Since May 2021, the pace of vaccination has steadily gathered steam. In July, India achieved the target set by the Union minister for health and family welfare Mansukh Mandaviya for the month—135 million Covid vaccine doses, with an average of 4.3 million daily doses. June, which saw 119 million doses administered, had also been a milestone for the vaccination programme with a 96 per cent increase in the number of doses administered in May, when an average of 1.9 million doses were given a day.

As of August 3, a total of 474 million doses had been administered in India, with 369 million adults having received at least one dose and 104 million fully vaccinated. There is, however, still a long way to go. India’s adult population is estimated to be around 940 million, as per the 2011 Census, which means 1,880 million doses are needed to fully vaccinate all. To complete the target of 100 per cent adult vaccination by the end of 2021, we now need to hit a rate of 9.3 million doses per day.

“We will not reach any kind of mass immunity without vaccines,” says P. Srinath Reddy, chairman of the Public Health Foundation of India. “People need to be given affordable, accessible channels to vaccines and be assured of their protection and safety.” The Union government has assured an improved supply of vaccines in the months ahead. As important is delivery. The government had set aside 25 per cent of the vaccine manufacturers’ production for private hospitals, but the decision to include the private sector to both pick up speed and increase the spread of vaccination hasn’t yielded the desired results yet.

The underutilisation problem

Government data reveals that private clinics and hospitals accounted for only 7 per cent of all vaccinations over the past two and a half months. The figures speak of the private sector’s shortcomings. From May to June 15, around 830,000 doses were administered by private hospitals, while a total of 12 million doses had been procured directly by the sector in May. According to the ministry of health and family welfare (MoHFW), as of end of July, over 30 million unutilised vaccine doses remained with states and private centres. The figure of underutilisation is also larger in some states as compared to others—as per state governments’ data, although 3.5 million doses have been supplied to private hospitals in Andhra Pradesh since May, only 463,000 doses have been used till date; and in Tamil Nadu, of the roughly 10 million doses administered so far, only 5 per cent were at private centres. These states have already written to Prime Minister Narendra Modi, asking for a re-allocation of unused doses. Other states are asking for a reduction of the reservation quota—like Odisha chief minister Naveen Patnaik has asked Modi and Union home minister Amit Shah to reduce the allocation for private hospitals to 5 per cent from the existing 25 per cent.

The Union minister for commerce and industry Piyush Goyal has castigated the private sector for falling way short of expectations. “You all [in the private sector] demanded and I remember how much you fought with me and sought for the vaccination to be opened up for the private sector. Today, you are not even buying those 25 per cent of vaccines allotted to you,” he said. “I remember one industry group said it will do a crore vaccinations and another said it will go to remote areas and do it. Nobody has gone to Bihar, the Northeast, Jharkhand and Chhattisgarh to run campaigns to remove vaccine hesitancy and use up that 25 per cent quota.”

The key factors

According to the government, there are four key problems of usage with private centres. First, many are not placing orders for the full quantity of doses earmarked for them. Second, even after ordering, the full payments have not been made in some instances. Third, some clinics are not lifting the full quantity of dispatched doses in one go. And, finally, even when the doses are fully acquired, their actual administration is falling short.

“We must use the vaccines available with the private sector optimally,” says Dr V.K. Paul, chairman of the national task force on Covid management. “People should be encouraged to consider that channel of availability as well.” According to the joint health secretary Luv Agarwal, states too need to step up their planning for vaccination drives. “After one knows how many vaccines will come two weeks ahead, they need to engage with the community and vaccination centres and ensure that the doses available reach the people,” he says.

The problem of full utilisation in the private sector is also a problem of policy. “Earlier, the private sector lobbied hard for the right of hospitals to directly procure vaccines from manufacturers and set their own prices for vaccination. The policy shift that came on May 1 was therefore designed to largely benefit prominent hospitals and corporate chains,” says Malini Aisola, public health expert and co-convenor, All India Drug Action Network (AIDAN). It allowed for bulk ordering directly from manufacturers and, as a result, the size of orders from larger corporate chains could not be matched by small-to-medium businesses. “With such a big price difference between public and private clinics, most people, particularly in small towns, wish to opt for the public clinics,” she adds.

Where did we go wrong?

In May, the government allowed Ayushman Bharat-empanelled hospitals to begin conducting vaccinations. This was soon expanded to include private hospitals that met certain basic accreditation requirements, with an aim to increase the number of centres. Indeed, larger chains were able to negotiate bulk orders directly from manufacturers for branches of their group across locations. According to an MoHFW official who wished to not be named, “One hospital group, acting as a single corporate entity, even placed orders for close to 20-25 of its hospitals across multiple states.” Since the profit margin for such bulk orders was higher, manufacturers began to prioritise supply for these. It reached a stage mid-May when small primary health centres (PHCs) and community health centres (CHCs) in Delhi, for example, did not have any vaccines, but the same could be booked at private hospitals.

In addition to this, corporate chains began a new business strategy where a premium in the name of a service fee was charged for drive-throughs, or corporate and RWA doorstep vaccinations. As a result, in May, the prices for a single dose of Covaxin was Rs 250 at a public clinic in Delhi, but went up to Rs 2,500 for a drivethrough at a private hospital. “New models were added by larger private hospitals for which higher prices could be charged. Smaller clinics and nursing homes were starved of doses and stopped vaccinating. The very objective of involving the private sector—expanding vaccination centres and geographical access—was undermined,” says Aisola.

