India’s vaccine strategy is neglecting the vulnerable, poor. There is a way out
Are we pushing our older and vulnerable population into harm’s way and delaying vaccination for the poor?
The government says that a third wave is a distinct possibility in the near future. It has consistently maintained that older people, i.e., 45+ and among them, the 60+ are especially vulnerable to severe outcomes, reiterated in the new affidavit to the Supreme Court. Also, recent studies show that a single dose offers only limited protection against infection from the Delta variant and somewhat better, but still low protection, against hospitalisation. Two doses are needed for sufficient protection, especially for older persons.
Yet, currently, three out of four first doses and two out of three total doses are going to the youngest 18-45 age group, while the vulnerable 60+ get just one out of 10. 90% of all jabs are first doses. We are vaccinating very few of the 60+ and also delaying their second dose, leaving them vulnerable to the third wave.
Since May 1, the youngest have got over five times the number of doses given to the oldest and most vulnerable age group (60+). If these doses had gone to the oldest instead, we could have had 100% coverage (first doses) of the most vulnerable 60+ by now. As it is, less than half of them have received one jab and the delay in the second lifesaving dose has meant that only one out of six are fully vaccinated.
Some states show it’s possible to be more responsible. In Rajasthan, Tripura, Himachal Pradesh, Sikkim, Uttarakhand, Mizoram and Goa, more than three-fourths of the 60+ have got their first dose. Achieving these levels needs hard work and rural outreach, taking vaccines closer to people. But states, especially now, are chasing numbers and the young are many and easily available.
How soon can we reduce the gap? Given the improved supply, we can, by the end of July, give first doses to all 60+ and second doses to all who got their first jab more than eight weeks ago. The first cohort needs about 40 million doses and the second cohort about 35 million, a fair 60% share of the planned 120 million that the Centre’s affidavit says will be available in July, and a much smaller share of the 220 million expected by the chair of the National Technical Advisory Group on Immunisation in India.
Like in the United Kingdom, which inspired the 12-week gap (we extended it up to 16), we should reduce the gap between doses for the oldest age group and fully vaccinate them as quickly as possible. Among the 18-45, those with co-morbidities can be prioritised, as done for the 45+ earlier.
Not just the young, the new vaccination policy also privileges the rich. For a family of five, Covaxin costs ₹14,000 in the private sector while it’s free in the public sector. If you can afford it, you can get vaccinated faster because the private sector has vaccine stock while the public sector often does not. As the health minister said on April 25, “Undoubtedly, the private and corporate sector route will empower a large number of people to get themselves quickly vaccinated … those who can afford to get them at the private and corporate sector rates shall go ahead.” A faster vaccination schedule for richer people is thus part of stated policy.
But private presence is limited and very spatially concentrated. Half the districts have no private vaccination sites and over three-fourths have less than five. On June 21, when we vaccinated more than eight million people, nine states accounted for eight out of ten private sites and in each of them, most sites were in a few major urban districts. For example, in Telangana, Hyderabad and its surroundings accounted for 150 of 157 sites, while Kolkata, its neighbour, North Twenty-four Parganas and West Bardhaman, made up 212 of 241 sites in West Bengal.
We need to reduce the private allocation or revert to the previous arrangement. Private sites can still vaccinate. Their supplies should be replenished based on use. The continuing reservation of 25% of vaccine production for less than 4% of vaccination sites is mindless. Low private demand will not even help to cross-subsidise, which the government has openly admitted as an objective in the latest affidavit.
But, it’s not all bleak.
Crowded vaccination centres and long waits usually deter women from vaccination. The changes since May 1 led to rising gender inequity. The gender ratio worsened in almost all states (Andhra Pradesh a notable exception), with a higher share of 18-45 in vaccination associated with a worse gender ratio. Four out of five districts saw worse gender outcomes. Perhaps, men were more likely to go and women dissuaded from going to paid urban vaccination sites, which had much of the vaccine stock in May. However, as vaccines became available at public vaccination centres, this inequity has reduced and is now back to levels of late April.
The other improvement is in spatial equity. Even in April, about 35 districts accounted for 25% of all vaccinations and 113 districts (about 15% of all districts) for half the vaccinations. Many of these are large urban centres with richer people but also admittedly with a high share of infections. Over May and till June 21, this became worse and in early June, only 25 districts were responsible for a quarter of all vaccinations. Since June 21, this has improved. And last week, about 47 districts accounted for a quarter and 148 for half the vaccinations, indicating that vaccines are being spread out more widely.
A more equitable vaccination policy is achievable, especially after the ramp-up post June 21. Two of four major inequities, gender and geography, have been mitigated to some extent. We need to fix the other two, by focusing on the vulnerable and the poor.
Partha Mukhopadhyay is a senior fellow, Centre for Policy Research
The views expressed are personal