When the Indian government, under ‘Liberalised Pricing and Accelerated National Covid-19 Vaccination Strategy’, earmarked for the private sector 25% of total monthly covid-19 vaccines produced in the country, it did not seem to have considered the evidence. In India – a mixed healthcare system – though the private sector provides a majority of curative and diagnostic services, when it comes to preventive and promotive services, the private sector’s contribution is relatively small. In the almost four-decade-old universal immunisation programme of India, private facilities deliver 10% to 15% of total vaccines. The share of the private sector in mass vaccination campaigns such as Japanese encephalitis, polio, measles, etc has been even smaller.
Differential rates
Then, as part of the liberalised strategy, manufacturers were also allowed to charge differential rates in which the cost of vaccines to the private sector was fixed at four-to-nine-fold higher than the rate for the government. The stated rationales for differential rates and earmarked allocations were to allow manufacturers to earn profit and to push the private sector to support the vaccination drive in India.
Ever since the liberalised vaccination strategy was implemented in early May, while Private Sector COVID-19 Vaccination Centres (PSCVC) received sustained and uninterrupted vaccine supply; the COVID-19 Vaccination Centres (CVC) in the government facilities struggled and had regular vaccine ‘dry days’ and were often shut down intermittently. The outcome was that those who could afford to pay had easier availability and early access to vaccination than the rest; further widening the vaccine inequity. Many public health experts flagged that PSCVC was just 3% to 5% of total CVCs in India; however, these had been assured a quarter of total vaccines produced every month. Yet, the vaccine sharing formula was not revised when the government announced a partial amendment in the liberalised strategy on June 7.
In the last three months, there have been major impacts of differential pricing and vaccine sharing formula. One, the four–nine times higher price of vaccines for the private sector essentially meant that of the total cost of COVID-19 vaccination in India, people would have ended up spending more than the government spending on vaccines. This effectively counters the government’s claim that COVID-19 vaccination is free in India. Second, the differential rate of vaccines in two segments of a market, under government oversight, implicitly legitimised high differential pricing and has weakened the moral right and stand of the government to regulate the prices in future. Third, an easier access to paid vaccination (majority were in urban settings and major cities) skewed the vaccine availability (by income groups and geography) and introduced inequities, contrary to what a government policy should to- to ensure equity, against a stated principle in India’s National Health Policy 2017.
On August 3, Union Minister for Health and Family Welfare, Government of India, responding to a question, informed the parliament that in the last three months the private sector has contributed only 7% of total vaccination in India against the allocated vaccine share of 25%. The minister also informed that the vaccine manufacturer has now been informed not to earmark the entire 25% of the vaccine and should supply as per the demand from the private sector and allocate remaining vaccine to the government.
Tacit acknowledgement
This is a tacit acknowledgement of failure of the private sector vaccine sharing formula. There is a long way to go for India’s vaccination drive. The country has administered 50 crore doses, and at least around 1.38 billion more vaccine doses are yet to be administered to the adult population. However, it is time more is done, and the policy makers need to review the entire vaccination policy and do more corrective actions.
Refining strategy
To start with, policy makers need to consider emerging evidence to refine strategy. First, the fourth national seroprevalence-survey has estimated a variable pool of susceptible populations amongst States. There is sustained transmission in a few States, high test positivity rate in many districts and effective reproduction number rising above in many States. These demand implementation of a better targeted vaccination by geography, population groups and other parameters. However, the availability of vaccines continues to be a constraint. Second, only 7% of total vaccine being administered by private sector, a capped service fee of Rs. 150 in private sector has been termed unviable by them, and a high differential price is arguably a ‘lose–lose situation’ for all stakeholders including vaccine manufacturers, private sector, government and the citizen, where none is gaining much and it is affecting vaccination drive. It is time the government should consider a few steps.
First, revert to 100% procurement by Central Government (in any case, now 93% would be administered by government) as before April 30. This would give the government more flexibility in allocation, facilitate the targeted vaccination and tackle inequities. Second, renegotiate single price with each vaccine manufacturers for both public and private sectors. This could be higher than what the government currently pays but uniform for a vaccine. Third, once the government provides free vaccines to the private sector, an ideal situation would be that the cost of service charge in the private sector is also paid by the government; however, a more pragmatic way is that government revises the service charge in private sector upward to make these viable.
The COVID-19 vaccination in India is a tale of a series of policy and delivery failures never witnessed in the history of health programmes in India. However, the bigger threat is that in failing to implement COVID-19 vaccination drive effectively, the trust of the citizen in government health service delivery has been further eroded. It is call for urgent policy corrections to regain the trust.
(Dr Chandrakant Lahariya, a physician-epidemiologist, is a public policy and health systems expert and co-author of ‘Till We Win: India’s Fight Against The COVID-19 Pandemic’.)
