Covid vaccine rollout needs to be decentralised

The Covid-19 vaccination drive is set to enter a new phase to cover people eligible for vaccination beyond the first prioritised group of healthcare and frontline workers. Those who were vaccinated at the very beginning of the immunisation drive are also getting the second dose of the vaccine. Vaccination has been initiated in all states and union territories where over one crore healthcare and frontline workers have been covered. The coverage of vaccination, however, is not uniform throughout the country. Many states have reported vaccine hesitancy even among healthcare workers who are at the forefront of the battle against Covid-19. The lower-than-expected achievement of vaccination despite the availability of vaccine supplies has led to questions about the potential wastage of doses in some places. Besides, it has led to the demand for making Covid-19 vaccines available in the private market.

In the current phase, the vaccination drive is fully funded by the government. It is not yet clear how the next phase covering people above 60 and those above 45 with co-morbidities will be funded. Those supporting the demand for letting the private sector handle Covid-19 inoculation cite the slow pace of vaccination in the public sector, and the fact that many people in the next phase can afford to pay for their vaccine shots. This view is based on the assumption that the public sector is inefficient and incapable of handling a large vaccination drive. This is fallacious because it was the public sector healthcare system that led disease eradication campaigns in the past such as smallpox and polio that were driven mainly by the effective delivery of vaccines in every nook and corner of the country.

The bulk of the essential child immunisation programme is state-driven, though India is yet to reach 100 per cent coverage of life-saving vaccines. All this does not mean that the private sector has no role in immunisation as such. The private sector has been a supplier of essential vaccines and also plays a critical role in delivery in urban areas, particularly of a host of new optional vaccines. The private sector has been involved in Covid-19 vaccination for healthcare workers at many centres.

The idea of keeping the Covid-19 vaccine drive in the public sector was to ensure that those who need the vaccine first should be prioritised, given the limited supplies in the initial weeks and months. Affordability or willingness to pay for the vaccine was not a factor while formulating this strategy. Even developed countries, where affordability may not be a dominant factor as in India, decided to keep vaccination in the state sector. It is a different issue that the same countries did not bother about the issue of access vis-à-vis poor countries. The bulk of available supplies in global markets were cornered by developed countries through direct and advance purchase mechanisms, leaving little for several countries in Africa and Asia with little or no supplies. Those asking for Covid-19 vaccines available in open markets should bear this in mind.

The glitches seen in the public sector-led immunisation drive in the initial days are being progressively fixed. Other inefficiencies can be identified and addressed in many ways to optimise the use of available doses of the two vaccines. The rollout needs to be decentralised. Instead of a Centrally framed and implemented plan, we need state-level immunisation programmes based on epidemiological factors driving the pandemic in each state. If the pandemic curve in Maharashtra and Kerala is different from that of other states, vulnerable groups there need to be prioritised for vaccination even if they don’t fall in the priority groups decided by the Centre.

The same should apply while implementing vaccination at the state level. All districts within a state may not need the same quantities of the vaccine. Such a targeted approach can make the vaccination programme efficient. At the political level, taking states into confidence while formulating the plans can help address issues like those raised by the Chhattisgarh government. By being proactive and transparent with vaccine-related information with state governments, the Health Ministry could have avoided politicisation of the vaccination rollout and perhaps prevented hesitancy too.

Another aspect relating to the wider availability of the vaccines is their pricing. For the government sector, Serum Institute of India (SII) and Bharat Biotech negotiated a special price. The SII has already said that the price of its vaccines in the private market will be much higher, factoring in administration fees or margin of doctors, cold chain costs etc. It means there will be differential pricing. If such dual pricing is allowed before all priority groups are vaccinated and before enough doses are available to feed both private and public sectors, it can lead to pilferage from public supplies and black marketing. Profiteering by unscrupulous elements in the private sector, as seen in Covid-19 testing and treatment, can’t be ruled out. Higher pricing of say Rs 2,000 for two doses for private markets could also dissuade economically weaker people who are not on priority lists or have co-morbidities from vaccination. The number of such people is substantial and if they are not vaccinated, it would be difficult to achieve the goal of ending the pandemic through vaccination.

The pandemic has deepened existing fault lines in society, between the rich and the poor, between haves and have-nots, globally and domestically. Telemedicine for non-pandemic-related health problems is tricky for those on the wrong side of the digital divide. If Covid-19 vaccine supplies are diverted to private, for-profit markets at the current stage of the pandemic, it will only add to existing inequities. Instead, the Central and state governments can utilise the opportunity to boost the public system with new investments. This will not only help in vaccination, but also help achieve other goals such as the eradication of tuberculosis and childhood diseases, besides redeeming people’s faith in the public sector health system.