India impossibly short of vaccinating its entire adult population against COVID-19 by the end of 2021

India’s vaccination drive rests on a wing and a prayer as it looks set to miss the target of vaccinating all adults by the end of the year.

A vaccination camp at Kaurhagi in Morigaon district of Assam. Photo: Anupam Nath / AP

India’s vaccine drive is increasingly looking like a limited overs cricket match in which the chasing team’s asking rate climbs higher and higher and out of reach because the strike rate hopelessly trails the required rate. As a result, Team India’s bosses in the Health Ministry—whose leadership changed recently with as yet no visible benefit—appear impossibly short of their target of promising to inoculate the entire Indian adult population against COVID-19 by the end of 2021.

In July, 132.56 million vaccinations were delivered, the highest monthly total since vaccination began on January 16. However, the fact that vaccination in July was just 11.6 per cent more than in June indicates a tapering off of the spectacular spike in daily vaccination rates that was witnessed in the eight days starting June 21. In that period, an average of 6.10 million doses were delivered a day. To put those figures in context, in the entire month of June, an average of 3.96 million doses were delivered a day. This meant that the average during the eight-day streak was 54 per cent higher than the average for June, revealing just how volatile the daily vaccination rates have been.

Spectacular as the June performance was, in the context of the fiasco in May when daily vaccination rates plummeted by more than one-third over April levels, these trends reveal grave weaknesses in the Indian vaccination drive. Among the most outrageous of these is the official insistence that all Indian adults would be vaccinated by the end of the year. In fact, the achievements on the vaccine front have fallen far short of the Narendra Modi government’s assurance to the Supreme Court in late June that it would deliver 516 million vaccines by July 31. In reality, only 463 million doses were delivered by then. In terms of the average rates for July, this meant that the vaccination drive was trailing the target by more than 12 days. This shortfall is not trivial; it reflects the complete unravelling of the government’s vaccination “strategy” that was initiated on April 19. In fact, every single element of this exercise in deregulation, termed the “Liberalised Pricing and Accelerated National Covid-19 Vaccination Strategy”, is responsible for the mess that the COVID-19 vaccination drive is now in.

The sin of deregulation

In fact, the shortfall can be traced to the fact that, by the government’s own admission in the Supreme Court in June, State governments and private hospitals were to deliver about 160 million of the 516 million doses. They were supposed to source supplies “directly” from vaccine producers or their agents. It is not as if the States did not try; many floated tenders in vain as global vaccine producers, already stretched to the limit, were unwilling or unable to respond. The story of private hospitals was a little different. Since the two main Indian vaccine producers—Serum Institute of India (SII) Pvt. Ltd, the producer of Covishield; and Bharat Biotech International Ltd (BBIL), the producer of Covaxin—had never supplied vaccines through private marketing channels earlier, they had limited marketing reach. As a result, they preferred to deliver vaccines to the large private corporate hospital chains rather than to small nursing homes, clinics or private practitioners, who could have possibly enhanced the reach of the vaccination drive. It is obvious that the move to reserve one-fourth of the scarce vaccines for the private sector was not just ill-thought-out, it was positively egregious because it actively promoted vaccine inequity in a deeply unequal society.

It is obvious by now that the government’s only “policy” has been to rely on projections and forecasts of vaccine production by the two vaccine suppliers. By doing this, the government only lobbed the ball further down the road whenever it was cornered by questions about production at the two main COVID-19 vaccine production sites. In particular, the Modi government has been shy about admitting to problems in the production of Covaxin at BBIL’s site in Hyderabad. For instance, in April it said that BBIL had a production capacity of 20 million doses/month. However, the reality is that only 55.44 million doses of Covaxin were delivered by July 31; if what the government said in April were true, Covaxin supplies ought to have been 100 million doses between April and July, a shortfall of 45 per cent.

Undeterred by the reality staring it in the face, the Modi government in its affidavit to the Supreme Court in late June claimed that Covaxin deliveries would amount to 400 million doses between August and December 2021, an average of 80 million doses/month. To put this claim in perspective, Covaxin deliveries are to magically increase 5.5 times, from 15.13 million in July to 80 million in August. The only saving grace is that Covishield deliveries have improved significantly since mid June: 117 million doses in July at an average rate of 3.78 million doses/day. The government’s claim made in June that Covishield supplies would amount to 500 million doses may turn out to be true.

The joker in the pack

In June, Covishield supplies were at an average rate of 3.39 million doses/day; by July, it had improved to 3.78 million doses/day. Thus, it appears reasonable to expect that Covishield deliveries will be close to their upper bounds of around 115-120 million doses/month; anything significantly more than that in the next few months can be ruled out unless there is a dramatic improvement in SII’s capacities. Clearly, the joker in the Indian vaccine pack is Covaxin. BBIL, already beleaguered by a scandal over its vaccine in Brazil, has been impacted by its much-delayed application process to get Emergency Use Authorisation approval for Covaxin from the World Health Organisation, which would allow it to be used more widely in other countries, and is trailing hopelessly behind its production commitments. If SII has reached its top-rated capacity, enhanced supplies from that source is unlikely in the next few months. If the output of Covaxin, which accounts for just about 12 per cent of all jabs delivered, fails to pick up significantly, the scope for a significant increase in India’s vaccination rate appears unlikely.

