Covid

Through the Looking Glass – A Book Review

I have never reviewed a book on my website, so this is a first.

Recently, I read Akhilesh Tilotia’s Through the Looking Glass. Tilotia is a management graduate who has worked both in the private sector and in the government. He was an officer on special duty to the minister of state for civil aviation, Jayant Sinha, for a period of three years, in the first term of the Narendra Modi government. (On a separate note, an apology to the Lewis Carrol fans who might have been conned into clicking on this link).

In this book, Tilotia offers a clear perspective on what it is like to work for the government as an outsider, why the government does not achieve what it normally sets out to do and what can be done about it.

There are two things I immensely liked about the book. First that it is written in simple English, something that many people who write on public policy and economics cannot seem to do, and second that Tilotia tackles the very tricky issue of how politics impacts public policy in India or why the government operates the way it does.

Running for an election, even at the corporator level, is very expensive. It needs a lot of money. To fight a Member of Parliament election, the expenditure allowed is up to Rs 70 lakh. And on paper that’s what the candidates spend. Of course, the real spending is much more. The question is where does this money comes from.

As Tilotia writes:

“The sources of funds are rarely disclosed or discussed in detail. Local, regional, national or even global entities may have an interest in a particular candidate or a party winning or losing. Who the candidate may be beholden to for his election is not obvious at the time of, or post the election.”

This works at both the state level and the national level. State level politics in India tends to be funded by builders in many cases. Hence, there is always a quid pro quo.

There is a very limited culture of making political donations in India. Corporates don’t like the idea of their employees being politically active. And those who are politically active, either need to hide their affiliation or face its consequences.

In this scenario, the politician is perpetually worried and unsure about where the money to fight the next elections is going to come from. As Tilotia writes: “The politician is ever on the look-out for funding commitments over the course of his political journey, whether as challenger, candidate or elected representative.”

Clearly, the incentives here are misaligned, and politicians, like other human beings, respond to incentives and don’t do the things they should be doing. If this problem can be solved, then politicians in India will be in a much better place to focus on the future than the political funding, Tilotia believes.

Due to this, what we call the system fails to deliver, leading to people who can opt out of the system, doing so at the first possible opportunity. This exit is visible in people cocooning themselves in gated communities, making sure that there are diesel generators which ensure the availability of electricity even when there is a power cut, sending their kids to private schools, buying vehicles to move around because the public transport is not up to the mark and so on.

Tilotia calls this the private cost of India’s public failure. And it just doesn’t lead to exits. It is detrimental on two other counts. First, as Tilotia writes: “The cost being high forces the spending of a large part of India’s wallet on basic necessities keeping Indians tethered on a low quality of life.” And second “public failure hits the poor and the vulnerable the hardest.”

The private cost of public failure has clearly been visible in the last 15 months as the Covid pandemic has spread. The out of pocket health expenses for many families who have had to spend money on treating the disease have gone through the roof.

This is primarily because the health system in many parts of the country is broken and/or virtually non-existent. Of course, this has led to a slowdown in economic activity, given that many families have run out of money, some others have ended up in debt and others having seen what has happened around them, are saving for future Covid waves. In this way, the private cost of India’s public failure, has turned into a public one.

Tilotia’s book is also an excellent ready reckoner for those looking to work for the government in mid to senior level positions and hoping to get some taste of how it is likely to be.

On the flip side, the book barely has any masala in it, though I found the callout feature of comparing the state of Jharkhand with Infosys, very interesting. And so was the small bit about the uncanny resemblance about the accounts of the state of Himachal Pradesh and Air India.

In that sense, the book is not something like Sanjaya Baru’s The Accidental Prime Minister.  Personally, I understand why the writer stuck to saying what he wanted to say in a straightforward accessible manner, but some masala would just have made a good book even better. For starters, Tilotia could have told us about how good the food in the Parliament’s canteen is. Are we really missing out on something?

When It Comes to Vaccines, Govt Tells Us One Thing, Supreme Court Another

On May 13, the government told us that between August and December this year, the covid vaccine availability/production will be ramped to around 216 crore doses. Tweets were published by several government handles. (You can take a look here and here).

Many media reports were also published regarding the same. As the Mumbai edition of The Times of India reported on May 14: “Setting out its roadmap to vaccinate the around 95 crore 18-plus population, the Centre said on Thursday India should be able to access nearly 217 crore doses between August and December.”

The following table shows how the 216-crore number was arrived at.

Source: Ministry of Health and Family Welfare. In case you are unable to see the table, click here.

