Why India’s private sector wants to give booster shots – and what this reveals about flawed policy

With sizable stocks of unused Covid-19 vaccines in India’s private hospitals inching closer to an expiry date, the private healthcare sector has asked the government to allow booster shots to be given to fully vaccinated people.

Over 50 lakh doses of Covid-19 vaccines are lying unused in private hospitals in Maharashtra, data from the state public health department shows. In Mumbai alone, private hospitals are sitting on about 19 lakh vaccine doses. The number is higher in Pune at 20.48 lakh doses.

Scroll.in was unable to access data on the national stockpile of vaccines in private hospitals, but with stocks lying in Delhi, Hyderabad, Bengaluru and other cities, it is bound to be substantial.

At several private hospitals in Maharashtra, officials said vaccine stocks are slated to expire between January and March next year. The shelf life of Covid-19 vaccines in India varies from six months for Sputnik, nine months for Covishield and one year for Covaxin, if stored properly.

India currently allows only two doses of the Covid-19 vaccine to be administered to its citizens. About 40 countries, mostly in the rich and developed world, which have already achieved very high levels of vaccination coverage, are allowing their citizens to access a third dose, called a booster dose, to beef up decaying antibodies against the novel coronavirus.

But the World Health Organisation has criticised this policy, reiterating the need to first immunise high risk populations across the world. Last week, Dr Tedros Adhanom, director, WHO, said six times more booster doses have been administered globally than first doses in low-income countries. “This is a scandal that must stop now,” he said.

The global situation finds striking parallels within India. Nearly 60% of the adult population in the country is yet to be fully immunised. Despite this, the private sector is pushing for booster doses, largely because it has already tapped the small segment of the Indian population that is willing to pay for vaccines.

A problem rooted in differential pricing

On November 12, the Association of Healthcare Providers, which includes private hospitals among its members, wrote to the health ministry asking for booster doses to be approved to strengthen waning antibodies among vaccinated Indians.

But in conversations with Scroll.in, private hospital executives admitted the main considerations were commercial. Unless booster doses are approved, they won’t be unable to offload the stocks they have already purchased.

India has a differential vaccine pricing policy – vaccination in government centres is done free of cost, while the private sector is allowed to charge upto Rs 780 for Covishield and Rs 1,410 for Covaxin for a single dose. Since May, the government had announced that the private sector would be allowed to purchase 25% of total vaccines domestically manufactured every month.

The policy was criticised by many public health experts and economists, who warned that it would create inequity and inefficiency in the vaccination programme. The unsold stocks of vaccines piling up in private hospitals appear to validate the criticism.

R Ramakumar, economist and professor at Tata Institute of Social Sciences, said the government “allowed private hospitals to buy more than their capacity to immunise”.

Government data reflects this. Dr NK Arora, who heads the National Technical Advisory Group on Immunisation, which helps the government take decisions on immunisation and on strategising introduction of new vaccines, said the private sector currently accounts for 4% of total vaccination in the country, despite having access to 25% vaccine doses.

Ramakumar said, “Private sector bought vaccines with the intention to make profits. Even as it pushes for boosters, the decision, whenever taken by the government, must be on scientific grounds.”

Arora said the government will release a policy document on booster shots in a few weeks. “But our stand is clear: immunise the eligible population with both doses before considering a booster shot,” he said. “Why should a person sitting in a city get a booster shot because there is stock in a private hospital while a person in a rural area waits for his first or second dose?”

Dr Balram Bhargava, director of Indian Council of Medical Research, told PTI on November 22 that “there is no scientific evidence to support the need for a booster dose against Covid-19”. Bhargava, like Arora, said the government’s priority is to vaccinate the entire population with the second dose.

Arora added, “Private hospitals have to utilise vaccines through CSR [corporate social responsibility funds) and ensure there is no wastage.”

But private hospitals in Mumbai say they have exhausted all such possibilities. “We have tried to immunise the slum population through CSR [corporate social responsibility] funds but there is still stock left,” said Gautam Bhansali, consultant in Bombay Hospital. There are about 10,000 doses lying unused in the hospital, expected to expire in early 2022, he said.

Bhansali said the reason for low uptake in the private sector was the easy vaccine availability in the public sector from August. “About 5-10 people come for vaccination daily, down from 100-200 until August,” he said.

A dose of Covishield costs Rs 780 in a private hospital, while Covaxin is priced at Rs 1,410 and Sputnik V at Rs 1,145. All three vaccines are available in government centres for free.

One of the reasons affluent Indians preferred vaccination in private centres was the fear of overcrowding in government centres. But Suresh Kakani, additional municipal commissioner in Mumbai, said government centres are now exceptionally well-managed, which has diverted crowds from paid private vaccination to free public facilities.

In Mumbai, where private hospitals are sitting on over 19.05 lakh doses, the city’s municipal corporation has over 10 lakh doses in stock. “We are in a comfortable situation. There is adequate supply from the Centre and the state government,” said Kakani.

There is another reason why the government is unlikely to purchase the unused vaccine stocks of private hospitals. “The government cannot buy our stock because they are buying from manufacturers at a much lower rate,” said Dr Joy Chakraborty, the chief operating officer of PD Hinduja Hospital who heads the Association of Healthcare Providers in western India.

The case for and against booster doses

Apart from the private sector, another segment that wants the government to allow booster doses is India’s health worker community. The Indian Medical Association wrote to the health ministry earlier this month asking for booster shots for healthcare workers.

States like Kerala and Maharashtra have also written to the Centre with a similar recommendation, saying booster doses could help high-risk populations brace for a third wave of Covid-19.

But evidence of the efficacy of booster doses is mixed.

A study published in the New England Journal of Medicine on September 15 found that those administered booster shots in Israel had 19.5 times less chance of severe Covid-19 infection than those who had received only two doses, and 11.3 times less chance of confirmed Covid-19 infection. The study, however, did not analyse whether booster shots had reduced deaths among the infected group.

In a document released on October 8, WHO said it was not yet established for how long vaccine-induced immunity lasts. The document observed that most of the studies on booster doses are “observational studies”, and declining antibody level does not necessarily mean declining vaccine effectiveness.

“In a period of continued global vaccine supply shortage”, WHO noted, “improving coverage of the primary vaccination series should be prioritized over booster vaccination.”

Dr Soumya Swaminathan, chief scientist at WHO, said vaccine immunity is expected to last for at least a year. On the discussion on booster shots in India, Swaminathan told Scroll.in that the country first needs to “definitely cover the eligible population with two doses” before it can consider a booster dose.

India has so far fully immunised 40 crore people, covering over 40% of the adult population. More than 80% have received the first dose. At least 21.64 crore vaccine doses are in stock with states. The government is finding it hard to reach the last mile, especially in rural and tribal areas where vaccine hesitancy is prevalent. Many districts are now sending health workers door-to-door to counsel and immunise the remaining population.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.