Covid-19 vaccine: The accessibility challenge

January 16, 2021 will go down as the day India started the largest vaccination programme in the country’s history.

While this is the first phase of the roll-out, which will seek to target at least 300,000 healthcare workers spread over 2,934 sites across the country, a larger deployment for the masses is expected soon. In that scenario, a big question is the issue of accessibility. India’s rural population is vast, and according to the latest findings from Gaon Connection Insights, a rural research platform, nearly 26% of households surveyed have confirmed that their family members were tested for the Coronavirus. A whopping 59% reported that at least one person in their household had tested positive for Covid-19. And with such deep penetration of the virus in the community, the question of accessibility of the vaccine acquires even more importance.

“The roll-out of the vaccine is a huge mountain to climb, and I am not sure to what extent our government, our various state governments, are prepared in order to climb it,” says Neelesh Misra, founder of Gaon Connection. Misra argues that this is not because of any fault of the government, but the sheer scale of the country. Added to this scale is also the question of purchasing power. India is still a country where a large percentage of the country’s demography lives below the poverty line. And this directly affects who can buy the vaccine and who cannot.

According to Gaon Connection’s survey, 44% of the respondents said that they would pay for the vaccine as and when it is out. But here’s a catch. When the same question was asked to those who are below the poverty line (BPL), only 37% of BPL card holders pointed out that they were willing to pay.

Nidhi Jamwal, deputy managing editor of Gaon Connection, argues that this 44% figure in itself isn’t large, but there are nuances hidden in it. “Yes, almost 44% of people we surveyed said that they were willing to pay for the vaccine, but at least two-thirds of this figure said that they would want the vaccine to be priced at ₹500 or less. And, as for the figures from those who are below the poverty line, it is not surprising that a majority wouldn’t want to pay for the vaccine,” she says.

Moreover, all the vaccines, including the two candidates approved for the roll-out, come in two doses. The survey results show that only 5.3% of households surveyed said that the cost of the vaccine didn’t matter and that they would go for it at any cost.

Economics and the roll-out

Experts argue that the problem of accessibility is more complicated than the simple question of providing a subsidy.

“Accessibility isn’t just who is willing to buy the vaccine but also how they will get it,” explains Misra. He argues that for the roll-out to be smooth, the onus is on the government to ensure that black-marketing of the vaccine is curbed from the first day. “If the roll-out to the masses, whenever that begins, is not smooth, then we might again get into that era of long queues. Or, a system where those with means and reach, will somehow manage to acquire the vaccine, and those at the bottom of the ladder would be left without it. These are the problems the government needs to close at the very beginning,” Misra says.

But although the Covid-19 vaccination programme is the largest one the country has seen so far, it would be wrong to say the country doesn’t have expertise in driving a large-scale immunisation campaign. The best example that experts cite is the pulse polio campaign. Misra points out that pulse polio was a success, but it wasn’t that it didn’t have problems in the beginning. In fact, other health experts have pointed out that during the time when it was rolled out in 1995, problems like inaccessible geographic terrains, high population density, poor sanitation, and the push-back from a certain section of the population were barriers the government had to face at the outset.

Economists assert that for the Covid-19 vaccine campaign to be successful, it needs to be driven by the country’s public health system.

“India's immunisation programme is a good example of how a public health system can be marshalled on a mass scale,” says Reetika Khera, who teaches economics at the Indian Institute of Technology Delhi. “The government must approach this as a public health issue where positive externalities (i.e., where the benefits of vaccinating someone extend beyond that person) necessitate government intervention. To begin with, in the mass roll-out, the government ought to provide it free for all economically and medically vulnerable groups,” she adds.

Khera’s views are echoed by Anant Bhan, a researcher in global health and bioethics. “Our healthcare system has indeed become largely privatised of late, but there is a general consensus amongst experts and economists that for this to succeed, it ought to be through the public health system,” he says, emphasising that the vaccine also needs to be free for the marginalised sections.

Jean Dreze, an economist who is a former member of the National Advisory Council under the previous United Progressive Alliance (UPA) government, concurs. “The poor bore the brunt of this pandemic the most,” he says, adding that the vaccine should be offered free to the poor.

Dreze adds that any kind of targeting system has in-built exclusion errors within it. “Any targeting system is bound to involve substantial exclusion errors. One might argue that exclusion errors may not matter so much, because it is not necessary to vaccinate the whole population in order to achieve collective immunity. But targeting would still be unfair to poor people who are excluded, in the initial phase when collective immunity is still far off, and that phase could last a long time,” he adds.

But some economists also point out that any kind of government subsidy is tied with the kind of vaccine the government is procuring. For Sakthivel Selvaraj, director, health economics, financing and policy at Public Health Foundation of India (PHFI), a subsidy involving vaccines requiring a complicated logistical system and cold chain storage than, say, the Oxford vaccine would not be possible.

So far, some states have announced their intentions of giving the vaccine for free. Though the mass roll-out is still some time away, the question of accessibility and equity has become more pronounced than ever.