Several ministers reiterated this message. Prakash Javadekar, who holds multiple portfolios in the government, said: “India will get 216 crore new vaccines by December. India will be able to vaccinate more than 108 crore people with the help of these vaccines.” The health minister Dr Harsh Vardhan also made a similar statement.

The underlying message here was that the vaccine shortage, if any, would not be a problem in the months to come. Over the next few days, WhatsApp and other social media kept buzzing with this message. The above table was shared over and over again. The Be Positive crowd had a field day. So far so good.

The trouble is that the numbers in the table are just that, numbers. Allow me to explain.

75 crore doses of the Covishield vaccine are expected to become available between August and December, a period of five months. This implies a production capacity of 15 crore doses per month on an average.

In a submission to the Supreme Court on May 9, the government had said that the manufacturing capacity of the Serum Institute, the company which manufactures Covishield, is expected to go up from 5 crore doses per month to 6.5 crore doses by July 2021. Increasing production capacity from 6.5 crore doses per month to 15 crore doses per month is going to be some task.

Of course, the government always has the option of importing the Astra-Zeneca vaccine doses (which is locally manufactured as Covishield). But even if the government decides to import, the difference between the local production capacity and the projection of 15 crore doses per month on an average, is huge. Further, any imports will come at the expense of denting the atma nirbharta narrative.

When it comes to Covaxin, the estimated production between August and December has been assumed to be at 55 crore doses. This implies a production of 11 crore doses per month on an average.

The central government told the Supreme Court on May 9 that the manufacturing capacity of Bharat Biotech, the company which currently manufactures Covaxin, is expected to go up from 90 lakh doses per month to 2 crore doses per month, and further increase to 5.5 crore doses per month by July 2021. So, 5.5 crore doses a month is half of the 11 crore doses per month that is required as per the government’s calculation.

Of course, it needs to be remembered that the intellectual property for Covaxin is shared between Bharat Biotech and the Indian Council of Medical Research. Hence, Covaxin will also be manufactured by three public sector manufacturing facilities. These are Indian Immunologicals, Hyderabad, Haffkine Biopharmaceuticals, Mumbai, and Bharat Immunologicals and Biologicals, Bulandshar.

Based on this, the government told the Supreme Court: “This is projected to enhance Covaxin‟s current manufacturing of 1 crore doses/month to nearly 10 crore doses/month in the next 8-10 months.”

So, Covaxin’s production is expected to touch 10 crore doses per month only in 2022. At least, that’s what the central government told the Supreme Court. Nevertheless, that did not stop them from telling you and I, that 11 crore doses per month of Covaxin will be produced on an average between August and December. Given this, the vaccine production projections made by the government, don’t pass the basic smell test. 

And we aren’t done with this yet. A close look at the above table tells us that it also includes doses from vaccines which haven’t been cleared for production. In fact, this was precisely the point made by the two amici appointed by the Supreme Court ( Jaideep Gupta and Ms Meenakshi Arora) in the Suo Moto writ petition that the Court is currently hearing.

As Wikipedia points out: “An amicus curiae (literally, “friend of the court”; plural: amici curiae) is someone who is not a party to a case who assists a court by offering information, expertise, or insight that has a bearing on the issues in the case.”

As the Amici told the Supreme Court:

“The [central government] has claimed that it will be able to vaccinate a substantial number of persons (around 100 crore persons requiring 200 crore doses) by December 2021. However, no projections have been shared with this Court regarding how this target would be achieved. Based on reports, it appears that the [central government] has factored a number of vaccines that are currently in their development stages to reach its projected number of 200 crore doses. This approach would be misguided as the success and efficacy of vaccines that are currently in the stage of clinical trials is uncertain and cannot be guaranteed.”

The interesting thing is that the central government hasn’t presented any projections of vaccine availability to the Supreme Court and in an affidavit submitted to the Court on May 9, it said: “It is difficult to predict the projections for vaccines given that it depends on variable factors such as introduction of new foreign vaccines, capability of increased production by existing manufacturers, among others.”

Of course, the variable factors did not stop the government in confidently telling us that 216 crore vaccine doses would become available between August and December, later this year. Something, it didn’t have the confidence to tell the Supreme Court on May 9, it told the country on May 13, four days later, and has been saying it over and over again since then.

What this tells us is that the submissions to the Supreme Court are clearly not good WhatsApp material and hence, things can be said as the way they are.

Nevertheless, the Solicitor General, during the course of his oral submissions to the Supreme Court, did say: “He is in a position to address these concerns of this Court and that the UoI aims to vaccinate approximately 100 crore persons by the end of December 2021.”

Nonetheless, there is a huge difference between an aim, a plan, and a projection, as we have seen in the calculations earlier in this piece. Numbers are just numbers and can easily be tortured to arrive at what one wants to say. The table accompanying this piece is an excellent example of this phenomenon.  

