As India opens up vaccines to all adults over 18, Modi’s original plan lies in tatters

As of May 1, every adult over the age of 18 in India is eligible to be vaccinated. At the moment, though, the bulk of those between 18 and 45 are more likely to have access to a government-sent SMS about being vaccinated than a vaccine itself. That is because India’s vaunted vaccination campaign has fallen off the rails.

Several states have deferred the rollout of vaccines to those in the 18-45 band, citing insufficient stocks – despite the Centre claiming for months that there are no shortages. Private vaccination centres will potentially have to shut down, after one manufacturer said that they cannot expect doses for the next five to six months.

Questions have been raised about the decision to sell emergency-authorised vaccines on the open market and charge Indians for doses. The complex pricing formula that sees manufacturers charging different rates to the Centre, states and private hospitals has come under fire from the Supreme Court.

A combination of flawed planning, the failure to factor in a massive second wave of the virus and – in response to the ongoing surge – a sudden change of tactics has led to the current state of confusion and uncertainty. There is little clarity on how and when a sufficient proportion of the population will be immunised.

The result: a vaccine production effort that was touted as successful enough to support both India and countries around the world is turning out to be woefully insufficient at home and irredeemably delayed for dozens of other nations.

It didn’t have to be like this.

India had a natural advantage in the race to contain Covid-19. It is one of the few nations with large-scale vaccine manufacturing, and experience with national immunisation programmes.

It is by no means as rich as either the United States or the United Kingdom, but it could well have followed the two countries in their approach of dedicating effort and resources into the domestic vaccination effort – to make up for woeful handling of the virus in 2020.

Instead, Prime Minister Narendra Modi decided to take a different path.

Self-reliant model

From the very beginning, Modi touted two aspects of India’s vaccine drive that were evidently key pieces of the puzzle:

• “Made in India” vaccines and,
  
• The country’s ability to distribute doses to other nations, both as grants and exports.
  

Speaking on January 22, a week after India began its inoculation drive, Modi claimed that, “on the world’s biggest need today, we are completely self-reliant. Not just that, India is also helping out many countries with vaccines.”

Implicit in this statement was another key calculation: Modi’s government did not believe India needed to rush into vaccinating everyone right away. And of course, his government – and not the states – would make all the decisions.

Reports in December, and the complacency on display through the first three months of the year make it evident that the government believed that the virus was unlikely to make any sort of comeback after case counts unexpectedly began to fall in 2020.

Touting self-reliance – one of Modi’s buzz words – meant that India was shutting out all vaccines manufactured outside the country. The country would be entirely dependent on two domestic producers: the Serum Institute of India, which makes Covishield, a version of the Oxford-AstraZeneca vaccine, and Bharat Biotech, which makes the indigenously developed Covaxin.

The Centre would procure from these two, and provide vaccines to states to deliver to the priority populations – giving little leeway to chief ministers to tweak the rollout based on local needs.

Remember, each person needs two doses of a vaccine. The best-case scenario for the combined output of these two manufacturers was 65 million-70 million doses a month at the start of the year, with hopes of that going up to 160 million doses a month. That higher figure now seems likely only in July.

Either way, no calculation of their combined supplies suggests India would have been able to cover the 400 million people above the age of 45 that it had set as a target for August, let alone all adults.

Permitting vaccine exports, which the US has not done, and even turning them into a big public relations push for the country, meant that India would not even have access to supplies of all these 65 million-70 million vaccines produced in India.

Yet this was such a point of pride for the government that in late March, when shortages were starting to be apparent at vaccination centres, India’s ambassador to the United Nations boasted that “we have supplied more vaccines globally than have vaccinated our own people”.

Vaccine exports

Some have argued that those exports were not a choice – despite the government’s PR efforts – since many of them were contractual obligations for the Serum Institute, which had signed agreements with AstraZeneca and Covax, a global vaccine distribution mechanism.

There are two reasons to question this argument.

First, while counterfactuals are complicated, the Serum Institute may not have signed those deals – or at least not quite in the same way – if the Indian government had invested “at-risk” in its vaccine in 2020, and chose to purchase the bulk of the initial consignments. It is true, that we don’t know the full terms of the deal between SII and AstraZeneca.

