Chhattisgarh took the right step towards vaccine equity – but the High Court blocked it with quotas

India opened up Covid-19 vaccination for people in the age group of 18-44 years from May 1. Due to a shortage of vaccines, Chhattisgarh decided to undertake the vaccination in phases, prioritising those who are socially and economically vulnerable.

As per Chhattisgarh’s guidelines for vaccinations of people in the 18-44 years age group, in the first phase people under the Antyodaya Anna Yojana – a food scheme for the poorest and most vulnerable families – were to be vaccinated, followed by those Below Poverty Line. Those Above Poverty Line were to be vaccinated in the final phase.

Multiple petitioners filed intervention applications against the state’s vaccine guidelines in the Bilaspur High Court under an ongoing suo motu case on the concerns of people of the state during the pandemic. The High Court in its order of May 4 opined that prima facie, the sub-classification of persons to be vaccinated on the basis of their “financial status” alone “may not be correct or sustainable”. The Bench directed the State to fix reasonable ratios of vaccines that may be allotted to various groups based on factors such as vulnerability, chance to spread the disease and the number of eligible persons in the group.

The government of Chhattisgarh passed a circular on May 5, stating that a committee has been set up immediately under the Chief Secretary to determine the vaccine policy, as ordered by the High Court. The order also said that till the committee develops the new vaccine policy, the vaccination of 18-44 year olds will be postponed as administering vaccines to people covered under Antyodaya would amount to violation of the Court order.

In the next hearing, which was held on May 7,the High Court said that Chhattisgarh government must resume the vaccination of 18-44 age groups with interim quotas of one-third each for the Antyodaya, BPL and APL categories.

Chhattisgarh policy in line with global view

Globally there is a consensus on ensuring vaccine equity. While the pandemic has affected all classes and groups, the most vulnerable have had to face the worst consequences. Inequitable access to health services, measures for prevention, and social protection in the face of loss of livelihoods are just some of the reasons for this. The pandemic has exacerbated existing inequities and therefore it is essential that all government policies must recognise and address this. The Chhattisgarh government’s policy tried to do this.

Similar recommendations are seen in the WHO SAGE Roadmap For Prioritising Uses Of COVID-19 Vaccines In The Context Of Limited Supply. The roadmap suggests that for an epidemiological scenario of Community Transmission (which Chhattisgarh is in now), with limited vaccine availability (for 11–20% population), the priority groups should be as follows:

• Older adults not covered till now
• Groups with co-morbidities or health states determined to be at significantly higher risk of severe disease or death. Efforts should be made to ensure that disadvantaged groups where there is underdiagnosis of comorbidities are equitably included in this category.
• Sociodemographic groups at significantly higher risk of severe disease or death (depending on country context, examples may include: disadvantaged or persecuted ethnic, racial, gender, and religious groups and sexual minorities; people living with disabilities; people living in extreme poverty, homeless and those living in informal settlements or urban slums; low-income migrant workers; refugees, internally displaced persons, asylum seekers, populations in conflict settings or those affected by humanitarian emergencies, vulnerable migrants in irregular situations; nomadic populations; and hard-to-reach population groups such as those in rural and remote areas).
• Health workers engaged in immunization delivery (routine programme-specific and COVID-19).
• High-priority teachers and school staff (depending on country context, examples may include: preschool and primary school teachers because of the critical developmental stage of the children they teach, teachers of children where distance learning is very difficult or impossible).

The Human Rights Advisory on Right to Health in view of the second wave of COVID-19 pandemic (Advisory 2.0) released by National Human Rights Commission has also reiterated the need for ensuring that those “most vulnerable and at the most risk like destitute, homeless, prisoners, migrant workers, beggars, etc”, and people without Aadhaar or any other documents are vaccinated through special efforts.

In Chhattisgarh, the Antyodaya scheme covers socio-economically vulnerable groups and people, including Particularly Vulnerable Tribal Groups, single and widowed women, people having chronic diseases, people with disabilities, people who are destitute, people who are homeless and people who have been freed from bonded labour. Therefore, the Chhattisgarh policy on prioritising the poorest for vaccination was in tune with national and international guidelines on equitable vaccination.

Universal coverage is ideal – but shortages force prioritisation

The ultimate aim of all governments must be to ensure universal and free vaccination. However, as seen in directions above, in case of vaccine shortages, prioritisation based of vulnerability must be done.

Equitable distribution of vaccination means that the people who are most affected by the disease or its consequences, need to be prioritised and provided vaccination. The idea that equitable vaccination means having equal quota for all socio-economic groups is erroneous. The view that prioritising the most vulnerable is against social justice principles is deeply flawed.

Chhattisgarh has been a front-runner in the country in vaccinating those above 45 years, with more than 70% of that age group having received the first dose. The state also allowed walk-in facility which facilitated coverage of those who have no access to internet or smartphones. The state has already announced free vaccination for all its population.

If the state had received enough vaccine doses from the central government it could have rolled out a universal and free vaccination programme. Unfortunately the central government’s vaccine policy makes it very difficult for any state to achieve universal coverage. Therefore, until the central government’s policy is reversed, the state on its part must continue to prioritise the most vulnerable, while finally aiming for universal coverage.

Dr Sulakshana Nandi is a public health practitioner working in Chhattisgarh.