But then on WhatsApp who is bothered about the details and the nuance. So, the main aim of the government was to project a confident be positive narrative and it did just that.

To conclude, it is safe to say that there is one truth out there for the Supreme Court and another for the country at large.

India’s Vaccination Mess and How to Sort It

Chintan Patel and Vivek Kaul

The second wave of coronavirus continues to unleash its horror in India. This crisis has brought in focus the significance of mass vaccinations being carried out at a very quick pace. Without vaccinating a vast majority of our population against Covid-19, there is no pathway to normalcy and achieving herd immunity.

Policy-makers in India have finally awakened to this reality or at least that is what we hope. That they have been found so lacking – in planning, preparation, and priorities – speaks volumes of the caliber of our political and bureaucratic class.

As a piece in The Times of India, dated May 10, points out, at the current rate of vaccination, it will take around 1,000 days to vaccinate the adult population of 94 crore (around 94.3 crore to be precise). But assigning blame will not solve this crisis. Timely, considered action and policies might.

In this article, we try to assess the logistical readiness of a mass vaccination plan by looking at the capabilities and capacities at each step of the vaccination process. Specifically, we look at current and future vaccine supplies and discuss key issues related to vaccine administration.

Vaccine Supply

There are two vaccines available in India currently – Covishield manufactured by the Serum Institute of India (SII) and Covaxin manufactured by Bharat Biotech. In addition, we will be importing Sputnik V from Russia starting this month, with a small amount already having come in, and are likely to receive shipments of Astra-Zeneca vaccines from the United States. Also, Zydus Cadilla has announced that it expects to get emergency authorisation for its 3-dose vaccine shortly.

The table below lists the different vaccine sources and their estimated/committed doses for the next six months. Projections beyond October are subject to too many assumptions which can lead to wide variations in estimates. For now, a six-month planning and estimate window seems appropriate. Even then, these are estimates that may prove to be incorrect.

Expected vaccine Supply (in crore)

Source:

  1. Covishield : SII CEO statement reported by Reuters on April 21. India’s Serum Institute to raise output to 100 mln AstraZeneca doses by July, not end-May | Reuters
  2. Covaxin: Bharat Biotech statement reported by NDTV on April 21. Bharat Biotech Scales Up Covaxin Production To 700 Million Doses Annually (ndtv.com)
  3. Sputnik: India Today report on May 1. First batch of Russia’s Sputnik V Covid vaccine arrives in Hyderabad, to be sent for regulatory approval – Coronavirus Outbreak News (indiatoday.in) and Sputnik V, Covishield, Covaxin: What we know about India’s Covid-19 (BBC). 
  4. Astra Zeneca: Press statement by White House, reported by CBS News on April 26. COVID vaccine: U.S. aims to share up to 60 million AstraZeneca doses with other countries after FDA review – CBS News
  5. Zydus Cadilla: Press report. Zydus Cadila Likely To Seek Approval For Its COVID-19 Vaccine This Month (moneycontrol.com)

Let’s discus the above table in a little more detail. 

These are broad estimates derived from publicly available information as on May 7, 2021. The intent behind this exercise is to consolidate information emerging from various sources to provide a coherent and a reasonable picture of the vaccine supply scenario.

There might be major changes in either direction, that is, actual supply might increase due to new production or distribution agreements or actual supply might decrease if manufacturers are not able to deliver to their committed/planned volume. As we said earlier, this is a broad estimate.

1) The estimates for Covishield are based on their total production capacity projections given by Adar Poonawalla, the CEO of Serum Institute of India (SII). SII’s current production capacity is between 6 to 7 crore per month. We have assumed it to be at 6.5 crore per month. By July, SII expects to raise its production to 10 crore, as reflected in our estimates starting August. We assume that an increase in production will start hitting the market in the next month. 

On April 28, 2021, the government of India placed an order with SII for 11 crore doses for May, June and July. Over and above this, SII has announced that it has a separate order of 11 crore doses from state governments and private hospitals. But the delivery schedule for those orders is not publicly known.  

To add another layer of ambiguity on the demand side, SII is also obliged to export 20 crore vaccine doses in 2021 as part of its agreement with Astra-Zeneca and World Health Organization. Currently, vaccine exports have been halted due to the domestic crisis in India. It is possible that export of Covishield doses will resume once the crisis abates. In fact, 5 million doses of the Covishield vaccine which were to be exported to the United Kingdom have now been made available for inoculating those in the 18-44 age group.

Thus, our estimates allocate the entire production of Covishield for domestic use. Please note that if export of Covishield vaccines resumes, the actual supply numbers for India will be lower than estimated numbers.

