By Abha Rao
The Covid-19 pandemic has upended the lives of people across the world, and the arrival of a vaccine (or vaccines) has been eagerly awaited. Less than one year since the start of the global pandemic, we are on the verge of the approval of several vaccines for use in the fight against Covid-19.
India has ordered approximately 1.6 billion doses of the Oxford-AstraZeneca vaccine, which, at two doses a person, will cover 800 million people. At a cost of $3-$4 per vaccine, it is expected that we will spend about $6 billion (about Rs. 45,000 crores) on procuring the vaccine. If the costs of logistics, human resources, training, storage, supplies, and other associated costs are factored in, the final tally may well be in the territory of Rs. 60,000 crores. This amount represents approximately India’s entire central annual health budget.
It is clear is that the Covid-response has adversely impacted other public health programmes, including existing immunization programmes, maternal and child health programmes, tuberculosis control, etc. and disrupted the delivery of other programmes essential to health (e.g., mid-day meal schemes), both in terms of budgetary and human resource allocations. Spending the equivalent of the central health budget on the Covid vaccine and associated costs will have other long-lasting impacts on public health.
Let us take a closer look at one important element of the central health budget: India’s Universal Immunization Programme (UIP), which comes under the National Health Mission. The UIP costs approximately Rs. 10,000 crore annually and provides 390 million doses of vaccinations for 29 million mothers and 26 million infants each year. India’s extensive immunization programme is something to be justifiably proud of, and rates of immunization have gone up steadily over the last few decades. Nevertheless, a large proportion of Indian children – along predictable regional, gender, and caste lines – remain unvaccinated or have an incomplete course of vaccination.
Rates of immunization have already declined due to the pandemic – both due to the reluctance of families to visit health centres, and the diversion of healthcare workers to Covid-related duties – and there is now a serious concern that the immunization programme will be further handicapped by the all-encompassing focus on delivering the Covid-19 vaccine.
The Oxford vaccine requires storage at between 2-8 Deg C. Currently, our total cold storage capacity, including both public and private facilities, is about 500 million doses. Thanks to the UIP, our vaccine distribution systems, both in terms of cold storage chains and human resources, are largely functional. There are nearly 29,000 points of vaccine delivery (the final stage of the cold storage chain), the vast majority of which are in rural areas, in keeping with the requirements of the UIP. As such, our problem is one of scale – current cold storage facilities fall well short of the storage that 1.6 billion doses of the Covid vaccine will require, and many more healthcare workers will have to be trained to deliver the vaccines to 800 million people.
Other problems remain: the distribution centres, which maintain the deep freezers and ice-lined refrigerators, are primarily in urban centres, and concentrated in the more developed states (Tamilnadu, Gujarat, Maharashtra). Our existing facilities are beset by many issues, including power cuts, and poor temperature control and maintenance, which render many vaccines stored under such conditions unusable. There is some concern that the emphasis on the Covid vaccine programme will come at the cost of storing and delivering other vaccines, and risk compromising our overall immunization goals.
India has never had a nation-wide immunization programme on the scale of the proposed administration of the Covid vaccine. Successfully administering the Covid vaccine to nearly 2/3rds of our population will require ramping up existing vaccine delivery systems dramatically and immediately, but there have been few details about how this will be accomplished. One assumes that the entire existing health infrastructure – clinical facilities, healthcare workers, medical supply manufacturers, etc. – will be commandeered in the single-minded goal of delivering the Covid vaccine.
While this is an impressive goal, and if achieved, a significant accomplishment, one cannot help but imagine how much better India’s public health status would be if this kind of commitment, effort and spending had been dedicated over the years to broader public health programmes – identifying and treating patients with tuberculosis or diabetes or acute respiratory infections, expanding the reach of existing children’s nutrition and immunization programmes, addressing anemia in women of reproductive age, or preventing malaria – that collectively could have saved and continue to have the potential to save and improve the lives millions of Indians.
Abha Rao is a public health researcher with training in family studies, human development and medical anthropology, with an interest in sexual, reproductive, and maternal health issues.
Research Scientist & Assistant Professor
Ramalingaswami Centre on Equity & Social Determinants of Health
Public Health Foundation of India