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Resolving Vaccine Inequity in India: A Policy Review



Introduction


India is faced with a vaccine crisis amidst the pandemic as another wave of infections beckons. At the outset of vaccine production, the production capacity was underutilized due to approval issues & procurement barriers in January 2021. The Indian government procured only 42% of the 50 million vaccines for domestic use (Covishield) manufactured by Serum Institute of India in its first order[1]. In addition to production & procurement of vaccines, there has been the issue of inconclusive negotiations with global vaccine suppliers. At present, only 25% of the 16 candidates have received approval and 18% have been deployed for use while the rest are active in the process of trials and negotiations. In the realm of international trade, about 80% of the 183 countries apply zero-duty on vaccine imports. However further examination shows that the duties on vaccine-related inputs like syringe, needles, adjuvants etc. ranges from 2.6% to 12.7%. which raises cost and impacts supply of vaccines. India imposes a 10% custom duty along with a 16.5% I-GST. However, the same has been waived off amidst the second wave.


Overall, only 6.1% of people in India are fully vaccinated & around 20% administered with one dose as of July 2021. In addition, only 856 doses are given to women for every 1000 doses for men in India as of June 2021. In this context, it is important to examine the demand side factors that influence the equitable distribution of vaccines in India.


Fig 1.


There has been a notable supply demand mismatch in India. In the month of January, there was a supply glut of over 75% as compared to the demand. This began to come down gradually as March witnessed a gap of 55% followed by April with 17% of excess supply. As the government brought the age group of 18-44 under the ambit, the country witnessed a turnaround, with a gap of 34% excess demand for vaccines.


The impact of supply-demand mismatch has trickled down across India, where there is high inequitable distribution among the rural and urban areas. The tables below depict the state wise rural vs urban data on vaccination so far and also the best & worst performing rural states in India based on the number of doses administered as of July 2021.


Fig 2. Source: The Hindu


Fig 3.




1. Inequity due to vaccine supply constraints


1.1. Value Chain – Universal Immunisation Program


As per the vaccination targets laid out by the government, the first phase of the Covid-19 vaccination drive was to run from January 2021 to August 2021. The existing Universal Immunisation Program value chain had a key role to play in the attainment of the targets besides the involvement of key private actors, government stakeholders and an existing electronic supply chain management system.




Assuming at least 40% of the existing Universal Immunisation Program infrastructure was dedicated to the Covid-19 vaccination program, whilst the regular immunisation program of the country continues, a gap was observed in the anticipated government targets and what was achieved as of June 2021.




Government target was to administer 600 million doses by August 2021. However, as of June 2021 India had administered 260 million doses. Administering 550-600 million doses, with the present infrastructure could hardly be achieved by the end of December 2021.

As per the November 2020 Credit Suisse report, to vaccinate most of the adult population India needed 1.7 billion doses and has the capacity to produce 2.4 billion. As per the report, the bottleneck lies in the distribution and cold storage capacity (particularly refrigerated vans) rather than the availability of the vaccines. Data has shown major gaps in distribution capacity required to not just achieve the government targets, but also to optimally utilise the capacity that public infrastructure has. Given the temperature sensitive nature of the Covid-19 vaccines, the cold chain system – both in terms of equipment and cold chain handlers have a key role to play in this.


1.1.1. Gaps in the cold chain equipment

  1. Data shows that cold chain points in India are inequitably distributed. 52% of the 29k cold chain points are located across just 6 states in India. (Look up what states these are and if there is an urban rural cut)

  2. Analysts have suggested that transportation has posed to be a key issue, in particular the number of refrigerated vans available. This is also a major problem given the first 5 stages of the value chain are dependent on the availability of refrigerated vans for being transported from one location to the other.



1.1.2. Gaps in cold chain handling


India has an existing real-time supply chain management system known as Electronic Vaccine Intelligence Network (eVIN). eVIN had been implemented in 32 states and Union Territories as of August 2020. A survey of 230 eVIN cold chain points across 12 states in 2018 projected the following gaps.

  1. 30% reported a lack of backup cold chain handlers in the absence of a primary cold chain handler

  2. 23% reported vaccine wastage – a key reason for which is inefficient handling of temperature sensitive vaccines or inability to handle the existing cold chain equipment.


1.1.3. Implications of these gaps

Cold chain infrastructure holds a 30% weightage in the state preparedness assessment, i.e. states with poor quality of cold chain infrastructure tend to rank lower in the state preparedness rankings, i.e. tend to be less prepared for the covid-19 vaccination.