Currently India faces a supply problem. In May, the supply of vaccine doses is expected to be around 8-9 crore. As one of us had earlier estimated, the total number of vaccine doses needed to vaccinate the remaining part of India’s adult population, stands at around 178-190 crore doses. The gap between what is available as of now and what is needed, explains the prevailing chaos when it comes to vaccines.

2) For Covaxin, once again, our estimates reflect the total monthly capacity. Bharat Biotech, the makers of Covaxin, have announced that they will be able to ramp up their annual production capacity to 70-80 crore vaccine doses by July. In an interview given in late April, Krishan Ella, the CEO of Bharat Biotech had remarked:

“Last month we produced 1.5 crore doses, this month we are reaching 2 crore doses, next month we will be making around 3 crore doses followed by 7 to 7.5 crore doses. We are ramping up the production and by July-August we will be able to reach 70 to 80 crore doses production capacity per annum.”

Using this as a guideline, we have budgeted 2 crore Covaxin doses for May, which ramps up to 3 crore in  June, rising to 6 crore doses per month starting in July (6 crore per month x 12 = 72 crore per year).

3) The first pilot batch of 1,50,000 doses of the Russian Sputnik V vaccine, was shipped to the Hyderabad based Dr Reddy’s Laboratories in early May. We have not counted those since the number is too small for this estimation exercise. As per the agreement between Russian Direct Investment Fund which is marketing the vaccine and Dr Reddy’s, 12.5 crore doses are to be imported to India between April and June 2021 .

We have split that number up from June to September (12.5 crore/4 = 3.13 crore), given that a bulk of these vaccines have not been delivered as yet . For October, we have kept the number at 3.13 crore. It is likely that the Sputnik V dose availability might go up after a few months since six local manufacturers are supposed to manufacture 75 crore doses of the vaccine after the initial batch of imports. The timing of the locally manufactured Sputnik V is difficult to predict. So, as a rough estimate we have retained the 3.13 crore figure for October as well.

4) It is likely that the US might begin to share some of the stockpile it has of the Astra-Zeneca vaccine, with India. We have estimated that to be 1 crore doses a month, starting in June.

5) Zydus Cadilla is expecting to get an approval for its three dose Covid vaccine in May. Their initial production capacity is slated to be 1 crore doses per month, which is expected to rise to two crore doses per month. Given that the vaccine has not yet been approved we stick with the initial capacity of one crore doses.

This vaccine is a three dose vaccine, hence, the “value” of a single dose is two-thirds of the other vaccines – all of which are two dose vaccines. Thus, the equivalent monthly supply estimate for Zydus Cadilla is 0.67 crore (two-thirds of one crore).

6) Another indigenous vaccine made by Biological E based in Hyderabad may become available in August. Since the vaccine hasn’t been approved yet, we have not included it in our supply estimates.

7) During any vaccination drive, some amount of vaccines get wasted due to improper handling, theft and human errors. The following chart shows the rate of vaccine wastage in a few states as of May 10.

Source: Ministry of Health and Family Welfare.

We have not included wastage in our analysis to keep things slightly simple. Having said that, doses lost due to wastage will decrease the available supply for inoculation. 

Finally, with these caveats, we can say that there will be a supply around 102 crore additional vaccine doses between May and October 2021. What this means is that vaccines will continue to be in short supply in the short-term.

The efforts highlighted above to get the various vaccines available in India are all positive steps. But as the numbers indicate, the supply pipeline is not adequate to meet our vaccination needs of close to 180 crore vaccine doses.

The primary reason for this shortage is that the government of India waited too long to place vaccine orders and when it did, it didn’t order enough doses.  This can be seen in the chart below that compares the vaccination order timelines for different countries.

Source: https://epaper.telegraphindia.com/imageview_359302_24528134_4_undefined_19-04-2021_1_i_1_sf.html.

In fact, as Satyajit Rath, a veteran biologist formerly associated with the National Institute of Immunology, Delhi, told the Deccan Herald, regarding the government barely stocking up on vaccines: “This was part of a pattern of treating the epidemic as a short-term crisis, somewhat like natural disasters such as an earthquake.”

Now let’s take a look at the possible steps that can be taken to augment the vaccine supply.

A supply of more than 100 crore doses of different vaccines by October, if achieved, will be no mean feat. But even that is not fast enough given our vast population. The following steps can be taken to increase the supply of vaccines. These are medium term solutions and will likely yield results over the 6-12 month horizon. This means that the supply of vaccines will continue to be an issue over the next few months. 

