Sharpening India’s vaccination strategy
With the second wave apparently departing and with some invaluable time in hand, there arises a crucial opportunity to sharpen and focus our vaccination strategy in order to best prepare for an imminent third wave
The months straddled by the second wave of Covid-19 stand out for tumultuous and vagarious changes in vaccination policy.
In April, the central government released a liberalised vaccination strategy which expanded the eligibility to the 18-45 years age group. Pure confusion pervaded about our objectives with the strategy. Were we trying to combat the ongoing second wave (which was impractical) or to prevent a future third wave (which didn’t warrant such a hurried, knee-jerk response)? Were we primarily trying to dampen mortality or infections or both? Much of such confusion still persists despite the partial reversal of the liberalised strategy in June.
Nonetheless, with the second wave apparently departing and with some invaluable time in hand, there arises a crucial opportunity to sharpen and focus our vaccination strategy in order to best prepare for an imminent third wave. Although vaccine supplies are projected to increase in upcoming months and many states have recently shown some improvement in vaccination performance, the current indiscriminate approach to vaccination is least desirable.
There is a need to prioritise vaccine recipients based on vulnerability and epidemiological profiles so as to maximise population health gains, in case the increase in vaccine supply does not suffice.
This applies mainly to the 18-45 years age group, though undoubtedly also to the remaining age groups. Apart from persons with comorbidities, certain other categories such as hawkers, vendors, and rickshaw drivers have been frequently argued as meriting targeted vaccination since they could act as super-spreaders apart from being prone to infection.
However, there is a need of adopting a broader definition of who is vulnerable. Those with lesser access to health facilities; those with fewer luxuries to practice isolation and social distancing; and the rural population, for example, are important vulnerable categories, since they can contribute to greater morbidity and mortality.
Many targeted strategies, such as user fees exemptions in public health facilities, have traditionally been characterised by pervasive inclusion and exclusion errors. For the very same reason, they have been held as inefficient from time to time. The challenge at hand is magnified when it comes to targeting vulnerable groups for vaccination. Identifying these vulnerable groups, most of which belong to the informal sector, can be an exacting exercise and may come with a greater likelihood of inefficient targeting and leakages. However, unlike in the case of user fees, there is a strong case for a targeted vaccination strategy despite the potential inefficiencies. The most practicable, expedient, and least resource intensive methods to identify and target vulnerable sections have to be conceived for this purpose.
Since segregating these vulnerable groups is difficult, certain readily available proxy means could be adopted for targeting these groups.
Take for example the Pradhan Mantri Jan Arogya Yojana (PMJAY), which covers more than 100 million families based on certain deprivation and occupational criteria, from the Socioeconomic and Caste Census (SECC). Until June 25, nearly 160 million PMJAY e-cards had been issued. A cursory look at the deprivation and occupational criteria shows that most categories of PMJAY beneficiaries would meet one or more criteria for vulnerability. It should be relatively easy and efficient to target these populations given the infrastructure that is already in place. Also, nearly 80% of PMJAY beneficiaries are from rural areas. A similar precedent already exists from last year, wherein PMJAY officials identified and traced high-risk beneficiaries from their database through call centres to facilitate early diagnosis and treatment.
There is a particularly strong case for subsidising Covid-19 vaccines under the PMJAY health insurance scheme, given the positive externalities, low moral hazard, and other such desirable traits. Public and private empanelled hospitals can be roped in for the purpose, and measures such as temporary “express empanelment” of private hospitals may be envisaged as was done last year. The fact that the central government has already conceived a vaccine pooling mechanism for small private hospitals in the country can only be complementary. This could also promote more equitable utilisation from the 25% share of vaccines that has been reserved for the private sector, which is disproportionate and inequitable in existing circumstances.
Anticipation of colossal implementational challenges shouldn’t form a pretext to condone inefficient and indiscriminate policies or practices. Neither should one be driven by pedantic notions of idealism and perfection. Sagacious and resourceful use of existing capacities should be the motto.
Soham D Bhaduri is a physician, health policy expert, and chief editor of The Indian Practitioner
The views expressed are personal