Written by Pradeep Bhargava
There is a famous saying, “Don’t fix it if it ain’t broke”. I wish there was another guidance – “Don’t break it, if it is working”.
This is about how an astute, cohesive, and extremely well-executed plan of Covid-19 vaccination in India from January 16 to April 30 was ‘broken’ under the glamorous packaging of ‘universalisation’, ‘delegation’ and ‘privatization’.
My focus is only on two critical aspects of the vaccination strategy – demand management and supply chain handling.
An upfront disclaimer is that other critical aspects like pricing of vaccines (free or progressive rates), administering of vaccines (CoWin-driven/ walk-in/priority lots), sourcing (imports or domestic) or an equitable pricing regime for the vaccine manufacturers are not in the scope of this article.
My arguments are in three parts
1) A Sound Start (January to April)
2) Total Breakdown (May)
3) Reset Mode (June/July Onward)
The Sound Start of Vaccination in India
The launch of Covid-19 vaccination in India on January 16 was the result of an extraordinary and well-orchestrated plan which involved many stakeholders. To start with, there was the daring decision of Serum Institute of India, Pune, to produce and stock the vaccine even before getting the Emergency Use Authorization from regulatory authorities. It was a risky decision. Union Health ministry, rightly, identified the priority groups for vaccination, starting with healthcare workers (HCWs) and frontline workers (FLWs) as the earliest beneficiaries. The procurement and stocking points at primary/secondary /tertiary locations were lined up across the country by the government.
Progressively, more than 60,000 sites were identified, staff trained, standard operating procedures shared. CoWin platform was readied for eligible citizens to register and then book appointments at the designated sites. As the vaccination, and vaccine supplies, increased, new bands of beneficiaries were added — people above the age of 60 years plus, along with 45 year olds with co-morbidities, followed by everyone over the age of 45 years. Addition of bands and hence flow of citizens was tuned in to the likely availability of vaccines, which were being distributed by central, state and local governments. Only the central government was buying the vaccines from the two approved manufacturers, and distributing across the country, in line with population as well as tuned to the number of active cases. Vaccines were sold to private hospitals at the same price at which central government bought them, and they were allowed to add a charge Rs 100 as their administrative costs while vaccinating.
This worked very effectively until the end of April. The numbers support this claim. Vaccinations administered across India went up from 33 lakh in January to 103 lakh in February, to 415 lakh in March and then to an all-time high of 916 lakh in April. This cumulative count of 14.67 crore vaccination between January and April included 2.67 crore of second dose. Hence, nearly 12 crore Indians were vaccinated in this period. Walk-in was the mode used for second doses. There were occasional hiccups at some centers due to uncertainty of supplies. But perfect hygiene was ensured at all sites and AEFI (post vaccine complications) reported was below 0.012% (completely acceptable level).
Since new groups of beneficiaries were added in finite steps, and in line with expected supplies, at no point was there an overload on either the CoWin system or at the vaccination sites. The orderly conduct ensured dignity as well as efficiency of the system. There was complete involvement of state governments which alone decided the share of quotas for different districts and municipal corporations. They considered the geographical distribution of population and logically allocated vaccines to all the hospitals and sites. And a large number of private sector hospitals, irrespective of their size and clout, were fully involved in the vaccination drive.
Breakdown of Decorum, Equity, Efficiency and Systems
Let me elaborate first the underlying forces and then the outcome. Interested and influential groups were getting restless and wanted to get their entire constituency (all age groups) vaccinated. While the Government calculations indicated that the nation would get fully vaccinated only by December (or latest by March) based on the enhanced availability of vaccine in the next few months, this group did not have the patience and wanted a mechanism which will put them ahead in the queue. So, what could the levers be?
The first was to abandon the age-wise slabs, and demand universalisation of vaccines. A country which had the production capacity of only about 30 lakh vaccines per day in April suddenly opened the flood gates and announced that from May 1, all 60 crore Indians in the 18-44 age group, plus 15 crores seeking second dose can get on the CoWin app and seek vaccination appointments. It is as bizarre as the numbers indicate. It led to chaos (not that all 60 Crore went on the app, but large numbers did).
A beneficiary being vaccinated at the NMMC hospital in Navi Mumbai on Saturday.
Express Photo by Amit Chakravarty
Even a country like Singapore opened vaccination for 40-44 age group after the 45-plus reached some level of vaccination, because they did not have enough supplies. That is the model being followed in European countries as well. USA opened up the entire age group since they have surplus vaccines. We imitated the USA model. We had huge vaccine deficit and were fully conscious that our capacity build-up was going to happen only in phases, from 10 crore vaccines a month in May to 20 crore in August, and possibly 30 crores in October. But the authorities did not blink their eyes in opening vaccines for all on May 1. And that too on a system which did not provide for queuing. If a citizen sought an appointment on the dates which were opened, and did not get it, she had to try all over again. And we all knew that the last of the vaccination would still happen in December, but everyone was asked to try from May itself. How agonizing and frustrating.
The next demand from this constituency was to let private hospitals do the direct buying from vaccine manufacturers and then let them vaccinate their choice of persons and at prices not regulated by government. Large private hospitals were happy to join this pressure group. Many state governments also got on the bandwagon wanting to exercise their rights under the ‘federal system’ of the Constitution to buy vaccines directly and not be at the mercy of the central government. Simultaneously, there was pressure on the government from manufacturers to increase the net purchase price of vaccines, since they (rightly) needed a fair return on their investment and needed funds for enhancing capacity.
