May 10, 2021

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covid vaccination: Why Covid vaccination of all adults would remain a tough ask for India amid a raging pandemic

After Nayana Achamma, a BA student in Kerala, cast her vote for the first time on April 6, she has been all agog to know the results of the assembly elections which will be out on May 2. But closer to the date, the anticipation for the results got supplanted by her eagerness for the Covid-19 vaccine, which opened for all adults from May 1.

“Right now, I just want to get the vaccine as fast as possible,” says the 18-year-old. “The second wave has returned with a lot more intensity. The sooner we get the vaccine, the better, right?” she reasons. When registrations opened for everyone above 18 years on the Co-WIN portal at 4 pm on April 28, Achamma was able to register after multiple attempts but to her disappointment, did not get a slot. “I’ll try again,” she says.

On May 1, the day vaccination took off, only a few states like Uttar Pradesh, Maharashtra and Gujarat could start the process, that too, symbolically, in a few districts. Most states missed the launch against a gloomy backdrop of acute vaccine shortage and a second surge of Covid-19 pandemic that has turned lethal, not sparing the younger lot, either.

Till now, barely 2% of India’s 1.35 billion population — mainly healthcare and security personnel plus some senior citizens — have got both the doses of the Covid-19 vaccines. Only this tiny proportion is somewhat shielded from the brutal new wave that has plunged entire cities and villages in despair and mourning. About 100 million, i.e. less than 8% of the population, have taken only one dose. In the last 24 hours India saw over 4 lakh Covid cases, the highest single-day spike globally, and 3,523 deaths.


Unquestionably, at this juncture, vaccines are the basic armour against the virus and mass inoculation is the need of the hour. The very fact that 133 million citizens registered on the Co-WIN portal on April 28, the day people in the 18-44 years age cohort was permitted to enrol, demonstrates how younger Indians are willing and eager to get themselves vaccinated at the earliest. However, vaccinating all adults, some 90 crore Indians, is fraught with multiple challenges. These include a massive shortage of jabs, friction between the Centre and some states, confusion arising out of differential pricing and, above all, the severity of the current wave, which has jammed the nation’s healthcare infrastructure and even forced many youngsters to worry whether vaccination centres could emerge as superspreading spots.
Cardiac surgeon and chairman of Medanta, Dr Naresh Trehan, argues that hospitals still have enough capacity, appealing young Indians with no symptoms to come forth and get themselves vaccinated as early as possible. “Unlike the last time, the number of younger people who got infected and even died during this wave is out of proportion. I would like the younger lot to get vaccinated soon. Self-defence includes wearing a mask and getting vaccinated,” says Trehan, adding that the impact of the virus on those who have already got two shots is milder.

Shobana Kamineni, executive vicechairperson of

, echoed a similar view when ET spoke to her last week. “The more we vaccinate, the less will be the problem. The pandemic has to be tamed just like a forest fire. Right now, the fire is everywhere. Once more and more people get vaccinated and acquire immunity, there will only be small eruptions here and there, and only those need to be clamped down,” she said.



It is evident that scaling up of vaccination will alleviate the problem although it cannot immediately arrest the exploding number of cases as it takes time for immunity to build. The question is: How soon can India do that? Does India have enough vaccines to cover everyone above 18? In an email reply to ET’s queries, Adar Poonawalla, CEO of Serum Institute of India (SII), says his company is scaling up production capacity from the present level of 60-70 million doses per month. “By July we hope to produce 100 million doses monthly,” he says. SII has been manufacturing Covishield, one of the two vaccines currently in use in India, the other being Bharat Biotech’s Covaxin.

To the question of SII’s commitment to states and private hospitals, Poonawalla replies he can’t share specific details at this juncture. “As per the recent GoI directive, 50% of our capacity will be reserved for the Union government and the remaining 50% will be for state governments and private hospitals. That said, at this stage, it would be difficult to share specific details.”

