How India can crack the vaccine challenge

With the UK having started vaccinations against covid-19 and other countries set to follow soon, it is time to unveil India’s strategy and publicise it. The issues have been discussed internally in the government. The states, which will have to be at the forefront of implementation, are also being consulted. The prime minister has already announced the prioritisation of individuals to be vaccinated.

This is all to the good. There is a lot at stake because success in covering close to 700 million persons within 12 months would be a major achievement. It would help counter the perception, currently widespread, that India is a poor performer in health. It would also project an image of India as being well placed in the post-pandemic period and be a positive factor in promoting investment.

But for that to take place, there remain several critical issues on which decisions are needed.

The vaccine basics

While it is natural to talk of providing the vaccine to every individual, it is not necessary to aim at covering all 1.3 billion persons. Covering 70% would be sufficient to achieve herd immunity to stop the pandemic. That still amounts to over 900 million, but children under 10 and pregnant women should also be excluded because none of the vaccines has been tested for these groups.

The operational target is therefore less than 700 million and if this has to be achieved within a year we need 1.4 billion vaccine doses, assuming a two-dose vaccine. Securing 1.4 billion doses over a 12-month period is a challenge, but we are well placed compared to other developing countries because we have a large vaccine production capacity.

The Serum Institute of India is the largest vaccine manufacturer in the world. It is producing the AstraZeneca-Oxford vaccine and will also produce the Novavax vaccine. It is expanding capacity to 1.2 billion doses per year, and half of this could be available for India. Other Indian manufacturers engaged in clinical trials to produce a vaccine are Zydus Cadila, Bharat BioTech, Dr Reddy’s Laboratories and Biological E.

Choosing the vaccine to use in the vaccination programme is not a simple matter. The vaccines in the pipeline are based on very different technologies—messenger RNA, adenovirus, and the traditional approach using an inactivated virus. Each vaccine will differ in its degree of efficacy, side effects, and impact of different age groups depending on the presence of co-morbidities. To complicate matters, the extent of these differences will not be fully known at the time regulatory approval is given.

It makes sense in this situation to use multiple approved vaccines and track the outcome systematically using Aadhaar-linked to batch numbers of the vaccine and also the specific vaccination occasion. Since several millions will be vaccinated every month, an effective tracking system would enable us to identify problems with particular vaccines which were not caught in the tests on the basis of which regulatory approval was given. We can then quickly weed out the vaccines that are less effective.

The government has discussed supply situation with major domestic producers. It is not known whether firm advance orders have been placed, but it has been reported internationally that India is one of three countries that has “tied up” over 1 billion doses. If this is indeed so, it augurs well for the programme.

Funding the programme is a contentious issue. Should the vaccine be free for all beneficiaries or only for some, with others having to pay for it? On balance, differential pricing in a public-sector programme will be extremely cumbersome and it may be best to keep the public sector programme completely free combined with a private sector channel in which the individual would have to pay.

The central government should bear the full cost of the vaccine and the syringes for the public-sector programme. The states will also incur some additional costs for delivering the vaccine and training personnel. Given the severely-strained financial position of the states, the central government could also consider a special grant to each state to cover the whole or part of these costs.

This implies that the Centre may have to provide an additional ₹35,000 crore for the vaccination programme in the budget for 2021-22. Any adverse impact on the Centre’s fiscal deficit on account of this expenditure would not attract criticism.

The centre and states

Both the Centre and the states have critical roles to play. The central government has said it will be exclusively responsible for procuring vaccines for the public programme. It will almost certainly also take direct responsibility for covering all health workers in central government hospitals, the military and paramilitary forces under its control, and key functionaries in essential services like the railways, air traffic control, airports, etc. This part of the programme would require less than ten million doses and could be rolled out in the first few months.

The bulk of the vaccine supply would have to be allocated to the states. They would be responsible for vaccinating the frontline health workers in both state government and private sector hospitals, the police, teachers, and municipal workers, etc. Most importantly, it is the states that would have to deliver the vaccine to the general public.

The actual identification of individuals falling into the different priority groups will have to be done by the state governments. Identifying older persons with comorbidities will be an onerous task since there is no database. States will have to depend on persons coming forward and self-declaring.

It is essential to ensure that the distribution of limited vaccine supplies across states is done on a transparent basis. It could be the proportion of total population; the proportion of new covid cases; or covid deaths which indicate the intensity of the infection or the age composition of the population. Each of these three criteria would give different results. All can be used by giving them weights.

