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Why India’s Vaccine Prospects in 2021 Continue To Be Bleak

Why India’s Vaccine Prospects in 2021 Continue To Be Bleak

A notice about the shortage of COVID-19 seen at a vaccination centre in Mumbai, April 8, 2021. Photo: Reuters/Francis Mascarenhas

On June 26, 2021, the Government of India (GoI) submitted a second affidavit to the Supreme Court of India on the progress of India’s COVID-19 vaccination drive. This affidavit expands on some points made in the first affidavit and provides new information on India’s vaccine strategy. The most important takeaway from the affidavit is regarding vaccine production and availability.

To begin with, let us list some facts in chronological order.

Early estimates and claims

In March 2021, GoI told a standing committee of the Rajya Sabha that Serum Institute of India (SII), which produces Covishield, had a production capacity of 70-100 million doses per month. Other press reports suggested that the SII had a capacity of only 60-70 million doses per month, which may rise to 100 million doses per month in May 2021. GoI also told the standing committee that Bharat Biotech (BB), which produces Covaxin, had a production capacity of 5-10 million doses per month. Press reports put BB’s capacity at 6 million doses per month, which may rise to 15 million doses per month in May 2021 and 58 million doses per month by December 2021.

Putting together these numbers, India should have produced a minimum of 76 million doses per month in April 2021. In fact, India administered 88 million doses in April, facilitated by a draw on the stockpiles accumulated by SII between January and March. Further, the monthly aggregate for April concealed intra-month variations. One-third of the doses in April were administered in the first week of April. After April 7, the vaccination rate fell from 50 lakh doses per day to an average of 27 lakh doses per day.

The acute shortage of vaccines in April 2021 led to major changes in the strategy. First, GoI agreed to provide Emergency Use Approval (EUA) to more “foreign” vaccines in addition to the two “Made in India” vaccines. Secondly, a “liberalised vaccine policy” was introduced on 19 April. The ill-thought-out 50:25:25 ratio of allocations across GoI, State governments and private hospitals was rolled out w.e.f. 1 May, and market prices of vaccines were allowed to triple and quadruple.

The continuing crisis in May

The growing crisis of vaccine production and the irrationalities unleashed by the liberalised vaccine policy made May 2021 a miserable month. First, the total number of doses administered fell from 88 million in April to 60 million in May. Daily vaccination rates in May averaged just 1.9 million doses per day. Secondly, state governments failed to procure vaccines directly from producers. Thirdly, most of the allocations for private hospitals were usurped by a handful of large corporate hospitals in big cities.

In sum, the liberalised vaccine policy was assessed as disastrous. The Supreme Court called it “prima facie arbitrary and irrational” in an interim order.

On May 9, 2021, GoI had submitted a first affidavit to the Supreme Court of India. In this affidavit, GoI claimed that SII could produce 65 million doses per month and BB could produce 20 million doses per month. If these numbers were true, India should have produced 85 million doses in May. However, only 60 million doses were administered in the month. Something was seriously wrong.

At this juncture, GoI claimed that it would administer 120 million doses in June 2021. In other words, the vaccination rates would double from 1.9 million doses per day to 4 million doses per day. GoI did not stop there; it made two more claims. One, a total of 516 million doses would be administered by July 2021. Two, 2.16 billion doses would be administered between August and December 2021. However, these announcements were received with disbelief given the past record of failed claims and promises.

The improvement in June

To GoI’s credit, it administered 118 million doses in June 2021. However, there were significant intra-month variations in the vaccination rate. Over the first 20 days of June, vaccination rates rose only moderately to 3.1 million doses per day. In the remaining 10 days, the vaccination rate jumped to 5.5 million doses per day. It was this last-week blitzkrieg of vaccinations (specifically, between 21 June and 28 June) that helped GoI achieve the target for June.

This last week of June was important for GoI. On 7 June, GoI had announced a partial rollback of the liberalised vaccine policy. From 21 June, the 50:25:25 ratio was changed to a 75:25 ratio, with GoI directly procuring 75% of the doses and the remaining 25% left for direct purchase by private hospitals. This new strategy had to be inaugurated with a bash. Thus, curiously, the number of doses administered rose from 3.2 million on June 20 to 8.9 million on June 21. Daily vaccination rates moderated in the following days but continued to average above 5 million per day till June 28.

