How India screwed up its Covid-19 vaccination program

Last month, Indian Govt announced major changes to its Covid-19 vaccine policy and national vaccination program.  The new policy is unique in entire world. Until last month, India's vaccination program was just like any other country. The vaccines were given based on preference scale. Healthcare & frontline workers were on top priority and this was followed by age groups, senior citizens and people with preexisting conditions etc. The younger people were at the lowest scale of priority to be vaccinated last. Earlier, only central government purchased vaccines from companies at negotiated prices, channel the vaccines into central Govt healthcare system for dispensation as well as distribute it to state governments to do the same at local levels. Private hospitals were also deputed in vaccination drive under a strictly regulated price regime.  The prices of vaccines were strictly regulated by Central Govt which was negotiated with companies and procured at Rs 150-200 ($2-3) per dose for Astrazeneca/Covishield and Rs 295 ($4) for Covaxin. Vaccine dispensation in private hospitals was capped at Rs 250 ($3.4) per dose. India also allowed liberal export of vaccines to foreign countries as grants and on commercial basis.

Recall that second wave of pandemic in UK was devastating. But British Govt did not change its vaccination program in any way. The vaccine program remained on preference criteria of vulnerability groups of population. Frontline workers were the first to get vaccinated followed by orderly vaccination based on age groups & people at risk of virus. But in India, central government changed its vaccination program in worst way possible in middle of second wave. Deregulation of vaccine pricing, throwing financial burden of vaccination on state governments, making state governments compete against central government, against private hospitals and against each other in a Battle Royale for procurement of vaccines.  New vaccine policy is opaque and Govt has not given full clarity on many aspects of it. Regardless, some of the critical changes were as follows.

Decontrol of pricing - Indian Govt adopted new model of vaccine pricing & procurement. Vaccine pricing is now hybrid system with several price scales. Central Govt, State Governments and Private entities (institutions, hospitals etc) can procure the vaccines directly from vaccine companies at different prices. Under the hybrid price system, 50% all vaccines manufactured by companies will be procured by Central Govt while rest of 50% of vaccines will be directly procured by State/Local Governments, Private hospitals and private companies.

Abolition of age based vaccine roll out - The Age based preference scale of dispensation of vaccines is now gone. Anybody above 18 years of age can apply for vaccination. Obviously, applying for vaccination doesn't give you vaccine because there is acute vaccine scarcity. So people have to take token (on mobile App registration) and wait for their turn.

 

States can buy foreign made vaccines - States & private hospitals were permitted to directly procure vaccines manufactured in foreign countries provided they bear the costs of imports.

New Vaccine policy threw national vaccination program into chaos & paralysis - Rat Race between State Governments, Central Government & Private hospitals to procure vaccines - Decontrol of vaccine pricing cause sharp rise in vaccine prices - State Governments made to bear cost of buying vaccines 

With decontrol of pricing, vaccine companies raised their vaccine prices by 2 to 4 times. Covaxin which was earlier priced Rs 295 under old system of centrally regulated procurement was raised to Rs 600 for State Governments and Rs 1200 for private hospitals. Covishield which which was priced at Rs 157 under old system was raised to Rs 400 for State Governments & Rs 600 for Private hospitals. This steep rise in vaccine prices generated huge backlash from State governments, Supreme Court, political opposition and even the politicians of the ruling Modi Govt.  Modi Govt was thus forced to renegotiate with vaccine companies and attained some price relaxation for central & state Government vaccine procurement. The vaccine prices were again revised. Prices of Covaxin was reduced from Rs 600 to Rs 400 and prices of Covishield were reduced from Rs 400 to Rs 300. Vaccine companies did not reduce their vaccine prices for private hospitals.

The new vaccine prices were in complete contradiction to earlier claims of success story of vaccine pricing in India. Modi Govt few months ago boosted that it has negotiated lowest price for Covishield/Astrazeneca vaccine with SII at Rs 157 per dose which amounts almost same as what EU is paying at $2.18 per dose of vaccine (read 1 & 2). But now with prices of Covishield doubled to nearly $4 per dose, India will be paying more than EU & USA for the same vaccine. And its worse than that. The cost of Covishield in private Hospitals is around Rs 900 per dose. This is because of GST Tax & inoculation charges which are also borne by consumer. So Indian people going to private hospitals have to shell out $12 per dose of Covishield. With Covaxin, the rates in private hospitals are around Rs 1500 that is around $20, close to price paid by US Govt for a dose of Pfizer vaccine.

While rise in vaccine prices is bad enough, the State Government now also have to spend money out of their own local budgets for procuring vaccines. States will have two channels for vaccine supplies - direct central Govt grants and state's own procurement directly from vaccine makers. Its estimated that 8 poorest states of India will have to spend as much as 30% of their local healthcare budgets to procure vaccines in open markets. Healthcare spending in states is abysmally low and states diverting 30% of their healthcare budgets will mean that resources have to diverted from other programs. State Government budgets are already strained due to fall in revenues in Covid induced economic depression. 

