Taking stock of India’s COVID-19 vaccine procurement situation
For India’s COVID-19 vaccination roll-out to be successful, the government needs to start publishing timely open public procurement data about the entire vaccine supply chain.
The second wave of this pandemic is upon India and we have taken over the rest of the world in number of cases and number of deaths. The loss felt by us in the last two months has been staggering and we will continue to feel this loss for many generations. What went wrong?
Most of the measures we need to resort to combat this pandemic have been eerily similar to the measures taken ninety years ago during the Spanish Flu — washing hands, social distancing, masks, and rudimentary contact tracing. The one thing that has stood as a new and powerful addition in our arsenal has been vaccine production. The process of developing a vaccine is incredibly complex and time consuming and over the past year it has been sped up at every stage: faster creation of viable vaccine candidates, clinical trials, approval, large scale manufacturing, and distribution. A process that usually takes anywhere between 4 to 5 years was managed within barely a year. Everywhere in the world COVID-19 vaccines are being approved, manufactured, allocated and distributed at unprecedented rates. To ensure accountability within this process , equity in distribution and to counter the fragility of this entire situation, it is important to have data on everything — especially around how different government buy goods, works, and services related to the entire vaccine supply chain.
With the approval of almost 20 different vaccine sources and confirmed purchases of over 9 billion vaccine doses, the scale and complexity of this global operation comes with risks that threaten public health. The fast paced research and procurement cycle means that there are various opportunities for faulty distribution systems, theft, corrupt procurement systems, and favouritism. These areas for corruption must be identified and addressed to create equitable and safe access to the vaccines and ensure efficient use of public funds depleted by the emergency response. This can be done by publishing the details of the purchase and distribution of the vaccine in an open and transparent manner.
Even under normal circumstances, public procurement is the biggest risk for corruption within the government and the healthcare sector even more so with pharmaceutical shortages, inflated drug prices, and the distribution of falsified and substandard essential medicines. The pandemic has amplified this situation.
The one thing that can help turn this situation around is a mass vaccination program. India has successfully pulled this off at least once before with Polio. India’s intensified vaccination drive over the last few years means that it does have some infrastructure in place already. However the scale at which manufacture, storage, distribution and vaccination must occur now is a whole different beast. The government has vowed to vaccinate about 300 million people or 600 million doses by August 2020. We are now halfway through this timeline, in the middle of a tsunami of a second wave and the government has only managed to reach 20% of this target. The growing second wave could have been eased greatly with more vaccines.
India’s vaccination strategy:
To understand the situation, we must first look at the country’s vaccination strategy.
It occurred in three phases:
Phase 1 was from January 16th to March 1st and involved vaccinating healthcare workers and front line workers. To date, of the 30 million Front Line Workers and Health Care Workers meant to be vaccinated, around 14.8 million people have had both doses.
Phase 2 which started from March 1st to May 1st targeted 45 yr + age groups and to date have vaccinated around 27 million people with two doses.
Phase 3: On the 19th of April, the government released the “liberalized pricing and accelerated National covid-19 vaccine strategy” which came into effect on the 1st of May announcing to an already vaccine deficient nation than all people between 18–45 could also get vaccinated. Till date — 8 million people have gotten their first dose (around 1.3% of the 18–45 yr age group)
Also according to this strategy, 50% of the vaccine stocks released each month would be released to the central government and the other 50% could be distributed (at a price set by the manufacturer) to states, private hospitals and companies.
While the eligible population (over 45 years, HCW’s, FLWs) can get the vaccine for free, the rest of the country would pay a price. The centre would distribute its 50% as it sees fit. Finally, all vaccinations have to happen through the CoWin platform.
