What will it take to vaccinate India against Covid-19?

India’s Covid-19 vaccination drive will roll out next week. The government is aiming to vaccinate 300 million people – a quarter of the country’s population – by the end of the summer. The two approved vaccines in India’s arsenal need to be administered in two doses, which means 600 million shots will have to be delivered in the next six months.

That’s more than 20 times the number of pregnant women and children vaccinated as part of India’s universal immunisation program.

Delivering the vaccines at that scale would require a scale of operation “we have not seen anywhere before”, said Prashant Yadav, a health care supply chains expert at Harvard Medical School. “It would require over tens of thousands of vaccination clinics working seven days a week vaccinating from morning to evening in an extremely well-coordinated manner.”

The government has released a detailed blueprint of its plan of action, describing it as “broadly similar to the election process”. Helmed by the National Expert Group on Vaccine Administration for Covid-19, a three-tier administrative architecture has been put in place with committees and task forces at the state, district and block level.

But how exactly will the system work? Scroll.in spoke to health experts, syringe makers, cold storage companies, among others, to understand the key challenges ahead.

Registering for the vaccine

The government has decided to first administer the vaccines to high-risk groups: healthcare workers, frontline workers, people above 50 years of age and those with co-morbidities like diabetes, hypertension, cancer and lung diseases.

This is a prudent strategy, say health experts, followed by most countries across the world since scientific models indicate that inoculating old people first leads to the greatest reduction in cumulative deaths.

To begin with, only pre-registered people will be eligible to receive the jab (on-the-spot registration is not an option). Registration is to be done on the COVID Vaccine Intelligence Network (Co-WIN) system that has been described as a “digitalised platform to track the enlisted beneficiaries for vaccination and COVID-19 vaccines on a real-time basis”.

(The platform can be accessed at http://www.co-vin.in/. The link is yet to go live for the general public at the time of writing this.)

Registration would involve authentication through a photo identity card. There are 12 options for this, which includes all major government identity documents such as voter identity card, driving license, Aadhaar, among others. Co-WIN would also allow people to list their comorbidities, if any. “Common Service Centres” would be set up to help people register.

On successful registration, the beneficiary would receive an SMS on their registered mobile number with details of the time and place of vaccination.

Free or subsidised or market rates?

The government has suggested that the vaccine will be free for “most prioritised” beneficiaries, such as healthcare workers and frontline workers. Which means the rest will probably have to pay, but there is little clarity how much exactly. The government has said they are yet to come to an agreement with the manufacturers.

Reports suggest that the vaccine may be subsidised for the other eligible groups in the first round of immunisation.

Some say that the government should do more. “Given this is a national emergency, the government must make it free for at least 60-75% of the population,” said K Sujatha Rao, former Union health secretary.

Vaccinating 30 crore people in half a year

Rao believes the government’s timeline is too ambitious. Delivering two doses each to 30 crore people by September is possible, she said, “provided nothing else is done by the entire government at the cost of other health programs and other government programs”. The target cannot be achieved “if there are say elections to also be organised, for example,” she noted.

The government’s plan entails vaccinating 100 beneficiaries per day in one particular vaccine centre, manned by a five-member team. Health workers associated with India’s immunisation drives say that could be difficult to achieve, particularly in the rural areas.

“It is going to get difficult and difficult as you get into rural India with technical snags and server crashes,” said Prabir Chatterjee, a doctor currently based in rural Bengal, who has spent several years working in the government’s pulse polio and other routine immunisation programs.

‘Planning alone not sufficient’

There is not much of a global model to emulate either. Countries where vaccination has begun are already running behind schedule.

“In the last four-five weeks we have seen that planning alone is not sufficient,” said Yadav. “Flawlessly executing the vaccine distribution and vaccine administration plan requires very strong trust and rapport across multiple levels of government. There is the need to have agile decision making structures when parts of the plan don’t work because of last minute issues on the demand side or the supply side.”

Worryingly, India’s response to the pandemic has been marked by clashes between the Centre and states, making the lack of coordination all too evident on several occasions.

Dose-demand mismatch?

As is obvious, only after inoculating these high-risk groups, the program will extend to the rest of the population. This is, of course, subject to availability of enough doses at India’s disposal.

India has, so far, approved two vaccines: Oxford-AstraZeneca’s Covishield vaccine manufactured by the Pune-based Serum Institute and Bharat Biotech’s indigenously-produced Covaxin vaccine. The latter, which has no large-scale efficacy and safety data, will be used in the “clinical trial mode” – recipients will be tracked like they were in a trial.

