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On 1 May, within two months of delivering the first dose of vaccine to the elderly general population, India launched the third phase of its covid vaccination programme by opening it to everyone greater than 18 years of age. Under normal circumstances, this would be viewed as a signal of a strong government response. However, the ground reality and the national mood are markedly different: a second wave has been raging across the country, several states are reported to be out of vaccine stocks, and only about 2% of the entire population and less than 10% of the elderly (>60 years) were fully vaccinated as of 30 April.

The liberalized phase 3 strategy, announced on 19 April, rests on three main pillars: i) creating a separate (non-Union government) channel for states and private hospitals to procure 50% of the country’s total supply; ii) allowing price differentiation by vaccine manufacturers across the two channels; and iii) expanding eligibility for vaccination to everyone aged above 18 years. The premise of this approach is that it will: i) unleash latent demand from India’s younger population, and ii) expand supply through the provision of financial incentives to manufacturers.

As the third phase is currently underway, let us consider some of the circumstances that prevail.

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Inelastic supply: Despite the enhanced incentives in the non-government channel, supply may not expand in the short term due to constraints in raw material supplies and production capacity. Our analysis indicates that the high vaccination rate seen in the first week of April among those in the priority segment (above 45 years) cannot be maintained with the projected vaccine supply rate until at least the end of July, let alone cater to add-on demand from the younger population.

Crowding out of demand from the elderly: Vaccination slots are limited by supply, and opening vaccination for the younger segment will impose negative externalities on the elderly by crowding out available slots. Access barriers for online registration and appointment booking are far lower for the younger population than the elderly, as seen from the several million registrations recorded on the government’s CoWin portal within the first few hours of 28 April, when it opened up slots for all adults. Elderly patients who attempt a walk-in registration may be discouraged by long queues and the associated higher risk of transmission, and may decide to return unvaccinated. An analysis of vaccination data related to the previous eligibility expansion to the 45-60 years group (before and after 1st April) shows that although the overall vaccination rate increased, the growth among above-60 recipients slowed down, leading to 16.5 million fewer vaccinations in this segment. The crowding out will be even higher for those who cannot afford the higher prices of vaccines administered by the private sector. Finally, the vaccination decision-making process will become more complex and cognitively burdensome for the elderly, as they choose between different vaccine brands and sales channels, each with a different price. This can lead to inaction or delayed action, thereby further increasing vaccine hesitancy.

The immediate policy goal should be to maximize public health benefits (such as reduced covid hospitalizations and mortality) within the constraints of limited vaccine supply, and not merely to maximize total vaccinations. Towards this goal, each additional dose must be delivered so as to maximize its marginal benefit. Global evidence thus far suggests that, irrespective of the virus variant, each unvaccinated elderly person faces a higher chance of experiencing serious illness if infected compared to each unvaccinated young adult. Further, each hospitalization of a seriously ill elderly patient causes greater strain on the health system, given the prevalence of co-morbidities and age-related complications. Finally, every seriously ill elderly patient also imposes a large economic burden, as immediate family members spend time and providing care, resulting in lost productivity.

Central and state governments must adopt a two-pronged approach to ensure that the public health impact of limited vaccine quantity is maximized in this situation.

Demand generation: With help from civil society organizations, governments must ramp up efforts to mobilize demand among the elderly. In addition to relying on frontline workers (such as accredited social health activists or ASHAs and auxiliary nurses), who do this for routine immunization, they should invest in aggressive and focused social media campaigns aimed at the immediate and extended family members of the elderly. These outreach efforts must go beyond the primary goal of changing attitudes (like vaccine hesitancy, for example) and trigger actual action by helping them overcome barriers of access and information.

Supply rationing: Although it is not possible to roll back expanded eligibility, states should devise guidelines that track coverage among the elderly, set daily/weekly targets for the age-mix of patients to be vaccinated, and use these to achieve a preferential allocation of appointments to the elderly. If demand from the elderly continues to be low, slots can be opened for other segments on a dynamic basis (say, at the end of each day) to ensure that vaccine supply is not wasted.

On a tactical level, however, the mixing of younger and elderly segments should be minimized, as the former is likely to comprise more asymptomatic individuals who are unaware of their infection status and may inadvertently transmit the disease at crowded vaccination centres. The CoWin portal for all registrations and vaccinations would provide the government the data required to feasibly implement such guidelines and monitor compliance.

Abhishek Reddy and Syed Junaid, analysts at Max Institute of Healthcare Management, Indian School of Business, contributed to this article.

Sarang Deo & Sripad Devalkar are, respectively, professor, operations management and executive director, Max Institute of Healthcare Management; and associate professor, operations management, Indian School of Business

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