Ideally, each state should be informed as early as possible how many doses it can expect to get and at what pace so it can plan the roll out of its programme. Vaccination for covid-19 will be much more difficult than polio inoculation because it requires an intramuscular injection instead of oral drops. Injections are normally given by nurses, but they are in desperately short supply, and it doesn’t make sense to divert them from their normal jobs to deliver vaccinations.

Fortunately, an educated person can be trained relatively quickly to give an injection. The states should use the time available between now and March, when the first vaccinations are likely to begin, to train personnel. Private sector pharmaceutical companies and hospitals could be roped in to help with the training.

A major problem with centrally-sponsored schemes in the past is that they suffer from excessively rigid guidelines being laid down by the Centre. State capacity and ground level conditions vary greatly across states and experience shows that state governments must be given the maximum flexibility in implementation. For example, the prioritisation of individuals may need to be supplemented by prioritisation for geographical areas that are hotspots. The willingness to grant flexibility will be a test of cooperative federalism.

The private sector

Many will argue that the free vaccine paid for by the government should be delivered only through government hospitals and dispensaries. While this can work well in countries where there is an established National Health Service, the situation in India is very different. Large proportions of the population, especially in urban areas, rely on private medical practitioners.

Once we go beyond vaccinating government employees and start covering the general public, it does not make sense to make vaccination a state monopoly.

Private entities such as pharmacists and testing labs could be enrolled as authorised agents of the state government to deliver vaccinations. They could administer the vaccine to eligible persons, identified by Aadhaar as being part of the priority list, and charge a small fee for administering the vaccine. Those preferring to go to government dispensaries could still get a vaccination entirely free. Decentralised delivery will help to avoid crowding in public sector dispensaries which can easily turn into super-spreader events.

Private hospitals and clinics should also be allowed to buy approved vaccines from the market and offer them to the general public for a fee. This need not be at the expense of the public sector effort.

The Pfizer and Moderna vaccines for example may not be picked up by the national programme, because they are much more expensive and require sub-zero storage conditions. But if they receive regulatory approval (Pfizer has already applied), private hospitals and clinics which may be able to provide the sub-zero storage required, at least in the major cities, should be allowed to import and offer them to the public. There are precedents for vaccines not in the national programme being imported in the country for distribution by the private sector.

It may be difficult to get supplies from the market in the early months. However, availability could improve later because many developed countries have placed advance orders many times their national requirements. As these excess quantities are released, supplies will improve.

Domestic availability is also likely to improve over time since the government may decide not to buy up all the production. Vaccines produced beyond the orders placed by the central government and firm export commitments should be allowed for purchase by the private sector.

Furthermore, private companies may be willing to vaccinate their workforce at their own expense, perhaps including even their families. If they can procure the vaccine from the market, they should be allowed to do so, reducing the burden on the government. They should be allowed to use CSR funds for this purpose.

It will be important to avoid price controls on vaccines supplied to the private sector at least for the first two years. There will be people willing to pay for new and more expensive vaccines, perhaps because they believe they are more efficacious or particularly suited for their individual circumstances, or because they are being provided in a more convenient and congenial manner. They should be allowed to do so.

Denying high-income individuals access to state-of-the-art vaccines available abroad will lead them to go abroad to get vaccinated. In fact, some of our private hospitals may be tempted to set up vaccination clinics in Nepal or Sri Lanka to offer these vaccines with much lower costs even after accounting for airfare.

Communication is key

It is commonly said that everyone is “anxiously waiting for a vaccine” but there are also genuine concerns about safety. Many groups in developed countries have expressed concern that their regulators have been under political pressure to clear vaccines through emergency authorisation, cutting short normal due diligence in testing for safety.

Since the vaccine cannot be mandatory and has to rely on voluntary uptake, we need an effective communication strategy to counter fears. This calls for high levels of transparency on the criteria going into drug approvals and also on the results from the early vaccinations. It would help to launch a campaign with prominent people being vaccinated publicly on TV to increase public confidence. This group should include all MPs and MLAs , the usual official dignitaries, and people from Bollywood and sports.

A clear articulation of strategy could provide the basis for a consensus across states and other stake holders on the fight against covid-19.

Montek S. Ahluwalia was deputy chairman of the former Planning Commission