Representative image. Photo: Reuters/Baz Ratner.
Prime Minister Narendra Modi recently held a high level meeting to review planning for a vaccine against COVID-19, as and when one becomes available. Many researchers around the world are currently focused on developing a vaccine, so preparing for effective distribution and utilisation in advance is welcome. There are five particular ways in which India needs to prepare itself – and right away.
1. We must develop an accurate directory of all available healthcare providers, in both the public and private sectors, and of health facilities, payers, geographic/administrative areas, and administrators. The directory will be required to plan and monitor vaccine distribution and delivery. A line list of all health providers in each health facility and geography on day one of the vaccination campaign will also help with prioritisation.
2. Along with the directory, a complete population enumeration will help identify vaccine requirements, draft geographical targets, develop vaccination schedules and monitor coverage. This will obviously be a huge effort, so the pandemic may justify the Indian government’s use of the 2011 census database, and we must debate and finalise the policies that will guide their use. A population enumeration will also help identify high-risk groups that in turn will help with prioritisation.
3. We need a single system to track vaccines from factories to health facilities to, ultimately, those who receive the vaccination. Such an end-to-end system is critical to ensure actual vaccination and prevent fudging of data. There are two ways to track the progress of the existing routine childhood vaccination programme, and they don’t talk to each other. So there is always an information discrepancy that results in an incomplete understanding of vaccination efforts. We should learn from our experience of these programs and create a unified system.
4. India needs to digitise all the data pertaining to (1), (2) and (3) or the scale of efforts could quickly get out of hand. We should fully develop and test digital systems before the first vial becomes available for public use.
5. We must procure the requisite resources – including human, hardware and infrastructural – on a timely basis, including those required to maintain cold chains, plus mobile phones and data plans for all frontline vaccinators to provide real-time data. We will also need to train providers to manage vaccine-related side effects at the primary level, provide educational and awareness materials for receivers in different languages, develop a citizen grievance mechanism and hire independent agencies for quality audits. As vaccination for COVID-19 will be technically be additional work for vaccinators, the state has to finalise an incentive system to motivate them. A coordinator could be identified from the existing cadre of public health officers at every district whose only responsibility could be to prepare the district for vaccination en masse.
We need to start doing these things right away – even when we don’t know whether and when a COVID-19 vaccine will be available – for a reason. India’s capacity to execute a large-scale vaccination drive has benefited from its experience with childhood vaccination programmes. However, after three decades, the country’s vaccine coverage was only 62% in 2015, according to the National Family Health Survey. It would be foolish to expect better or even comparable coverage for a totally new COVID-19 vaccine for a ‘client’ base many times larger than that for childhood vaccines. So it will be too late if we wait for successful vaccine development. In fact, haphazard vaccine delivery may end up causing social upheaval, political unrest and inequitable use of vaccines.
At the same time, completing preparations on time is another challenge. Fortunately, we already have experienced frontline health workers in place in rural areas. With political will from the highest level, we can borrow their expertise and wisdom. We have a weak urban health system, so we must develop separate plans for urban areas, especially for COVID-19, whose causative pathogen has spread wider through cities than through villages. The government can partner with civil society for last-mile reach, with international agencies to learn from routine vaccination programmes, with academic organisations for evaluation and audits, with PR agencies to develop effective communication tools and with technology companies to develop search and monitoring platforms.
We do incur some risks. For example, we may not have a vaccine at all. However, the aforementioned initiatives can also help fortify India’s public health system towards achieving sustainable development goals related to health. Many of these recommendations are already part of Ayushman Bharat and National Digital Literacy Mission. Preparing for a COVID-19 will also force us to identify high-risk groups and create interoperable IT systems, which constitute common-sensical activities even in non-pandemic situations.
At the same time, some other risks may not be so benign. For example, a complete population enumeration may provoke anxieties about the needs and preferences of minority groups and marginalised communities, and may even revive concerns about the national population register. Therefore, effective communication about the purpose of enumeration will be essential.
India has an opportunity to set an example to the entire world about how a country can be ready for the day when a vaccine becomes available. Since preparing for that day will take at least a few months of effort, let’s start today.
Dr Shrey Desai is a physician and public health researcher at SEWA Rural, a voluntary organisation, in Gujarat.