No one doubts the enormity of the task at hand when it comes to the procurement and administration of the Covid-19 vaccine to India’s large population. There has, perhaps, never been a health project as large and logistically complex as the one ahead of us.
To start, even when focusing on just Phase 1 vaccinations of 300 mn people (currently slated to occur between January and August 2021), the Indian public health system will require 600-650 mn doses of the selected vaccine. This assumes getting vaccinated is voluntary, with no national law for mandatory administration. An estimated 10% of vials might become unusable due to the multi-modal transportation involved, including the last mile delivery on cycles or foot to many a remote village. This phase will also have to cope with the vagaries of all seasons; beginning with winter, moving into the hot summer and ending with the monsoons.
Procuring the requisite quantities of the vaccine is an exercise yet to meaningfully begin in India, since none have so far been accorded emergency authorisation. Unlike some western nations, there have been no prior negotiations with manufacturers for committed contracts to purchase vaccines that are backed by earnest money-advances. The fortnight-long US experience rolling out the vaccine has already shown that global availability will be a critical issue to contend with. With the first domestic producer Pfizer-BioNtech unable to keep pace with the demand from those most at risk, the US has moved quickly to approve Moderna, the vaccine next in line. With the European Union also set to approve vaccines for emergency use soon, availability of these authorised vaccines is only going to come further under pressure.
In India, the Serum Institute in Pune, which appears to be the preferred candidate for effecting a bulk of the supplies, has 40 mn vaccines in stock, with a monthly manufacturing capacity of about 20 mn. For part of these, its principals AstraZeneca-Oxford University have made national commitments in the UK where emergency authorisation is imminent (with Pfizer-BioNtech already authorised). The Indian manufacturers led by Bharat Biocon and Cadila Zydus, whose products are in the mid-stages of clinical trials, are yet to secure the requisite final permissions from the Drug Controller of India. Understandably, they are hesitant to pre-emptively undertake mass-production without the authorisations or promise of a buyer.
Another possible source for India is the newly created WHO-COVAX facility assisted by GAVI (Global Alliance for Vaccine & Immunisation) that has talked to both Pfizer-BioNtech and AstraZeneca-Oxford, as well as their Indian contract-manufacturer, the Serum Institute. With a goal to purchase 100 mn doses to start with, and ultimately distribute 2 bn globally, the initiative is backed by contributions from wealthy and middle income countries including India, as well as by private donors such as Bill & Melinda Gates Foundation. Given the goal here is to assist poor nations, particularly in Africa, where a late pandemic outbreak is taking heavy tolls in populated nations such as PDR Congo, Nigeria, Ghana, and Ivory Coast, India (which is no longer considered part of this least developing nations’ grouping) should realistically expect only a small quantum from this source.
Similarly, pinning our hopes on Russia’s Sputnik V or China’s Sinovac is also not viable for the time being. Their safety and efficacy have not been proved through authorisations in the West, and there have been no clinical trials in India. That said, given their pricing will be lower than the Western developed vaccines, and that the effectiveness of the Sputnik vaccine may improve after its proposed technical collaboration with AstraZeneca, this could be another crucial window for India to explore.
While securing large numbers of vaccines in a competitive global market may seem daunting, on a more positive note, it is heartening to see that other requisite apriori measures for a massive vaccination drive are well under way. Over the years, Indian health authorities have learned valuable lessons from the vaccination efforts on 11 common diseases, as well as through the exercise of universally immunising about 29 mn pregnant women and 27 mn new-borns annually. Drawing on the logistical challenges refined through our national and provincial elections, the countrywide vaccine-exercise can also borrow from the well-oiled election machinery for initiatives such as enrolment drives, household visits certifications, and the training of thousands of staff at all tiers of administration.
