As 2020 comes to a close, there is some hope on the horizon on the pandemic front with several Covid-19 vaccines in the offing. In an email interview with News18, noted economist and former deputy chairperson of the Planning Commission Montek Singh Ahluwalia shared his insight on what shape the vaccination programme may take in India, the impediments that may arise and how to overcome them.
Q1. Are you optimistic about the vaccination programme?
A. I am very glad that the government is planning a massive public vaccination programme and consulting with the states. The scale of what we have to do will dwarf every country except China. We don’t have to vaccinate the whole population. Seventy percent will do to develop herd immunity and we shouldn’t include children under 10 or pregnant women since none of the vaccines have been tested for safety for this group.
But that still means vaccinating almost 700 million people and if we do this within twelve months it will be acknowledged as a major achievement. It is good that the issues are being discussed internally and the states are being consulted. But there is much that still needs to be resolved. Which of several vaccines should we use? What is the relative role of the Centre and the states? How much flexibility will the states have? What will be the role of the private sector? We need to resolve these issues very quickly.
Q2. How do we choose which vaccine to use?
A. There are several vaccines under development all of which are likely come be available in the next few months, some earlier than others. These vaccines are based on very different technologies and have very different levels of efficacy and safety and this also varies by age group. And we won’t really know all this to begin with.
In the face of so much uncertainty it would be best to work with multiple vaccines to begin with and then narrow down as we learn more. The Prime Minister has said that on these issues we will be guided by scientific expertise and I think that is the right approach. We should rely on the experts in this area.
Q3. Is State-Centre coordination imperative for vaccines? Do you feel this could be a roadblock?
We have to recognise that it is the states that will have to bear the bulk of the burden of administering the vaccine, whereas it is the Centre that will be procuring it. So coordination is very important.
Front-line health workers are the agreed priority globally and the Centre will presumably vaccinate its own health workers in central government hospitals, but the numbers involved are very limited.
The overwhelming majority of the health workers in the country are in the state-run health system and this is also true for other essential services. More importantly, when we come to vaccinating the general public, it is only the states that can do it. The central government can lay down national guidelines for prioritisation but the actual identification of the individuals who meet those criteria has to be done by the state.
To do a good job, states must have early information of how much vaccine they will get and in what time phasing, so they can plan their vaccination roll-out strategy. The sooner the Centre indicates what vaccine supplies it has tied up, and how it will be distributed to the states the better. This is one example of coordination.
However, I would also emphasise that the desire to coordinate should not lead to inflexibility. One thing we have learned from the experience of centrally sponsored schemes in the past is that central ministries tend to lay down rigid guidelines which are often not suited for the ground conditions in the states and then try to enforce them mechanically. I hope the ministry of health will not do this. The scale of what needs to be done is massive and we should give the states flexibility, asking them to report on achievements in a regular manner.
Q4. On the issue of vaccines, the Punjab chief minister has said states like his should get priority as demographic structure means they have old people with comorbid conditions. Do you think demographic profiles can be one yardstick?
A. The important point is that the criteria for distributing the vaccine across states should be transparent. One can think of different criteria: distributing it across states in proportion to population, or in proportion to the rate or prevalence of infection, or even the fatality rate. The Punjab CM’s point is that Punjab has experienced a higher death rate because it has an older population.
Each state will favour the formula which gives it the most favourable result. One could adopt the approach the Finance Commission has traditionally done and use a combination of different criteria. These issues can be discussed with the states and a transparent formula adopted. Once adopted it should be followed to avoid allegations of unfavourable treatment.
Even if this is done, there will be controversial choices to be made. Suppose one state is faster in rolling out vaccination than another. Should the unutilised allocation of the slower moving state be assigned to the faster moving state until the pace picks up? All these issues can and should be discussed, perhaps in the next meeting of the CMs.
Q5. Should Covid vaccine be made a part of the national immunisation plan?
I am not sure what that implies other than that the vaccine should be given free. In my view, the vaccine from the public programme should be free for recipients. However, the national immunisation plan does not deal with adults and children (which are the main focus of our national immunisation program) are not the highest priority for Covid vaccination. In fact, I am told that children under 10 should not be vaccinated because none of the vaccinations have been tested for efficacy for this age group.
Q6. India’s medical infrastructure is weak. We would need experts to deliver the vaccine. Should the private sector be roped in for this?
A. This is a very important issue and I think we must work out a clear mechanism for involving the private sector. At present, the private sector accounts for the bulk of the medical treatment availed of by our citizens especially in urban areas. We can involve it in various ways.
