BackTwo big gaps in our vaccination programme that need attention
Our rural drive to immunize people is hampered by capacity constraints and demand weaknesses
PremiumMy column a fortnight ago documented my observations from nine weeks of travelling across the country from April to mid-June. I feared that the pandemic’s reprieve was temporary. The past two weeks of further travel have only fuelled my fears.
As lockdowns across the country have eased, people are returning to earlier patterns of behaviour. This is not unexpected. They have been restrained mostly by force instead of being informed, enlisted and engaged in a campaign against a pandemic that will be under control only once the vast majority of Indians are fully vaccinated.
The fact that India’s vaccination programme has been hamstrung by a short supply of vaccines has dominated public discourse; this requires no elaboration. But insufficient attention is being paid to two other equally important matters. First, the capacity of our health system to vaccinate people (simply ‘capacity’, henceforth). Second, public demand for vaccination, including the issue of vaccine hesitancy (‘demand’) .
Given the vaccine shortage, state governments responsible for vaccination have been preoccupied with procuring doses rather than focusing on their capacity to vaccinate and on demand. Some states are doing better, but on the whole the situation should alarm us.
The matter of capacity is currently plagued by oversimplification and lack of nuance. Capacity assessment and planning at the aggregate level—national, state or even the district level—is of little value. What matters is planning and building capacity where our people live. Lots of vaccinators and a good cold chain in a district or taluka town are of no use for distant villages. Only the right level of detail—for each village and mohalla—can ensure population coverage.
The public health system’s facility closest to villages is called a ‘subcentre’. It is an extension of a PHC, or primary health centre. Most PHCs have about 5-8 such subcentres. The PHC is the first point of in-patient care and access to a doctor for most people, but subcentres hold the key to any vaccination programme. They are closest to habitations and designed to be staffed with people trained to give intramuscular injections, among other things. Enlisting private hospitals and clinics for additional capacity is good, but is of little use outside cities and large towns.
Each subcentre is supposed to serve a population of 5,000. In practice, the number served varies, as does the count of villages or urban wards, with their distances from the subcentre varying from 2km to 10km. India has over 150,000 subcentres. The capacity can only be determined by details at the subcentre level—the actual presence of trained personnel, the time available for covid vaccinations without compromising other public health programmes and emergency services, refrigeration facilities at the PHC and sufficiency of ice boxes for distribution to subcentres, transportation adequacy for the movement of ice boxes, and more. That this system has been effective in handling polio and the Bacille Calmette-Guerin (BCG) vaccines is no assurance on covid vaccine capacity because polio is an oral dose given to children, not an injection, and the BCG injection is only given to infants; moreover, the numbers handled in any given period are much smaller.
There are two other significant issues that determine our effective capacity.
First, the data entry requirements for covid are onerous. Even in places where network connectivity is smooth and an adequate device available, it takes 5-15 minutes to verify and enter the data for one individual. Subcentres do not have staff for data entry. This is done by someone who would otherwise be conducting vaccinations. But the reality of poor internet connectivity across vast swathes of the country increases the cycle time for data entry, or forces paper-based record-keeping for uploading later into the online system at the PHC. None of these are trivial issues. They deprive health personnel of significant time, reducing capacity.
The second is a problem with the basic operating model in many places. Vaccinations in these parts of the country are only happening at subcentres. People are expected to come to where the vaccine is—a ‘people-to-vaccine model’. An alternate model would have the subcentre staff go to villages or mohallas and hold vaccination camps—a ‘vaccine-to-people model’. Unsurprisingly, the difference in the efficacy of the two models is stark. Only a meticulously planned vaccine-to-people model can cover our entire population and help deal with demand side issues. This is what we must move to nationwide. It would require additional personnel, and facilities such as transportation, camp site material, and more. Many states appear to have given little thought to this, let alone take necessary action.
Our lack of vaccination capacity will soon hobble our campaign to tackle the pandemic. The disadvantaged and vulnerable will be hit hardest. The shortage of vaccines has obscured the need for capacity planning and addressing other executional inadequacies. As the supply of vaccines improves, these other gaps will become apparent. And the far more intractable demand-related issues, like vaccine hesitancy, will become glaring. And then I fear the draconian measures that may be adopted to force people. More on that in my next column.
Anurag Behar is CEO of Azim Premji Foundation
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