The re-revised vaccination policy, which continues to reserve 25 per cent of vaccines for private entities, was challenged in the Supreme Court recently. One of the petitioners, R Ramakumar, professor at TISS Mumbai, talks about how this amounts to reservation of the vaccine for the rich
Professor R Ramakumar. Photo courtesy: R Ramakumar
On June 7, Prime Minister Narendra Modi had announced a re-revised national Covid-19 vaccination policy. They replaced the earlier ‘liberalised’ vaccine policy with the current policy where the Union government would reserve 25 per cent of vaccine stock for distribution among private players; and free vaccination would be made available for adults under 45. This new policy was implemented on June 21.
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On June 22, John Brittas, Rajya Sabha MP from Kerala, and R Ramakumar, professor at Tata Institute of Social Sciences (TISS) submitted a plea in the Supreme Court challenging this new policy to reserve 25 per cent of vaccines for private players. Through their petition, they sought 100 per cent procurement of vaccines by the central government.
Ramakumar is an economist and professor in the Centre for Study of Developing Economies, School of Development Studies at TISS. He also edited and introduced the book ‘Note-Bandi: Demonetisation and India’s Elusive Chase for Black Money’, published by Oxford University Press India. Mid-Day.com spoke to him to understand the rationale behind the plea and the lacunae in the current vaccination policy. Excerpts from the interview:
You challenged the revised policy adopted by the Central Government to reserve 25 per cent of the domestically manufactured Covid vaccines for private hospitals. Can you share what prompted this?
To begin with, globally, the good practice of every welfare state is to treat vaccines as a global public good and provide it free to all residents. So, this has been a global practice, including in capitalist economies like the United States, United Kingdom, Germany, France, etc. Now, in India, this must be the case for an additional reason -- it is a constitutional obligation of the Indian state. The right to free vaccine has been read out as a subset of Right to Life under Article 21. There are a few more reasons for why vaccines should be free and universal. India is not a high-income country. A large proportion of the monthly incomes of households will have to be dished out to purchase vaccines, which will exacerbate the problem of vaccine hesitancy. So, all these are reasons why 100 per cent of the vaccines should be procured centrally by the Union government. This should be distributed based on socially desirable criteria to all states, which should then be administered to all people freely. This is the most efficient, transparent and equitable method of vaccine distribution.
However, the Government of India on April 19, with effect from May 1, deviated from this practice significantly, and said only 50% of the vaccines will be given free of cost, that too to those above 45 years of age. Now, this was the first major deviation that the government undertook from the globally accepted practice of free and universal vaccination.
Some of us wrote a lot about this ‘liberalised’ vaccine policy, protested through our writings and so on. A lot of medical professionals and public health professionals argued against this practice. The Government of India finally understood this. The experience in the month of May clearly showed that this policy shift was a failure. The state governments were unable to procure vaccines that they required from the open market. There was considerable lack of access, exclusion, and unaffordability in administering of vaccines.
It was in this context that the government partially withdrew the ‘liberalised’ vaccine policy, with effect from June 21. However, our argument is that the reversal is only partial. Only the 25 per cent allocation to the state governments has been taken over by the government. The 25 per cent allocation of the private hospitals has been left untouched. Now, as a result, vaccines will become completely unaffordable to a significant section of the Indian population. Given the price of vaccines at private hospitals, only the rich can go and purchase vaccines from there; this is a reservation of vaccines for the rich. It is unheard of anywhere in the developed world.
This policy design, we believe, is perverse, discriminatory, and inequitable. This is the argument based on which we have moved to the Supreme Court, challenging the partial revision. We say that the 25 per cent allocation set aside for private hospitals also should be taken over by the Union government and procurement should be centrally managed by the government. These vaccines should be given free of cost to all states for further distribution to people.
This does not mean that private hospitals have to be disqualified from distribution. State governments, once they receive the vaccines from the Union government, can allocate some amount of vaccines to private hospitals, which used to be the practice earlier too. We are not opposed to that. Our point is that all procurement should be centrally undertaken by the Union government. An additional reason why we are arguing for this is because this 25 per cent quota allows the vaccine companies to retain the freedom to earn extraordinary profits from that volume of sales. If the Union government undertakes centralised procurement, then 100 per cent of vaccines can be purchased at a regulated price. The vulgar private profiteering in the middle of the pandemic can be avoided.
What are the setbacks of this 25 per cent vaccine reservation policy? What are its inherent inequities?
You will understand this when you look at the prices of vaccines that will be sold through private hospitals. For Covaxin, which is priced at about Rs 1,410 per dose, this would mean that roughly Rs 2,820 rupees would be needed to purchase two doses for an individual. This amount is roughly half the monthly income of a person standing on the poverty line in India. Whoever wants to take this vaccine will have to dish out half of their monthly income for one person. If there are two people, 100 per cent of their average monthly income will be wiped out. So, this is clearly unaffordable and will push millions of Indians out of access to vaccines.