Most states are aware they won’t receive adequate vaccine supplies to cater to the new demand. While BJP-ruled states are largely silent on the matter, those ruled by other parties, such as Maharashtra, Rajasthan and Chhattisgarh, have openly expressed their anger and apprehension, saying they don’t have enough stocks. Nor have they received any firm commitment or timeline from suppliers to cover the age cohort of 18-44, they say. This is even as private hospital chains like Apollo, Fortis and Max began vaccination for this age group on May 1.



Once you probe a little more, the friction between the Centre and states comes to the fore. States that are not ruled by the BJP are worried about the possibility of the Centre taking the entire credit for the exercise even as it washes its hands of it and makes the states contribute to the cost of vaccines for 18-44-year-olds.

Health Minister of Chhattisgarh, TS Singh Deo, minces no words when he says: “It is petty to say so, but the certificate coming out of Co-WIN portal will have the prime minister’s photo. However, for vaccinating 18-plus, states will also pay. Our state, for example, is paying some Rs 1,000-1,200 crore. We wanted our own portal, but the Centre has not agreed to our proposal.” Chhattisgarh has placed an order for 25 lakh doses of Covishield and an equal quantity of Covaxin.

Vaccine supplies for the new phase have become more complicated with the Centre announcing that states will have to procure doses for the 18-44 years cohort directly from manufacturers. Vaccine makers have been instructed to reserve half the output for the Centre and the remaining doses for states and the private sector, with differential pricing for each. This is in contrast with the Union government’s policy on universal immunisation until now, with the Centre buying the doses and distributing it among the states. “All these decades, the central government always procured vaccines and supplied them to the states. Due to its huge market, India always got very competitive prices. In fragmented markets and at a time when the product is scarce and demand is high, the seller is at a huge advantage,” says K Sujatha Rao, former secretary, Union ministry of health and family welfare.

Additionally, to have 30 states enter into individual contracts, ensure supplies and do quality assurance checks would be duplication with no advantage and end up wasting huge amounts of time for overworked health departments, she argues Then there is the vexing issue of pricing, with the manufacturers announcing different prices for the Centre, states and the private sector. Vaccines that are directly imported, by private players or states, will be priced separately. Uttar Pradesh, for example, has announced that it would float a global tender to import 40 million doses.


Indian manufacturers have announced the price list. One dose of Covaxin will be sold for Rs 1,200 to private hospitals, Rs 400 to states and for Rs 150 to the Centre. As far as Covishield is concerned, SII is charging Rs 600 from private hospitals, Rs 300 from states and Rs 150 from the Centre.

“A business that is in the business of earning profits will sell to one offering a higher price, in this case the private parties. So where do the states stand in the queue?” asks Rao. Considering India has so far practised equitable vaccination with the government procuring the vaccine for all government entities, there was no reason to deviate from that now, she says. “The private sector, if it so wishes, can collaborate with the government and provide the vaccine at a nominal fee or buy vaccines in India and abroad and make a variety available for those who can afford those prices,” she says.

SII’s Poonawalla argues that charging higher rates from select customers is important as he would need more resources for ramping up the production capacities of his factories: “The initial supply price of Covishield for government programmes, including in India, has been the lowest. Private market price is 3-4 times higher. This is partly due to large volumes and because a majority of the population gets vaccinated for free through the government. We must, however, be able to sustain and reinvest in scaling up our capacity and save lives.”

Meanwhile, India Inc has begun purchasing vaccines directly. ITC, for example, has decided to support all its eligible employees and their family members with vaccination under the company’s medical assistance policy, with support for vaccination also being extended to service providers and partners in the value chain across the country, according to Amitav Mukherji, head of the corporate human resources of the company.

Dr Satyajit Rath, an immunologist with the Indian Institute of Science Education and Research in Pune, warns that vaccination will not have an immediate effect on the current, ongoing surge – “that will play out over the next few weeks since it takes at least three weeks after a vaccine dose for people to acquire any immunity”. “Covid-19 vaccine reduces the chances of catching infection, but does not make it zero, and reduces the chances of dying of Covid-19 even more, but does not make even that zero,” he adds, emphasising that there should be clear, sober messaging on vaccination.

