India Questions New Dehli’s Changes to National Vaccination Program

Why has India's central government offloaded its vaccine burden to individual states?

India had vaccinated around 141 million people when a new wave of Covid crippled the country in April. That sounds like a lot, but in a country that boasts nearly 1.4 billion people, vaccinations had barely scratched the surface. India’s vaccine rollout had. until this point, been orchestrated and paid for by India’s central government. Only two vaccines were approved for use, Covaxin, an indigenously developed shot produced by the Hyderabad-based Bharat Biotech International Ltd, and the AstraZeneca Plc shot manufactured by the Pune-based Serum Institute of India Ltd. New Delhi negotiated a fixed price with each manufacturer, securing vaccines for 150 rupees each.

Then, mid pandemic surge New Delhi announced an unexpected shift in its vaccination strategy. It’s a change that has left many concerned and with good reason. The announcement to expand the vaccination campaign to all adults below 45 starting next month is a late but welcome move. India now has a daily infection rate of almost 350,000 and daily deaths are headed northwards of 3000 a day. The issue India now faces is that New Delhi appears to be worming its way out of both responsibility and accountability for vaccination by shifting a big part of the financial burden to India’s 28 state governments.

What this means in effect is that new vaccines need to be purchased from manufacturers on a state-by-state basis, assuming all states have adequate funding to afford to vaccinate their populations. Many don’t. Additionally, letting private hospitals buy shots at 600 to 1200 rupees ($8 to $16) apiece — and sell them to patients at even higher prices is a recipe for profiteering and vaccine discrimination.

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Narendra Modi’s government has essentially created the perfect environment for a vaccine bidding war between states. Limited supplies have to be sent somewhere and this choice may very well come down to wealthier states being able to outbid their poorer neighbors. Limiting vaccine choice to the two indigenous vaccines also means that it’s a closed and very protected market the manufacturers can exploit, rather than opening the option to states for purchasing alternate vaccines from other sources. 

India currently suffers the unfortunate consequence of an earlier Covid lockdown, 75 million newly impoverished people to add to the additional 60% of the population that lives below the poverty line, according to a 2020 article.

The World Bank classifies nations into four broad income categories on the basis of which they are assigned three poverty lines. The lower-middle-income category, in which India also falls, has countries where per-capita annual gross national income is between $1,026 and $3,995 (between Rs 78,438 and Rs 3 lakh). In these countries, those earning less than $3.2 a day (around Rs 78,000 per year) are considered to be below the poverty line.

To place that figure into context, that’s over 812 million — in addition to the 75 million mentioned above — people that cannot afford to pay for vaccination. It’s 812 million reasons to ensure that any vaccine discrimination or policies that encourage discrimination or profiteering are outlawed. It’s 812 million reasons to question Narendra Modi’s proposed changes to India’s vaccination strategy.

A political storm looms

Modi is currently facing rising and vocal criticism from across India. A number of factors and poorly thought-through policies have contributed to his current predicament.

  • Emergency hospitals constructed in 2020 to deal with expected bed shortages for the first waves of Covid were disassembled this year, Modi confident that India had beaten the virus. The Sardar Vallabhbhai Patel Covid hospital in Delhi was first built in 2020 in a record time of 12 days by the DRDO after a spike in cases. The facility was dismantled in February this year after the number of cases came down. It has now been re-opened with reduced capacity, as similar facilities across the country are desperately being recommissioned. 
  • The vast majority of the factories that produce oxygen in India are located in the eastern part of the country — more than a thousand miles from major cities like New Delhi and Mumbai. This has created major bottlenecks in transporting oxygen tanks, which cannot be flown. It has created a once in lifetime logistics nightmare that is costing people’s lives. Seven months ago, the country had grappled with a similar oxygen shortage amid a rapid surge in case numbers. But this time, it’s much worse and hard questions are being asked.
  • India’s hospitals are substandard and lack of investment and development in healthcare has been highlighted by the harsh Covid surge, as patients die in taxis, ambulances, and on the streets outside hospitals, waiting in the desperate hopes of being admitted to buildings that are functioning at double their intended capacity. Many simply die at home, unable to secure oxygen, medication, or a bed and overcrowded facilities simply increase risk to both staff and patients.
  • New Delhi has done little to regulate price gouging and a basic drug like the anti-viral, Remdesivir now retails for around 300% more than its list price on the black market.
  • Despite the surge, rallies and local politics continue unabated. About 8.6 million voters were expected to cast ballots on Monday in the eastern state of West Bengal, in the final phases of a contest set to wrap up this week. Also voting in local elections was the most populous state of Uttar Pradesh, which has been reporting an average of 30,000 infections a day.

Modi’s new vaccine strategy entails the following. State governments and private hospitals can order up to 50% of the vaccine stock to inoculate the younger population (under 45), while New Delhi will provide for free the other half to complete vaccination of those over 45. Serum (AstraZeneca) has announced individual vaccine prices of 400 rupees for states, and 600 rupees for private hospitals. Bharat’s rates (Covaxin) are 600 and 1200 rupees, respectively. That’s a significant hike from the original price Modi had negotiated, of 150 rupees.

Worrying questions that must be asked

Does the original vaccine price negotiated by New Delhi still hold with manufacturers and if so, why are states not able to avail themselves of the same price.? Why are vaccine manufacturers engaging in price gouging with the states and who stands to profit from this?

Everyone is in agreement, except, apparently the architects of India’s new vaccination strategy. The only acceptable cost to India, one that would allow for vaccination to be effective and widespread, without discriminatory practices affecting delivery, would be 0 rupees per shot. Free vaccination, delivered in a way that cannot be influenced by price-fixing and queue jumping. Shifting onus onto states for providing the funding for all their citizens is both short-sighted and irresponsible.

It suggests that Modi may very well be playing politics with lives, seeking to shift the responsibility for the insanely complex task of vaccinating over a billion people elsewhere. If it goes wrong, which it is now almost guaranteed to, fingers will point elsewhere. They shouldn’t. The responsibility to ensure equitable and accessible vaccination for all rests squarely on the shoulder of the central government. On Modi’s shoulders and there can be no shirking this responsibility. 

India already suffers from global vaccine disparities and discrimination. World Health Organization director Tedros Adhanom Ghebreyesus wrote in a recent op-ed in The New York Times

“Yet of the more than 890 million vaccine doses that have been administered globally, more than 81 percent have been given in high- and upper-middle-income countries. Low-income countries have received just 0.3 percent.”

One Billion Vaccines

It’s an unimaginably daunting task, fraught with pitfalls, and only one clear course of action. For any vaccination campaign of this size to succeed and to ensure people are vaccinated within a period of time that allows for a meaningful impact on the current strains of the coronavirus, strong leadership stemming from a central point is required. Rather than engaging in multiple contractual arrangements for the purchase of a limited resource, the government should focus on a single supply point, namely itself.

Massive wealth inequality exposes more than half of India’s population to possible vaccine discrimination. It is the duty of a responsible government to ensure these individuals are not treated prejudiciously in the vaccination process. Speed is of the essence here and bidding wars will merely serve to slow the process. Allowing wealthy hospital chains to buy into vaccine stock will further prejudice poorer communities.

All in all, Modi may be well advised to seriously reconsider his new vaccination strategy. It smells a little fishy and it would appear to be designed to fail.

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