Instead, even two weeks before India’s vaccination campaign began, the country had yet to sign purchase orders. It chose to follow an ad-hoc, piecemeal approach to vaccine buying over the next few months rather than commit to large orders. That it, until mid-April when the second wave had turned into a medical calamity.

Here too was an unwritten assumption: that the Serum Institute would reserve a large amount of its production for India, even without purchase orders. But at the same time, the company could make up for the Modi government’s unwillingness to financially support it by doing deals and accepting funds from other countries.

Second, we know that exports were indeed a choice because, simply put, India exercised it. The country has prohibited vaccine exports since March, with no clear timeline for when they will be permitted again, according to Foreign Secretary Harsh Shringla.

“[India’s] requirement is significant and pressing and whatever we produce we will need for our domestic vaccine programme,” Shringla said.

All falls apart

By April, as case numbers in India went through the roof and vaccination centres reported shortages from around the country, all three elements of the vaccine strategy had turned to dust.

After months of self-reliance, India abruptly permitted foreign-made vaccines to enter the market. Vaccine exports were cut off – angering countries expecting supplies and allowing China to muscle in where India had been hoping to exercise soft power. Suddenly, the idea that the country could take its time vaccinating everyone had to be discarded.

Instead, Modi’s government announced a “Liberalised and Accelerated Phase 3 Strategy of Covid-19 Vaccination” from May 1, that without explanation altered the whole structure of India’s vaccine procurement, handing over much more power to the manufacturers and much more responsibility to the states.

It made everyone eligible for the vaccines, even though the drive had so far covered less than 5% of the earlier target group of those over the age of 45.

Scroll.in has written earlier about some of the baffling aspects of this new policy and the oddity of getting details of the strategy from a private manufacturer, rather than from the government.

More than 10 days after it was announced, there is little clarity on some key questions:

• How will manufacturers decide whom to distribute to, between states and private hospitals, which are to procure from the same stock? Who will regulate and ensure this distribution is equitable?
  
• Will there be transparency on the volumes? Will citizens get to know which entity, state or private, is getting how many vaccines, on what timescale and at what price?
  
• Manufacturers have reduced their prices for state governments after the Centre requested them to. What explains their earlier prices? How could they simply lower them by large amounts? Will the lower price affect volumes? Will it tilt supply towards the private hospitals that are paying more?
  
• What is the Centre’s target for vaccinations through each of these channels? How many Indians does it seriously expect to pay up to Rs 2,400 for vaccines at private hospitals?
  

Grand plan

States have publicly said that they were not consulted on the changes to the policy and, in particular, the differential pricing. Many observers have questioned the decision to let a substantial number of vaccines be sold at a price, rather than be provided for free. The silence from the Centre has made many wonder if the decision to open up private sales is the quid-pro-quo with vaccine manufacturers, since they have been forced to renege on their contracts with other nations.

Experts are clear that age and comorbidities are the still the best indicators of how Covid-19 will affect someone, and that opening up to all adults may force the vulnerable to wait longer. It remains unclear why the Centre chose to open up to 18+ – unless the leadership was simply giving in to political pressure.

Unless the Supreme Court is able to extract responses – since many of these questions came up in a hearing on the Centre’s policies – prior record suggests we’re unlikely to get answers. The vaccination campaign may yet stabilise through May, with more supplies turning up in the form of imports, though few expect any substantial change to the figures before July.

At least one chief minister, Andhra Pradesh’s Jagan Mohan Reddy, has decided to be more realistic than the Centre’s “there is no shortage” communication, telling his state that vaccinations for the 18-45 band will only begin in September, since the next few months will be reserved for those over 45.

Amid all this, as India enters the new phase on May 1, what is clear is that Modi’s grand vaccine plan – to not invest beforehand, to keep targets relatively languid, to permit exports and publicise India’s support to the world, to emphasise self-reliance – has had to be consigned to the dust-heap. Will the changes actually have the effect of liberalising and accelerating India’s much-needed vaccine campaign?