However, the biggest challenge now is simply the lack of supply of adequate doses of vaccines. While India produces about 80 million doses a month of Covishield and Covaxin, the two vaccines which have received emergency use authorisation, public health professionals say the situation will only exacerbate with the expansion of vaccination drive. “Neither Serum Institute nor Bharat Biotech will have adequate supplies in May. We have raised expectations and demand without sufficient supply — that’s going to hit state governments in a big way, unless they come out and say they are not going to start in May and that they will do so in June or July,” says Dr N Devadasan, who has worked in public health for over three decades and is currently a technical advisor to Health Systems Transformation Platform, set up by Tata Trusts.

Dr Rath, too, cautions against raising expectations at a time of severe shortage of vaccines. “Vaccination campaigns need to ensure the reliability of vaccine availability; the current situation of uncertainty where people make online appointments which are cancelled at the last moment or worse, end up with no vaccine supply at the centres, increase vaccine hesitancy. Not much may be promised, but what is promised needs to be delivered,” he says. With supplies likely to change from week to week, Dr Rath says states’ decision-making around the vaccine drive must be dynamic and flexible to accommodate this. He suggests that states must include in priority groups those at risk of serious outcomes of infection (such as the elderly and those with co-morbidities) and those with a high likelihood in major transmission points.


The current vaccine policy could lead to inequity as well, as larger states might be able to negotiate a better price than others, says Dr Devadasan. “You could end up having huge variations among states. Also, some states have announced that they will give vaccines for free while others have not — will the latter be charging patients? That could then be a significant amount.” The Union government, he says, must intervene because vaccines are a public good.


Globally, governments have been providing Covid vaccines to residents for free, including in the United States. Indonesia is one of the few countries which has allowed its private sector to pursue a separate plan to procure doses and launch vaccine drives but even there, companies cannot make employees pay for it. Though some people might be reluctant to risk infection by stepping out to get the vaccine, Dr Rath says chances of infection in a hospital or vaccination centre are less simply because masking and related rules are strictly enforced. “The locations where the infection is likely being transmitted are households and small social gatherings and marketplaces where masking and physical distancing are not well maintained.”


Another hurdle in maximising vaccination, say experts, is the clause that 18-44-yearolds have to mandatorily register online. Dr Prashanth NS, a faculty member at the Institute of Public Health, says that in the previous phases, nearly everyone who came to get vaccinated at primary health centres in and around BR Hills in Karnataka’s Chamarajanagar district — the predominantly rural and tribal region where he is based — walked in, without prior registration. “Once you say registration is required, that will be a huge exclusionary barrier for several people who are more in need of the vaccine than others,” he says.

It’s meaningless to argue that there is high penetration of smartphones in rural areas because that does not immediately mean an ability to register and use apps. In and around BR Hills, for instance, Prashanth says there has not been much enthusiasm for the vaccine — in that context, the additional barrier of online registration will only hamper immunisation efforts. “Never in the history of our country have we required registration for vaccination. We’ve done vaccination very well with ASHAs (Accredited Social Health Activists) and ANMs (auxiliary nurse midwife) — why are we not leveraging that, instead of using apps?” he asks.

One concern flagged by Dr V Ravi, virologist and former professor at NIMHANS, is the low uptake of vaccination among elders. States, he suggests, could continue with the previous strategy of prioritisation, in the face of supply constraints. “At least 80% of elders should be saturated first, then those with co-morbidities and, finally, the youngsters.” This has been the strategy followed by countries like the UK where vaccination was finally opened to those below the age of 50 years in descending order of age after everyone in the priority category had got at least one dose.

In India, since the rollout of vaccines in mid-January, the jab graph formed humps with occasional falls in between due to supply shortage, festivals and the recent surge of Covid cases. With the rising Covid numbers and deaths in places like Delhi, the graph is worrying. It’s likely that the newly eligible cohort of 18-44 years will propel the jab graph northward once more. After all, vaccines are one ray of hope for Indians battling the pandemic.