Fixing India’s Covid-19 Vaccine Supply Crunch
We need to tailor vaccination expectations to the constraints of India’s situation, writes former Health Secretary K Sujatha Rao.
As disconcerting the galloping rise of the Covid -19 cases has been, more troubling was the sudden suspension of vaccination in several states on grounds of non-availability of the vaccine. This was followed by an unseemly denial by the Union health minister alleging that states were spreading rumours of shortage when there was none. Alongside the issue of shortage, has also been the growing demand from different quarters for expanding the eligibility for vaccination from the current 45 years to all above 18, disagreeing with the Union health secretary’s statement for the need to prioritise and provide vaccine to those who need and not those who want. Needless to say, the situation has become complex necessitating a greater understanding of tailoring our expectations to the constraints of the situation.
How We Got Here
On Jan. 3, India’s Central Drugs Standard Control Organisation issued an emergency authorisation to two vaccines – Covishield produced by the Pune-based Serum Institute of India Ltd. and Covaxin, produced by the Hyderabad-based Bharat Biotech International Ltd. As per media reports, the government is said to have entered into an agreement for the supply of 166 million doses of Covishield and 10 million doses of Covaxin, to be supplied at the rate of 60 million Covishied and one million Covaxin per month.
So far, as of date, over 90 million doses have been used; of which, 11.4 million have been for the second dose. This is against the target of 230 million Indians to be vaccinated by end-July, 2021.
While that is a daunting target, the progress has been impressive - from 0.19 million coverage on Jan. 16, to 88.3 million by April 7 vaccinating at an average of 1.8 million/ day in an estimated 44,000 vaccination sites. However, attaining the target will require doubling the daily turnover and also ensuring uniformity of performance.
The Speed Bumps
Achieving the objective of 230 million vaccinated persons and expanding the eligibility criteria is, however, contingent on the steady and regular supply of the vaccine. This is constrained by two factors:
- The first is the inability of getting the much-needed raw materials from the United States – bags, vials, cell culture media, single-use tubing, specialized chemicals, etc. that have now been banned for export seriously disrupting production. SII is currently producing 50 million doses per month and has indicated its ambition to double it in two months provided it is able to access the raw materials without interruptions.
- The second is the expansion of production capacity. Both the companies have, for a while, been seeking financial assistance to enable expanding production capacity. There is an urgency here, as there is a lead time of no less than two months to install machinery or reboot existing facilities to expand capacity.
On both these constraints, the union government has delayed action. It needs to swiftly take up the matter with the U.S. authorities for exemption, on the argument that over 93 countries around the world are dependent on the vaccine manufactured by India; and expeditiously finalise the financial package to speed up capacity expansion.
Approve More Vaccines
There is also a need for the government to act swiftly on two more issues, The first would be to approve more candidate vaccines without delay. It is recently learned that Gamalaya’s Sputnik has been approved and an agreement for the supply of 200 million doses entered into. Production now must be closely monitored. Alongside, there is yet another candidate – Johnson & Johnson that has the approval of the Food and Drug Administration in the U.S., which could perhaps be permitted a smaller sample for the bridging study and approved likewise. Expanding the vaccine portfolio will help us access more vaccines.
Decentralise To Cut Wastage
We also need to improve efficiencies in utilisation and drastically reduce vaccine wastage. The average wastage is 6.6% with Telengana touching a high of 17.6% followed by Andhra Pradesh at 11.6%. It is reported that with the expansion of eligibility criteria and the doses per vial standardised to 10 against the earlier 20, wastage has been drastically reduced and brought down to half. Since this programme is riding on the Universal Immunisation Programme, the distribution and processes are smooth and functioning including quality assurance. What is needed is decentralisation to states to enable local planning for closing or opening vaccine sites; engaging civil society to reduce vaccine hesitancy; and speed up utilisation in states where uptake continues to be slow.
India’s options for containing the pandemic are narrowing as it can ill-afford another lockdown. The universal use of masks and rapid vaccination are the only two policy choices for achieving 70% coverage for herd immunity that is necessary for reducing infections and deaths. Surveillance data, on the other hand, say for Kerala conducted in March, shows that while the age band of 40-70 years has a sero-prevalence of an average of 11%, it is 10% for the cohort 18-40 years. It is not known what the situation is like elsewhere.
Given the shortage of vaccines, India cannot afford to have a single or universal policy and needs to make it more targeted. This then implies undertaking such sero-prevalence studies in all states so that prioritisation is based on scientific evidence and not public perception.
Balancing Global Commitments
Another issue is concerning international obligations. Of the 38 million doses the global alliance programme Covax has so far distributed to 84 countries, 28 were from India. Another 40 million doses were due as in March.
Under the vaccine diplomacy initiative, India exported 60 million doses, half on commercial terms and 10 million as grants. That obligation may have to be followed up perhaps as they would need for their second dose. While so there is growing pressure from the United Kingdom and European Union for vaccines.
While the need for global solidarity is important, the vaccine inequality is striking with the rich countries having already booked up to 4.6 billion vaccines, the middle income 670 million while the poor are stuck with none. So while domestic compulsions will have to also be weighed in, the international situation is volatile with a clear upper hand with the richer countries who know the art of twisting arms of poorer economies.
A Tightrope Walk
Though India’s ability to regulate and control risky behavior is tough, the choice is narrow. If fresh lockdowns are to be avoided, we need to enforce masks by investing in massive multimedia campaigns for information, education, and communication, like it was done for polio and HIV.
India will need to act smart. It needs to enter into advance purchase agreements with other vaccine suppliers that may price its product higher but one that can be afforded by the richer sections and more so if covered by insurance. It should also speed up approvals and financial packages for ramping up domestic production for expanding supply, expand age bands as supplies improve and decentralise implementation decisions to states to enable better efficiencies, and allow export after ensuring at least five months stock. There will be trade-offs, but there is no escaping the tightrope walk.
K Sujatha Rao is former Secretary of Health and Family Welfare, Government of India; and the author of ‘Do We Care? India’s Health System.’
The views expressed here are those of the author and do not necessarily represent the views of BloombergQuint or its editorial team.