How fast can vaccines solve India's COVID-19 crisis? It's complicated.

CHENNAIIt’s 9 a.m. local time, and the security guard at a primary health center in Chennai, a major city in south India, is turning away people at the gate. Most have come to get their second shot of Covaxin, one of two COVID-19 vaccines currently available in India that both require two doses. Some hold up their phones and say they’ve got an appointment from the government vaccine app. But the guard tells them they’re too late. A case of vials enough for only a hundred shots had arrived earlier in the morning. “People were waiting from 6 a.m.,” he says. “It’s over.”

As India battles a deadly second wave, its once-hesitant citizens are rushing to get vaccinated. But supply is short—and, some worry, it will soon get scarcer. In an effort to ramp up vaccination, the government recently announced it would expand vaccine eligibility to everyone over 18 beginning May 1. But that means adding 600 million people to the 300 million over 45 who are already eligible.

In addition, the government deregulated vaccine procurement and pricing in a move that experts say could lead to widespread inequity. Less than 9 percent of the country’s population, some 1.4 billion people, have received one shot so far; less than 2 percent have been fully vaccinated.

India currently produces around 75 million vaccine doses a month and is expected to boost that to 100 million doses by June. New options are coming from Russia, which has promised to send five million doses of its Sputnik V vaccine in May while India fast-tracks it for approval. The U.S. also might send its overstock of the AstraZeneca vaccine, which is already authorized for use. Even so, the numbers are far short of the billion-plus doses needed to vaccinate the 900 million who are about to be eligible for a shot.

The deregulation announcement sent state governments as well as some private companies and hospitals scrambling to book orders. But the vaccine math is painfully clear: Even states intending to order extra doses have now said they will not be able to roll out jabs for the cohort age 18 to 44 on May 1.

“We’re nowhere near the original target of 300 million vulnerable [people], and now we’re trying to add more demand,” says Prabir Chatterjee, former director of the State Health Resource Centre in Raipur. “It’s all muddled up.”

Beginning the pandemic with an advantage

India entered the pandemic with a vaccine advantage. It is one of the world’s largest suppliers of vaccines, with the capacity to produce 1.5 billion to 2 billion doses a year. The country also has decades of experience in large-scale immunization. But unlike the U.S., the Indian government did not invest in ramping up capacity last year and was slow to place orders with manufacturers. That’s due in part to complacency after a dramatic decline in cases after September led many to believe India had escaped the worst of the pandemic.

Launching the country’s vaccination program on January 22, Indian prime minister Narendra Modi lauded the country’s ability to produce its own vaccines and help other countries.

Now, with the average daily number of cases exceeding 350,000 for the past week, and thousands dying each day, the government is scrambling to expand vaccination. Apart from expanding eligibility, the government has halted vaccine exports and is pumping millions of dollars to ramp up supply of AstraZeneca and Covaxin. It has also fast-tracked approval of the more expensive mRNA vaccines from Moderna and Pfizer-BioNTech, in addition to Sputnik V.

But in a controversial move, the government has decentralized vaccine procurement, allowing manufacturers to sell 50 percent of their supply directly to states and to the private sector at different prices. Critics say the pricing policy complicates the supply scenario, allows profiteering at a time of crisis, and could create vaccine inequity in an already unequal society.

Usually, the Indian government procures vaccines directly from manufacturers at a fixed price, and leaves distribution to local authorities. And originally, the government of India had negotiated a price of between U.S. $2 and $2.75 a dose from the Serum Institute of India (SII), which produces the AstraZeneca vaccine, and Bharat Biotech, which makes the indigenously developed Covaxin.

Under the new policy, however, Bharat Biotech announced it would charge state governments roughly $8 per dose; for the private sector, $16. The SII said it would charge $5 and $8 respectively. By comparison, AstraZeneca is charging Europe $2.15 and the U.S. $4 per dose. These higher rates were met with widespread public criticism.

“There’s always a tension between profits and public health,” says Madhavi Yennapu, senior principal scientist at the National Institute of Science Technology and Development Studies (NISTADS) in New Delhi. “But we can’t leave things to the market if we want public health objectives to be met.”