Central Govt has also allowed States to directly buy vaccines from foreign companies but this isn't producing any results. Foreign vaccine makers have so far refused to sell to State Governments in India citing several reasons. Foreign vaccine makers say they wanna deal directly with central Govt and also want approval of their vaccines from central regulators. Recall that Pfizer is demanding indemnity from Indian Govt to launch its vaccine in India which has stalled the talks since last few months. Also importing foreign vaccines is highly costly. Russia is exporting its Sputnik V vaccine to India for price of around Rs 1000 ($15). This is more than three times the price of Covishield/Astrazeneca vaccine which State Governments are currently procuring from vaccine company SII. 

 

New vaccine policy vaguely says that States & Private hospitals can buy vaccines in open market but this can create problems. With decontrol of prices, the vaccine companies are charging 2-3 times more for vaccines than what private companies are charging to State & Central Government. Given the fact that vaccine companies have far greater incentive to sell to private hospitals, it automatically put state governments in back seats.

New vaccine policy is like Pie in the Sky - All adults are eligible for vaccines but there are not enough vaccines available - new vaccine policy doesn't address fundamental problem of Vaccine scarcity due to lack of local mass production - National vaccination rate very low and actually declining - Indian Govt did not make any effort in funding for vaccine development & research - Govt did not give funding to private companies for capital investment to expand manufacturing capacity

 

 

India's daily vaccination rate and comparison with China which has almost same population as India

 

Healthcare experts, Private Hospitals, State Governments, Supreme Court and even the Vaccine companies themselves see new Vaccine policy problematic to say the least.  Basic problem with India is that there aren't enough vaccines so vaccines need to be used judiciously. That was the main purpose of preference based vaccine eligibility in the old policy.  Now without enough vaccines, opening vaccine eligibility to all adults will delay and deny the vaccines to vulnerable population. Of course, all adults can apply to get inoculated but they have to wait for their turn (Govt has created an App for registration for vaccines). If you don't wanna wait to get inoculated for free at Govt hospitals, you can find some private hospitals to get inoculated but you have to spend Rs 2000-4000 ($27-$54) for both doses of vaccines depending upon type of Vaccine you want. Government has also increased the vaccination gap between Astrazeneca/Covishield doses from 6-8 weeks to 12-16 weeks. While this wouldn't be a problem under normal circumstances but UK researchers have found that single dose of Astrazeneca vaccine is only 33% effective against Indian variant of Covid-19. So delaying second dose of Covishield by 3-4 months may be an unwise decision by putting people at risk.

 

Decontrol of vaccine pricing, import of foreign vaccines & privatization of vaccine program is not any achievement. This is actually a great blunder as it will undermine our real goal of vaccination program which is getting the entire population vaccinated at free of cost. India is a very poor country and poor people simply can't afford to spend to get vaccines at private hospitals. Giving a perspective in numbers, annual per capita spending of households on healthcare is less than Rs 2500 ($30). India's per capita national income is around Rs 20,000 ($300) for bottom 50% of population and medical debt has pushed 55 million Indians into poverty in a single year (read 1 & 2). The pandemic in last one year alone has driven 75 million Indians into poverty. Cost of vaccinating three members in a family with two doses of vaccine at private hospitals will cost more than $100 or Rs 7500. Such high cost of vaccination can be borne by upper class & middle class of population but rest of the poor population which is in majority will have to depend upon free vaccination at Govt centers which are mostly out of stock (read 1, 2, 3, 4, 5, 6)

India needs at least 2 Billion vaccines to inoculate majority of population. That is considering that we won't need a third dose or any more booster doses in future. Only answer to India's vaccination needs is domestic mass production at cheap rates. Importing of foreign vaccines will be costly and India has to stand in a long waiting queue to buy vaccines. Moderna has already said that its order book is full & cannot supply any vaccines to India this year.  Pfizer says it might supply 50 Million doses to India this year but talks with Pfizer are stalled due to indemnities demanded by the company from Indian Govt. This is another problem with foreign imports. The negotiations between Indian Govt & foreign companies are done behind closed doors. It would be interesting to know the exact terms & conditions of indemnities demanded by Pfizer from Indian Govt. Is Pfizer demanding guarantees of any sovereign assets from Indian Govt?  Regardless, the 50 Million doses that Pfizer may supply to India is only 5% of our vaccine needs.