Taking note of this, the Centre revised the vaccination policy on June 21. Now, bulk purchases for multiple locations are no longer an option. Every single hospital has to put in an individual requirement request via Cowin for its doses. The state governments were also given the power to ensure equitable sale of vaccines so that smaller private centres can also have the opportunity to purchase vaccines. While the government will buy 75 per cent of the vaccines, 25 per cent of a manufacturer’s monthly production could be kept for the private sector. There is no price cap on what manufacturer’s decide to sell to private players at, but a price cap introduced on the service fee—Rs 150 per dose. Thus, starting prices are now Rs 780 per dose for Covishield, Rs 1,410 for Covaxin and Rs 1,145 for Sputnik V in private clinics across states; but free of cost at state- or Centre-run centres.

However, the rate of vaccination at private centres remains low. Experts say the glitch lies in the ‘minimum order of 3,000 vials’ requirement. For small to medium chains, such a large procurement is a difficult financial proposition, especially when there is a cap on the profit they can make when they sell the product further on. “There should be a provision for smaller orders…. Either the manufacturer price should be open to negotiation to bring down the difference between a government and private sale or smaller orders should be allowed,” says Girdhar Gyani, president of the Association of Healthcare Providers, which recently carried out a survey of 70 private hospitals across India to understand their vaccination status. As per the survey, 25 hospitals said the government has not appointed any nodal officer to address their concerns, while 39 hospitals said nodal officers have been appointed, but states are not making any efforts.

How do we fix the problem?

Experts have suggested lowering the cost of vaccines sold at private hospitals. “The price at private hospitals is Rs 1,000-1,200 on an average for one dose. Two shots mean Rs 3,000. For a couple, getting fully vaccinated would mean Rs 6,000. Then, there are other family members. How many can afford this? The past few months have been difficult for the working class and the poor. There has been no source of income for many,” says Dr Devi Shetty, chairman of Narayana Healthcare. “The government must negotiate deals in terms of money and delivery time of doses.”

On August 4, though, in response to BJP MP Sushil Kumar Modi’s query in the Rajya Sabha, Mandaviya said: “In a month, we saw that 7 per cent to 9 per cent vaccines procured by private centres remained unused, so we decided to take those doses in the government quota. Therefore, it is not necessary to reduce the quota for the private sector. The vaccination is happening smoothly.”

A recipient of the Sputnik V vaccine gets photographed at the R.N. Tagore Hospital, Kolkata (June 12, 2021); (Photo by Debajyoti Chakraborty)

The Centre has already committed an advance of Rs 4,500 crore to the Serum Institute of India (SII) and Bharat Biotech. Yet, production hasn’t improved significantly. The SII is producing around 110-120 million doses a month with no plans to scale up, while Bharat Biotech is producing around 25 million a month, despite having said in January that it will increase to 40 million a month soon. “The argument that manufacturers can sell at a higher price to private chains as an incentive for more production isn’t working. Production is down as the manufacturers have reached their current capacity, not because they don’t have the money,” says Aisola.

Another solution experts offer is that the central and state governments procure all doses and the private sector buys it off them at the same price. “Private clinics should be an alternative means of accessing vaccines for those who want to pay for it,” says Gyani.

Odisha’s capital Bhubaneswar, which has vaccinated its entire adult population, has done an exemplary job of optimising its private sector. The government asked all districts and municipal corporations to conduct a meeting with hospitals to sensitise them on the procurement process and to note down their demand and capacity to vaccinate. Based on this, doses were allocated. Uttar Pradesh’s Gautam Buddha Nagar saw similar success—40 per cent of the vaccinations carried out in the district in July were done by private centres.

“We faced no procurement problem at all,” says Dr Anupam Sibal, group medical director of Apollo Hospital, Delhi. The Apollo Group has been the largest vaccinator in the private sector. They clocked a million doses in just three weeks and aim to complete 20 million by September. “We did face some issues with vaccine hesitancy—every time there is a report in the media, people question the safety of the vaccines. Our doctors have been answering questions through open house and phone-ins to educate people. We have also conducted research on the protection offered by vaccines. That has helped many overcome their hesitancy,” he adds.

Fortis Bengaluru, a leading private vaccinator in the city, says it, too, had to work to augment demand once doses were opened up for all above 18. Dr Priya Sreedharan, medical director of Fortis on Bannerghatta Road, says the hospital has seen a rise in demand post vaccine awareness campaigns. “We had to tell people that you can get Covid after a vaccine but it will be a milder version,” she says.

With India’s reproductive (R) number rising over 1, which means that more than one person is being infected on an average by an already-infected person, and around 43 districts reporting a total positivity rate of over 10 per cent, experts say all efforts must be put in to use up the entire monthly supply of vaccines in the country. According to the MoHFW, the ‘R’ value remains higher than 1 in eight states, including Himachal Pradesh, Jammu and Kashmir, Tamil Nadu and Kerala. Swift vaccination, add experts, should be a priority, particularly in states like Kerala, Assam, Haryana and Maharashtra, where seropositivity is low, indicating that people have not had previous exposure to the virus or developed antibodies against it. A third wave’s impact can only be minimised through sufficient immunisation.