Covid-19 vaccines are coming: Are we adequately prepared?

Many vaccine challenges lie ahead that should be addressed now for an all-India vaccination plan to be rolled out smoothly, writes Montek Singh Ahluwalia

As covid continues unabated, much hope is being placed on vaccines as key game changers. Things have indeed moved fast in this area. Instead of the 10 years that it normally takes to develop a vaccine, three (Astra Zeneca/Oxford, Moderna and Pfizer) are already in the last stage of human trials, with several others at earlier stages. Although no vaccine has been approved thus far, experts predict that we will have more than one vaccine approved in the course of 2021. However, there are many issues that need to be addressed if we are to get it right.

Covering a substantial portion of the population is only possible through a national programme under which every individual would get vaccinated free. Adequate funding for the programme will be critical. The estimated cost of the two doses of Astra Zeneca’s vaccine is $6. If we set a modest target of covering, say, 20% of the population (260 million people) in the first year, the vaccine cost alone will be ₹11,000 crore. When other costs, including the costs of syringes, transportation, storage distribution and physical administration, are added, the total cost may well be ₹20,000 crore in the first year.

Although health is a state subject, states are under severe financial stress and will expect the entire cost to be borne by the Centre. This, in my view, is appropriate, and adequate provision must be made in the budget for 2021-22 to be presented in Parliament on 1 February.

Assuming funding is assured, the government has to decide on which vaccine to use, and it has to do it when the first vaccine has yet to be approved. Some like the Novavax and Moderna vaccines may not be practical for India, since they require storage at minus 70 degrees Celsius, which would be difficult to ensure. Even so, we will have to choose between a variety of other vaccines which may have different levels of efficacy and safety, and also costs.

The usual method of government procurement, inviting bids to determine the lowest cost, may not work. Since there will be scarcity initially, it may be necessary to negotiate with individual producers to determine the best possible deal we can get. But with vaccines expected to be approved at different points of time, there is a case for retaining flexibility to be able to use vaccines that become available later and may prove to be better. The government needs to work out in advance how it will handle the procurement problem so that vaccinations can commence early and yet flexibility is maintained for the future.

Distributing a limited supply of vaccines across states also poses difficult choices. It could be on the basis of the total population or the extent of infections. Within each state, there will have to be criteria for prioritizing who gets the vaccine. The World Health Organization (WHO) has proposed giving priority to health workers and other essential workers and categories of citizens most at risk. We could build on this approach. Ideally, these issues should be resolved after consulting states in the spirit of cooperative federalism. The actual identification of beneficiaries in each state will have to be left to states.

Parallel to the public vaccination programme, private hospitals/doctors could also be allowed to offer vaccinations to individuals willing to pay, using any vaccine approved by the Drugs Controller. Vaccine supplies will be scarce in the early stages, but if some hospitals can get supplies of approved vaccines, possibly the more expensive ones that are not picked up for public programmes, the private sector should be allowed to use them.

A key policy imperative for private vaccination is that no price control be imposed on these vaccines. This may attract criticism from those who worry about extortionate pricing, but price control in a situation of scarcity would only lead to a drying up of availability. As long as the government looks after the needs of the common man, allowing those who can afford to meet their needs from the open market will only reduce demands on the public programme, allowing more people to be covered across the country.

Another policy issue is whether export controls should be used to force domestic producers to meet domestic needs first. India has the highest vaccine manufacturing capacity in the world and one of our objectives in the current situation should be to promote India as a global supplier of vaccines. Imposing export controls, which prevent suppliers from fulfilling export orders they have accepted, would undermine India’s credibility.

The government should instead be more proactive in placing orders as early as possible, both domestically and internationally. It makes no sense to fail to tie up supplies, and then interfere with producers meeting export orders contracted earlier with foreign buyers.

While many Indian companies are conducting trials with foreign vaccines, and will undertake contract manufacturing, there are also two vaccines developed in India: the Indian Council of Medical Research/ Bharat Biotec and Zydus /Cadilla. Successful development of an indigenous vaccine would be a major gain not only because it may be better tailored to Indian conditions, both genetic and logistical, but also because it would demonstrate India’s scientific capability.

Promoting an India-developed vaccine should not, however, involve compromising quality in terms of efficacy or side effects. Indigenously developed vaccines should obtain regulatory approval from the WHO and regulators in some major developed countries. This will be essential to gain acceptance even in developing countries. The government could provide financial assistance to the developers of these vaccines to cover the cost of obtaining international approval.

The government has set up an inter-ministerial committee under Dr. Vinod Paul, member Niti Aayog and formerly of the All India Institute of Medical Sciences, to look at all aspects of policy pertaining to the vaccine. Perhaps the committee should prepare a comprehensive report that addresses all issues, including those raised above, which could then be discussed with states, and a consensus view evolved.