Sharp differences have arisen in state vaccination efforts and it’s clear which approach is superior
The covid vaccination rate in India dropped from 7.6 million jabs per day in September to about 5.5 million per day in October. The supply of vaccines has steadily increased through this period, so the fall is not because of a dose shortage. It is also not a deliberate deceleration of the programme. We are nowhere near 100% vaccination coverage even for the adult population; so actually, we need to continually improve the vaccination rate. As of now, an estimated 35% of the adult population has received two doses and 78% have got one dose, implying that 808 million more doses need to be injected for two-dose coverage of our entire adult population. So, what is going on?
Eight weeks ago, in this column, I had described how and why our vaccination programme will struggle to reach full coverage, with each next 10 million doses getting harder and second-dose coverage even harder within that. Let me cite that piece: “We may soon be awash with vaccine supplies, but we will not know who these have to be delivered to, when and where, and how to make it happen. The last 25% of the country will be the hardest, and most of them would be the most vulnerable and disadvantaged. A few, but too few, states are acting systematically on all this. If we don’t rapidly improve our on-the-ground execution, it may well be a year before India is fully vaccinated." There is no pleasure in being proven right on such a matter.
Last week, the press reported that the Union minister for health emphasized the criticality of accelerating second- dose coverage—in a review with the state health ministers. This is exactly the right thing to do, given the current situation and trajectory. As of last week, over 103 million second doses were overdue. ‘Overdue’ means that the second dose has not been injected even after the prescribed gap between the two of 12 weeks for Covishield and 4 weeks for Covaxin. As of last week, of these 103 million second doses, over 39 million were more than six weeks overdue, and about 16 million were up to 4-6 weeks late.
At the Azim Premji Foundation, we have the benefit of an unfiltered view of the vaccination drive’s ground reality. We are working to help this programme in over 2,000 primary healthcare centres (PHCs), serving a population of over 70 million, across 20 states. This work stretches from slum settlements in metros to some of the most difficult terrains and hardest to reach places in India. That is how we observed the problems we did 12-16 weeks ago, so I could write what I did 8 weeks ago. What do we see now?
First, the core issues hobbling the programme stay the same. Very poor data on the residential locations of people who have been vaccinated has led to inadequate planning. Combined with weak on-the-ground capacity to mobilize people to get vaccinated, all of this has made for ineffective management at the basic unit of operation, the PHC, despite the best efforts of local teams.
Second, many more states are now attempting to deal with the challenges systematically. In the past 12 weeks, there has been a noticeable improvement on most fronts, but in the face of the complexity of on-the-ground challenges, these have been insufficient to address the core issues.
Third, there continue to be significant cross-state differences. While all states have improved, some only barely so. Even now a few operate through ‘brute force’ rather than thoughtful planning and rigorous execution. This is one reason why outcomes in the form of speed and thoroughness of vaccination coverage continue to vary widely across states.
Fourth, without doubt the basic administrative capacity and culture of states is influencing the trajectory of the programme. But a few states that would be ordinarily classified as in the bottom half on such capacity and culture are doing well because their state-level leadership is deeply connected with the ground reality, instead of sitting in the state capital and issuing orders. On the other hand, some that would be classified among the top are doing poorly.
These are among the states that are operating through ‘brute force’: setting tough daily targets, for example, and expecting ground-level officials to solve problems that are systemic through local workarounds. A more reprehensible example of this approach is to threaten communities with the withdrawal or stoppage of basic (and often legally mandated) social security measures, such employment under the rural job guarantee scheme, rations from the public distribution system, etc. In contrast, states with their leadership in touch with ground reality are adopting a problem-solving approach that supports and enables PHC-level officials.
Fifth, most people in the public health system and relevant officials in the overall administrative system are working very hard. Even those who may have been slackers are getting drawn in by this momentum. Understandably, very many are deeply fatigued. They have been at the frontline of the campaign against covid since April 2020, including through the cataclysmic second wave. The ‘brute force’ approach, in the states which have it, worsens their problems.
I will report back in a few weeks. In the meanwhile, we can only hope that more and more states realize that the only path to full vaccination is detailed planning and sound execution, and not ‘brute force’.