The central government, surprisingly, acceded to all these demands and agreed to open up vaccination for 18-44 age group, restricted its direct purchases of vaccines to 50 per cent of the total supplies, permitted state governments and private hospitals to do the other half of purchasing, 25 per cent each. It also agreed to increase the purchase price of vaccines to be paid by state governments and private hospitals (while preserving its own purchase price at previous levels). It permitted private hospitals to operate outside of the CoWin platform while dealing with corporate accounts who could now usher in anybody. The private hospitals were now free to charge the price it chose from the client it chose.
The immediate implications of these decisions were disastrous
* In the month of May, the total vaccination came down to 4.88 crore as against the total supplies of 7.94 crore, and the vaccination of 9.16 crore in April. This could be a transient issue, since ultimately the missing vaccines will surface some day and a smooth flow will emerge. But a disruption of this order is a serious issue when the nation is struggling to provide vaccines to all.
* Of the 1.2 crore vaccines bought by private hospitals directly from the manufacturers in May, 50 per cent (60 lakh) went to nine big hospitals and remaining 50 per cent were sold to 300 small hospitals. Lots of hospitals were denied supplies. There were in excess of 4000 private centers vaccinating in April. The number has come down to 1400. It means that people, who had visited sites nearer their homes, now had to travel far away for their doses. Lesser number of centres also meant bigger crowds, disrupting the calls for physical distancing.
* The pain, frustration, disappointment that an average citizen was experiencing in getting a slot is huge. People across all age groups (and this is a large number) were trying to book a slot. It was almost like getting a lottery prize. All this was happening when fair number of “others” were able to walk in and get their shots without having to browse for hours.
* Within a month of “opening up” vaccine procurement for state governments (their original demand), most of states went back to the central government, demanding centralized purchases as their efforts to procure vaccines were not yielding any results.
* It is important to note that the total number of citizens getting vaccinated is determined by the supplies, and does not change by altering the age groups or allocations. The mechanisms made operative in May are taking away the equity and transparency in the process, while adding to the pains for most.
An empty Covid-19 vaccination centre in Delhi due to the non-availability of vaccines for the 18-44 year-old age group, at DDU Marg in New Delhi on Saturday. Express Photo by Praveen Khanna
How to Fix It
Experience of May has revealed that the way forward needs to follow these two channels
* Demand Management: Nearly 60 crore Indian population between 18-44 years of age needs to be broken into three brackets – those in the 35-44 years of age (20 crore), 25-34 years of age (23 crore), and 18-24 years (17 crore).
It can be proposed that, with effect from any practical date in June, the eligibility for vaccination is restricted only to people in the 35-44 years bracket. Anyone below the age of 35 should be asked to wait for the next announcement. (However, those above 18 who have received their first dose post May 1 should be entitled to get their second dose when the applicability surfaces).
This will reduce the load across, make CoWin more responsive and efficient, and reduce the waiting period for ordinary eligible citizens. The private hospitals can continue to handle corporate or special clients, but only for the eligible age group.
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As a fair number in the 35-44 years age group get vaccinated, and the supply increases (which it will), the next bracket of 25-34 years can be opened up. Before that announcement is made, we need to factor the second dose load which will start building up.
As the supplies enhance, the last lot of 18-24 age group can be ushered in. At no point of time should the system be made to work for a capacity it is not designed for, and ignore the key parameter called supplies.
This will also bring in equity and dignity into the entire operation. If we don’t set this right, we will have India getting vaccinated in next few months, while Bharat will wait for their turn till last quarter of this year. Let us not forget India is not safe if Bharat is not vaccinated.
* Supply Chain Management: Vaccine manufacturers have a technology intensive profile, and generally deal with a finite number of customers with well laid-out contracts. They cannot be made to function like some FMCG companies dealing with stockists and retailers.
By asking them to deal with 28 state governments and possibly 2,000-3,000 private hospitals, we are distracting them from their core role. No wonder some big hospitals are walking away with bulk supplies coming in the way of a more diverse distribution.
The entitlement of higher price realisation by domestic vaccine manufacturers must be respected. Hence, we can go back to the original system where the central government buys the entire quantity from the vaccine supplier and then resells to both the state government as well as the private hospitals who place the orders on and make the payments to central government.
The total price realisation for the manufacturers can be honored with the central government buying at a weighted average price. Thankfully, this has already happened. Recognizing the cracks in the ability of state governments to independently procure vaccines, Prime Minister announced on June 7 that the central government will now do the procurement on behalf of all state governments The next transaction needs to be between central government and states/private hospitals on the agreed commercial terms.
Private hospitals can pay to the central government what they would have paid to the manufacturers. More number of private hospitals can be accommodated in this model and even some of the remote states will be serviced more efficiently.
Conclusion
Vaccination is the only infection prevention tool humanity has. All other interventions like enhancement of hospital bed capacity, ventilators, oxygen supply, medication etc are essentially damage control measures.
Efficient, expeditious and equitable vaccination mechanism is the solemn responsibility of the state and all stakeholders engaged in the process. Orderliness and dignity of relatively less privileged cannot be set aside. There is an opportunity for us to set right the recent distortion and get ready for vaccinating all our citizens by end of 2021, in the fairest manner for all.
The author is a past president of Pune-based Mahratta Chambers of Commerce Industry and Agriculture, and past chairman of CII, western region. Views expressed are personal.