For such a strategy to work, releasing and monitoring data on a few aspects becomes very important
- Public health infrastructure for vaccinations
- Procurement capacity and distribution pipelines for the vaccines
India’s public health infrastructure for vaccinations
Last mile delivery of vaccines
The Indian rural health care system is a three-tier system comprising Sub-Centres, Primary Health Centres (PHC), and Community Health Centres (CHC). Even before the pandemic, there was a 18% shortfall in Sub-Centres, 22% in PHCs and 30% in CHCs . It is estimated that in rural India, there are around 3.2 beds for every 10,000 individuals.
The Universal Immunization Program (UIP) which was started in 1985, through which the vaccination is rolled out vaccinated around 26 million infants and 29 million pregnant women every year with around 12 million sessions. In India these vaccinations are usually driven by Auxiliary Nurses, ASHA workers, and Anganwadi workers. The nurses conduct the vaccinations while the ASHA workers and Anganwadi workers gather the citizens and create vaccination drives. There are around 2.1 Lakh ANM’s across the country which is a shortfall of about 10,000. There are at least 5000 sub-centres that do not have any ANM’s . Of the 2.1 lakh nurses, only half of them have been assigned COVID-19 vaccination duties.
There is a need to improve last mile delivery in the form of more training, more infrastructure, and more nurses. Especially if the government is to keep up the promise of vaccinating 30% of the population by August 2021. This is four times the number of doses that have been administered so far. An added complexity is that two doses of the vaccine is required for there to be effective protection, and the government’s response to this has been a technological one (with the CoWin platform being used to register and keep track of vaccinations) which will alienate almost 50% of the population
As of today, there are more than 400 tenders published on the Indian governments public procurement portal (Mar 2020 — May 18 2021) toward healthcare centre construction and maintenance. The following is a map of where most of the tenders are located and as it can be observed while some states like Haryana have published more than 150 tenders to construct and maintain health centres, large vulnerable parts of the country have not published anything.
Procurement capacity and distribution pipelines for the vaccines
Distribution pipeline
Cold Chain Infrastructure (A cold chain is a temperature controlled supply chain from production to delivery): The approved Indian vaccines (unlike the Pfizer vaccine) have the advantage of being stored between 2–8 deg c, temperatures that are easier to work with and transport.
There is some cold chain capacity (in place largely because of the polio vaccines) of 29000 cold chain stores across India and with 37 million tonne capacity in the form of Walk in Coolers, Walk in Freezers, Deep Freezers, Ice lined refrigerators
However, they are distributed non-uniformly across the country (as is observed from the figure below). Most cold chain operators have less than 5,000 tonne capacity and few of them are in compliance with World Health Organization (WHO) norms.
This system is now dealing with significantly more vaccine stock — and acutely so (about 6–8 times more than a normal year). There is a need for procurement of cold chain management and transport supplies across the country. Public procurement of these supplies (like cold chain carriers, back-up power generators) needs to be done in an open and transparent manner for equitable distribution of these commodities across the country.
Cold chain management tenders can be found on the public procurement portal (Mar 2020–18 May 2021) from across the country either hiring, construction, or maintenance of walk-in freezers, vaccine carriers and cold rooms. The map below indicates the frequency of cold chain tenders from the portal(specifically for health) over the past year across the country. This is clearly not an exhaustive list of all cold chain tenders but just the ones that are published.
Procurement of COVID-19 Vaccines
Lastly, procurement of vaccines needs to be monitored. Especially, during a crisis such as this where speed is of the essence, the risk is amplified.
Vaccine procurement is particularly vulnerable as public pressure to respond fast is increasing. A fully transparent process to vaccine purchases will help provide accountability at each stage off from production to the shot in the arm. This helps reduce corruption by providing the public with information on who is buying what, how much, from whom, and at what price.
Difficulties in vaccine procurement, management and last mile delivery will affect the most vulnerable populations the most.
Most of the information from the Union government about the procurement of vaccines currently is through press releases and therefore hard to track or monitor.
