Grand cover-up: The Narendra Modi government's celebration of one billion COVID vaccine doses

The Modi government’s gloating over administering one billion cumulative doses of the COVID vaccine is designed to erase from public memory its monumental failures in tackling the second wave and ensuring a free, universal, equitable vaccination with foresight and better preparedness.

People wearing face masks featuring Prime Minister Narendra Modi to celebrate the completion of 1 billion vaccine doses, in Ahmedabad on October 24.

Administering over one billion cumulative doses of COVID vaccine within nine months since the COVID vaccination campaign began on January 16 is no mean achievement in a country with a population of 1.38 billion and diverse logistical difficulties. While it should make every citizen proud, the extravagant celebrations in the wake of reaching that landmark figure on October 21 was grossly misplaced and unwarranted. Given the manner in which the government went about it, the attempt obviously was to use the occasion to launch a blitz campaign that would help to whitewash its monumental failures in the management of COVID-19 in the last 20 months, in particular the vaccination campaign.

As on date, India has reported around 34.2 million confirmed cases, which is next only to the numbers in the United States. The nearly 0.46 million reported COVID-related deaths, many analysts believe, is a gross underestimation. The actual number, according to a recent Canadian study, is six to seven times the official figure. Who, if not the government under the leadership of Prime Minister Narendra Modi, whose praise the ruling party members are singing today, should be held answerable to all those thousands of families who lost their loved ones during the second wave of COVID (March-June) because of oxygen shortage and lack of intensive care unit (ICU) beds? These shortages were the result of the government’s lack of foresight and preparedness.

“India scripts history,” Modi tweeted on the day of the milestone. “We are witnessing the triumph of Indian science, enterprise and the collective spirit of 130 crore Indians.” There was also the op-ed page article in several dailies, ostensibly penned by Modi himself, and the Prime Minister’s 10th address to the nation during the COVID-19 pandemic, with the misplaced emphasis on the “Made in India, Make in India” slogan. In none of his utterances, tweets or writings did Modi pause to refer to these unfortunate events that could have been avoided. Yes, the second wave was perhaps inevitable with the highly transmissible Delta variant spreading all over the country. But with better planning and upgrading of the existing health infrastructure and human resources, many of these deaths could have been avoided. No one but the government is to be blamed for this unforgettable countrywide tragedy that unfolded in the wake of the second wave.

Covishield, the Indian brand name for the Oxford/AstraZeneca vaccine (AZD1222) developed by British scientists and manufactured and packaged in India under licence by the Serum Institute of India (SII), constitutes nearly 88 per cent of the vaccine doses distributed and administered in India. Covaxin accounts for the remaining 12 per cent. To boast about “the triumph of Indian science” is a gross overstatement in this context.

Yes, the SII needs to be applauded for its entrepreneurship in being the first to secure licence and the contract to manufacture the vaccine in India. Without that effort, India’s COVID toll would have been far higher. We will return later to the problems with the development and production of the indigenous Covaxin, which is yet to obtain the Emergency Use Approval (EUA) from the World Health Organisation (WHO) even nine months after its approval by the Indian regulators, the Central Drugs Standard Control Organisation (CDSCO) and the Drugs Controller General of India (DCGI).

Not content with the Prime Minister’s own celebratory and self-congratulatory words, the government’s publicity cell worked more like an event management company rather than the public information arm of the administration that it is. Huge billboards and hoardings across many cities carried large images of Modi with “Thank You Modiji” displayed prominently on them.

Leaders and followers of the Bharatiya Janata Party (BJP) of various hues, including Union Minister of Power R.K. Singh, claimed wrongly on social media, Twitter in particular, that India was the first country in the world to achieve vaccine coverage of 1 billion and hailed “Modiji” for this stellar achievement. China achieved a total coverage of over 2.2 billion on the day when India reached 1 billion doses. More significantly, with a vaccination rate of over 10 million doses a day on a consistent basis, China has fully vaccinated nearly 80 per cent of its population, whereas India has fully vaccinated only about 21.5 per cent of its population as on date (Fig. 1).

The Ministry of Health and Family Welfare (MoHFW) released a “vaccine anthem”, a three-minute song by the singer Kailash Kher, along with an audio-visual, as part of the day’s celebration. The Archaeological Survey of India illuminated 100 monuments across the country, including the Red Fort, the Khajuraho complex, the Konark Sun temple and the Qutb Minar. Ships anchored in different ports of the country were made to hoot at a specified time and fully vaccinated people were given free ropeway rides in Gujarat, Kerala and Uttarakhand. The fact that all this fanfare centred on Modi was orchestrated with an eye on the forthcoming Assembly election in Uttar Pradesh should not be lost on anyone, especially when vaccine allocation to the States in July was remarkably skewed in favour of Uttar Pradesh. The largest allocation (of both Covishield and Covaxin) was made to Uttar Pradesh, which in turn has resulted today in the highest dose administration there among all the States.

