Home >Opinion >Columns >Equitable vaccination coverage is among our biggest challenges

We live in an uncertain world. What has happened in India in the past few weeks is testimony to this fact. The country has been taken aback by the recent surge in covid cases and it has exposed the fault lines in our healthcare system. Vaccinating our people in large numbers in the quickest possible time is going to be crucial if we want to get past the deep scar that this pandemic has caused.

With 1.3 billion people, India faces a seemingly mammoth immunization challenge. The country started its covid vaccination drive on 16 January 2021, with vaccine jabs for healthcare and frontline workers. On 1 March, India embarked on the drive’s second phase and opened vaccination for people aged above 60 and those between 45 and 60 with co-morbidities. Beginning 1 April, everyone aged 45 and above was eligible for vaccination, and finally, starting 1 May, everyone above 18 was made eligible for it.

The vaccination challenge that India faces has changed fundamentally in recent days, with supply constraints and multiple vaccine prices being the major issues, as opposed to just vaccine hesitancy, which was seen as a big problem in the initial phase of the drive. However, once we fix the issue of vaccine supply and vaccination coverage expands in the coming months, the country’s key challenge will be that of ensuring equity in vaccine access.

First , the government will have to address the under-provisioning of healthcare facilities in poorer states. The accompanying figure shows the negative association between the target population and income levels of states. The trend line is negatively sloped, which suggests that poorer states, on an average, have a larger target population to vaccinate. However, other data analysis shows that states with larger target populations also tend to have weaker health and human infrastructure. Hence, the government will have to come up with alternatives to ramp up capacity in poorer states to ensure the timely vaccination of their target populations.

Equitable vaccination coverage is among our biggest challenges
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Equitable vaccination coverage is among our biggest challenges

The second key challenge the government faces is that of bridging the rural-urban divide in vaccination coverage. As per estimates, there are nearly 850 million people in India who are aged 18 years or above, of which almost 70% reside in rural areas. While the decision to partner with private health care providers is welcome, it also poses a new problem for which states need to be prepared. As data reveals, there is an under-provisioning of private healthcare providers in rural areas. States with higher rural populations tend to have fewer private hospitals per million people. The situation appears to be exactly opposite for government hospitals, where we see better coverage in states with higher rural populations. One may tentatively infer two conclusions based on these numbers. First, as the vaccination drive gathers pace, we may see urban India, which accounts for most of the country’s private healthcare providers, surging ahead at the expense of their rural counterparts. Second, government hospitals will continue to play a crucial role in the success of the vaccination drive in the second phase and in bridging some of the urban-rural divide. However, it may not still be enough to ensure timely vaccination of rural India’s vulnerable population.

What can be done to address these challenges? As far as the vaccination pace is concerned, it will likely improve with the entry of private healthcare providers offering vaccines. However, there is significant scope for further improvement. As per the ministry of health and family welfare, India currently has the capacity to administer nearly 3.2 million vaccines daily. However, average capacity utilization was only 60% in government as well as private hospitals even before supply constraints became an issue. The government also needs to resolve the logistical issues, such as the smooth functioning of its CoWin app, to speed up vaccinations. Additionally, there is vast scope for capacity expansion in the private sector. At present, the government has partnered with only about 10% of India’s private sector hospitals for administering vaccines. To enhance coverage, states and Union territories must be encouraged to leverage the private sector to the maximum. The government should also consider removing the cap on the number of shots each centre can give daily, especially government health centres.

The bigger challenge remains one of ensuring equality in vaccination coverage. The government will have to prioritize India’s poorer and rural districts to ensure timely vaccination of the country’s target population. First, the government should consider using additional physical infrastructure, especially in rural areas, for the purpose. Given the widespread presence of government school buildings and their proximity to people, these can be used for the vaccination drive. Second, close to 140,000 government health sub-centres have been kept out of the vaccination programme so far, for lack of requisite infrastructure. These sub-centres do not have full-time medical officers, and usually function with just a single room. The government should consider deputing medical officers temporarily to these sub-centres and setting up make-shift cabins to treat those with adverse effects without compromising social distancing norms. As majority of these sub-centres are in rural areas. Including them in the effort will boost the vaccination drive in rural India.

Abhishek Anand is a graduate student at the Harvard Kennedy School.

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