For instance, in Bihar when cold storage capacity is weighted against their population, the cold storage capacity index stands at a 13.93 on 100 and Bihar is one of the worst performing states in the state preparedness assessment.




1.1.4. Implications of these gaps for the rural segment


These gaps in the cold chain infrastructure have larger implications for covid-19 vaccine distribution across the country but the impact tends to get exacerbated in the rural segments of the country:

1. Transportation - In the value chain of vaccine delivery, transportation occurs majorly through refrigerated vans. Not only is the shortage in the number of refrigerated vans a pressing concern, the problem intensifies for areas that do not have access to motorable roads, which is the case for many remote rural areas in India. Innovative solutions such as light weight vehicles that can run on these roads, or even supply through drones are being explored.

2. Storage – Vaccines need to be stored in very low temperatures as we know and for lower temperature storage, there is need for electricity. For rural hospitals with erratic power supply, this could pose a major challenge. Both solar units and non-electrical cold chain equipment play a critical role in this.

3. Last mile delivery – Even if the vaccines arrive at the primary health centers, the last mile delivery from PHCs to outreach centers is the trickiest part and can contribute to vaccine wastage.

1.2. Recommendations

  1. Gaps in non-electrical cold chain equipment which do not rely on electricity needs to be ramped up to avoid problems of vaccine wastage.

  2. Cold chain handlers must be provided rigorous training to handle temperature sensitive vaccines. eVin itself has had a major contribution in accurate reporting of stockouts and facilitating smooth training of over 41k cold chain handlers but this needs to be further optimized to its best potential.


To successfully overcome any gaps in availability of equipment or any inefficiency in handling, we may learn from Madhya Pradesh’s RISS (Routine Immunisation Supportive Supervision initiative. – 14 medical colleges came forward to nominate senior professors who would then be trained in routine immunization & cold chain. They would then act as supervisors for the routine immunization program in the state. A similar multi stakeholder initiative to provide clear instructions on cold chain handling on ground, with defined tasks for each stakeholder could potentially work well on a rural district level in India and help overcome the gaps highlighted.




2. Inequity due to vaccine hesitancy


Even before the COVID-19 pandemic, the WHO had declared vaccine hesitancy as a major threat to global health. In India, there are many reasons for vaccine hesitancy amongst people. The hesitancy ranges across socio-cultural perspectives.


2.1. Vaccine Hesitancy Amongst States


The spatial variation in vaccine hesitancy seen across different states in India can also be attributed to socio-cultural factors in these regions.


Fig 8. Source: Ideas for India


For example, as shown above, Tamil Nadu is on the higher end of vaccine hesitancy while Kerala fares much better. One reason for this disparity is because of the reluctance shown by Tamil Nadu healthcare workers to take the vaccine during its initial roll-out.


But as can be seen below, the rate of vaccine hesitancy is lowering amongst states like Uttar Pradesh, Maharashtra and Gujarat. But it is increasing with time in Tamil Nadu, Andhra Pradesh and the like.


Fig 9. Source: Ideas for India


2.2. Education and Social Class


India’s educated and privileged section of society is hesitant to take the vaccine because of the rushed nature of the vaccine’s launch and the lack of ready data available on its side effects.


On the other hand, the marginalised section of society are hesitant to take the vaccine because of many reasons. Firstly, they fear the vaccine is a death sentence - that it slowly weakens and kills. Secondly, they fear it causes sickness thereby depriving daily wage workers of their day’s earnings. They also fear they would not be able to afford healthcare if they got sick from the vaccine.



2.3. Urban and Rural Hesitancy


The urban society believes the vaccine is unsafe because it causes sickness and side-effects. The rural section of society does not trust the vaccine and believes the vaccine causes impotence and infertility in people. Certain sections of the population also believe that the vaccine contains cow’s blood and pig’s meat, both objectionable due to religious beliefs.




2.4. Hesitancy in Men and Women


There is a disparity in the uptake of the vaccine between men and women. It is largely due to misbeliefs that the vaccine is unsafe for menstruating women and that it causes infertility. It is believed that the vaccine cannot be taken by women when they are menstruating, hence women are less likely to get vaccinated. The data below shows the gender disparity of vaccine uptake amongst states.





2.5. History of Vaccine Hesitancy in India


There have been cases of high vaccine hesitancy in India in the past due to religious, cultural and other superstitious factors. For example, the small-pox vaccines were considered impure by the high caste Hindus, as they were made from cows and the fear of angering both the cow and the goddess of smallpox were rampant. Even the enlightened ones of the day, such as Gandhi had an abhorrent attitude towards vaccines, considered the administration of the vaccines in human bodies as some kind of sacrilege. Because of this hesitancy against the smallpox vaccine, the government of the day had to strongly arm the population to take the vaccines against their will, which they accomplished with the help of the military and the police.