While GoI did manage to showcase the new vaccine strategy as a spectacle, many observers were unconvinced. According to one reasoning, daily vaccination rates were deliberately suppressed in many States for about a week till 20 June to show a sharp jump on 21 June. According to another take, the sharp jump in vaccinations between 21 and 28 June was achieved by a temporary but exhaustive draw from the stockpiles of vaccine producers.

These reasonings may not be wrong. In fact, after 28 June, daily vaccination rates fell again. In the four days between 29 June and 2 July, the average vaccination rate was only 3.6 million doses per day. It is yet unclear if the vaccination rates achieved between 21 June and 28 June can be sustained in July 2021.

It is here that the second affidavit submitted by GoI to the Supreme Court on June 26 comes in handy. The rest of this article deals with two questions. First, can GoI achieve the promise of administering 516 million doses by July 2021? Secondly, can GoI make available 2 billion doses between August 2021 and December 2021?

The claims for July

The affidavit arrives at the cumulative target of 516 million doses by July 2021 in the following way. GoI would receive 346 million doses through the three orders placed with SII and BB. Sixty-six million doses were ordered in January, 120 million doses were ordered in March and 160 million doses were ordered in April. In addition, it has received 10 million doses as part of its share as a beneficiary in the COVAX initiative. Together, these four sources take the availability to 356 million doses.

But where are the remaining 160 million doses going to come from? GoI placed a fourth order in June 2021, but the affidavit notes that supplies from this order would begin only from August. This is where the affidavit makes a leap of imagination.

On May 13, 2021, in a presentation made to the media, GoI had mentioned that it expected the State governments and private hospitals to directly procure 160 million doses as part of the liberalised vaccine policy of April 19. The second affidavit adds these 160 million doses to the expected supply of 356 million doses from the first three orders to arrive at a total of 516 million doses (see Table below).

Slide from GoI press conference, May 13, 2021

The problem, however, is that state governments and private hospitals never received 160 million doses, partly because there were not available in May and partly because the liberalised vaccine policy was partially aborted in June. In an annexure table, the affidavit itself provides the actual purchases by State governments and private hospitals in May: 42 million doses i.e., 26.4 million doses by state governments and 15.6 million doses by private hospitals. In other words, 118 million doses less than 160 million doses.

If we add the 42 million doses directly procured by State governments and private hospitals to the expected GoI procurement of 356 million doses, we get a total of 398 million doses and not 516 million doses. As on 30 July, India had already administered 330 million doses. Thus, what remains available for July is 68 million doses only. But GoI, the affidavit states, expects to administer 120 million doses in July.

The number of doses administered in July can rise from 68 million (what is available) to 120 million (what is claimed) doses under two scenarios.

The first scenario is if the orders that are to flow in from August begin to flow in from July itself. Here, we are talking of the part of the fourth order placed on 4 June. The affidavit estimates this supply between August and December 2021 at 440 million doses comprising of 250 million doses of Covishield and 190 million doses of Covaxin. SII needs to supply only 26.7 million more doses in July to meet its obligations under the three orders. If SII’s capacity is about 70 million doses a month, about 43 million doses of Covishield from the fourth order can be supplied by SII in July itself. This would take the availability from 68 million doses to 111 million doses.

Such generosity need not be expected in the case of Covaxin from BB. The affidavit reveals a rather pathetic performance by BB in meeting supply obligations. As on June 12, BB was yet to deliver about 1.8 million doses that were ordered by GoI in March. Further, of the 50 million doses of Covaxin ordered in April, the quantity supplied as on 12 June was zero. Until BB covered both these deficits, it cannot be expected to begin supplying from the fourth order. It is likely that BB may not meet its obligations under the third order even by end-July.

A second scenario is if adequate imports of Sputnik V happen to cover for other deficits. According to the affidavit, a maximum of 20 million doses of Sputnik V may be expected to arrive until July 2021. Of these 20 million doses, 3.3 million doses have already arrived and have been administered by June 30. What remains is 16.7 million doses. If we assume that all these 16.7 million doses would arrive in July, it can also be added to the availability.

Putting the two scenarios together – i.e. if both would hold true in July – 43 million doses of Covishield and 16.7 million doses of Sputnik V can be added to the figure of 68 million doses. It gives us a total of 127.7 million doses, which is marginally higher than the 120 million doses expected to be administered in July. However, it is unlikely that both the scenarios would hold true. If at least one scenario fails to hold true, the number of doses administered in July may be lower than in June.

