Will India really have enough vaccines to cover the entire population by the end of 2021?

India’s Covid-19 vaccination programme is in a mess.

Although in absolute terms, the 180 million doses administered since January may seem like a remarkable achievement, that covers less that 15% of the total population. Only about 3% have received two doses, while India needs to cover 60-80% of its population to reach the herd immunity needed, though scientists are uncertain what the exact required threshold will be.

More worryingly, the programme has been losing steam. After vaccinating 24 million in one week at the start of April, India has been able to administer only around 12 million doses over the last two weeks.

While some of this may be down to vaccine hesitancy, the main problem seems to be supplies: India does not have enough doses. Despite the government claiming for months that there are no shortages, and even as 66 million vaccines were exported both as part of commercial deals and donations, it has become more and more evident that India simply did not anticipate the need for a speedy vaccine rollout.

Since mid-April, the government has sought to change tack. It introduced a new ‘liberalised and accelerated’ vaccine strategy, though many questions have been raised about how efficient the revised plan is.

And, after prodding from citizens, states and the Supreme Court, the Indian government has – for the first time – put a target for when it believes enough doses will be available for all citizens. In a press conference on May 13, NITI Aayog’s VK Paul said, “two billion doses will be made in the country in five months for India and for people of India. Vaccine will be available for all as we move forward.”

India has an adult population of about 1 billion people, and most vaccines that will be available in the country require two doses for full vaccination. With some wastage factored in, the 216 crore doses – 2.16 billion – mentioned here should be enough to cover India’s needs.

But how reliable are these predictions? Remember, the same people who announced these figures told Indians in January that the pandemic had been defeated, that there wouldn’t be a second wave and that most of India had ‘herd immunity.’ With a vaccination programme that has been faltering and seen major shifts in policy, can Indians actually expect to have 100% vaccine coverage, for adults at least by the end of 2021?

There are a number of ways to read this chart.

First, the very fact that it exists is useful. We have written about how little transparency there is about India’s vaccine calculations, allowing the government to skirt accountability. Now, the Centre has set a target that citizens can hold it accountable.

Second, five of the eight vaccines mentioned on this list have not been approved for use in India, or indeed anywhere else.

Two of them, Bharat Biotech’s unique nasal vaccine, and Gennova’s mRNA one, are at the very beginning of the clinical trial process. Although the globe has seen remarkable success at vaccine development in a short period of time over the last year and a half, there have been ones that were abandoned or found to lack efficacy.

Of the remaining, three other manufacturers – Novavax, Biological E and Zydus Cadilla – are closer to seeing a potential approval of their vaccines.

For context, Novavax was one of the first manufacturers expected to sign deals promising to provide hundreds of millions of doses to countries around the world, including India, in 2020. But despite positive numbers from clinical trials, the company has struggled to get approvals and announced in May that it would take at least until July to be cleared in the United States.

Novavax had signed up with the Serum Institute of India to manufacture a version of the vaccine for India, and the government had expected it to be the largest source of doses for the domestic inoculation programme.

Biological E and Zydus Cadilla have also taken longer than expected during their phase 3 trials.

The Indian Express put together a useful table of the vaccines promised, and where they stand in terms of approavls.

Carnegie India also put together a table with similar estimates and further details on the status of each vaccine candidate’s progress:

Of course, this is a natural part of planning for the pandemic. Since 2020, countries have had to make bets on vaccine development in the hopes that some will make it past the approval stage in time and provide protection. The last 12 months have, however, provided clear evidence that estimates of both approval and manufacturing timelines may be off.

The government’s decision to primarily communicate a best-case scenario set of figures may hurt it, though officials admitted that these figures were optimistic. Equally important, how quickly can the government change tack if its clear one of these bets is not going to pay off?

Third, the production numbers are more optimistic than the manufacturers’ own estimates.

Take the estimate for Serum Institute of India producing Covishield, the Indian version of the Oxford-AstraZeneca vaccine. The government estimated that it could produce 75 crore doses, meaning 750 million doses, between August and December.