2.6. Vaccine Hesitancy can be addressed primarily by Building Trust


From the data that is available, we can infer that the main hesitation to get a Covid-19 vaccine stems from a fundamental lack of trust in the health care systems, the private entities that created the vaccines in a record time and in the government that is regulating and promoting its use. These fears are further fueled by rumours and conspiracy theories that vary from infertility to impending death, to those who are administered the vaccines. We need a multilateral approach aimed at a community level, to avail these fears and build trust in a diversity rich country such as India. Through our study, we have identified three approaches that will reduce the hesitancy in undertaking the vaccines, based on case studies of successful vaccinations in India and the rest of the world. Each of the recommendations focus on a particular facet of region, gender & marginalized community rather than a top-to-bottom hierarchy.


2.6.1. Overcoming Hesitancy in an urban/semi-urban middle class population


The COVID-19 Symptom Survey (CSS) conducted in partnership with Facebook, provides insightful data that lists the top reasons for vaccine hesitancy, typically among the middle class population. This section of the society has access to both regulated and unregulated information, attainable through their social media.



As illustrated in the chart above, the majority of this section citing any of the top 4 reasons can be nudged to undertake the vaccine, by ensuring that they are directed to factual data and information. For example, in the US the CDC’s V-safe portal hosts vaccine information in a simple manner that alleviates the common misconceptions around vaccination to a common man. By addressing the after-effects, experience and transparent reporting on the minimal adverse cases, can help in building trust. In addition, having the information in vernacular languages, at least the mainstream classical languages in India can further improve in increasing awareness and reducing hesitancy. Another prime example is the usage of WhatsApp by the Singapore government to provide updates or inform the citizens; being one of the most common apps in India, WhatsApp can be effectively used to direct and correct information and updates by the Government.



2.6.2. Localized strategy to overcome linguistic barriers and gender divide


A localized strategy based on the linguistic and gender divide, can further steer certain sections of people to get vaccinated, particularly among women. The WeMUNIZE program implemented in Nigeria, uses a combination of digital record keeping and community engagement to increase early childhood immunizations[2]is an example for this strategy. The project recruits primarily women for their team of trained volunteers and supports them with free mobile phones, empowering women to help their communities and overcome social barriers. A similar approach in women promoting the vaccines would aid in dispelling the fears of vaccines with regards to menstruation within their local communities. In addition, it is also easier to believe a person who is promoting the vaccine in the same language as that of the local community.



2.6.3. Examples of how vaccines hesitancy was overcome in specific (marginalized or tribal) communities


The tribal belt in Tamil Nadu’s Nilgiris district that has 98% vaccinated, is an example of reaching out to tribal or marginalized communities. The vaccine hesitancy was prevalent with rumours of death in a few months & impotency in men. The tribal leaders were convinced to get vaccinated first by the NGOs and doctors who have been working in their midst for long, so that the rest could follow. The NGOs drafted locals from the community to create songs in their native tribal languages that extolled the benefits of the vaccines.




3. Inequity due to technology barriers



3.1. Registration for vaccine through online portal has resulted in adoption challenges


Our findings suggest that the heavy reliance on technology for last mile administration of the vaccine coupled with the technological divide across different sections of society, is one of the prime causes for vaccine inequity in India. Earlier this year, the Supreme Court of India stated that “a vaccination policy exclusively relying on a digital portal for vaccinating a significant population of this country between the ages of 18-44 years would be unable to meet its target of universal immunization owing to such a digital divide”. Statistics show that marginalised sections of the society are bearing the brunt of this digital divide and it will in turn also have serious implications on the fundamental right to equality.



This digital divide for registered users is especially visible amongst the following specific demographics:


Rural v. Urban

Nearly 24% of the Indian households have internet access. However only 15% rural households while 42% urban households have access to the internet. The discrepancy in the vaccination rates in rural and urban India reflect this divide. While ~70% of the Indian population is rural, only 14% of rural population has received at least first dose (June 2021) while 27% of the urban population has received at least one dose. While this disparity cannot directly be linked to digital divide but may be one of the several factors.