But, more pertinently, this excessive bragging by the government detracts from the fact that though nearly three-fourths of the adult population has received at least one dose, only a little over one-third has received both doses of the vaccine. In early May, former Union Minister Prakash Javadekar stated that the government had drawn up a blueprint for administering about 1.88 billion cumulative doses by the end of the year. The milestone figure of 1 billion doses is thus only a little over half of the government’s own target for the year end. This means a mammoth task lies ahead in the forthcoming two months. As we shall discuss later, in all likelihood, many millions will get fully vaccinated only by mid-2022.

Vaccination trends: peaks and troughs

Figure 2 shows the vaccination trend since the campaign began till date. Peaks in April (the week ending April 9), in June (the week ending June 25) and then in September (the week ending September 17) can be seen. During the peaking week in April, a total of about 25 million doses were administered, giving a per day average of about 3.6 million jabs. But immediately after that, the pace dropped steadily to reach a minimum of about an average of 1.3 million shots a day in the week ending May 21. Then the pace picks up to peak again in the week ending June 25, giving a daily average of about 6 million shots, only to drop to a minimum rate of 3.5 million in the week ending July 16.

The peak in the week ending on September 17 is in part artificial. According to reliable sources, the daily vaccination rate was deliberately suppressed for some days before September 17, which was Prime Minister Modi’s 71st birthday, so that the milestone figure of recording 2 crore (20 million) vaccinations on that day could be announced with fanfare and celebration. This was duly done. The rate fell immediately after to touch a minimum of about 4.5 million doses a day during the week of October 9-15 and then again increased slowly. Interestingly, during the week when cumulative vaccine doses administered touched the milestone figure of 1 billion doses, the average daily rate was only 5.3 million. In fact, in October the per day average was only 5.5 million jabs.

Had there been no peaks and valleys in the trend, and had there been a consistently increasing trend in the daily vaccination rate, the milestone of one billion could have been reached a few months earlier, say by August, and the drive would probably have been on course to fully vaccinate the nation by the year end. Unless the production is greatly ramped up, and the pace of coverage is increased significantly from the rate of around 6 million doses a day in October end, the gap between total vaccinations and the target for the year end will only grow bigger and bigger.

Mismatch between targets for vaccination coverage and availability has been a constant characteristic of the Indian COVID vaccination campaign. The waxing and waning of the vaccination trend reflect irregular vaccine production and discrimination in doses supplied to the different States. Many States faced an acute shortage of vaccine supply in May. In April, the combined production capacity of the two vaccines produced in India was only about 2.5 million doses a day. It was projected to increase to about 3.8 million by May. Even if this had been attained—which, however, did not happen even until July end—the available doses would have been less than what would be required at the peak average rate reached in April.

But exacerbating the mismatch, the government on May 1 limited its centralised procurement to only half of the vaccine doses produced in the country and asked the States and private hospitals to procure the remaining half directly from the market. Most States lacked funds for direct procurement. The Centre’s abrogation of its responsibility of providing vaccine to all was only increasing the already existing disparities in allocation and distribution of vaccines among States. This also contributed significantly to the shortfall in overall coverage. Fortunately, the Centre realised its mistake soon enough and on June 21 returned to centralised procurement of the entire production.

In early August, the government told Parliament that the total production capacity of Covishield was expected to increase from 110 million doses a month to over 120 million doses a month and that of Covaxin from 25 million to 58 million doses a month. In September, the SII claimed that it would be able to supply 220 million doses of Covishield to the government in October. It is not yet clear if the projections for Covaxin have been achieved.

Bad planning

This failure to scale up production to meet the increasing demand happened primarily because of the issue of intellectual property rights on the vaccines and exclusive production licences for Covishield and the indigenous Covaxin held by SII and Bharat Biotech India Ltd. (BBIL) respectively. While the rights for Covishield production would have been dictated by the British-Swedish multinational AstraZeneca, the grant of exclusive manufacturing rights for Covaxin to BBIL until July defied logic.

Covaxin was developed by the Indian Council for Medical Research (ICMR), an arm of the Ministry of Health and Family Welfare, and the rights for Covaxin are equally shared by the government and BBIL. Given the scale of the pandemic, BBIL’s own manufacturing capacity should have been ramped up right from the start with direct funding from the Centre, and the production should have been augmented by licensing State and Central public sector enterprises (PSEs) with idle capacities to meet the inevitable surge in demand.

This wisdom seems to have dawned on the Modi government only as late as August when it stated that to augment the domestic COVID vaccine production capacity the government had extended support to BBIL and enabled technology transfer and licence for manufacture to three PSEs (one State and two Central) under “Mission COVID Suraksha”. But these three units are yet to start production.