Both companies have argued that the adjusted rates were necessary for scaling up capacity. In a statement released on April 26, SII CEO Adar Poonawalla said that “the original prices were set extra-low based on advance funding from those countries for at-risk vaccine manufacturing.” But after requests from the government of India, SII lowered the price for state governments by over a dollar, while Bharat Biotech lowered its price by almost three dollars.

State governments don’t have the experience or leverage to negotiate good prices with industry, and so they may still end up competing with each other or with the private sector for vaccines, says Chandrakant Lahariya, an independent public policy and health systems expert based in New Delhi. States with more resources could end up grabbing more doses. And if private hospitals acquire their own stocks, the young urban elite could get their shots before the more vulnerable migrant laborers.

“The vaccine supply is not enough, and now by opening up the age group and then allowing the private sector to take a share, you risk depriving the poor who most need the vaccine,” Lahariya says.

Trouble with equal access

Disparities in vaccination were already evident in the earlier phase of immunization, with the urban middle-class and rich people turning up for their shots in greater numbers than the poor. The skew was attributed to a combination of vaccine hesitancy due to a controversy around the approval of Covaxin, a lack of public outreach, and the inability of daily workers to give up a day’s wages to go to the clinic.

Outreach is especially important, experts say, because hesitancy can recur. At the vaccine center in Chennai last week, 50-something Vishwanathan, who goes by one name, was checking availability for his elderly mother, who was overdue for her second shot. She had delayed her visit because she was alarmed by the death of a popular film star a few weeks after vaccination, he says.

Technology can also be a barrier. The government’s vaccine registration app is convenient but limits participation in a country where half the population does not have access to the internet.

This registration-based approach has not been tried in Indian immunization programs before, says Giridhara Babu, an epidemiologist with the Public Health Foundation of India who was involved with the country’s polio eradication program. Previously, he notes, authorities prepared detailed district plans and social mobilization strategies to reach vulnerable communities. Indians, he says, tend not to seek healthcare except in emergencies.

“To expect people to know about this app and then take the responsibility to register runs counter to health-seeking behavior in the country,” Babu says, adding that this approach could slow vaccine uptake.

While walk-ins are allowed in most centers, some local authorities have said that any rollout for the 18 to 44 cohort will be based only on online registrations. The rule appeared to be intended to prevent crowds from besieging vaccine centers after May 1. More than 12 million signed up on April 28, when registration for the younger cohort opened, briefly crashing the website.

The road ahead

Babu says authorities must now plan for the second half of the year, when supply constraints ease and new vaccines come to the market. With a $210 million grant from the government, Bharat Biotech plans to increase annual production to 700 million doses by the end of the year. Russia has provided licenses to five Indian manufacturers to supply 850 million annual doses of Sputnik V for India and other countries.

Indian firm Biological E aims to produce one billion doses of the Johnson & Johnson vaccine by the end of 2022, funded in part by the U.S. Another Indian firm, Cadila Healthcare, hopes to get approval for its own vaccine, ZyCov-D, in the next two months, with a target annual production of 250 million doses.

India could also tap its storied but underutilized public sector capacity, says Yennapu of NISTADS in New Delhi. Vaccine research and development in India dates back to the British colonial era, which included global efforts to develop smallpox and plague vaccines. Manufacturing saw a major expansion in the 1970s, and some of those government facilities now lie idle.

“With some upgrading, we could bring this unused capacity into service for future waves or epidemics,” Yennapu says.

Although some of this projected supply will be shipped to other countries, the government must start thinking about the strategy now, says Babu. “We need to strengthen our microplanning to speed up vaccination after June,” he says. “Who are we going to vaccinate, where are they, how are we going to get to them?”

Raipur’s Chatterjee agrees, adding that it’s not unreasonable to consider targeting age groups or geographic areas, as long you’re taking care of the most vulnerable. The earlier decision to vaccinate everyone older than 45 was shaped by the patterns of the first wave, while the recent drive to expand vaccine eligibility has come at the behest of hard-hit states, where younger people are falling ill in the second wave.

“You could argue that [the state of] Maharashtra should vaccinate everyone because that’s where the main pandemic is,” he says. “But we have to figure out where you get the money and materials from, and whether we want to be that selective. We have to have that discussion; we have to do the planning.”