How to vaccinate a billion people
The inventor of the polio vaccine Jonas Salk said: “Our biggest responsibility is to be good ancestors”. India is approaching a big decision; whether we will take one to two years or three to five years to vaccinate 1.3 billion people. History will judge whether we were good ancestors by this decision. The difference could be thousands of lives, millions of livelihoods, hundreds of bankruptcies, unsustainable public finances, and ₹2-3 lakh crore in bad loans.
In recent times, the one government initiative that has physically reached a billion people is Aadhaar enrolment. In 2009, some of us were grappling with how to enrol at speed, scale and quality. We realised that the traditional model, where the government procured thousands of enrolment kits would not cut it. We 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. 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 ₹50 per successful Aadhaar generated. This public-private partnership is how we managed comprehensive coverage — and fast. The result: 600 million residents got their Aadhaar in four years, and a billion in 5.5 years. The response to the pandemic needs to be even faster.
India is uniquely placed to offer vaccination for the entire population at speed and scale. The experience of Aadhaar enrolment is helpful, as is the infrastructure provided by Aadhaar. Now that everyone can be authenticated online, either using Aadhaar or using mobile phones, be it by biometrics or OTP, it 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.
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 Indian Council of Medical Research 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.
Sure, things remain uncertain. Some vaccines may be unsuccessful; some may require two doses or may need to be repeated after a few months. The capacities may be overstated, and some of that capacity will be exported. Even after that, it is still reasonable to assume that India will have adequate vaccine supplies at some stage. If any of the vaccines fail, the capacity earmarked for the failed vaccine can be used to manufacture a successful vaccine of the same type.
Given what we know of India’s capacity for vaccine manufacture, it is important that the system design for vaccination roll-out is based not on vaccine scarcity, but vaccine adequacy. Even if we don’t start that way, India should reach adequacy by the end of 2021. We are not distributing a precious resource, we are trying to deliver fast and far, a vaccine that everyone needs.
India has a long and accomplished history of immunisation. But that infrastructure can’t be used because the immunisation that is now required — over one billion, possibly two billion, vaccinations in less than two years — is very different in speed and scale to the current system, which is limited to 25 million infants born each year, and pregnant women. The Covid-19 vaccine will have to be universal. And finally, if we load Covid-19 vaccination on the current vaccination infrastructure, it will be overwhelmed. 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. Our success in polio is commendable, but it is vital to remember polio is an oral vaccine that an untrained care worker can administer at the recipient’s home.
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. However, 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 fortuitously a better, cheaper vaccine comes along, then the procured stocks will become worthless. At this time, the issue is likely to be politicised and the usual finger-pointing, CAG audit will start and cripple further efforts.
There is a better way.
(This is the first part of a two-part opinion piece on a possible framework for vaccine delivery in India. The second part will appear on Tuesday)
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