If India wants to cover at least 80 percent of its eligible population, i.e., 80 percent of the population above 18 years of age by the end of this year, then it must increase its vaccination rate by about 100 million doses/month. At the current rate of vaccination, which is about 2.2 million doses administered per day, only 30 percent of the eligible population will be vaccinated fully by the end of this year.
The gap that exists between vaccine requirement and supply, to cover even a section of the eligible population, could have been reduced significantly by better planning.
The need
The slogan of the COVAX initiative co-led by the World Health Organisation to ensure equitable access to vaccines across the word is, “No one is safe, unless everyone is safe”. It implies that near universal vaccination is essential to avoid a resurgence of the virus, as we are now witnessing with the second wave in India.
To achieve universal vaccination in India we would need to administer 1878 million doses to vaccinate the approximately 939 million adults in the country (assuming 2 doses/person).
Of these, about 35 percent doses (i.e. about 650 million doses) would be needed in urban areas. Given that the population density in urban areas is higher, increasing the risk of contagion, and that infrastructure to administer the vaccine is also more easily available, the government could have planned to cover the urban population first. At the current rate of vaccination, it may be difficult to cover even the urban population completely by the end of this year. The story varies by states as well.
(This figure shows the expected time to cover 80 percent of the population at the current rate of vaccination in each state. At least, 9 states in the country, home to 58 percent of India’s vaccine-eligible population, will be unable to cover this target even by the end of next year, i.e. by December 2022)
There is some evidence that suggests that the number of vaccination sites in each state has a statistically significant positive correlation to the daily vaccination rate (R=0.64***). This correlation holds at the district level also. There are states that are relatively faster even with fewer sites per 10,000 eligible persons. For example, the number of sites in Kerala for every 10,000 eligible persons are about 30 percent lower than the national average and it still shows a faster rate of vaccination. It is among only three states that have administered at least one dose to over 20 percent of their eligible populations, the other two being Chhattisgarh and Himachal Pradesh. These two states have a much higher number of vaccination sites per 10,000 persons. On the other hand, there are states that have slower rates of vaccination despite a relatively higher number of sites, e.g. Gujarat and Tamil Nadu.
This may be mediated by other variables as well, but the correlation suggests that increasing the number of sites, and consequently making vaccination available closer to home for people, may have an impact in increasing its uptake.
The supply
The biggest constraint however is on the supply side. Currently the only two vaccines available in India are COVISHIELD, developed by Oxford-AstraZeneca and manufactured by the Serum Institute of India (SII), and COVAXIN, developed based on the strain isolated by the National Institute of Virology and licensed for manufacture to Bharat Biotech.
According to public reports, Serum Institute of India has a capacity to produce 70 million doses per month. Government of India’s approval for Rs 3,000 crore investment is supposed to enhance this capacity to 100 million doses per month by the end of May 2021. Bharat Biotech has a much smaller manufacturing capacity of about 6-15 million doses per month as per media reports. The company's CEO has announced that they will be able to produce 30 million doses in May-2021 and ramp up production to about 60 million doses per month by August 2021.
The current monthly production of both these vaccines together stands at about 70-85 million doses per month. Accounting for their export commitments (about 15 percent of total production), this means that supply of vaccines in India is currently about 60-70 million doses per month. Accounting for the doses already administered, we need a supply of about 170 million doses per month from May onwards to cover even 80 percent of the population by the end of this year. For universal coverage by year end we need about 220 million doses/month.
Hopefully, some of the requirement will be met through a supply of other vaccines that have now been approved. Reports suggest that about 650 doses of Sputnik are supposed to be available totally in India. The time over which these will become available is not clear, but if the supply starts by June 2021 at least, then along with the promised increase in capacity of existing vaccines, we can reasonably expect some of this huge gap of 170-220 million doses/month to reduce a bit.
But the fact remains that there does not seem to be a plan in place even now to reduce this gap between need and supply, as rapidly as needed. Multiple reports have pointed out that manufacturing capacity in the public sector could have been repurposed and utilized to produce COVAXIN which was developed by the National Institute of Virology under the Indian Council of Medical Research , a public sector institution.
With better planning, and shared licensing to other public and private manufacturers, much more capacity could have been added to increase the speed of India’s indigenous vaccine production. It is only last week that the government gave permission to Haffkine Institute to manufacture COVAXIN on a technology transfer basis. It is not clear why the Government waited till vaccine shortages were felt across the country to make this decision. India’s population has not increased overnight. Our vaccine requirement was known even 6 months ago.
The Cost
Even more surprising is the government’s decision to allow manufacturers to declare the price of their vaccines, at which, states and private hospitals will then procure these directly. The shortage is not going to reduce substantially anytime soon. The decision to allow sale in the market during a severe shortage, and a virtual monopoly in manufacturing, may slowdown the vaccination drive in the country even further.
Both producers have already declared their prices. SII has said it will charge state governments Rs 400/dose and private hospitals Rs 600/dose. Bharath Biotech has said it will charge Rs 600 and Rs 1200 respectively to state governments and private hospitals. The pricing itself makes it evident that both companies will prefer to sell to private hospitals. In such a situation, government hospitals which are likely to see larger crowds, will suffer larger shortages.
If say 10 percent of the eligible population accesses vaccines in private hospitals in each state, the cost of covering the remaining eligible population at Government hospitals will be about Rs 79,000 crores. This is estimated assuming an average cost based on prices declared by manufacturers of both vaccines. This varies across states from about Rs 440 crore for Himachal Pradesh to Rs 12,800 crore for Uttar Pradesh. The variation across states is shown in Figure 2. Some of the states that already have slower vaccination rates face higher cost burdens and this may result in a further reduction in the pace of vaccination in these states.
Further some states may have a higher proportion of the population that can pay the cost of vaccination at private hospitals as compared to others. For example, if we take the per capita state domestic product as the basis, this varies from about Rs 2,607/person in Bihar to Rs 15,417 in Delhi. The central government must, therefore, play a role in ensuring equitable access across regions, even as it allows state government to determine strategies for vaccination that will work best for their circumstances.
In its budget for 2020-21, the Centre had earmarked Rs 35,000 crore specifically for COVID-19 vaccination. This translates to about Rs 186/dose, given the total number of doses needed to cover the entire eligible population. This is more than the regulated price of Rs 157/dose for COVISHIELD that the central government is paying. The SII had claimed that it is already making a normal profit at this price.
There will be some cost to set up infrastructure for vaccine administration, storage, etc., but a significant proportion of this cost is already sunk, and therefore the marginal cost of administering vaccines will be small in most cases. Private hospitals are currently allowed to charge Rs 250/dose to cover their infrastructure and personnel cost in administering the vaccines that are available for free via government allocation.
If we consider this as the normative price that includes the cost of the vaccine and the infrastructure needed to administer it, then at Rs 250 per dose, the total cost to cover the entire eligible population will be about Rs 47,000 crores - only slightly higher than the allocation in the Union Budget specifically for COVID-19 vaccination. This is a very small amount for the Central Government. At Government regulated vaccine prices, assuring reasonable but not super profits to the producers, providing free vaccination for everyone is very easily possible.
Universal vaccination, free of cost, promoted through campaigns, made easily accessible to people from all classes, across regions, may be the only way to ensure maximum coverage in an equitable manner. Vaccines are the best weapon in our fight against COVID-19. That vaccines have been developed so quickly is indeed a laudable achievement. It is imperative now that the government gets the dissemination right.
The author is an Associate Professor at the National Institute of Advanced Studies, Bengaluru
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