1) The central government should work closely with both SII and Bharat Biotech to enable them to hit maximum production capacity. Additionally, both manufacturers should be asked to furnish a weekly supply schedule for better planning and coordination, if that is not already happening. With multiple buyers in the mix now (with state governments and private hospitals) such a supply schedule assumes even greater significance.

2) India is the vaccine manufacturing headquarters of the world. According to Central Drugs Standard Control Organisation, there are 18 private and three public sector vaccine manufacturers in the country. One potential route to increase vaccine supplies is to leverage spare local vaccination manufacturing capacity to increase supply of Covaxin using licensing and/or royalty agreements with Bharat Biotech.

The intellectual property for Covaxin is jointly owned by Bharat Biotech and the Indian Council of Medical Research (ICMR), a government body. In fact, an arrangement along this line is already in motion where the Mumbai based Haffkine Institute, one of the oldest biomedical research institutes in the country, has been granted permission by the central government and funding by the Maharashtra government to start production of Covaxin.

Vaccines production from this plant is expected to take atleast one year. Other efforts, similar to this could be spawned with other vaccine makers after an assessment of technological and supply chain feasibility. However, based on the Haffkine timeline, it is clear that such efforts will not help in the short term. Having said that, we don’t know if the current wave is the last wave of Covid. 

3) India can import additional vaccines from the United States. The United States has a contract with Astra Zeneca for 30 crore doses of which six crore doses are either in stockpile or will be shortly available. Since the Astra Zeneca vaccine has not been approved in the US, India can apply a concerted effort – both diplomatically and/or financially- to receive a substantive portion of the stockpile.

India should also look at importing additional vaccines directly from vaccine makers. The Municipal Corporation of Greater Mumbai has such plans.

Among the major vaccines approved and in use elsewhere, the Johnson and Johnson (J&J) vaccine is the most attractive given that it is a single-shot vaccine and it does not need extreme cold storage. The J&J vaccine may not be the best use of taxpayer money, but one that private companies could pursue and make available to the general public at a higher cost. 

Vaccine Administration

Vaccine supplies are no good if they don’t translate into inoculation. En-masse administration of vaccines depends on several factors including number of vaccination sites, available personnel, location of sites, and public willingness to get vaccinated. Let’s look at this in some detail. 

The following chart shows weekly vaccination rates in India.

Source: dashboard.cowin.gov.in.

Here are some observations from the above graph.

1) The vaccination rate was quite low till early March. The spread of the second wave of covid clearly catalysed the public into action and the vaccination numbers rose steadily till the first week of April, barring a small dip towards the end of March.

From just over 4 lakh vaccinations in the week of February 27 to March 5, numbers jumped to almost 2.5 crore in the week of April 3 to April 9. After hitting that peak, numbers have dropped down to around 1.15 crore vaccines for first week of May. This is a drop of around 54% over just one month. As covid has spread, our vaccination rates have been dropping.   Vaccine supply shortages are mainly responsible for this drop in inoculation in recent weeks, and the lockdown imposed across large parts of the country may also have contributed to this.

2) The peak rate of around 2.5 crore weekly vaccines is an important statistic. It translates to a monthly rate of 10 crore vaccines – more than the projected supplies for May but about 30% short of the projections for June. What this tells us is that the distribution capacity can handle the imminent vaccination volume, but will need to start ramping up soon to keep up with the projected supply.

3) According to the Cowin dashbord, as of May 7, there were 58,214 vaccination sites (55,822 government sites and 2,292 private sites). Along with using government hospitals in the urban centres, the government has wisely activated the rural healthcare system for vaccine delivery as well. 

The rural healthcare delivery system in India is a three-tier system. The smallest unit, called sub-centres, are health outposts which are meant to be the first contact point between the community and the healthcare system. A group of sub-centres are served by a single primary health centre which has a doctor (medical officer) and nurses on staff. A group of primary health centres feed into a community health centre– which is akin to small hospital with specialist doctors and diagnostic equipment.

A study of the vaccination sites in different states on the Cowin dashboard reveals that many states are using sub-centres, primary health centres and community health centres, as vaccination sites. The rural population is being targeted here.

However, as is often the case, enterprising citizens often outthink policy makers, resulting in unanticipated policy outcomes. In this case, there are reports that urban Mumbaikars, who are digitally more savvy than the rural folks, are showing up in rural areas to get vaccinated. This phenomenon highlights the need to make the registration process more accessible to all.

Now let’s look at state wise vaccination data.  As of May 7, 2021, around 16.75 crore vaccine doses had been given. How do different states compare in this vaccine drive?  The table below provides some insights.

Vaccination Rates (in %)

Source: Author calculations based on data from Cowin dashboard and Unique Identification Authority of India. 