Realistically, less than 120 million doses may be expected to be administered in July 2021. It translates to a maximum of 3.9 million doses per day, which would be far lower than the daily vaccination rates achieved between June 21 and 28.

Projections for August-December

Between the first and second affidavits, in a press conference on 13 May 2021, GoI had projected vaccine availabilities for the five-month period of August 2021 to December 2021. As per this projection, 2160 million doses would be available between August and December. Many, including this author, had criticised these projections as wrong and unrealistic. There were two reasons: one, the projected availabilities of the approved vaccines were higher than possible given the existing capacities; and two, many vaccines included in the projections were unlikely to be approved before December, as they were either in the second or third phase of clinical trials.

It appears the critics were right. In the second affidavit, GoI has admitted that the target of 2160 million doses was unrealistic. It has also brought down the projected availability to 1350 million doses, or to 63 per cent of the original claim. Vaccine candidates like Novovax, Gennova and BB Nasal were excluded from the second affidavit (see table below).

Slide from GoI press conference, May 13, 2021
Table from affidavit submitted by GoI to Supreme Court, June 26, 2021

GoI’s revised claim is that if 516 million doses become available until July 2021, and 1.35 billion doses become available between August and December, the total availability would be 1.86 billion doses, which would be close to the 1.9 billion doses required to administer two doses to everyone above the age of 18 years. It is on this expectation that many Union ministers claimed that India would fully vaccinate 100 per cent of its adults in 2021 itself.

We have already seen that 516 million doses are unlikely to be available by July 2021. In fact, the revised target of 1.35 billion doses for August-December 2021 may also be unattainable. Let us consider each vaccine separately below.

* Five-hundred million doses of Covishield are expected to be supplied by SII in the five months. This is realisable, but only if SII consistently supplies 100 million doses per month. In fact, SII had failed in supplying to its capacity in the months of April and May.

* Four-hundred million doses of Covaxin are expected to be supplied in the five months. This may prove to be a real Achilles Heel for GoI. BB will have to first supply the remaining 45 million doses committed under the second and third orders in July. Even this might be difficult, as BB’s current capacity is nowhere close to 20 million doses per month. The first affidavit of GoI had claimed that the capacity of BB would rise to 55 million doses per month from July. To begin with, this is highly unlikely. But even if we expect BB to spring a surprise on us, its total production in five months cannot exceed 250 million doses.

* Hundred million doses of Sputnik V are expected to be supplied in the five months. It is a fact that the Russia Direct Investment Fund has a contract with six Indian firms to produce 650 million doses per annum. This translates to 54 million doses per month. But what is unclear is how much of it will become available in 2021. At present, there is lack of clarity, particularly given that GoI itself has brought down the projected availability of Sputnik V from 156 million doses to 100 million doses between May and June. Even this quantity of 100 million doses is unlikely to materialise under the present conditions. An additional complexity is that the two doses of Sputnik V are different and require separate production capacities.

* The remaining expected supply of 350 million doses are of vaccines that have not been approved so far: 300 million doses of Corbevax from Biological-E and 50 million doses of Zydus Cadila vaccine.

* In the case of Corbevax, an order has been placed with an advance payment of Rs 1,500 crore. Some reports suggest that at-risk manufacturing has begun in June but GoI’s affidavit states that availability may be delayed till September. Mandated approvals are likely to be further delayed. Biological E reportedly has a production capacity of 75-80 million doses per month, although it is unclear by when the company will hit this speed. Other reports suggest that Biological E has been asked to stockpile doses between September and December. In short, all the 300 million doses are unlikely to become available by the end of 2021.

* In the case of Zydus-Cadila vaccine, the company has applied for EUA but has not been granted one yet. Production is expected to hit 10 million doses a month by mid-August. However, given past experiences, production at full capacity may be delayed by a few more months. As such, it is doubtful if 50 million doses will be made available by December 2021.

In all, considering possible disruptions and delays, it is unlikely that more than 800-900 million doses will become available between August and December 2021. This would be an improvement over the present. However, it would still leave India short by 600-700 million doses to fully vaccinate everyone above the age of 18 years.

By then, if vaccines are developed for those younger than 18 years of age also – i.e. close to 300 million persons – the task would be rendered more arduous. India would then need an additional 600 million doses to become available. In such circumstances, the task of fully vaccinating everyone in the population may extend to even 2023.

R. Ramakumar is professor, Tata Institute of Social Sciences, Mumbai.

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