Fig. 12



Age Based Divide


Among persons aged 15-29 years, nearly 24% in rural areas and 56% in urban areas were able to operate a computer. Nearly 35% of persons of age 15-29 years reported use of internet during the 30 days prior to the date of survey. The proportions were, nearly 25% in rural areas and 58% in urban areas. Around 54% of the Indian internet user base is between 20 and 39 years old according to a survey conducted in 2019. People over the age of 40 formed the lowest share, while youngsters in the age group of 12 to 15 years made up about 14 percent share of the total internet user base. The disparity amongst the older and younger demographics is evidenced in the vaccine registration rates across age groups that tend to be higher in the 18-44 age group rather than the 45+ age group even though the vaccine has been available for uptake by the latter, for a much longer time. The vaccination rates also reflect this discrepancy. Of the 191.9 million first doses of Covid-19 vaccines across different age groups by June 2021, according to data uploaded on the Co-WIN dashboard, 50.5 million doses went to people in the 18-45 age group, 79.2 million to those in the 45-60 age group, and 62.2 million to those above 60. Even though the availability to get vaccinated has been available to above 60, for much longer, the number of vaccinations are still relatively much higher in the younger population. This is likely a function of the age based internet divide.


Fig. 13


Gender Based Divide


Reports suggest that only about 42.6% of Indian women have ever used the internet as opposed to 62.16% of the men. The divide is further exacerbated in rural India. Further, in urban India, an average 56.81% women ever used the Internet compared to an average 73.76% the men. The internet access amongst rural women is a low 33.9% women in rural India ever used the internet as against 55.6% among men.


As mentioned above, the vaccination rates are also tilted in favour of men as opposed to women with approximately 240 million men and 210 million women having been vaccinated.




4. Solutions Proposed by Government


4.1. Walk-in Registrations


The Central Government in its affidavit to the Supreme Court has stated that it has provided the option for walk-in registrations at vaccination centres. It stated that out of 32.22 crore beneficiaries registered on Co-WIN, 19.13 crore (59 per cent) beneficiaries have been registered in the onsite / walk-in or non-digital-mode.


While this may assist in bridging the digital divide, it comes with issues of human error in entering the data upon walk-in registration and in turn these communities not being provided with vaccination certificates.



4.2. Common Service Centres


Walk-in registration option provided by several State governments at CSCs. There are 2,53,134 Gram Panchayats in India, as on 31 March 2020 only 2,40,792 Gram Panchayats are covered with at least one registered CSC. However, this may involve a large risk of overcrowding and a game of chance.




5. Government interventions to address vaccine inequity


5.1. Government of India is concerned and is aggressively discussing vaccine equity


To overcome varied challenges, the Government of India urges the states to utilize the Common Service Centres and Call Centres to facilitate prior booking by citizens for vaccination. Also encouraging the health workers associations to issue statements in favor of immunization utilizing mass media and contacting influential people to appeal to people to be vaccinated. To combat the disinformation campaign and vaccine hesitancy.


The government has also launched an e-voucher to buy a vaccine slot at a private hospital for another person to boost the vaccination among the economically weaker section. The Ministry of Health and Family Welfare has presented a roadmap to the supreme court to show that 51.6 crore doses will be available by July 31; additional 135 crores will be delivered between August to December. Globally, India is pushing for vaccine equity by rejecting “vaccine passport” in the G7 meet and advocating for a focus on vaccine equity.



5.2. Government has also launched policies to ensure vaccine equity in masses


To boost the vaccination, Sitasharan Sharma, MLA of Madhya Pradesh, offered free mobile recharge to any person in his respective constituency, additionally also offering a reward of 10-lakh for panchayat if 100% inoculation is achieved.


Previously to achieve equity in the Pulse polio immunization campaign, the Government of India addressed social and cultural concerns to remove vaccine hesitancy by doing micro-planning and involving communities, faith leaders, and religious leaders to allay the religious and cultural resistance and rumors that to keep the country free from polio. The government worked with WHO- National Polio Surveillance Project (NPSP) that provided knowledge transfer, operational guidelines, technical know-how, and best practices that were achieved in polio and measles catch-up campaign to overcome vaccine hesitancy and increase the immunization rates for measles-rubella campaign.



There have also been significant attempts by developed countries to reduce vaccine inequity. The US launched a National Month of Action that focuses on providing incentives and a vaccination outreach campaign. The campaign focused on the following:


  • Community canvassing: It includes calls and texts to people who are in the low vaccination rates and canvasses neighborhoods in the close walk0in clinics to get vaccinated on the spot. Partnering with more than 100 organizations to organize events for low vaccination areas

  • Mayor Challenge: Mayors participate in this challenge to take actions to boost the vaccinations by the month through canvassing efforts, partnerships with local businesses, and incentives to the residents.

  • COVID-19 College Challenge: Universities take a pledge to take action to get students vaccinated. During this challenge, the administration will provide the resources like training sessions, toolkits, and educational material to assist the universities.

