Since the start of India’s COVID-19 vaccination drive, more than a crore healthcare and frontline workers have received at least one dose of the vaccine. The slower-than-expected pace was widely criticised, particularly by people advocating for greater private sector participation. As the drive enters its next phase, the government appears to have given into the criticism and announced that as of March 1, in addition to free access in government vaccination centres, eligible individuals will have the option of being vaccinated in private centres for a maximum fee of Rs 250 per dose.
While recognising these positive efforts to accelerate vaccination those at risk, we raise apprehensions about allowing private administration of vaccines for payment and underline the need to incorporate safeguards to ensure public health objectives are met. Because vaccination is a critical public health measure in responding to the pandemic, free provisioning of vaccination, as was done for healthcare workers and frontline workers, is key to removing financial barriers to access for targeted groups. Therefore, it is surprising that the government chose to make vaccination chargeable at Rs 500 in the private sector despite a budgeted outlay of Rs 35,000 towards COVID-19 vaccination and a stated commitment to provide additional funds.
Both the vaccines currently in use were granted restricted emergency-use approvals to provide some degree of protection to the most vulnerable. Asking the public to pay for vaccines that have received only emergency approval on the basis of limited data raises ethical concerns. Ideally, the government should have continued vaccination that was free-of-cost to beneficiaries while scaling up vaccination by engaging private institutions on a model of fair and reasonable remuneration for services.
Yet, the government has done well on two fronts. First, enlisting private hospitals empanelled in the Ayushman Bharat-PMJAY, CGHS, state-level insurance schemes has targeted the inclusion of 20,000 private vaccination sites, which could end up being double of the government centres. Second, the price of Rs 150 per dose which was negotiated with manufacturers, is lower than what the government had previously paid. With this development. India is also sending an early signal of the feasible drop in vaccine prices to the global community.
We are glad that the government has seemingly avoided repeating the mistake made with COVID testing where the excessively high price cap of Rs 4,500 provided extravagant margins to private players.
More vaccine choices are expected in the coming months given a promising vaccine pipeline and several candidates entering late stages of development. A further reduction in prices is inevitable but for the fact that market forces left to themselves yield imperfect results in healthcare. Therefore, the government must enable competitive pricing and ensure that procurement prices are within a reasonable realm of the costs of production.
The government has decided to supply doses to private centres to prevent leakages and black marketing. This is vital for other reasons. So far, the government has procured only a fraction of the doses that will be needed to complete vaccination of priority groups, including an estimated 27-crore elderly and high-risk individuals yet to be given the vaccine. Doses will need to be acquired over the course of immunisation.
India has upheld the principle of equity in donating doses and facilitating exports. The government must continue to act in global solidarity and demonstrate leadership by sharing affordable vaccines, especially when poor nations are falling perilously short of doses and wealthy countries having swept up the majority of vaccine supplies.
Retaining control of the supply and distribution of vaccines will permit the government to take a calibrated approach to maintain uninterrupted supply of doses during a crucial period of the domestic vaccination programme while also balancing commitments to the COVAX facility and other international demands. It would also enable the government to prioritise distribution in the event of upsurge of cases in parts of the country or the spread of variants.
The experience so far of vaccination indicates the need for further strengthening of protocols and systems for monitoring and reporting of adverse events following immunisation (AEFIs). News reports about cases of serious adverse events (SAEs) and deaths of vaccinated individuals document problems of insufficient screening of vaccine recipients; non-responsiveness by local authorities when first informed about an adverse reaction; and lack of diligence and lapses in reporting and investigating SAEs at the state level. This has led to a significant lag in the National AEFI Committee’s causality assessments of SAEs. Timely causality assessments are crucial for fine-tuning screening of individuals and contraindications of the vaccines. Transparency in the handling of SAEs and sharing findings are essential for building public confidence and reducing vaccine hesitancy. In light of the dramatic ramping up of vaccination in coming weeks, the existing weaknesses in AEFI monitoring need to be immediately identified and remedied.
Despite proactive government measures aimed at improving access and affordability of COVID-19 testing and treatment, private players, particularly corporate hospitals, refused to comply with regulations. To ensure that the public health goals of vaccination are achieved, the government must put in place checks to ensure compliance of screening procedures, vaccination protocols and proper monitoring of AEFIs. Additional systems to assure free medical care in case recipients suffer adverse events and safeguards against negligence also need to be put in place.
This article first appeared in the print edition on March 2, 2021 under the title ‘Public health, not private profit’. Aisola works on public health issues. Das is a theoretical physicist