Detailed written instructions on every aspect of the exercise, a la the election holding process, have either been sent to the state governments or are under finalisation. In a similar vein, the identification of frontline workers and their familiarisation has already begun at the state, district and sub district levels. The village level anganwadi workers (12.8 lakh plus their 11.6 lakh helpers) will be at the forefront of an outreach programme, and will play a pivotal role in persuading those most at risk to take the jab and not resist based on the disinformation routine in mass vaccination campaigns. To be successful, everyone must believe that Covid-19 is not just an urban disease, or that the vaccine may be high-risk given the hurried launch.
With our public health expenditure remaining below 1% of GDP, the existing primary health centres (23,673 functional) that act as diagnostic and control centres in the rural areas, will have to serve as the fulcrum of the entire process. Unfortunately, several centres remain grossly understaffed or ill-equipped. Of the available 239,000 vaccinators in the country, about 150,000 cannot be diverted from their routine vaccinating duties. Furthermore, in many PHCs, we would need to move fast to ensure appropriate-sized vaccine cold storage facilities, i.e. walk in coolers and freezers in larger centres and ice-lined refrigerators and deep freezers in smaller ones. If our different modes of transportation are not well synchronised, we will also have to augment the nationally mapped 29,000 cold storage facilities.
For maximum impact, we must empower district collectors (and deputy commissioners as called in a few states) to be legally in charge and run point in their jurisdictions. They must be vested with appropriate powers, as done during elections and natural disasters, to requisition any private or public vehicle, material or manpower to implement the programme.
While the Union Ministry of Health is the obvious focal point to lead a nationwide charge that may last two or more years, the requisite coordination between 20 odd ministries and departments is also under way. Prime Minister Narendra Modi, with his proven on-the-ground administrative experience in managing disasters and development programmes, has been periodically reviewing the preparations by scientists, health administrators and state governments. It has been made clear that in technical matters, it is the scientists and technocrats’ point of view that would prevail over the bureaucrats’ or their political masters’. The Finance Minister has also committed to finding the requisite financial resources for procuring, transporting, storing and administering vaccines. Given the scale, urgency and highly contagious nature of the virus, it is unlikely that any critical initiatives, including financing, will be left to the state governments.
When it comes to financing, the pricing of the vaccine to the public must be a top consideration. While charging the full cost would definitely ease the burden of this expensive operation, there remains no doubt that the benefits of getting vaccinated are not just confined to the individual, but to the society and country at large. In an economic sense, the external benefits make the vaccine a “merit good”; something the poor usually receive free of cost. The suggestion that all income taxpayers be charged while others get it free of cost is also not likely to help much since the proportion of taxpayers in India is small, and there would be disproportionally high costs of collection.
Given this reality, we need to move fast on multiple dimensions—first, by proceeding to secure the cheaper locally produced vaccines, starting with the contract manufactured vaccine by the Serum Institute (priced at Rs 250 per dose) and then the ones developed by Bharat Biocon, Zydus Cadila and others in the pipeline. Assistance similar to the recently started Production Linked Incentive schemes (PLI) may be extended to domestic Covid-19 vaccine-makers, and we need to put in place pre-emptive purchase contracts with them. Given the speed at which we are moving, it may also be necessary to give in to demands to indemnify local vaccine makers against liabilities arising from alleged side effects (assuming these are few and far between). Simultaneously, where possible, we should authorise imported vaccines and allow them to be sold on the open market. Perhaps, re-purposing the PM Cares Fund, set up specifically to mitigate the impact of coronavirus, to now go exclusively towards the public purchase of vaccines will enthuse more potential donors.
As we progress, scores of unanticipated issues will inevitably crop up that will demand immediate resolution. Take, for instance, the current need to quickly understand the implications of the recent variant of the coronavirus found in the UK. As the last few months have shown, this is an ever-evolving dynamic situation, but there is no reason our leadership and vast national machinery cannot be mobilised to meet the demands of this gigantic mission.
Dr Ajay Dua, a public policy specialist and a developmental economist by training, is a former DG ESIC and Union Secretary.