Speaking on August 2 on a TV show in which this writer was also a participant, Dr N.K. Arora, Chairperson, National Technical Advisory Group on Immunisation, dropped a bombshell by announcing that the “initial batches” of Covaxin BBIL produced at its new site in Bengaluru failed “quality tests”. However, while claiming that vaccine manufacturing “is almost like rocket science”, he predicted an “exponential increase” from BBIL’s new site. He said a significant “ramp-up” would happen within the next four to six weeks. “We are expecting 10-12 crore [100-120 million] doses [a month] from BBIL,” he said. These are significant claims, but BBIL has only flattered to deceive since vaccination began.

Two other factors spoil the otherwise rosy picture Dr Arora painted. For one, since an inactivated virus vector vaccine suffers from some inherent production scaling-up problems (read interview with the eminent immunologist Dr Satyajit Rath in Frontline , June 18, 2021), scaling-up production in a short time frame is not just difficult but also hazardous. The second problem arises from the manner in which BBIL has been given a free pass at the expense of the public sector vaccine production units. As a result, not only have hopes of a recovery from the systematic emasculation of the public sector undertakings (PSUs), dating from the pre-Modi years, been wasted but public health has also been jeopardised in a pandemic. Although three PSUs have been authorised to produce Covaxin, it is unlikely that they will start production any time in the next few months.

These production shortfalls have grave implications for the asking rate at which vaccines must be delivered if India is to vaccinate its entire adult population by the end of 2021. Even if Covishield production stabilises at the rate of 4 million doses/day and even if Covaxin production improves by 50 per cent from the current level of about 0.48 million doses/day, the average daily availability of vaccines is only likely to be 4.72 million doses/day. The facts of arithmetic are as follows: India’s adult population of about 940 million need 1,880 million doses. By August 4, 485 million doses had been delivered, leaving 1,395 million doses to be delivered. This implies that in the 149 days between August 4 and December 31, the daily vaccination rate has to be a whopping 9.36 million/day. If India vaccinates at its July rate of 4.28 million/day, it will require 326 days, almost half a year beyond the target the government has set for itself. Even if BBIL’s production somehow increases by 50 per cent in the short term and if Covishield supplies are at about 4 million doses/day, it will still take 295 days for the entire adult population to be vaccinated. Even in this more charitable case, complete vaccination for adults will be achieved in May 2022. All this means that the Modi government is at the mercy of the two vaccine producers; Covaxin has been jinxed from the start, and any production crisis at SII runs the risk of bringing the entire drive to a grinding halt.

Excessive reliance on private sector

The Modi regime’s vaccination drive has been a series of errors at every step, resulting from egregious disregard for the interests of public health in the midst of a pandemic. As Dr Chandrakant Lahariya points out (see interview on page 59), the first “cardinal mistake” was to so utterly rely on the private sector for vaccines. This was particularly appalling because the government had leverage with BBIL; after all, its agencies under the Indian Council of Medical Research network had played a crucial part in developing the vaccine, which is reflected in the government’s share of the intellectual property in Covaxin. The excessive reliance on the private sector was compounded by two errors: one, letting the two companies “channelise” production to private hospitals at prices that were different from what the Union government was paying and, two, asking States and private hospitals to separately source supplies “directly” from the two manufacturers. The utter senselessness of the move was obvious when the government backtracked on these measures. But valuable time was lost even as people were desperately scrambling for vaccines.

But the biggest of the cardinal errors, according to Dr Lahariya, was the decision to open up vaccination in May for the 18-44 age group, a section of the population that was generally known to be less likely to be seriously affected by the virus. This was when vaccines were in extremely short supply and a large section of the 45+ age group had not even been vaccinated fully. This was not just a mistake, it actually gravely compounded an already serious crisis. The decision to start vaccinating the 18+ population was made at a time when public reaction to diminishing vaccine supplies in mid April was already turning strident. The move to include the younger age group was apparently a desperate act of bravado aimed at pandering to sentiment.

It appears that the low-hanging fruit has already been plucked, meaning that the difficulties in expanding vaccination will only mount in the days ahead. The expansion into rural areas, the complexities of delivering a higher proportion of the second dose and the wide regional variations in vaccine delivery are likely to slow the pace of vaccination unless there is transparent and quick-footed oversight over supplies. By August 5, India had vaccinated 42 per cent of the adult population with a single dose; only 11.5 per cent had been fully vaccinated. The intrepid data cruncher James Wilson, who has just compiled vaccination rates across States, said on Twitter that dose deliveries are trailing the national average in States such as Maharashtra, Jharkhand, Assam, Punjab and West Bengal. Significantly, these are also States where the seroprevalence rates are significantly lower. This calls for a targeted vaccination drive that diverts supplies to these States, including Kerala where the seroprevalence rate is among the lowest. Vaccines can thus be used as an important tool in countering the spread of the pandemic. But this calls for a quick review of the approach, something the Modi regime has proved incapable of.

The numbers that the government has been providing have no sanctity, partly because of the way the data are presented but also partly because of subterfuge. For instance, there are serious inconsistencies in the affidavits the government presented to the Supreme Court; in fact, there are instances when there are two different numbers of Covaxin production capacities mentioned in the same affidavit. As Dr Lahariya points out, vaccines are not a magic wand, especially in their ability to curtail the onward transmission of the virus, although they can be an important tactical tool if used effectively. He points out that the timely availability of appropriately stratified data can allow vaccines to be used effectively in limiting the pandemic. Alas, open access to data is anathema to the Modi government, especially because of its image-conscious obsession.