At the start of the phased vaccination campaign on January 16, the target set for Phase-1 was for the priority groups of health care workers (HCWs) and front-line workers (FWs). Even now, however, a substantial number in both the groups are yet to receive the second shot. Even after nine months of the vaccination drive, as of October 20, while 10.3 million HCWs had received their first dose, only 9.1 million had received both doses, a shortfall of 1.2 million.

On March 1, the campaign included the most vulnerable groups—people aged 60 and above and those above 45 with comorbidities. However, given the surge of the second wave and its devastating impact, on April 1 vaccination was thrown open to everyone above 45. According to official vaccination data, as of October 20, of the estimated 210 million in the 45-59 age group, 169 million have got their first dose and only 87.6 million (41 per cent of the total) are fully inoculated. In the most vulnerable group of 60 years and above, of the estimated 143 million, 106 million have had their first shot but only 62 million (43 per cent) have received the second jab as well. Clearly, there are significant shortfalls in both the groups even now.

If the primary aim of the vaccination drive was to minimise the risk of death from COVID, particularly in the wake of the second wave, the vulnerable group of 45 years and above should have been vaccinated fully by August. But this would be attainable only if the vaccination coverage rate of about 4 million a day, which was achieved in early April, had been maintained. But as we discussed earlier, the pace slackened, particularly owing to production shortfall.

But even as the number of vaccinated people above 45 was falling below the target, the government on May 1, apparently under pressure from some States and other quarters, widened the vaccination coverage to include everyone above 18. Initially, this far less vulnerable 18-44 age group could get vaccinated only upon payment from the 50 per cent doses that the State governments and private hospitals would procure from the open market. However, from June 21, after the government went back to centralised procurement of all vaccine doses, the 18-44 age group had access to free vaccination at government centres as well.

The move to expand vaccination coverage to everyone aged 18 and above drew criticism from public health experts who argued that the goal of vaccinating all the people above 45 should have been achieved first in a situation where vaccines were in short supply. As we have seen, the more vulnerable above-45 group still remains to be fully vaccinated.

Some positives

A couple of positives have occurred, however, during the ongoing campaign. Vaccination among the rural population had lagged significantly behind the urban in the beginning. But in recent months, the rural population has emerged as the dominant fraction among the vaccinated, accounting for nearly 75 per cent of the coverage (see Figure 3).

Similarly, the gender divide was quite significant early on in the campaign. But now male and female fractions are almost equal: women are only marginally behind the men by about 30 million. As on date, men account for 546 million and women for 510 million doses (see Figure 4).

As we saw earlier, fully vaccinating (with two doses) the total adult population requires the administration of 1.88 billion doses. A coverage of nearly 1.06 billion was achieved on October 30, showing an increase of 6 millionin 10 days after the milestone of 1 billion reached on October 21.

The campaign has still to administer 820 million doses in the following two months, that is 410 million doses per month. This translates to about 14 million doses a day if the goal of fully vaccinating the entire adult population by the year end is to be achieved.

Now this would seem impossible to achieve given the average rate of vaccination at 6 million doses a day towards October end. The current rate suggests that as many as about 125 million adults will remain unvaccinated in January 2022. It is pertinent to also note that, given the recommended inter-dose gap of 12-16 weeks, people who get their first dose of Covishield in early November will have to wait at least until February 2022 for their second dose.

Those who get their first jab in December will have to wait until March-April 2022. The time frame can be reduced if either the rate picks up significantly above the current 6 million mark or if the inter-dose gap is shortened (this should be done only if the underlying science warrants it).

The above discussion, of course, assumes that adequate vaccine doses will be available over the next two months. But that does not seem to be the case as the current production capacity of Covishield is only about half of what is required per month to meet the target. Covaxin’s production capacity still appears to be stagnant at around 25 million doses a month. The uptake of Russian Sputnik V, the other vaccine approved by the CDSCO, has so far been only about 1 million doses. The other potential vaccine candidates of Zydus Cadilla and Bio E are yet to get the CDSCO/DCGI nod and go into production.

Apparent surplus

Interestingly, however, even though the numbers indicate that there should be a shortage of vaccines even with the current significantly increased rate of production of Covishield, nearly 127.4 million doses remain unutilised with the States and Union Territories, according to the Ministry of Health and Family Welfare data. From the days of acute shortage in April and May, today there seems to be a surplus. But this surplus is only an apparent one, given the country’s demography, and there is an unmet demand in principle.

So why is there no uptake of these unutilised doses? The bottleneck would seem to be an aspect of the campaign itself which is preventing the coverage from being upped from the current rate. Is it the lack of human resources or is it a delivery chain problem? Is it vaccine hesitancy among the population? The effect of waning COVID-19 incidence? Or is it a problem with the management of the vaccination campaign itself? Only the Health Ministry can possibly answer.