In the above table, we show the five states that are performing the best and five that are performing the worst when it comes to vaccination rates, among states which have a population of over 1 crore. 

Uttar Pradesh has the worst vaccination rate, where only 4.6 % of the population has gotten at least one dose of the Covid vaccine, and just above 1% has been fully vaccinated. It appears that the energy spent by state leadership in image management, has come at the expense of an effective vaccine roll-out strategy.

Bihar, Assam, Tamil Nadu and Jharkand, are the other laggards with no state having fully vaccinated over 2% of their population (except Tamil Nadu which is marginally over 2%). In case of Assam and Tamil Nadu, among other things, the recent state assembly elections may have been responsible for low vaccination rates.

Among states that are doing well, Kerala and Gujarat – with their oft-cited competing models of development – are doing remarkably similar when it comes to vaccinating their people.  Uttarakhand, Jammu and Kashmir, and Rajasthan, are the other vaccination leaders.

The ratio of folks fully vaccinated is not starkly different between the leaders and the laggards – 4.83% for Gujarat vs 1.17% for UP – but the figures for people with one shot taken does show a significant difference (17.28% for Kerala vs 4.59% for UP).

Till the end of April, states were dependent on the centre for getting vaccines. So, the discrepancy in vaccination rates is likely to have been a function of the centre’s distribution decisions, as well. The central government has not released the criteria used for vaccine distribution to the states, something that they should be doing for transparency and efficacy auditing.

Having said that, Gujarat has clearly been a beneficiary of the allotment mechanism, receiving the highest quota of vaccines from the centre after taking its population into account. As an April 19 newsreport on moneycontrol.com points out:

“As on April 8, the supplies to Maharashtra covered just about 8.5 percent of the population. For Delhi, it was 10.4 percent. On the other hand, Gujarat, which can’t be regarded as the most impacted state if one goes by official numbers, had got enough vaccines for 16.4 percent of its population – the highest.”

It appears that when it comes to competition between states, Prime Minister Narendra Modi continues to root for his home state.

Starting  May 1, the state governments can procure vaccines directly from the manufacturers. Having states compete for what is essentially a fixed supply isn’t a great idea since it will not increase the total vaccines available nationwide. Instead, the states and private corporations will fight over the 50% pool that has been de-regulated.

So states that have more leverage with vaccine makers or more financial clout/headroom stand a better chance of pulling ahead in the vaccination race. It will be interesting to see the trajectory of vaccination rates of different states as they begin to place their vaccine orders in the coming weeks and months. Also, this is clearly creating an access problem for the poor.

Vaccine Logistics 

As the supply of vaccines increases in the coming months, the question is do we have enough health care workers and vaccination sites to keep up with supply. 

First, let’s look at the manpower question. As per the Fifteenth Finance Commission Report tabled in February 2021, there were a total of around 27 lakh healthcare workers in India in December 2017. These include registered nurses (RN), registered midwives(RM), lady health visitors (LHV) and auxiliary nurse midwives (ANM). Specifically, there were 20,48,979 RNs and RMs, 56,469 LHVs and 8,60,927 ANMs, serving in the country. All these healthcare workers are capable of administering a vaccine.

Now, consider a full-throttle vaccination campaign with 1 crore doses/day. Assuming that a healthcare worker administers 50 doses a day, we would need 2 lakh healthcare workers which is less than 8% of the total available personnel. Thus, it is evident that labour won’t be a bottle-neck to ramp up the vaccine drive. 

Next, let us look at how many potential vaccination sites are available. Recall that currently, around 61,000 sites are being used. As per the Rural Health Survey of 2019, there are 1,57,411 sub-centres, 24,855  primary healthcare centres and 5,335 community health centres, across the country.

Thus, even without counting government hospitals and private clinics, there are over 1,87,000 potential vaccination sites, almost three times than are being currently used. Thus, vaccination sites also are not limiting factors in scaling up vaccine delivery.

One potential hindrance in getting maximum number of people to sign up for the vaccines is the current vaccination registration process. A huge rush for vaccines has made the signing up process a bit of a lottery. In fact, techies have resorted to writing scripts to alert them when an elusive spot opens up. For everyone else, the process consists of repeated tries on loop.

One major problem experienced by folks trying to sign-up for a vaccine is the non-receipt of a one-time password (OTP). The OTP is a pre-requisite to move ahead in the registration process, and many folks have been unable get past the OTP step. Technical glitches in the early stages of an app/website roll-out are not unheard of, but given the importance of this issue, one would have expected the “routine” bugs to have been ironed out before mass adoption.

That such glitches are so widespread indicates that the en-masse registration was not planned with adequate lead time. Here too, like most aspects of the Covid response, the government’s lack of readiness is being exposed.