Serum Institute has claimed it has a stockpile of over 50 million doses and will soon have the capacity to produce as many as 100 million doses by March. However, the company has a commitment to make a share of its vaccines available to the Covax Facility, a World Health Organisation-led initiative to distribute vaccines to low and middle-income countries. It was not immediately clear when that arrangement would become operational.

Besides, the company also has orders from other countries to fulfil. So how much of Serum’s vaccines will cater to India remains to be seen. An email seeking clarity from the company went unanswered.

Bharat Biotech, for its part, has 20 million doses ready so far and plans to manufacture a total of 700 million doses by the end of the year.

By the Indian government’s estimates, 660 million doses (accounting for wastage) would be required to inoculate the first batch of high-risk individuals.

Some, therefore, believe a third manufacturer would have to step in to avoid extending the targeted timelines too much. “We need a third vaccine otherwise the waiting line will be very long,” said Ramesh Anbanandam, a professor at the Indian Institute of Technology’s department of management studies, who specialises in healthcare supply chains.

The other pressure points

But others like Yadav, the health care supply chain expert at Harvard, believe that Bharat Biotech and Serum Institute’s capacities are adequate. “They have sufficient capacity to meet the 30 crore target in the next six-eight months,” he said.

According to Yadav, the limiting factor may not be “vaccine dose supply as much as the operational infrastructure to deliver them”. Among other things, “trained vaccinators and auxiliary staff in very large numbers would be a constraint”, he feared.

Rao, the former Union health secretary, sounded a similar alarm: “Not many listed as possible vaccinators have the skill and so training is critical. Such training takes time as adherence to high levels of hygiene standards is a behaviour change that takes time and resources.” This, she said, was likely to plague the northern states in particular which have “a very adverse human resources to population ratio”.

Another thing that observers say needs close attention is the synchronous supply of consumables such as syringes. Industry executives insist they have things under control. “We have been trying to wake the government up since April; they finally woke up in October and started making orders by November,” said Rajiv Nath, who manages one of India’s biggest syringe manufacturers, Hindustan Syringes and Medical Devices. “So now there is more clarity regarding the demands and timelines, so we should be fine.”

But just stockpiling is not enough, say supply chain experts. “The government of India appears to be planning for adequate quantities for all of these materials in the aggregate, but ensuring their availability matches at the granular level depends a lot on information and incentives at the last mile of the supply chain,” said Yadav.

Or as Rao put it, the test lay in “ensuring that all consumables and vaccines are supplied in sync on a regular basis”.

Then there is the challenge of cold chains. Chatterjee, the rural doctor, feared cold chains could be “a major limiting factor”.

According to government records, India has 85,634 cold chain equipment spread across 28,947 cold chain points. Chatterjee said that was not going to be enough to handle the pressures of the Covid-19 vaccination program. “The freezers are going to run full, affecting routine immunisation,” he said.

Disruption of other services

Indeed, one of Chatterjee’s biggest worries is the impact Covid-19 vaccination drive will have on India’s other health programs, particularly in the rural areas. Already, India’s tuberculosis program has suffered severe setbacks because of resources being diverted to Covid-19.

“For months on end, staff will no longer be available for other work like deliveries, antenatal care, immunisation,” said Chatterjee.

Other public health specialists echoed his concerns. “There is every possibility of the routine immunisation programs being disrupted – again in the northern states where vaccinators are few,” said Rao.

However, Rao said there was a way around it: developing a cadre of dedicated Covid-19 vaccinators like India had for its smallpox program.

But Yadav feared that may not be enough. “The challenge will be how a clinic or public health centre carries out 10 hours a day of Covid-19 vaccinations while at the same time carrying out routine immunisation,” he said. Apart from the obvious shortage of staff and space, Yadav said there was the “issue of whether parents of infants will feel safe bringing their kids to a clinic with long lines of adults waiting for Covid-19 vaccination”.

Market to the rescue?

Is making the vaccines available in the open market then a way of dissipating the pressure? Yadav said it was the prudent thing to do given the private sector’s “huge capacity especially in the urban areas”. “It will require careful stewardship by the government to ensure not all vaccine supplies start getting pulled into the private market, but that is a manageable task,” Yadav said.

But there are detractors of the proposal, such as Indranil Mukhopadhyay, a health economist who teaches at the OP Jindal Global University. Given the obvious supply-demand mismatch at the moment, it was a bad idea to make the vaccines available in the open market immediately, he maintained.

“That might lead to black-marketing and overcharging and it will reach only the very rich because there isn’t going to be enough production to match the demand for a while at least,” he said. “That will defeat the public health purpose of the vaccine – which is to ensure a large population is inoculated so that there is some amount of immunity in the community.”

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.