Another grave mistake Indian Govt made was not funding our Pharma companies for vaccine research and to make capital investment in expanding production capacity. Recall that America & many other countries started financing research & development of vaccines from the get go. In US, operation warp speed funded the mRNA vaccine by Moderna along with other vaccine candidates like Astrazeneca, J&J, Novovax etc.  Apart from that US Govt also gave advanced assurances to companies for buying their vaccine production even if vaccines did not prove to be effective & may have to be discarded. These steps were taken considering that money is of little importance and real thing that matters is TIME & saving lives. Indian Govt did not understood the essence of TIME in vaccination program. Our Govt thought that we have unlimited time to complete national vaccination until we got a shock of second wave. 

 

While Indian Govt gave no funding to SII for capital investment, Bill Gates foundations funded as much as $300 million investment to boost manufacturing capacity of SII. Indian Govt should have funded SII to expand its manufacturing capacity 6 months ago. We should have authorized compulsory licensing on domestically developed Covaxin, after making them publish their Phase 3 trials data, so that other manufacturers could also make the vaccine. We should have invested in building manufacturing capacity of full chain of vaccine raw materials needed for mass production of vaccines. But all these things were not given any priority. Now after the second wave, Govt is making policy as we go along. The very basic lesson pandemic taught us is that we have to think in advance - 6 months, one year & 2 years in advance.

 

Expansion of manufacturing capacity can't happen overnight. We need infrastructure, factories, machines, vaccine raw materials, labor force & all kind of things. There is a time lag of several months for actual materialization of capacity expansion. Now under the brunt of second wave, all India can do is start preparation for third wave because we can't create vaccines out of thin air.  Its interesting to note that while Indian Govt is approaching WTO for TRIPS waiver on vaccines, India itself is not applying the same principle on its domestically developed Covaxin. On international forum, our Govt claims that we need transfer of technology and IP waivers so that all Pharma companies can produce vaccines without any restriction. But in India, Govt has refused to authorize compulsory licensing of Covaxin which it can easily do. This is completely at odds with Indian Govt position at WTO.

Anti-Science attitude of Indian Govt - Promotion of Homeopathy, Herbal Medicine & Cow Urine by Indian Govt as Covid cure & prevention - Religious populism, superstition & quackery undermining our vaccination program - Hindu Clerics are spreading anti-vaccine propaganda 

 

Indian Prime Minister Modi with Cleric & Godman Baba Ramdev.  Ramdev, a strong opponent of modern medicine & vaccines, is an important ally of ruling BJP Govt in India.

 

India has religious populist Govt which comprises of Hindu Clerics and RSS members (RSS is an umbrella of  Hindu militant organizations). The Govt is connected to Godmen Hindu clerics which are strong opponents of modern medicine. One such Godman cleric called Baba Ramdev has been promoting anti vaccine and anti medical science propaganda. The cleric has millions of followers in India and is a strong ally of Prime Minister Modi. Ramdev who despises modern medicines and vaccines has launched his own herbal products as alternatives to treat & prevent Covid-19. The quackery and snake oil medicines of Baba Ramdev are fully endorsed & promoted by Indian Govt. Indian Govt also has a Ministry of Ayush just like our ministries of Finance, Corporate affairs, Defense, Energy etc.  This ministry is dedicated for education, promotion & research of Alternate medicines like Homeopathy, Ayurveda & Naturopathy.  Basically, Indian Govt itself is fully engaged in promotion & propagation of anti-science programs in India. 

Alternative medicines promoted by Indian Govt to treat & prevent Covid-19 in India. These drugs have not been recommended or authorized by WHO, ICMR,  Indian medical Association or any other global health institution or regulator.

Ministry of Ayush has been promoting a herbal Drug called Ayush 64 for treatment of Covid-19 which Govt is distributing across the country. Govt claims to have done clinical trials for the drug but critical details have not been made public. The drug efficacy is not reviewed by any Global medical institution or health regulator of any foreign country, neither it has been authorized by WHO for treatment of Covid-19. Indian society is deeply riddled with superstition & ignorance and Cow worship being a central theme of it. Politicians of Ruling Govt have been touting Cow urine & cow dung as a cure for Covid-19 (read 1, 2, 3, 4). The propaganda against vaccines has resulted in fear & vaccine denial among people specially in rural India (read 1, 2 & 3).

Conclusion

 

India's vaccination program is in chaos. New vaccine policy doesn't make any sense. It makes people wonder on why and how Modi Govt messed up vaccine policy so badly. To answer this question, you have to understand the very basic nature of Modi Govt. Modi is like Donald Trump, a chaos Prime minister who cannot make any competent policy decision. Like Trump, Modi is surrounded by sycophants who cheerlead foolhardy & chaotic policies of Modi.

When second wave hit India, there was huge public outrage against Modi Govt for its mismanagement, lack of preparation & planning to deal with the pandemic. There were not enough vaccines, so Modi played a cunning trick. By declaring vaccine eligibility to all, Modi gave a false sense of security to Indians that if they pay higher prices, they will get vaccines.