With only 20 million vaccine shots available for the entire month of May for the 600 million people aged 18-44 years in India, many State governments have resorted to floating global tenders for COVID-19 vaccines. This situation is another example of political promises being made without sufficient planning. It also points to a lack of political will to find sustainable solutions; inadequate coordination between States and the Union government; and a focus on optics during a public health emergency of unprecedented magnitude. Each of these is an indictment of the response to the pandemic in India. If not now, when can the Indian state be more responsive and responsible?
Incoherent on all fronts
There are many cons of the Liberalised and Accelerated Phase 3 Strategy of COVID-19 Vaccination, which began on May 1. We discuss them in this article, particularly in view of the scramble among States at the international stage as a result of this strategy.
First, was the new liberalised strategy primarily intended as a fire-fighting measure in view of limited vaccine supply or as a stable, long-term measure? Reducing Central government monopsony can theoretically increase production. However, it is unlikely to manifest quickly enough to aid in successfully preparing for a third wave through vaccination, especially in the presence of limiting factors like reduced raw materials, which the government has itself admitted to. Supplies are projected to achieve substantial levels only by August 2021. However, considering that past announcements of vaccine production have not met the timelines, can we be assured of even that? Without any increase in supplies, expanding eligibility to the 18-44 years age group will only spread vaccines thinly, which makes little epidemiological and operational sense.
If it is intended to be a long-term and stable measure, it would exemplify an imprudent and inequitable vaccination strategy by any nation in the face of an unprecedented national emergency.
Second, uniform vaccine prices for all States can prevent exploitation of possible economies of scale. Leaving prices to an oligopolistic market favours unhealthy competition among States. The new vaccination strategy has now forced States to compete in an unfavourable international market, which negates any success at curbing domestic competition. States will have to procure doses at higher rates than a single national purchaser would. As a result of the new strategy, each vaccine dose will be costlier in India than in any other part of the world, until prices come down substantially. Making State governments pay higher prices for the vaccines essentially increases government expenditure, though the burden now has shifted to the States. Overall, the current approach is destined to be highly inefficient on all fronts for a country that is short of resources. The concomitant inequity is self-explanatory.
The solution is to boldly revisit the policy and use the limited vaccine supply for the adult high-risk and vulnerable group, identified as per the target population. This can be a State-specific decision led by subject experts without interference from the political circle. Don’t give false hopes to the rest, which can only lead to disillusionment, further diminish trust in government promises and compound other problems. Reconsider opening vaccination for the 18-44 years age group in August 2021, when vaccine supply is likely to stabilise. This can be done earlier if adequate supplies become available.
The current scramble by States on the international stage is not only destined to be inequitable and inefficient, but also propagates a discordant image for a country which, until late, boasted of extending humanitarian aid by exporting vaccines. It only behoves the Central government to bear the costs and provide vaccines to the States. However, the bare minimum that the Central government can do now is to coordinate with the States and on behalf of all the willing States, float a single global tender for vaccine procurement. This is unlikely to yield much as most vaccine manufacturers hardly have any spare capacity for the next few months, but a single powerful purchaser is more likely to tip the balance in India’s favour, apart from accomplishing obvious efficiency and equity gains. The benefits of being the single purchaser are not alien to the current government — the Centre’s own flagship healthcare programme, the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana, is an exemplar of such benefits.
More specifically, on vaccination, the Centre-State division of labour has traditionally been one where the Centre procures vaccines and the States administer them. It was effective vaccine delivery that helped the state deal with the public health problem of polio. The Central government procured the vaccines and States dealt with delivery. An emergency is the worst hour to abruptly disturb this equation and saddle the States with additional procurement responsibilities. The fact that the federal government has provided vaccines free to all even in the United States, which is a poster child of laissez-faire and arguably, an inspiration behind many of India’s recent health policy pronouncements, should be an eye-opener.
A rights-based approach
Article 21 of the Constitution is often interpreted as embracing the right to health. The rights-based approach in health in operational terms connotes accessibility, availability and affordability, and the significance of these magnifies multifold during an emergency of the proportions we are seeing today.
In recent times, various Indian courts have looked at COVID-19 vaccines and services from a rights-based approach. A health emergency comes largely within the purview of the Central government. It demands that the government act responsibly to ensure that COVID-19 vaccines are accessible, available, and affordable. It is never too late to take corrective measures.
Chandrakant Lahariya has done extensive work on the vaccination programme of India, is a public policy and health systems expert and the co-author of ‘Till We Win: India’s Fight Against The COVID-19 Pandemic’; Soham D. Bhaduri is a health policy expert and Chief Editor of ‘The Indian Practitioner’
