Editorial✍

How to vaccinate a billion people

India must be ready to vaccinate billion people:

  • With vaccines for Covid-19 not too far away, India is approaching an important part of fight against the pandemic.
  • Of huge importance will be the time Indian will take to vaccinate 1.3 billion people – whether 1-2 years or 3-5 years.
  • The difference could be thousands of lives, millions of livelihoods, hundreds of bankruptcies, unsustainable public finances, and Rs 2-3 lakh crore in bad loans.

India has many potential vaccines, and can make a large number of them:

  • India is the vaccine capital of the world.
  • Serum Institute of India is the world’s largest vaccine manufacturer, with a capacity to manufacture 1.2 billion vaccine doses a year. It has partnerships with vaccine makers Oxford/AstraZeneca, Novavax and Codagenix.
  • Zydus Cadila has started Phase 2 clinical trials of its vaccine ZYCoV-D. If successful, it says it can manufacture 100 million vaccines a year.
  • Bharat Biotech has begun Phase 2 trials of its indigenous vaccine developed with ICMR and the National Institute of Virology. It says it will have a capacity of 200 million doses per year.
  • Biological E has tied up with Johnson & Johnson. With the acquisition of Akorn India Pvt Ltd, it expects to have a capacity of one billion doses per year.
  • There are other firms, and other vaccines too.

India will soon have adequate vaccines:

  • In terms of accessing vaccines, there are still various uncertainties like failure of some vaccines at trial stages, potential requirement of repetitive does and possibilities of capacities being overstated, and requirements of exports.
  • Despite that, it is still reasonable to assume that India will have adequate vaccine supplies at some stage. 

Vaccination roll-out should be based on vaccine adequacy:

  • With the knowledge of India’s capacity for vaccine manufacture, we will soon achieve vaccine adequacy (everyone will get access to vaccines).
  • This means that the system design for vaccination roll-out should be based on vaccine adequacy, and not on vaccine scarcity (in case of scarcity, planning is made for who gets first etc.)
  • Assuming that India reaches vaccines adequacy by the end of 2021, it is important to try to deliver fast and far, a vaccine that everyone needs.
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Shortcomings in India’s current immunisation infrastructure

  • India’s current immunisation capacity focuses on children and pregnant women:
    • India has a long and accomplished history of immunisation.
    • However, the current immunisation infrastructure is limited to 25 million infants born each year, and pregnant women.
  • But covid vaccination will be much much larger in scale:
    • India’s current vaccine infrastructure is not sufficient for delivering covid vaccines, as the requirement would be of over one billion, possibly two billion, vaccinations in less than two years.
    • This needs much higher speed and scale than the current system, as the Covid-19 vaccine will have to be universal (and not restricted to infants and pregnant women).
  • Current vaccination infrastructure cannot be disturbed:
    • If we load Covid-19 vaccination on the current vaccination infrastructure, it will be overwhelmed.
    • If that happens, it is possible that for three to five years, the regular workload of all childhood vaccinations for infants will be disrupted, endangering over 100 million babies.
  • Current immunisation requires government procurement:
    • The current vaccine infrastructure requires the government buying the vaccines and then distributing them.
    • Government procurement works well when we have stable and proven vaccines.

Difficulty with Covid immunisation:

  • In the Covid-19 scenario, which is exceptionally dynamic and varied, there will be a large number of vaccines available with varying safety, efficacy, length of immunity, dosage, etc.
  • As soon as the first vaccines becomes available, there will be pressure on the government to purchase large quantities and start distributing immediately.
  • However, in this approach, the government, and ultimately the people of India, take on many risks.
  • If, after a few months, there are unacceptable side effects, or the vaccine does not work as well as expected, or if a better, cheaper vaccine comes along, then the procured stocks will become worthless. 
  • Such a situation will negatively impact the vaccination efforts.

Case study of Aadhaar enrolment in reaching a billion people

  • In recent times, the one government initiative that has physically reached a billion people is Aadhaar enrolment.
  • 600 million residents got their Aadhaar in four years, and a billion in 5.5 years. 

How it achieved speed, scale and quality:

  • In 2009, the government was looking for ways on how to enrol for Aadhaar at speed, scale and quality.
  • Direct procurement of kits will be too slow:
    • It was realised that the traditional model, where the government procured thousands of enrolment kits (including biometric devices) would not succeed.
  • Indirect procurement of kits:
    • The officials came up with a different model. The Unique Identification Authority of India (UIDAI) appointed registrars such as state governments, private and public banks, and the post office, to carry out enrolment.
    • In turn, these registrars hired enrolment agencies from a UIDAI-approved list.
    • The agencies bought UIDAI-approved enrolment kits directly from vendors of biometric devices.
  • Separate operators of kits:
    • The operators of the enrolment kits were certified through another ecosystem. Enrolment operations were quickly set up nationwide.
    • At its peak, there were some 35,000 stations that could enrol up to 1.5 million residents a day.
    • The reimbursement was Rs 50 per successful Aadhaar generated.
    • This public-private partnership (PPP) was successful at achieving comprehensive coverage — and fast.

Aadhaar could be used for authentication of individuals for vaccines:

  • India is uniquely placed to offer vaccination for the entire population at speed and scale.
  • Both the experience of Aadhaar enrolment, as well as the infrastructure provided by Aadhaar, are helpful.
  • Today, everyone in India can be authenticated online, either using Aadhaar or using mobile phones, be it by biometrics or OTP.
  • This creates a new paradigm. For example, we can allow anytime-anywhere vaccination, where a person can walk into a vaccination station nearby, have a choice to get authenticated with Aadhaar or phone number and get a shot — all in minutes.

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