As far as administering the vaccine is concerned, states could enrol approved agents from the private sector who would offer the vaccination to whoever wants it for a small fee, say Rs 100. Those who are only interested in a vaccination can get it free can go to the public hospitals and dispensaries, but others could go to their preferred private hospital or medical practitioner. AYUSH practitioners could be included in this group as also testing labs and registered pharmacies.
If the state government has made lists of eligible people with Aadhaar numbers, whoever is dispensing the vaccination can easily verify whether the person seeking the vaccination has an Aadhaar number which is eligible. The states should have the freedom to enrol private entities to support their effort.
I think there is also a broader role for the private sector in which it is recognised that there will be a free vaccination programme in the public sector, but it should be accompanied by a parallel private sector delivery channel, in which duly approved vaccines can be administered by charging a fee. The public programme should obviously have priority in getting supplies, but not all vaccines available will be taken up by the public programme.
Certainly the more advanced vaccines being developed abroad, such as Pfizer and Moderna are unlikely to be picked up by the public-sector programme, because they are more expensive and also require sub-zero storage conditions. However, some of our private hospitals, especially in the metros, may be able to provide these conditions. If these vaccines receive regulatory approval, there is no reason why those who want them and can afford the price should be denied access.
We allow import of advanced medicines in the interest of Indian patients. This principle should also be followed for vaccines and the new vaccines being developed should be allowed to be imported subject to regulatory approval. Supplies of these vaccines may not be readily available in the early months because developed countries have pre-empted available supplies but this pressure will ease in the next few months. Many advanced countries have tied up supplies several times their total need because they were not sure which would get approved.
Allowing higher-priced imported vaccines to come in may be criticised by some sections because it allows higher income individuals to get better access but this is true of medical facilities generally. Closing this window will only push high-income individuals to go abroad to get them. It would be much better to allow them to be delivered in Indian private hospitals. Much better to have them delivered in private hospitals in India which could even attract tourists from neighbouring countries as a form of “vaccination tourism”.
The private sector channel need not be limited to imported vaccines alone. They will also be able to get supplies from domestic producers in due course because the public programme may not take up all the supply that will become available as multiple producers start producing.
Q7. Should the price for vaccines be uniform?
A. There is no logic to enforcing a uniform price for producers of all vaccines. The cost of producing different types of vaccines varies and we have to allow producers to recover costs and earn a reasonable profit margin. I should emphasise that the vaccine should be completely free for recipients in the public sector programme. For the rest, we should follow the same principles that we do for drugs in general. If a drug is subject to price control the price is fixed on the basis of costs plus a reasonable margin.
I would advocate not imposing price control on a vaccine in the first two years. If we plan to provide the vaccine free to a large percentage of the population, that will set a benchmark which will prevent excessive pricing.
Q8. Shouldn’t Covid vaccines be made compulsory so as to stop spread?
A. I don’t think making the vaccine compulsory by law is feasible or desirable. It could be made a condition of employment in the government, and the corporate sector could do the same for its employees. Hotels and restaurants and shops could advertise that their employees are all vaccinated.
It could become compulsory for international travel just as smallpox vaccination used to be, but I suspect this will not be felt to be necessary as the pandemic fades out. I don’t think it will be feasible to introduce proofs of vaccination before boarding buses, or metros, or even trains.
This raises a broader point. People often say that everyone wants to be vaccinated but there are many who have doubts about safety and will wait until they are sure about side effects. The vaccines have not been tested for as long as they normally would have been because of urgency. So we need a communication strategy to convince people that the vaccination is safe.
We also need an active strategy for publicising vaccination. Having the usual prominent people vaccinated in public on TV will help. Even more important will be to have Bollywood stars and sports stars do the same.
Q9. Who do you think should get priority to get vaccines? Many young have also succumbed to Covid. So should only the old be the priority?
The national guidelines announced by the Prime Minister which puts front-line health workers first and other essential workers next followed by the elderly, especially those with comorbidities, is in line with international practice. However, I realise there is room for variation even here.
Some experts have pointed out that if we want to protect those most at risk then giving priority to the elderly is correct but if we want to limit the spread then protecting younger people who go out to work may be more important. States should have some flexibility on these issues in my view
Q10. About finances, how should the Centre and states share it?
A. I have already said in an article in Mint that in my view the Centre should bear 100 per cent of the cost of the vaccines and syringes in the public programme. The states will also incur some costs in administering the programme and we know their financial position is under great strain. I do not know whether the Finance Commission has made any recommendation on this issue – we have to wait and see when the report is released. But I think the Centre could introduce a grant to help the states administer the vaccine, at least for the first year.
This will increase the fiscal deficit next year but I don’t think anyone will criticise the decision.
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