient vaccines with private hospitals and not enough at the government facilities.
The matter was taken up suo motu by the Supreme Court of India, which termed the vaccination strategy ‘arbitrary and irrational’. The mandatory registration on CoWin and the limited slots available made booking a slot very challenging, even for those with electronic devices. All this was creating inequities in access to Covid vaccines, with those in urban settings and in higher income groups having easier access.
Change in plans
After more than five weeks, on June 7, 2021, the government of India reversed a few decisions in its strategy. Now, the Union government will procure and pay for 75 per cent of the total Covid vaccines available in India. The states will be responsible for delivery. Vaccines will continue to be free at all government facilities (which was the case earlier as well, except that the cost of vaccines for those aged 18-44 years was being paid by the state government). Vaccines at private facilities must be paid for by the people and the maximum service charge which can be levied has been capped at Rs 150.
The mid-course corrections are the right steps and likely to bring the Covid vaccination programme back on track. However, we need to remember that every preventive health service, including vaccination, has always been free for all citizens, through government health services in India. Therefore, the claim that the government is providing Covid-19 vaccination for free is specious. Had it been thinking of charging people for these vaccinations and then decided to make it free? The Central government has always paid for vaccination and it has again accepted the responsibility, as it should have done in the first place.
Revisit private sector allocation
The share of the private sector in the total facilities conducting Covid-19 vaccination is around 4 per cent; while they are assigned 25 per cent of vaccine share. It is not surprising that private sector facilities always have vaccines while government facilities don't have supplies. As vaccine supply is likely to increase in the weeks ahead, the proportionate allocation would be far higher than the private sector can use. Therefore, a better approach would be to allocate by the absolute dose requirement in the private sector. Alternatively, to keep it simple, the allocation of vaccines to the private sector should be proportionate to the facilities in that sector. This has potential to increase availability in the government vaccination centres.
In other countries across the world, irrespective of public or private facility for vaccination, people don't have to pay any fee. And that is an approach India should adopt, if it wants to call the programme really free for all citizens. Therefore, capping service charges at private facilities is a progressive step. However, the Indian government should consider purchasing 100 per cent of vaccines from manufacturers and providing them to the private sector (as was originally being done from January to April 2021) and even the service charge should be paid by the government, on behalf of the people. That would make vaccines really free.
Some credit for this policy reversal goes to the independent health experts, who provided critical technical inputs about loopholes and suggested areas of improvement in the vaccination strategy. It will benefit citizens in the future if the government pays more heed to independent experts in such technical and policy areas. While some policy and vaccine supply issues are being addressed, it is time that both state and union governments iron out delivery and operational issues as well.
A detailed roadmap for the Covid vaccination rollout, factoring in vaccines in the pipeline, should be developed at least till December 2021. An evidence-based communication strategy should be designed and earnestly implemented, to ensure that vaccine hesitancy is tackled, which is very essential to increase coverage.
A revised vaccination strategy is a step in the right direction; however, there is a lot more, which can be done. The approach should be to do everything needed to ensure that every citizen is protected from Covid, and vaccines are delivered in a hassle-free and timely manner.
The writer is a medical doctor, epidemiologist and India’s leading vaccine expert. He is the co-author of Till We Win: India’s Fight Against The COVID-19 Pandemic. His email address is firstname.lastname@example.org