Here is what we know so far…
The Budget
In India, the finance minister has promised over Rs 35,000 crores toward COVID-19 vaccines in the 2021–22 Union Budget (not all of it is accounted for in the detailed budget documents yet). This accounts for about 47% of the budget for the Ministry of Health and Family Welfare this year — or about 1.5% of the country’s GDP. This should be enough to vaccinate the entire population but according to the latest vaccination strategy the states are required to carry out the bulk of the vaccination, with 50% of the released vaccines. What will happen to the rest of the budgeted amount is still unclear and how the vaccines will be procured by all the states is still unclear. However, one thing is certain, as some states already start floating global tenders worth millions, this is going to cause inequity in vaccine distribution.
The only way to deal with this inequity is to be transparent and publish all the contract information for vaccine related procurement in a timely manner across states and the centre.
Vaccine Manufacture & Procurement
India, along with other countries, has already begun procuring vaccines and vaccinating individuals.
However, in India, even though there is an e-procurement portal and some loose guidelines in place, there is no accountability or information about the COVID-19 vaccine and related procurement on this portal. The data available is not in a format that can be analyzed. Across the country, there seems to be an instinct for opacity. All information about vaccine procurement is shared through press releases which the government strictly controls. This makes it very difficult for any measurement or monitoring.
According to this press release, to date the Indian government has purchased over 290 million doses of the COVID-19 vaccine and already spent an estimated amount of ~ Rs 5900 crore on procurement of COVID-19 vaccines.
According to press releases from the 3rd of May, about 95 of 120 million doses had been delivered by the primary vaccine manufacturers and the government placed another order for another 150 million doses over May, June, and July. As of the 18th of May, The centre had also distributed around 207 million doses of vaccine to the states of which 183 million have been used already. All of the information is obtained from images on press releases. Instead of obfuscating this information, publishing all the contracting data for the vaccine doses bought till date (by the centre and states) will help with the planning and monitoring of the vaccine roll-out.
The two main vaccine producers cumulatively make around 90–100 million doses each month. Currently, there are 19.5 million doses of vaccine available across the country until the end of May and 7.2 million doses available for direct procurement by the states. At current vaccination rate of ~ 1.5 million doses/day (compared to ~3 million doses/day earlier this year) these vaccines are likely to last an optimistic estimate of 20 days before states run out of vaccines again. Currently, a few states (Uttar Pradesh, Tamil Nadu, Kerala, Odisha, Jharkhand) have also started floated global tenders for COVID-19 vaccine procurement for a cumulative of 200 million doses. This is a step in the right direction that the Union government can learn from. Other than instilling trust in governance, this gives citizens the possibility to track the availability of these vaccines from the beginning of the contracting life-cycle as well as monitor the vaccine situation for the state.
States having to procure their own vaccines will lead to inequitable distribution of these doses, as different states will have differing levels of access to the COVID-19 vaccine because of their geography, socio-economy, daily case load, positivity rate.
If one word could encapsulate the current vaccine roll-out situation — it is confusion. There is a real need to ramp up production and procurement of vaccines across the country and this needs to be done transparently. Open Data is the only way to get to a more robust public health sector for the country. We need open public procurement of vaccine related tenders across the union and the states.
One of the biggest risks during any disaster is a lack of trust and, since the onset of this pandemic, one thing that has been continually asked of Indian citizens is trust. Trust when a country of a billion people are asked to go into a lock-down and lose their only source of income, trust when businesses have to shut down and stay shut for months at end. Trust that things will improve if you stay inside your home. For this degree of trust to work, there needs to be transparency from the agencies requiring this trust. In this case: governments. Government transparency is necessary so as to not slip into inadvertent totalitarian behaviour. Instead of a black box that is emergency procurement, what the country needs now is more information.
Timely, dis-aggregated information is necessary so that citizens, civil society organizations, journalists and the government itself can track spending toward relief measures. Transparency may not change the rate of vaccinations in India, but it will help build the trust needed for this herculean effort to be successful.
