[In-depth] India’s Vaccine Supply Conundrum

India’s Vaccine Supply Conundrum

Eight months after India began the world’s largest vaccination drive, it has administered jabs to just over ten per cent of its population. Despite opening up COVID-19 vaccination for all adults from May, India’s average number of doses dropped to very low levels in May. In the first 10 days of May, only 1.7 million doses were administered per day on average, lower than the 2.4 million doses administered in the previous 10-day period. If India is aiming to vaccinate all adults (940 million people*2 doses) by the end of 2021, the average daily dose has to increase to at least 7.3 million, four times the current rate. The high reduction in daily average doses administered in Maharashtra, Telangana, Andhra Pradesh, Karnataka and West Bengal led to the massive drop in India’s pace in May. The drive has lagged in recent months because of low supply and delays in approving new vaccines despite a promising start in January.

The 200 crore vaccines conundrum of India

The Centre’s ambitious plan of 200 crore doses by the year-end will require ramp-up of production, approval and manufacturing of new vaccines, and removing hesitancy and inequities in access. The world’s second-worst Covid-19 affected country just can’t seem to figure out a viable vaccination programme. Despite that, it isn’t shying away from ambitious targets. It’s been eight months since India rolled out what was touted as the world’s largest vaccination programme. Yet, numerous flip-flops, ranging from policies on procurements to approvals for vaccines, continue to plague the inoculation drive even though the country remains the world’s largest vaccine maker.

India has, so far, fully vaccinated about 10 per cent of its population. Of its approximately 94.5 crore people above the age of 18, only 9.54 crores, or about 10 per cent, have been fully vaccinated. As of June 9, a little over 20 per cent have received at least one shot. In contrast, over 42 per cent of the US population have been fully vaccinated so far, while at least 63 per cent in Israel have received one jab. Across Europe, over 30 per cent of various countries have been vaccinated. Meanwhile, India has set an ambitious target of vaccinating all of its population above the age of 18 by December. By the looks of it, that’s going to be a Herculean task, especially considering the laggard pace so far.

Degree of drop

From May 1 to 10, 1.77 million doses were administered daily on average in India compared to the 2.48 million doses administered between April 21 and 30. At the current pace, India will be able to administer 316 million doses by July 31, which is about 184 million doses lower than the target (upper bound) of 500 million.

Most probable and repeated topics of upsc prelims

How is India’s rollout going?

India has a population of over 134 crores. The country has been vaccinating at an average of 16 lakh doses a day since launching the vaccination drive in January. If the government wants to finish vaccinating all the 94.5 crore adults above the age of 18 by December, that number needs to go up almost five times.

For now, the government has over 53 crore doses of vaccines available with it (As of June 2021). If it has to provide over 200 crore doses by the end of this year, in addition to supply from domestic makers, it will also have to bank on supplies from the West, likely to kick in by August. 

According to a public health consultant, “We need 47 lakh population coverage per day as against coverage of 20 lakh per day because the vaccine production is only that much. There’s a huge deficit, so we have to be pragmatic.” According to him, the government’s changing vaccine strategies, including opening up vaccination to all adults when even the priority groups had not received their second dose, and then transferring responsibility to states when there were no vaccines available for purchase was like “declaring a war without armoury”.

What is the stand of Government?

The government now claims to have secured 74 crore doses for use from August. That includes 25 crore doses of the AstraZeneca vaccine, commonly known as Covishield manufactured by the Pune-based Serum Institute of India, and 19 crore doses of Covaxin, developed and manufactured by Hyderabad-based Bharat Biotech.

In addition, the government has also secured 30 crore doses from Hyderabad-based Biological E for its vaccine that is currently being developed.

The road to 200 crore vaccines

The move to procure the vaccines, meanwhile, came after weeks of confusion surrounding the vaccine policy. PM Modi, in his first televised address in June following the deadly second wave between April and May, reversed an earlier policy announced a month ago. “The Centre is taking back total control of vaccination now, and it will be implemented in the next two weeks. The Centre will give free vaccines to states for all above 18,”.

The announcement that, at least in principle, India as a national government takes the responsibility of providing free vaccines to all in a pandemic is a welcome, albeit a small step. The decision of rolling back the previous policy is partially welcome, although it is a case of ‘better late than never’. “Sadly, it seems that much of this decision-making is driven by image-related concerns, rather than by a practical focus on driving vaccination forward,”.

Need to Streamline the policy

The plan to purchase vaccines directly came a month after the government had devolved responsibility to the state governments to procure vaccines. That policy meant half of all vaccines produced in India went to the central government, and the rest to state administrations and private hospitals.

That has now been changed with the central government buying 75 percent of all vaccines, and the state governments receiving their doses for free instead of negotiating directly with manufacturers.

