How to secure India against Covid-19

A national mission, with public and private sector participation, focused on vaccinating all Indians can set a global benchmark
A research scientist works inside a laboratory of India's Serum Institute, the world's largest maker of vaccines, which is working on vaccines against the coronavirus disease, Pune, May 18, 2020(REUTERS)
A research scientist works inside a laboratory of India's Serum Institute, the world's largest maker of vaccines, which is working on vaccines against the coronavirus disease, Pune, May 18, 2020(REUTERS)
Updated on Aug 31, 2020 11:58 PM IST
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ByNandan Nilekani

How can India vaccinate a billion-plus people? How would the system work?

First, the government will maintain a list of approved vaccines. This list will change, as some get dropped, and others get approved.

Second, the government will set a rate per vaccination for each vaccine. Finally, after due diligence, it will create a list of Authorised Vaccinators. These could be government hospitals, reputed private hospitals, diagnostic chains, even pharmacies.

Another ecosystem will have to be nurtured to train and certify a few hundred thousand people on how to administer vaccines. Specifications and templates will be distributed for vaccination stations which can be permanent, pop-up, or mobile for making it available anywhere. The government will distribute a standard vaccination software on smartphones and laptops, for the data of every vaccination to be captured in real-time and sent to a central database with proper security, privacy and encryption.

With this approach, at least 100,000 vaccination stations can be set up across the country over a year, while vaccine production is simultaneously scaled up.

A critical requirement will be the supply chain, including cold chain infrastructure. Vaccine sales will be between approved vaccine vendors and the Authorised Vaccinators; they will have to figure out the cold chain. An entire economy could spring up — new mobile cold chains with refrigerated trucks, or repurposed existing cold chains.

People should be able to go to any vaccination station in the country anytime to get a shot. They can also book a slot online. People entering a station and then first authenticate themselves using Aadhaar, phone number, any other digitally authenticable ID. A certified vaccinator will vaccinate them. The data from the vaccination will be uploaded. This data will includes the name and ID of the vaccinator and the recipient, details of the vaccine, and the pre-paid voucher (more on this shortly). The money (for administering the shot) will be credited immediately to the Authorised Vaccinator, and the central database will issue an instant digital certificate. The certificate can be downloaded to the person’s smartphone, printed or stored in a digital locker. The whole process should take about 10 minutes. At 50 vaccinations per day per station, India could do five million vaccinations per day.

The digital certificate will be globally portable and verifiable. While the idea of an immunity passport has been questioned, a certificate of immunisation is part of the International Health Regulations for diseases such as yellow fever, there is a precedent for such documentation. With this, the vaccinated person would be able to travel anywhere. If we find that vaccines induce limited immunity, then there will be an expiry date on the certificate, and the person will have to get revaccinated. If it is a dual dose vaccine, then only a provisional certificate will be issued, with the date for the second dose mentioned.

The system can enable people to get vaccinated at a date, time, and location of their choice. All payments by the people getting vaccinated will be through pre-paid vouchers, and rates could drop over time with volumes. People who can afford it should and will pay for their vaccines. The government will pay to vaccinate all health workers, its employees and their families, and the poor and vulnerable. Payments can be enabled by giving a DBT voucher, which is only accepted for vaccination. Companies could provide vouchers for all their employees and their families. Philanthropies and corporate foundations could also distribute these vaccination vouchers. These vouchers could be digital or printed for those without phones. The government can issue guidelines to streamline procurement from vaccine manufacturers by Authorised Vaccinators.

Since monitoring is part of the life cycle of any vaccine, a digital record of vaccination and a link to self-reported side effects could strengthen India’s vaccine safety surveillance. A sophisticated system could be built on top of this vaccination infrastructure using anonymised aggregate data. For example, if there is a rise in cases of Covid-19 in spite of vaccination in some areas, it would indicate that the efficacy of one of the vaccines used is lower than anticipated. A rise in some symptoms would mean there are unexpected side effects. Artificial Intelligence could be used for predictive analysis.

Initially, when vaccines are scarce, this system will be rolled out in a small scale and only through Authorised Vaccinators from the government. The initial vaccines will be directed strategically at health care and other essential workers, and the vulnerable.

The task ahead is fraught with risks from new vaccines, privacy issues, and objections from those reluctant to get vaccinated. There will be important decisions on equity, inclusion, priority, privacy, and choice. Yet, we have no choice but to go ahead.

This system may look daunting, but we are fortunate that India has many digital building blocks which can be used. Apart from the JAM trinity, the payment system UPI can be used to create the infrastructure for pre-paid vouchers. This vaccination system is fully aligned with and will accelerate, the National Digital Health Mission announced by Prime Minister Narendra Modi on August 15. Everyone can choose to opt for a health ID and an Electronic Health Record along with their vaccination details. The digital vaccination certificate, as well as the electronic health record, can be stored in MEITY’s DigiLocker. The training modules for vaccinators can be set up on IGOT, the online learning portal, launched by the department of personnel and training and hosted on the ministry of education’s Diksha platform.

If advanced training is required, the ECHO platform being used by the ministry of health can be leveraged. Best practices can be learnt from the way in which the Election Commission conducts general elections. Call centres and other digital infrastructure created by the National Health Authority can be used to identify and inform those who should get government-funded vaccination based on Ayushman Bharat.

The Government e-Marketplace (GEM), set up by the ministry of commerce and industry, can list approved vaccines and prices for Authorised Vaccinators to order their supplies. The ministry of finance has experience in large scale DBT. Importantly, building a new delivery system for public health strengthens the ability of the ministry of health and other ministries such as women and child development to deliver other interventions at scale.

Many fine bureaucrats who worked on the Aadhaar project are at senior levels in the government or have just retired and will be happy to come forward to contribute their expertise. And any number of ace technologists will volunteer to make this happen as it is truly an emergency.

Vaccinating the whole country as soon and as safely as possible to get things back to some normalcy post-pandemic is the need of the hour. This needs to be accomplished by a national mission, not a departmental or ministry project. All arms of the government and public sector, private sector and civil society need to participate as partners. If we can take this approach, we will set a global benchmark on how to get past the pandemic. A combined response, leveraging each other’s strengths, is self-reliance (atmanirbhar) at its best.

(This is the final part of a two-part opinion piece on a possible framework for vaccine delivery in India)

Nandan Nilekani, chairman and co-founder of Infosys, was the first chairman of the Unique Identification Authority of India, which set up Aadhaar

The views expressed are personal

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Saturday, June 25, 2022