Rapid vaccination is the need of the hour, given the rising dangers thrown up by the Delta variant. So, there is a need to vaccinate a large chunk of the population at a quick pace. This is also why we argue that this reservation of vaccines for the rich, which is discriminatory and inequitable, will end up slowing down the pace of vaccination in the country and exacerbate the problem of vaccine hesitancy.
Recently, in Mumbai, there were reports about alleged vaccination scams in housing societies. Does the 25 per cent private reservation policy leave the window further open for such spurious activities?
In a sense, yes. The purchase of vaccines from the state government vaccination centres can be expected to be strictly socially controlled and regulated. If you leave the vaccine markets open to private hospitals/agencies, these kinds of scams are more likely to emerge in this country. This is one more reason why there is need for social control of the vaccination process and that is why we argue that the last 25 per cent should also be procured by the Union government. If vaccinations are undertaken at accredited state-level vaccination centres only -- with the state government having full control or autonomy over where such camps are required or whichever way they want to do it -- then these kinds of scams can be avoided.
There were claims from the Union government that there is vaccine wastage in states. How accurate is this claim?
We should not overstate the problem of vaccine shortage. Vaccine shortage on an average is about three to four per cent in this country. I completely agree that even this vaccine shortage should not be there. Even this small percentage should not be wasted because there are a number of states where vaccine wastage is actually negative. Kerala is a good example. This shows that some states in India are performing remarkably well in terms of vaccination. But some other states are finding it difficult because of lack of adequate preparedness in opening camps. That is the reason why state governments should take considerable preparations before opening vaccination camps, ensuring that the message has reached people on a mass scale, ensuring that vaccine hesitancy and different fears related to vaccination are removed from people's minds, and adequate attendance in vaccination centres is ensured. So, state governments have a large role to play in the vaccination process here to ensure that vaccine shortages are minimised as much as possible.
In a statement in May, the health minister said, “India will have 51.6 cr vaccine doses by July and 216 cr doses in the August-December period.” The latter target was brought down to 135 crore. How viable is the target?
These are highly unrealistic claims made by the Government of India. India’s production of vaccines at this point of time does not cross about 30 lakh doses per day. In other words, about eight to nine crore doses per month. We are still stuck around that level of production capacity. Most of the vaccines that the Government of India has publicised that would become available between August and December are still either in the Phase 2 stage or Phase 3 stage of trial. So, that means it will take considerable time before they are even approved for usage. Once they are approved for usage, then production has to begin. For that, laboratories and production lines have to be ready. So, there will be few more months by the time they start production for distribution to the states. I do not believe that before December, any large improvement in capacities will take place. That is the reason why I believe that these numbers put out by the Government of India are unrealistic. There will be an improvement in the availability of vaccines as we go by, but certainly not to the extent as claimed by the Government of India.
On June 21, it was reported that India administered 88 lakh vaccine doses – the highest single-day coverage. What is your opinion on the actual rate of vaccination in India, and when can we expect India to get fully vaccinated?
It is a one-day number. The next day, that number fell to a little over 5 million doses. That means that the 88 lakh doses per day target was clearly unsustainable. Given the realities of vaccine production in India, most probably, the number of 88 lakh per day was a publicity stunt. It was the first day of the new vaccine policy – i.e., the 75 per cent takeover by the central government that came into effect on June 21. The government clearly wanted a spectacle on the first day of vaccination. It was also to show the world that India has made a major change in vaccine policy and its vaccination rate has considerably improved.
Take the experience of states like Madhya Pradesh, which gave a few lakh doses on the first day, but just a few thousand doses on the second day. All this shows that all these vaccination trends were clearly stage managed. These are not reflective of the actual capacities of Indian vaccine companies to supply. The capacity of vaccine companies to supply is still about eight to nine crore doses per month and not more than that. You simply cannot provide more vaccines than what can be supplied by the vaccine producers. So, we should not go by this day by day numbers. We should basically look at longer, monthly averages, where you will see that even with these high numbers for a week or so, the average number of doses for June is unlikely to exceed 40 lakhs per day.
By this time, we should be vaccinating about a crore doses per day. That is why I believe that we should not fall for one-day spectacles; we should not fall for this media blitzkrieg. We should have a more reasoned, more patient view of the situation and that is still in the bleak.
At the present rate, India will be vaccinating 100 per cent of the population only by sometime in 2023. The present rate is highly inadequate. In fact, to complete vaccination in 12 months, we consistently require more than 75 lakh doses per day. We are currently at about half that capacity. That should be the consistently scored monthly average, and only then we can cover a considerable section of the population in about a year. We are already late. The problem will be that new mutant strains will come up the more we delay vaccination, and then the process will get even more complicated.