The move follows several other flip-flops in the vaccine policy since the government began the program in January with Covishield and Covaxin. The country had initially set a target to vaccinate 30 crore people, including health care and frontline workers, senior citizens, and persons with comorbidities by July, before vaccinating everyone else.

About 45 days later, the government in March, opened up vaccinations to anyone above the age of 60, or above 45 years and with existing comorbidities, to receive vaccines at government as well as private hospitals. That decision marked a significant shift, with the rollout for the general public being moved up, and a long-pending demand to allow the private sector to participate in the programme. At that time, the government didn’t have adequate stock to meet the growing demand, and the manufacturers too hadn’t ramped up capacity.

Under the second phase, vaccines would be free at government facilities and for a charge at many private hospitals. Then, in the mid of April, the Centre departed from its original plan and put the states and the private sector in charge. Since then, numerous states such as Rajasthan, Madhya Pradesh, Uttarakhand, Tamil Nadu, Maharashtra, Karnataka, Andhra Pradesh, Telangana, Haryana, and Delhi decided to float tenders, inviting global participation in procuring vaccines.

In May, when India began vaccinating its entire adult population, which is close to 70 percent of 136 crore people, under a “liberalised” vaccine strategy that placed greater responsibility on the states, Covid-19 cases had begun to peak, and states were desperate to procure vaccines. Indian states were left to compete/fight with each other in the international market.

This move caused confusion and perhaps affected the efficiency of the inoculation process. The impact of the decision on overall vaccination pace would be a question mark, because there are other limiting factors such as supply issues, and other uncertainties like difficulty in delivering vaccines, difficulty in finding slots etc. Sometimes, even if you got slots, you reached the vaccination site only to find out there are none available. All this could have been avoided if we had a more efficient system where we knew we were working with limited supply and figured out the best way to deliver it, while expanding our supply capabilities

Under the new vaccine policy, the Centre has also said 25 percent of vaccines will continue to be procured by private hospitals, which are free to charge for the vaccines. The government has said that it will monitor prices and strict action will be taken against any private vaccination centre or hospital charging more.

Will the new policy really help?

The new policy is obviously not going to be the only answer considering crucial challenges like inequity in access to vaccines, supply constraints etc. “But the policy might bring more efficiency and clarity in negotiations with manufacturers, because procurement will be from the central government and states won’t have to compete with each other; some of the smaller states were struggling because of finance and other constraints under the previous policy”.

The ideal public health response, in view of looming inequities in vaccine access, is to make the vaccines free. “And only if you had enough vaccines, you could divert it to the private sector for those who can pay. But in the absence of adequate supply, where various health systems are competing with each other for [a piece of] a limited pie, it is not the most efficient way.

Since people with financial resources and technological access will have the option of both corporate hospitals and primary health care centers depending on slot availability on the CoWin app, the policy, as it stands, will lead to them cornering slots or procuring doses faster those bereft of the privilege.

What else could have been done?

All of these [policies] are reactive in nature. The original decision of extending vaccination to everyone was not well supported by the supply situation. To cap that with what amounted to a responsibility-abrogating decision to make state governments as well as the private market buy vaccines was compounding the error.

While the new policy will smoothen out purchase negotiations and somewhat improve supply to states, “the competing private procurement, so long as the current situation of vaccine shortages continues, is likely to continue to be a small but significant drag on public vaccination campaigns and to add to vaccine inequities. “Until the supply situation begins to improve, which it might in another month or so, realities on the ground are unlikely to change immediately.”

The Centre needs to be honest and transparent about vaccine availability at every stage and the time it will actually take to inoculate everybody, particularly because the country has been lagging behind in its inoculation targets. Less than Rs 5,000 crore out of the Rs 35,000 crore budgetary allocation towards vaccination has been spent so far.

While Bharat Biotech is ramping up its own production capacity, one way to expand production quickly will be to use the 11 public sector units for production of the indigenous vaccine. “These units can be equipped with basic technology and infrastructure, and if Bharat Biotech transfers the technology, these PSUs can turn into production centres that can make enough Covaxin in the country.”

What are the other Covid-19 vaccination related challenges in India?

The issue of mandatory Co-Win registration as part of the new decentralized distribution strategy, which potentially adds to an entry barrier that could be tougher to navigate for users in the hinterland, both in terms of access to the platform and an English-only interface for users so far.

Mandatory online registration introduces a skew in favour of urban centers, given that a little over half of India’s population has access to broadband Internet, while rural tele-density is under 60%. It is more difficult for those with less access and greater unfamiliarity with technology, including access to a smartphone or computer.

The revised vaccine procurement process builds in a skew against smaller hospitals in cities and towns in comparison to their bigger counterparts in simply getting access to the shots, and a more disconcerting urban-rural divide in terms of where healthcare facilities are vis-à-vis the already-established supply-chain map.

Practice Question for Mains

  1. Critically comment on the Centre’s ambitious plan of 200 crore doses by the 2021 year-end. (250W)
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