Why India's vaccination drive faces many hurdles

The clock is ticking on India's Covid-19 vaccination drive. The world's second-most populous nation has to inoculate 35 crore citizens in the shortest possible time after it threw open jabs to everyone above 45 years. The race against time gets more testing due to the hurdles ahead, and some that persist from the previous phases.

First, vaccinators are short-handed, which compounds the poor healthcare infrastructure. Second, the private sector is dragging its feet, posing a big challenge to scaling up operations. The lack of engagement with people from the lower socio-economic background isn't helping the already slow exercise.

Over and above all these obstacles, vaccine hesitancy continues even among the urban and educated. Nearly 80 days after rolling out the Covid-19 vaccination, India has vaccinated less than one crore individuals with the required two doses to protect them from the rampaging pandemic.

What makes the task even more daunting is an overwhelming sense of urgency because of a rapidly ballooning second surge. The vaccination centres have been asked to keep open till 9 pm every day in April to administer as many shots as possible irrespective of whether the beneficiaries are pre-registered or not.

"The battle is on in every state as the virus has penetrated our defence,” said V K Paul, NITI Aayog member. “We need to vaccinate as many as possible while staging the process to prioritise vulnerable individuals who are likely to get very sick if infected,” noted K Srinath Reddy, president of the Public Health Foundation of India (PHFI).

Also read: Healthcare workers can no longer register for Covid-19 vaccine: Centre

But it’s easier said than done. From getting enough vaccinators to overcoming hesitancy, the challenges are numerous. With the disease striking many smaller towns hard, time is at a premium.

“It may be best to provide vaccines in an unrestricted manner just to curb the fast growth of cases at this time. Prioritising the elderly and those who are immuno-compromised or have preexisting conditions should still remain a priority but preventing the pandemic from getting out of hand and overwhelming the public and private health systems, as we saw in Brazil, is also important,” said Gautam Menon, senior biologist at the Ashoka University.

One of the biggest challenges would be reaching out to the marginalised and vulnerable, who are likely to be left out in the current vaccination scheme. “The current system (Co-WIN platform-based) is harsh on the poor and vulnerable as there is no element of outreach and engagement by the government,” observed T Sundararaman, former executive director at the Delhi-based National Health Systems Resources Centre.

Others agreed on the need to reach out to those in a much more proactive manner. “The existing system is a pull model, rather than a push one,” said Oommen John, senior public health researcher at the George Institute for Global Health, Delhi. “There has to be a completely bottom-up approach to increase vaccine uptake,” said health economist Rijo John, a former consultant to the World Health Organisation.

Read: Five things to know about the AstraZeneca/Oxford Covid-19 vaccine

In Pune, one of the Covid hotspots, Divisional Commissioner Saurabh Rao said the administration would undertake a “carpet bombing” type vaccination in the most-affected localities. The Union Health Ministry asked 11 states and union territories to identify many such localities to start extensive jab sessions since the key to winning the battle with SARS-CoV-2 is to quickly protect the vulnerable with vaccine cover.

Bottleneck

But as the states begin to plan for such exercises, they face the second bottleneck — finding adequate manpower. The public health system has over 3,00,000 qualified front line workers capable of administering the injection. But all of them will not be available for Covid shots all the time. “What we need is a carefully crafted micro plan to organise session sites nearer to the population settings,” suggested Giridhar Babu, epidemiologist at the PHFI and an advisor to the Karnataka government.

In Karnataka, vaccination centres have been given instructions to wrap up the drive for people in the 45-59 age group without comorbidities by four weeks. This would be a daunting target considering that 1.66 crore people in the state fall under this category, said health commissioner Dr K V Thrilok Chandra. With the health department facing a staff shortage since last year, the state has done away with the targets for individual vaccination sites. Instead, the advice is to conduct as many jabs per day as possible.

The first two days after opening up saw more than 30 lakh people getting the shots on two consecutive days. Since the numbers are expected to rise further, the need is to find more hands. “With more India-manufactured vaccines likely to get regulatory approval, the challenges will revolve around increasing vaccination centres and teams, while reducing vaccine hesitancy,” said Reddy.

Read more: As Covid cases surge in India, 77% of people more willing to take vaccine: Report

The manpower problem can be addressed to some extent by roping in the private sector in a large way but that has not happened so far. Till last week, the BrihanMumbai Municipal Corporation (BMC) had approved only 44 private hospitals for vaccination, whereas there are more than 1,000 private hospitals/nursing homes in Mumbai. The BMC has now given permission to 59 hospitals to conduct the vaccination, said Girdhar Gyani, director-general of the Association of Healthcare Providers (India) - AHPI.

Out of 460 hospitals empanelled with the Centre's flagship Pradhan Mantri Jan Arogya Yojana, only 55 are registered with Co-WIN to administer the vaccines. In the Mumbai suburbs of Vasai, there is hardly any vaccine available in the private sector.

Gyani said that AHPI, on behalf of private providers, was ready to coordinate with governments for identifying private hospitals and nursing homes with adequate infrastructure, but several public health experts told DH that in many states, private hospitals were simply not interested because of the low margin. Out of the Rs 250 a patient pays for a dose, the private hospital gets only Rs 100.

Prasanna H M, president of the Private Hospitals and Nursing Homes Association, said the private sector was ready to join the vaccination programme in strength, provided adequate supplies were provided. The association complains that supplies are being doled out piecemeal daily to the hospitals which are obligated to collect them from municipal bodies. Instead, the vaccines should be provided in bulk for an entire week.

Vaccine confidence

Another big worry for Karnataka and many other parts of the country is vaccine hesitancy, though a section of experts says that with the expansion of the scheme, it would fade. Barring the last two days, more than 30 lakh doses have been administered only once in the last two and a half months. While experts say that India needs to give 50-60 lakh doses daily, on an average, the number of daily doses remained stuck at 20 lakh-plus. Reddy said the government should create vaccine confidence through local community networks.

“One clear strategy to improve confidence in the currently available vaccines is to demonstrate real-world effectiveness, which entails the introduction of the vaccine at mass scale in high transmission districts and evaluating how the disease transmission is reduced. This will help boost confidence and encourage overcome vaccine hesitancy,” suggested John.

At the moment, the availability of doses from Bharat Biotech and Serum Institute of India doesn’t seem to be an issue, with the central government firmly assuring a steady supply. Maintaining cold chain logistics even in summer would also not be a problem because of a well-oiled existing system, thanks to India's universal immunisation programme.

“Protecting the vulnerable is more important as they are at risk of having severe illness or death. Once they are protected faster, the expansion for other age groups can be planned expeditiously,” noted Babu.

(With inputs from Akhil Kadidal in Bengaluru and Mrityunjay Bose in Mumbai)