‘Centre’s re-revised policy continues to allow inequity in access to vaccines’

Dr Rijo M John, adjunct professor, Rajagiri College of Social Sciences, Kochi. Photo: Rijo M John

In a June 7 address, Prime Minister Narendra Modi announced a re-revised national Covid-19 vaccination policy. Its salient points were: vaccine procurement would again be centralised (instead of the Centre passing on the burden to the states, as it had earlier done when it ‘liberalised' its vaccine policy on April 19); the Centre would reserve 25 per cent of vaccine stock for distribution among private players; and free vaccination would be made available for adults under 45. All these changes, Modi said, would come into effect on June 21.

Before that, India's Covid-19 vaccine policy mandated that the Centre could buy vaccines for Rs 150, while states paid Rs 300-600 per dose.

Notably, just a week before the prime minister's televised June 7 address, the Supreme Court had handed down a 32-page order slamming the Centre's flawed vaccination programme, which it said had left the states to fend for themselves. The SC asked the Centre to disclose how it had spent the Rs 35,000 crore announced for Covid-19 vaccine procurement in the last Union Budget. It also asked why the Centre could not spend this money on vaccinating adults below 44 for free. In effect, the SC wanted a national vaccination audit.

"The policy of the Central government for conducting free vaccination themselves for groups under the first two phases, and replacing it with paid vaccination by the State/UT Governments and private hospitals for the persons between 18-44 years is, prima facie, arbitrary and irrational," the SC bench headed by Justice DY Chandrachud said.

"If the Central government's unique monopolistic buyer position is the only reason for it receiving vaccines at a much lower rate from manufacturers, it is important for us to examine the rationality of the existing Liberalised Vaccination Policy against Article 14 of the Constitution, since it could place severe burdens, particularly on States/Union Territories suffering from financial distress," the bench said.

After Modi's June 7 announcement, West Bengal Chief Minister Mamata Banerjee questioned the new policy, asking why the Centre had reserved the right to distribute 25 per cent of Covid-19 vaccines to private hospitals - and not left this to the states. And the Left parties demanded a complete withdrawal of the 25 per cent vaccine reservation for the private sector.

The only two Indian states that have not yet vaccinated 10 per cent of their populations with even a single dose are Uttar Pradesh, where the BJP is in power, and Bihar, where the JD(U) rules in alliance with the BJP.

While Maharashtra, led by the Maha Vikas Aghadi government, has double-vaccinated less than 5 per cent of its population, it has vaccinated over 15 per cent with at least one dose. Pan-India, 3.74 lakh deaths have been reported and 25.48 crore Covid-19 vaccination doses administered as of June 13, 2021. Some experts estimate the true number of deaths is up to five times the official toll.

Mid-Day.com spoke to health economist Dr Rijo M John, adjunct professor, Rajagiri College of Social Sciences, Kochi, and a consultant with the World Health Organization, to understand the new vaccination policy's glaring inequities and examine possible solutions before the pandemic's likely third wave arrives.

Excerpts from the interview:

In its new policy, the Centre has reserved the right to distribute 25 per cent Covid-19 vaccines to private hospitals, and not left this to states. Shouldn't states, which have a better understanding of the situation on the ground, have a say in vaccine allocation and distribution internally?
I believe the vaccination procurement should be 100 per cent done by the Centre instead of leaving any percentage of it to the private sector or the states. However, the rules for allocation of these procured vaccines between different states must be decided in consultation with all the stakeholders, which include all the state governments, as they are at the end points of administering these vaccines. A policy paper on vaccine allocation and distribution in India that clearly outlines the framework for allocation between states and prioritisation of vaccine administration among different population subgroups within each state must be published by the Centre in consultation with the states. This document must be available in the public domain.

Is this 25 per cent reservation equitable? Vaccine manufacturers are likely to prioritise supplying to private hospitals, which pay a higher price for the doses - leaving fewer vaccines for the poor, who are the majority but cannot afford to pay.
The policy of leaving 25 per cent of the vaccine supplies to be procured by private sector hospitals at a price many times higher than the price the Centre pays creates an inequity in access to vaccines among the public by design. Those who have better economic means would have faster access to vaccines from the private sector, thus allowing these 25 per cent of the supplies to reach population groups which are not necessarily the most vulnerable to the Covid-19 disease. Ideally, in the interest of containing the pandemic at the national level, it is most desirable that the limited supply of vaccines is distributed in such a manner that the supply first reaches the neediest. This means population groups that are at the highest risk of serious disease and deaths from Covid-19 should be the first to get the limited vaccines. This can be done only if 100 per cent procurement is done by the Centre and distribution done based on a policy document as agreed on by all the state governments who are doing the job of administering these vaccines.

The Union health ministry has, in fact, gagged states from sharing vaccine stock and storage data with the media and others without its consent, claiming it ‘owns' this data. Isn't such opacity unusual and avoidable given that policy decisions must be based on data, and public trust in the vaccination programme seems to have eroded?
Data transparency is the key to managing a pandemic, and any public health crisis for that matter. It applies to efficient surveillance of the pandemic itself, as well as the vaccination programme. Maintaining granular data on these in the public domain will help public health experts analyse and draw meaningful insights on the progress and success of managing the pandemic, and will in turn immensely benefit the pandemic management itself. If the Government of India (GoI) has concerns about states sharing data on vaccine stock and storage, it should, on its own, be willing to publish such data in a timely manner for the larger public good.