SII has been struggling to produce more than 60-70 million doses per month over the first half of this year with inconsistent statements about whether a fire earlier in the year affected production. It has promised to ramp this up to around 100 million doses per month by July.

If it gets there, and can maintain that rate, it would be able to produce 500 million doses over the five months from August to December. How did the government come up with the 750 million figure?

Similar expectations have been put down for Bharat Biotech’s Covaxin, which will also be produced at three public sector units, though those in charge of at least one of these state corporations – Haffkine Biopharmaceutical Corporation – said in April that it would take until 2022 before they can realistically produce doses.

This table by Mint puts down the estimates of the government versus what the companies themselves have said:

Moreover, the manufacturers’ own numbers have often proven to be exaggerated. As Oomen C Kurian writes in a piece about Novavax, “the perceived production capacity based on claims by manufacturers and numbers on the ground have proven to have a considerable mismatch.”

Fourth, not all vaccines produced in India will necessarily be ‘available’ to Indians.

The central government permitted 66 million doses to be exported in the first three months of the year, before putting an informal halt to vaccine exports. The BJP has defended those exports, pointing out that 84% of them were part of commercial and licencing liabilities of the manufacturers.

Those liabilities still exist, particlarly for the Serum Institute of India, which had promised huge consignments of both Covishield and its Novovax variant to other countries and COVAX, the global facility to provide doses to developing nations. The company, now under tremendous pressure from those that it had committed to, has said that it hopes to “start delivering to COVAX and other countries by the end of this year.”

Will the government allow SII to export doses before the end of December? The policy choice here is complicated, since dozens of developing countries are entirely dependent on COVAX and India’s export ban has left them in the lurch. But the Indian government has come under pressure for its vaccine diplomacy earlier this year and boasting about sending more doses abroad than it had used at home. Will its image building efforts from earlier in the year push it into a policy corner now?

On the other hand, if it does allow any exports, the calculations for how many vaccines will be available to Indians will naturally change.

Fifth, although the numbers will likely be relatively small, India may end up having access to vaccines that are not made in the country.

US President Joe Biden has committed to sending up to 80 millions vaccines that his country has stockpiled to other nations, though it has yet to say which ones they will go to.

A global push for richer countries to share their stockpiled doses with developing nations will be tremendously helpful, though India may not be the first port of call as one of the few that actually has domestic manufacturing capicities.

Besides this, a number of Indian states and Union Territories have put out global tenders to buy vaccines directly. After initially getting no response, some have been rejigging their offers. Though expectations for these are generally low, because most vaccine production globally is already accounted for in terms of buyers, there is still always the possibility that India is able to draw in some doses through imports.

Finally, the impact of the US putting its weight behind an Indian-sponsored effort for a global vaccine patent waiver remains unclear.

Sixth, multiple doses may be needed.

Data so far has mostly been promising when it comes to the question of whether vaccines protect against the more severe variants so far, though the numbers are very preliminary. More research – and real life data – will presumably be needed before making such conclusions.

Still, manufacturers have began talking about and researching the need for a third booster shot in addition to the first two, and booster that focus on specific variants. The longer the pandemic lasts, the more chances that variants will emerge, some of which may prove to be more resilient to vaccines.

This may not initially matter for the government’s calculations for 2021, since it will be struggling to provide the intial two-dose regimen for the bulk of Indian adults this year. But it will have an impact on how manufacturers see production and the question of exports through the rest of the year. Plus, citizens who now expect to be reasonably protected by the end of 2021 may have to re-calibrate their expectations.

Overall, given the experience of the past six months, it seems unlikely that the next six will go exactly according to plan. While it is useful for the government to put down a target, the actual likelihood of having all Indians fully vaccinated by the end of 2021 seems shaky. That said, the numbers at least offer a roadmap towards full vaccination and make it clear that, after July, the focus will shift from shortages to India’s capacity to distribute the vaccines and to lower widespread hesitancy.