8. THE VACCINE COMPLACENCY
INDIA’S VACCINE ROLLOUT WAS ABYSMALLY SLOW, MARRED BY OFFICIAL COMPLACENCY AND A LACK OF VISION ABOUT ITS CRITICAL ROLE IN FIGHTING RETURN WAVES
VACCINE PRODUCTION IS AN AREA in which India had a head-start over even many developed nations. India is among the world’s largest manufacturers of vaccines, and early human trials of vaccines, including of one developed in the country, had shown great promise. The Centre knew that if these vaccines were cleared for use, India would have a reliable shield against the virus. By August 2020, even before the first wave had peaked, the central government had set up a National Expert Group on Vaccine Administration (NEGVAC) for Covid-19 to work out a comprehensive vaccination policy. NEGVAC invited FICCI (the Federation of Indian Chambers of Commerce and Industry) to help assess the national capacity for inoculation. In partner
ship with EY, a consultancy, it submitted a strategy paper that estimated India would need 130,000-140,000 vaccination centres, 100,000 healthcare professionals and 200,000 support staff to handle inoculation and logistics for those in priority groups (about 300 million) by August 2021 and for the entire adult population (about 800 million) by the end of 2022. It estimated that about 60 per cent of public health infrastructure would be required as vaccination centres and also noted that the public sector would only be able to supply 60-70 per cent of the manpower needed, meaning that the private sector would be required to play a major role.
SOON AFTER, things went downhill. For one, given the size of the population and the need for speed, the Centre should have realistically assessed the capacity of the two institutions shortlisted to manufacture the vaccines. Vaccination giant Serum Institute of India (SII) had tied up with a consortium of AstraZeneca and Oxford University to manufacture Covishield. Meanwhile, Bharat Biotech had combined with the National Institute of Virology to indigenously develop Covaxin. Together, these two were capable of manufacturing 110 million doses a month. With each vaccine requiring two doses, India would need close to 2 billion units to protect its adult population. This fact should have prompted NEGVAC to recommend advance bookings on a far larger scale, as the US, UK and other countries had done with other manufacturers. Also knowing that these two firms would find it practically impossible to meet all the demand by a deadline early enough to be effective, it should have actively explored tie-ups with other companies. “We failed to act fast,” says K.I. Varaprasad Reddy, founder and president, Shantha Biotechnics.
Lulled into complacency as the first wave receded after September, NEGVAC placed all its bets on Indian firms. In January, when it announced the vaccination drive, it began at a leisurely pace, starting with frontline and health workers and those above 60 years who faced the biggest risk. “Complacency at the highest policymaking level created confusion,” says health economist Sarit K. Rout of the Indian Institute of Public Health, Odisha. “The government underestimated demand, assuming that India had already won the battle.”
The second error NEGVAC made was not involving the private sector in its effort, despite knowing that government facilities would be grossly inadequate. Leading industrialist Azim Premji’s pleas to involve the private sector in a big way to speed up the process fell on deaf ears. The central government smugly continued its lackadaisical policy, till the second wave hit the country in March with the force of a tsunami. Then, in quick succession, the Centre first announced that those above 45 years of age would be eligible for vaccinations and a month later said those above 18 could also join the queue. Almost overnight, 750 million people were in line for vaccination, even though both Indian firms said they would be able to boost production only by July. (Given the shortage, so far only nine states have begun vaccinations for those in the 18-44 age group.) It also announced differential pricing for central, state and private purchases, which added to the chaos, leading the Supreme Court to advise price rationalisation.
Meanwhile, it gave Rs 4,500 crore to SII and Bharat Biotech to boost production in lieu of cheaper supplies for central procurement—something experts said it should have done six months ago. The Centre also announced that it would permit Sputnik, the Russian vaccine, to be imported for use on an emergency basis. It also allowed Indian companies to tie up with other pharmaceutical firms to manufacture vaccines. Private hospitals were also told they could buy vaccines directly from manufacturers, ending the monopoly of government procurement. “Policy makers initially implemented a vaccination strategy without much role for the private sector, losing time in terms of decision-making and production,” says public health expert Muralidharan Nair, partner at EY.
Some argue that India can break patents and commission other domestic manufacturers, but experts say it is not that simple. “Provisions in the Patent Act allow the government to invoke ‘compulsory licensing’ as this is a national emergency, but the issue is who has the capability and technical knowhow to make them,” says Gopakumar G. Nair, founder and CEO of GNA Patent Gurukul, a patent specialist firm. NEGVAC, which failed to foresee the supply crisis, and the Union health ministry, which got complacent about the vaccine rollout, must shoulder the blame for why India’s vaccination drive has faltered so badly.