The Centre has alleged that states are profiteering from vaccines. But isn't the 25 per cent private reservation leaving the window to do this wide open?
The profiteering would be larger if the 25 per cent is left to the private sector. If the procurement is 100 per cent handled by the Centre and distributed free of cost to each state, and vaccine administration is done based on a mutually agreed public policy document, where is the scope for any profiteering? I don't see that.

The Centre has also claimed states are wasting vaccine doses. Is this a correct assessment? Is some wastage inevitable along the supply chain, given the temperature and storage requirements of different vaccines?
Vaccine wastage is real and there is significant variation across states in this. It happens due to a variety of factors, including an inefficient supply chain, logistics and a lack of experience among healthcare workers who administer vaccines. It is not unusual to see vaccine wastage ranging from 30 to 60 per cent in routine immunisation programmes. So, wastage between 5 to 10 percent at the national level for Covid-19 vaccines is not too bad and is to be expected. However, the wastage exceeds 30 per cent for some states, while other states have had either zero or negative wastage. Clearly, it shows there is room for significant improvement in those states at a time when vaccine supply is severely limited.

India's vaccination programme was initially a Serum Institute of India (SII) and Bharat Biotech duopoly. Should other manufacturers have been allowed in, and sooner? Studies now show the Pfizer vaccine is effective against the highly contagious Delta strain first found in India (as is SII's Covishield).
It was clear from the beginning that the capacity of India's domestic vaccine manufactures was highly insufficient to meet our huge domestic demand, and the only prudent step was to allow the import of vaccines from other countries as early as possible. On the contrary, GoI did not accord approvals to vaccines from Pfizer and others in the early stages. India could have had a significant edge in its Covid-19 vaccination programme if it had access to internationally approved vaccines from early on. Its overreliance on just two domestic manufacturers may have significantly hurt the pace of vaccinations, and hence our ability to control the pandemic itself.

India, the world's largest vaccine manufacturer, exported more than 6 crore vaccine doses. But it failed to place enough timely pre-orders for its own citizens. Should we have prioritised Indian lives over vaccine maitri?
It is incorrect to say the 6-crore-plus vaccines were given as part of vaccine maitri. Only about 1 crore of those were GoI grants to other countries. Much of those 6 crore of exports were part of prior delivery commitments SII had made. Clearly, SII had a contractual obligation to export those. While other countries made at-risk investments in vaccine development with vaccine makers early in 2020 with the hope of obtaining vaccines on priority as soon as they are available, GoI never made any such investments. Yes, we should have prioritised Indian lives over vaccine maitri. But it is also incorrect to say SII should not have honoured its prior commitments as a private company just because GoI could not foresee India's vaccine demand accurately, make realistic assessments of our domestic capacity, and place the necessary procurement orders on time.

It seems the Supreme Court's stand forced the Centre's hand, and the latter announced a re-revised vaccination policy to be implemented from June 21. Do you believe the SC should take over and oversee the vaccination programme to ensure equitable distribution across all sections?
It appears that a partial reversal of GoI's vaccination policy was prompted by the interference from the SC. However, I don't believe it will be right for the SC to take over a programme administration that rightfully belongs in the domain of the ruling government. Instead, GoI must make necessary amends taking into account the true spirit of criticism from the SC and revise its vaccine policy to fully address the same. Unfortunately, I think GoI has not done it correctly even with its re-revised policy. The policy continues to allow inequity in access to vaccines.

You tweeted about the gender gap in vaccinations. Among the states, Delhi and Nagaland have a male-female first-dose ratio of 58:42; Uttar Pradesh 57:43; Punjab, West Bengal and Madhya Pradesh 56:44 (figures as of June 8, 2021). How worrying is this and what can be done?
Yes, even after accounting for the difference in the ratio of males and females in each state population, there has been a discrepancy in administered vaccine doses between males and females, with males generally getting a larger share of vaccines administered so far in many states. This may potentially impact how the pandemic spreads and the virus evolves in the future. Vaccine administration should be equitable in the sense that priority should be guided by the risk of serious illness and deaths, and not by any other considerations. As I mentioned earlier, a properly drafted public policy document on vaccine allocation and administration should be able to spell this out.

You also tweeted that most of the vaccine supply should ideally first go to the 60-plus population, yet a large chunk is going to the 18-45 group in some states. Is this because the latter group is going to private centres and paying for vaccines until June 21, when the re-revised policy kicks in?
The 18-45 group also has a good number of healthcare and frontline workers, who are getting their jabs on priority. But even if one accounts for this, there is a significant share of vaccine doses being administered to this group, which may be compromising the early delivery of vaccines to more vulnerable population groups such as those above 60, or other age groups with comorbidities who are at a higher risk of serious illness and deaths from Covid-19. The fact that a good portion of vaccines is going to the private sector and much of the vaccine administration is being done through the CoWIN app may be the reasons why the young are able to secure vaccination slots over the other age groups.

Did the Centre's earlier policy asking states to buy their vaccines directly from manufacturers create more shortages? Especially after the Maha Kumbh Mela and the multi-phase elections and rallies in some states became super-spreader events and contributed to the deadly second wave that claimed 3.74-lakh lives (per official figures).
I do not believe leaving the procurement to states particularly created any vaccine shortage. The acute vaccine shortage was sufficiently evident well before the policy was revised and stipulated that the states must do direct procurement of 25 per cent of vaccines. There is no doubt that the Maha Kumbh, election rallies, and any major crowd-gathering events would have accelerated the spread of Covid-19 in the second wave. So, a vaccine shortage on the one hand and the accelerated spread of the disease in the second wave together may have led to a more devastating situation for India, which may have increased the mortality much more than what it would otherwise have been.

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