The online registration will likely smoothen out over time, but currently it only caters to the internet-savvy comfortable in English. Online sign-ups may not totally work for all folks, both rural and urban. Systems that allow a registration method that is appropriate and accessible for those not comfortable with the current digital setup, need to be created. .As a start, the Cowin registration website needs to become multi-lingual.

The language barrier automatically excludes the majority of the country. As per the 2011 Census, only around 13 crore people identified English as first, second, or a third language. It is mind-boggling that the government decided to offer the registration process only in a language that the vast majority does not understand. That the registration process cannot support the major Indian languages, is again a sign of a system put together in haste.

Vaccine Hesitancy 

Vaccine hesitancy can also potentially derail the entire vaccination drive. If too many adults choose not to sign up for the vaccine, it won’t be possible to reach herd immunity quickly. In some ways, the severity of the second wave makes the most compelling argument for the need to vaccinate. Yet, for a variety of reasons, people tend to be hesitant.

Safety concerns, efficacy concerns, and ignorance (wilful or genuine) about the seriousness of Covid-19, are prime reasons that drive this hesitancy. WhatsApp messages and fake news exacerbate the psyche of suspicion and distrust. The best anti-dote to that is positive messaging and increased awareness about the benefits of vaccination. Given this administration’s core competence of narrative management, mass communication to encourage vaccine enlistment should not be a big hurdle.

As a more directed policy step to incentivise vaccinations, especially in rural areas, the central government could consider linking a Public Distribution Service (PDS)-based benefit with a vaccination dose. For example, for each vaccine dose a voucher for a few kgs of rice/wheat, which can be redeemed at the local ration shop, can be given.

This should not cost the central government much (other than perhaps transport and administration) since the Food Corporation of India storehouses are overflowing with way more grain than the strategic and operational buffer that needs to be maintained.

The pathway to a fully vaccinated Covid free India is not easy and won’t happen overnight. But, with proper planning and execution, we can make significant progress over the next several months. We all need to do our bit to succeed in this effort.

All, including Nero.

Only 3.78% of Adults Have Got Both Doses of the Vaccine

Honestly, I didn’t want to write this piece. But when a cabinet minister of the government of India uses basic maths to mislead, it didn’t leave me with much of an option.

Here’s what Dr Harsh Vardhan, who is the minister of health and family welfare and science and technology, tweeted earlier in the day today.

Regular readers would know how much I hate when people don’t know when to use percentages and when to use absolutes. Or the fact that they know and still do it, to mislead.

Harsh Vardhan’s tweet has multiple problems. Let’s look at it pointwise.

1)  The minister points out that the government of India has provided more than 18 crore vaccines free to states for vaccination. This is for vaccinating people who are 45 or more. So far so good. The thing is that India has the second largest population in the world. As per the World Bank it was at 136.64 crore in 2019, with China’s population being at 139.77 crore. With China’s population barely growing and ours continuing to grow, by now, we might be within the touching distance of China to become the country with the largest population in the world.

So, when it comes to things that need to be provided to all the population or a significant chunk of it, India is bound to be at the top. Also, vaccinating the population is not a race. It is the right thing to do.

2) Given this, it makes sense to look at what proportion of the population over the age of 18 has been fully vaccinated, meaning it has gotten both the doses of the vaccine. That’s a useful metric.

As I write this, the dashboard on the Co-Win website tells me that 3.56 crore individuals have taken both the doses. There are around 94.3 crore Indians who are aged 18 and above. This means that around 3.78% of the population (3.56 crore expressed as a percentage of 94.3 crore), for whom vaccines are available, has been vaccinated.

Yes, you read that right. Less than 4% of those age 18 or above, have got both the doses of the vaccine. Of course, this explains why Dr Harsh Vardhan’s tweet is an absolute number and not in percentage terms. This situation prevails nearly four months after the vaccination programme started.

That’s the real figure to look at simply because the aim of vaccination is to achieve herd immunity. As Ryan A Bourne defines herd immunity in Economics in One Virus as “a situation where enough people have immunity that any further outbreak of the virus fails to accelerate because there are too few individuals susceptible to infection.” Vaccinating a significant chunk of the population moves us towards the situation. And we are nowhere near that, the world’s largest vaccine drive notwithstanding. 

Data from the Financial Times, tells us that there are many nations in the world who have vaccinated a significant chunk of their population. This includes smaller nations like Israel and larger ones like United States. Very few countries where covid has spread as much as it has in India, have got a rate of vaccination as low as it is in the Indian case.