The other issue to be remembered here is that we are not counting those less than 18 years of age here. That is another 30 to 32 crore of the Indian population. If they get added to the vaccination net by later this year, then our task will get even more arduous. This timeline that I mentioned of 2023 was only considering those above 18 years. It will get further delayed if we are counting those less than 18 years also.
What is your take on the monthly manufacturing targets of individual vaccines? Is it sufficient?
Manufacturing targets put out by the Union government are highly unrealistic, as I said earlier. In the affidavit to the Supreme Court, they said that the total production capacity is 8.5 crore doses per month. That is, 6.5 crore doses per month for Serum Institute of India and 2 crore doses per month for Bharat Biotech. So, we should have administered 8.5 crore doses in May. But the actual administered doses were about 6 crore only. Now, look at the month of June. We said that we will have 12 crore vaccine doses -- the target that was put out by the Union government. Until now, about nine crore people have been covered. Only a few more days remain in the month. Will we reach 12 crore doses? This means the monthly targets put out by the government are not based on actual production capacities of producers. There are many grey areas, particularly in the production figures of Covaxin as put out by Bharat Biotech.
There have also been discussions regarding indemnity to foreign vaccine makers. How does an indemnity affect the pricing and availability of vaccines in India?
This is the basic problem that you will have when your vaccine companies are largely private. Vaccine companies which are private in nature will ask for indemnities. In those cases, where the government has had no role in investing in these vaccine companies, the government usually is unable to force these vaccine companies to agree to the indemnity clauses as it desires. So, basically this is a problem across the world. Across the world, governments have tried to address this problem by leveraging the early public investments made in these private companies towards R&D, towards the capacity expansion etc. Using this leverage, they try to force these private companies to agree to lighter indemnity clauses.
Many countries in the West also have created funds by shaving off a small portion from the price paid to these private vaccine companies. Any adverse effects on health are sought to be addressed through compensations from this fund, which is accumulated over time. So, different countries do it in different ways.
Clearly, in India, we do not have any fund like this. So, the government is right in arguing that the company should agree to a waiver of the indemnity clause. But then the companies will not agree. So, the government should follow the best practices followed across the world. They should look for innovative solutions to this problem, even as they ensure that availability of vaccines is not adversely affected by these conflicts.
The free-vaccine to all citizens above the age of 18, from the 75 per cent vaccine procured by the Centre – will this ensure equality in access to vaccines?
It does not, because it is only 75 per cent and not 100 per cent. The question is whether you are able to provide vaccines free of cost to the maximum number of people or not. Clearly, the pricing strategy adopted by the companies, and agreed to by the Union government, which survives in the form of exorbitant prices for the 25 per cent quota of private hospitals, militates against this objective. That is why we are arguing that it is an inequitable policy. The policy can be equitable and non-discriminatory, only if 100 per cent of the procurement is undertaken by the Union government and such vaccines are universally provided free to all sections of the population.
How do frequent policy changes impact the inoculation drive in the country?
The vaccination drive in this country, because of frequent policy changes, has been made very ad hoc in nature. There is absolutely no certainty in the vaccine policy. This is partly because of a completely confused state of mind of the government, which has refused to listen to public health experts, economists, and experienced civil servants.
The Union government did not have a clear idea about how the vaccination drive should proceed. Politics was privileged over science and reason in deciding policies. This was inimical to the evolution of an efficient, transparent and equitable vaccination drive. Of course, India has mismanaged the pandemic itself in the long run because vaccination is the most important instrument available to governments now to reduce the impact of the second wave and also counter a possible third wave. The slower you vaccinate your people, the more you will be vulnerable to future onslaughts of the virus. As a result of this ad hoc and poor planning for vaccines, the Government of India has left Indian people far more vulnerable to the virus compared to many other countries of the world.
What is the practical approach to streamline the vaccination process and ensure that every citizen gets vaccinated?
To begin with the Government of India has to take immediate and urgent steps to raise the production and availability of vaccines. It has to allow for a larger and diversified basket of vaccines in India. It should ensure production capacity is raised on a war footing. It should allow maximum number of public sector enterprises in vaccine production to enter the market and start production of Covid vaccines. This is the supply side.
On the demand side, first, the government should take steps to ensure that the problem of vaccine hesitancy is nipped in the bud. Secondly, access to vaccines is extremely important and this is where our petition tries to make a point. To make vaccines available to the largest number of people in the most transparent, efficient and equitable way requires that the Union government procures 100 per cent of the vaccines and then provides them free and universally to all people living in this country. These are the broad steps required going forward from where we are now.
Also Read: ‘Centre’s re-revised policy continues to allow inequity in access to vaccines’
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