  • Information Campaign: National Association of Broadcasters (NAB) will air vaccine education segments featuring the trusted voices of the community and medical professionals to share information on the benefits of vaccination, address questions and concerns, and publicize where individuals in the community can get vaccinated.

Internationally IMF is preparing Special Drawing Rights (SDR) allocation to boost the reserves and liquidity of its members. WHO is seeking to identify financing so that urgent needs of Strategic Preparedness and Response Plan and the ACT-Accelerator partnership can be met, with COVID-19 Technology Access Pool (C-TAP) promoting the sharing of know-how and technology. The World Bank will have vaccine projects up and running in at least 50 countries to mobilize the private sector to boost vaccine supply for developing countries.




Conclusion


It is therefore evident that India suffers from an inequity in vaccine accessibility and uptake, attributable to hesitancy, technological barriers and lack of proper distribution channels. As we have noted, the worst affected demographics are rural populations, women and low-income households. While the government has taken significant steps to bridge this gap, we believe that philanthropic intervention is necessary to assist the government in this process.




Meet The Thought Leaders


Shatakshi Sharma is a public policy advisor, has been a management consultant with BCG and is Co- Founder of Global Governance Initiative with national facilitation of award- Economic Times The Most Promising Women Leader Award, 2021 and Linkedin Top Voice, 2021. Prior to graduate school at ISB, she was Strategic Advisor with the Government of India where she drove good governance initiatives. She was also felicitated with a National Young Achiever Award for Nation Building. She is a part time blogger on her famous series-MBA in 2 minutes.


Naman Shrivastava is the Co-Founder of Global Governance Initiative. He has previously worked as a Strategy Consultant in the Government of India and is working at the United Nations - Office of Internal Oversight Services. Naman is also a recipient of the prestigious Harry Ratliffe Memorial Prize - awarded by the Fletcher Alumni of Color Executive Board. He has been part of speaking engagements at International forums such as the World Economic Forum, UN South-South Cooperation etc. His experience has been at the intersection of Management Consulting, Political Consulting, and Social entrepreneurship


Karan Patel is an undergraduate from IIT Madras. He is correctly employed with Dalberg Advisors as an analyst where he worked with multi-laterals and international foundations on gender, education and energy sectors. He has also interned in MIT Sloan, Qualcomm and IIM Ahmedabad giving him a plethora of experience in the corporate and academic world. He also started his own venture in hyperlocal air-quality monitoring. Karan is an avid sport-person and masala chai fanatic when not at work.




Meet The Authors (GGI Fellows)


​​

Udita Shome is a student at the London School of Economics and Political Science pursuing her masters in international Social and Public Policy. Udita is a graduate from the University of Nottingham where she completed her bachelor’s with a joint Hons in Politics and Economics. In the last four years she has worked with several not-for profits and media organizations. She has volunteered with several local charities in India and the UK and was awarded the ‘Highly Commended prize for Community Fundraising’ by Save the Children. Her key interest lies at the intersection of public policy and social inequalities and she is currently looking to start a career in the policy and development space.

Abhishek Sivakumar has been recently associated with political consulting at IPAC. A post-graduate MBA from Shanghai Jiaotong University & a UPSC Civil services aspirant, Abhishek has a keen interest in the Indian political & administrative domain in addition to the development sector & looks forward to a career in the field of policy & management consulting.




Kaustubh Rastogi is a lawyer by training, and has worked as an M&A and private equity lawyer for over 4 years in some of India’s leading firms after graduating from Gujarat National Law University. He is currently interning at Sattva Consulting working with their project management team on a COVID relief project. He is to start at Social Alpha, as an Associate Manager – Portfolio and Investments later this month.


Meghna M. is a student at IIT Madras, pursuing her Integrated Masters in Development Studies from IIT Madras. She's passionate about the development sector, particularly education and gender and hopes to make a career in these fields.








Geo Thomas is an Education and Content Manager at Climber Knowledge and Careers Pvt Ltd. He is a part of the core team at the current organisation, and work towards making quality education both accessible and equitable in India.






Vinay Hooda is a graduate of ESSEC Business School, France. He has worked with United Nations High Commissioner for Refugees and Reckitt. He was also a part of the founding team of an advertising startup. Vinay has volunteered with multiple NGOs for over 12 years for causes such as education, economic inclusion, and woman empowerment. Vinay is an avid reader and has read over 70 books on the history and post-independence politics of India.



If you are interested to apply to GGI Impact Fellowship, you can access our application link here.



References


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  39. https://www.who.int/news-room/commentaries/detail/a-new-commitment-for-vaccine-equity-and-defeating-the-pandemic


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