India had opened up COVID-19 vaccination for the 18-44 age category starting 1 May 2021. This was done under the ‘Liberalised Pricing and Accelerated National COVID-19 Vaccination Strategy’, under which three different market prices of the same vaccine (for three groups — the union, the states, and the private sector) were proposed; and the responsibility to directly purchase vaccines from manufacturers was shifted to the states and private sector.
A quota system of 50-25-25 to supply vaccines by the manufacturers was developed for the union, the states and the private sector, respectively.
Many Inequities In India’s Earlier Vaccine Strategy
The strategy received heavy criticism from subject experts. There were many technical and operational arguments against the new strategy.
To start with, for all government vaccination programs and campaigns, that is, polio elimination in India, the central government would procure vaccines and the states would be involved in the delivery.
The states did not have prior experience of vaccine procurement in India and were pushed into uncharted territory. The differential pricing for states meant that overall government spending on vaccines (though the responsibility was shifted to the states) would be far higher than if the central government would have made the purchases.
Independent experts had one common suggestion: during the pandemic, the COVID-19 vaccines should be free for all citizens and centrally procured at a single rate (all countries across the world are doing that).
An ‘Arbitrary & Irrational’ Vaccine Strategy
From Day 1 of the implementation of the new strategy, the vaccination drive nearly got derailed. There was a shortage of vaccines and the vaccination-for-all-age-group drive was slowed down, and for the 18-44 group was halted by many states. The vaccines being produced by Indian manufacturers were not enough to meet the increased demand. To surmount this challenge, nearly a dozen Indian states floated global tenders, only to be told that international manufacturers would deal only with the federal government. Thereafter, the chief ministers of many Indian states wrote to the union government to procure on their behalf and provide vaccine either at common rate or free to the states.
Alongside, with the new vaccine-sharing formula, there were more than sufficient vaccines with private hospitals and not enough at the government facilities. The matter was taken up suo motu by the Supreme Court of India, which termed the vaccination strategy ‘arbitrary and irrational’.
The mandatory registration on Co-WIN and limited slots made booking a vaccine slot very challenging, even for those with electronic devices and the know-how. All of these were creating inequities in access to COVID-19 vaccines with those in urban settings and higher income groups with easier access.
Govt’s Vaccine Policy U-Turn
After a gap of more than 5 weeks, on 7 June 2021, the Government of India reversed a few decisions in this strategy. Now, the Union Government will be procuring and paying for 75 percent of the total COVID-19 vaccines available in India. The states would be responsible for delivery.
The vaccination process will continue to be free at all government facilities (which was the case earlier as well, except that the cost of vaccines for the 18-44 category was being paid for by the state government). The vaccines at private facilities will be paid for by the people, and the maximum service charge which can be levied has been capped at Rs 150.
Every Preventive Health Service, Including Vaccination, Has Always Been Free
The mid-course correction is the right step, and likely to bring the COVID-19 vaccination program on track. However, we need to remember that every preventive health service, including vaccination, has always been free for all citizens, through government health services in India.
Therefore, the claim that the government is providing COVID-19 vaccinations for free is specious. Was it (earlier) thinking of charging people for COVID-19 vaccination and has now made it free? The central government has always paid for vaccination, and it has again accepted this responsibility — as it should have in the first place.
A Better Approach to Vaccine Allocation
The share of private sector in the total facilities conducting COVID-19 vaccination is around 4 percent, while they have been allocated 25 percent of the vaccine share. It is not surprising that private sector facilities always have vaccines while government facilities don't have enough supplies. As vaccination supply is likely to increase in the months ahead, if this formula continues, the proportionate allocation would be far higher than the private sector can use. Therefore, an approach could be to allocate by the estimation of the absolute dose requirement in the private sector.
Alternatively, an even better and simpler approach would be for the allocation to be proportionate to the vaccination facilities in private sector. This, more nuanced approach, has the potential to increase availability in the government vaccination centres.
In other countries across the world, irrespective of public or private facilities for vaccination, people don't have to pay any fee. And that is an approach India should adopt, if it wants to call the program ‘really free’ for all citizens. Therefore, capping the service charge at private facilities is a progressive step. However, the Indian government should consider purchasing 100 percent of vaccines from manufacturers and providing to the private sector (as was originally being done in Jan- April 2021) — and even the service charge for the COVID-19 vaccination should be paid by the government, on behalf of the people. That would be make vaccines well and truly free.
The Role of Health Experts & Judiciary in Holding Govt Accountable
Some credit for this policy reversal goes to the independent health experts who provided critical technical inputs about loopholes and suggested areas of improvement in the vaccination strategy. It will benefit the citizens in the future if the government pays more heed to independent experts on such technical and policy areas.
A lot of credit goes to the regular questions raised by the Supreme Court of India about various aspects of the government’s vaccination strategy. It shows the role that the independent health experts and the judiciary can play in shaping government policies and the health situation in India. A few weeks ago, the setting up of a national task force of 12 independent experts following an oxygen supply crisis is another example of the two coming together.
The Long Haul
While some policy and vaccine supply issues are being addressed, it is time that both state and union governments iron out delivery and operational issues as well. Developing a detailed roadmap for the COVID-19 vaccination rollout, factoring in the vaccine pipeline till at least December 2021, is needed. An evidence-based communication strategy should be designed and earnestly implemented to ensure that vaccine hesitancy is tackled, which is very essential to increase coverage.
The revised vaccination strategy is a step in the right direction; however, there is a lot more which can be done.
The approach should be to do everything that is needed to ensure that every citizen is protected from COVID-19, and vaccines are delivered in a hassle-free and timely manner.
(Dr Lahariya is a medical epidemiologist with extensive work on vaccines and health systems. He is the co-author of Till We Win: India’s Fight Against The COVID-19 Pandemic. He Tweets at @DrLahariya. This is an opinion piece and the views expressed are the author’s own. The Quint neither endorses nor is responsible for them.)
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