IMAGINE AN OLA OR UBER app which showed cars all over the city but with none assigned to you, no payment gateway and no analytics. Would this system have worked? Unlikely. And this has been the defining feature of Covid’s second wave— chaos. Hospitals are besieged by patients looking for beds, oxygen and intensive care facilities. Covid call centres set up by states are flooded with calls. Many patients directed to hospitals by call centres found that no beds were available. There have been reports of corruption and nepotism in the allotment of hospital beds and black marketing of medicines and oxygen cylinders.
In Delhi, the city worst hit by the second surge, the state government set up a helpline only on May 4—nearly two weeks into a crisis over oxygen shortages and unavailable hospital beds. It was left to a high court bench to suggest to the Delhi government that a mobile app be developed where people could upload details and a pool of doctors could give consultation.
The SARS-CoV-2 virus was unlikely to obey boundaries between the Centre and the state government nor the dual polity of India’s federal structure where health is a state subject. A unified command structure was clearly the need of the hour. Yet, neither state governments nor the Centre used the lag between the two waves of the pandemic to set up a nationwide disaster management system that could manage the sick people crowding hospitals or create pools of doctors who could remotely monitor patients.
A centralised technology-based real-time information dissemination system in each state, with nodes linked to a central monitoring control
unit under the Union health ministry, would possibly have been an ideal solution. While this would not solve the most pressing problem—a shortage of hospital beds and oxygen—it would help streamline the flow of these scarce resources and prevent malpractices. What we have instead are situation rooms, call centres and dashboards sitting in silos in ministries, departments and state capitals.
In early April, as Covid-19 cases began skyrocketing, the Department for Promotion of Industry and Internal Trade set up a 24x7 control room to monitor the movement of GPS-tagged oxygen trucks from their loading till delivery in various states. Details include the truck’s registration number, driver’s name and contact details, starting time, estimated time of arrival, and delays if any.
On April 28, the Uttar Pradesh government had given the deep dive into their IT-enabled system that tracks the movement of their quota of oxygen. UP has set up district level demand and supply monitoring war rooms under district magistrates. The war rooms monitor oxygen requirements in hospitals and homes as well as the need of critical medicines, plasma and ambulances. The challenge is poor public awareness and the fact that these set-ups could be getting inadequate inputs.
Punjab has a control room with a database of Covid patients and provides them doorstep delivery of medicines, food assistance and roundthe-clock medical advice. Karnataka has a war room which monitors the demand and supply of oxygen and critical medicines in government and private hospitals. .
In April last year, the Union health ministry set up a digital dashboard, showing pandemic hotspots across the country, lockdown protocols and coordination among various agencies. The dashboard has been replicated in at least 20 cities. These, however, are B2B solutions—the challenge for such dashboards and call centres is to connect with the people who actually need help.
A unified pan-India database, utilising tele-medicine, would have proved useful in eliminating some of the chaos in hospitals. Doctors would have remotely scanned patients and judged whether they needed a physical examination and hospitalisation or home quarantine. AI-powered bots could have helped sift through information available on social media to feed a central database and match available resources with requirements. It would also allow states to, say, monitor the movement of geotagged oxygen trucks or help redistribute resources, such as oxygen concentrators and medicines, and relocate health professionals. To borrow from the military’s concept of theatre commands—all resources in a theatre are under a theatre commander. These can be diverted towards other theatres that need to be reinforced.
Setting up such systems would be small potatoes for India’s IT-ITeS sector, which is poised for revenues of $194 billion (Rs 14 lakh crore) in the financial year 2021. Indian IT firms have set up complex solutions, such as Infosys’s Finacle that completely automated global banking processes or TCS’s Passport Seva project that streamlined the delivery of passports across the country.
IN THE ABSENCE of such software-driven solutions, there have been call centres of the kind set up by the Brihanmumbai Municipal Corporation (BMC). The model, conceived by BMC chief I.S. Chahal and set up in two phases (May 2020 and April 2021), deals with every aspect of Covid management, from checking whether a patient needs hospitalisation to allocation of beds. These centres operate in 36 BMC zones. Each zone handles at least two suburbs with a combined population of half a million.
Experts say what states have can at best be called BPO centres, not war rooms. They lack a real-time information dissemination system (RIDS). A BPO call centre could get overwhelmed in a crisis while an automated system would handle things far efficiently. One such RIDS, developed by the Bengalurubased QuGates Technologies, proposes a real-time digital surveillance mechanism to monitor the supply of essential Covid healthcare commodities. It links up consumers through mobile applications.
“Such a system has huge potential to scale up both horizontally (capacity and reach) and vertically (services) and can be reconfigured for any disaster management scenario,” says S. Sudhakaran, CEO, QuGates. The system uses an opensource portal. This can seamlessly network volunteers across self-help groups and provision resources beyond their area of operation, he says. An Uber for healthcare. ■ —Sandeep Unnithan