3) Also, what Dr Harsh Vardhan’s tweet does not tell us is that the rate of vaccination has been slowing down majorly over the last one month. During the week April 3 to April 9, the total number of vaccinations carried out stood at around 2.48 crore doses (includes both the doses). This has fallen every week since then and stood at around 1.16 crore doses, during the week May 1 to May 7. This fall of over 53% has happened primarily because the government was busy with elections and didn’t order enough vaccines until April 28, 2021.

4) When it comes to receiving the first dose, 13.49 crore Indians or 14.3% of the population that is being vaccinated has got the vaccine. On this parameter things look a little better for India.

To conclude, vaccinating a significant chunk of India’s population to achieve herd immunity, remains a real challenge. Further, while everyone cannot be vaccinated within a short-period, but misleading the country on it by misrepresenting data is not going to help anyone in anyway. 

Less Testing is Not Good for Covid Control

Several news reports and long threads on Twitter have pointed out that the number of covid tests across the country have fallen over the last few days. The total number of tests peaked at 19.45 lakh on May 1. They have since fallen to 16.64 lakh as on May 4. Other than not identifying people who have covid and don’t know about it, this is also not good for Covid control 

The following chart plots the total number of tests conducted every day, since May 20, 2020.

Source: https://www.covid19india.org/

Not surprisingly, as the number of covid tests have come down, so have the number of new covid cases. As of April 30, the total number of new covid cases was at 4.02 lakh, with the tests being at 19.2 lakh. They fell to 3.56 lakh as of May 3, when the number of tests fell to 15.05 lakh. As of May 4, the number of new tests stood at 16.64 lakhs, with fresh covid cases being at 3.83 lakh.

The following chart plots the fresh covid cases every day since January 30, 2020.

Source: https://www.covid19india.org/   

The fact that India hasn’t been testing enough has been true for a while now. As Bhramar Mukherjee, Soumik Purkayastha, Maxwell Salvatore and Swapnil Mishra write in The Hindu: “While testing and cases have grown at a comparable rate in the US, in India the growth in reported cases on an average has been nearly five times higher than the growth in testing. India is not testing enough.”

For the Indian case, the data for the period March 28-April 27 has been used, during which much of the recent surge in the number of covid cases has happened.

If we were to follow this method for the period between March 28 and May 4 (the latest data available), we get a similar kind of result. The number of fresh cases has risen at an average weekly rate of 45.98%, whereas testing has grown at 10.67%. This is in line with the point Mukherjee and her co-writers made in their piece in The Hindu. (Of course, it is also obvious looking at the slopes of the curves in the two charts).

If we look at a slightly longer time frame starting from March 1 and up to May 4, the average weekly growth in fresh cases stands at 43.58%, whereas the average weekly growth in number of tests is at 10.31%.

So, what does all this really mean? Let’s look at it pointwise.

1) Low testing leads to a lower number of fresh covid cases. This shows the central government and state governments where this is playing out in good light. With a lower number of fresh cases, they can claim that they are getting the pandemic under control.

2) With the number of cases falling, it also leads to a fall in what is referred to as the reproduction number. As Adam Kucharski writes in The Rules of Contagion, the reproduction number is “the number of new infections we’d expect a typical infectious person to generate on average”.

An estimate made by Sitabhra Sinha from the Institute of Mathematical Sciences in Chennai suggests that the reproduction number for India dropped to 1.16 for the week ending May 3. This is the lowest since March 19, when it was 1.19. Hence, data suggests that the spread of the infection is slowing down, with an average covid patient infecting a lesser number of individuals around him.

Of course, the question is whether this is a genuine drop or simply another manifestation of not enough tests being carried out.

3) The advantage of testing more is that more people who have covid can be identified quickly. This improves the chances of people surviving the disease. But then this is not the only issue at hand, for the government.

As Ryan A Bourne writes in Economics in One Virus: “As economist Alex Tabarrok has explained, there’s good reason to think that there is an inverted-U shape of Covid-19 cases as testing numbers increase. At first, conducting more tests leads to finding additional cases.” Of course, this makes governments look bad in the short run. And governments obsessed with narrative want to control the growing number of fresh covid cases, this way or that way.  

4) Other than increasing the chances of survival, testing also slows down the spread of the epidemic. As Bourne writes: “When testing is widespread and regular enough, conducting more tests actually reduces Covid-19 cases…[as]… potentially infectious people can isolate themselves immediately and notify those they have been in contact with sooner.”

What this does is it minimizes “the window of transmission between people becoming infectious and ultimately isolating—the time the person would likely be out spreading the disease.”

It leads to a genuine slowdown in the transmission of the disease and not just a slowdown at the data level. Hence, it is important that the governments keep encouraging testing.