By Dr Chandrakant Lahariya
Vaccines come with positive externalities since the benefits extend beyond those vaccinated. That is, if enough people are vaccinated, even those who haven’t got the vaccine are less likely to contract the disease. It is this for this reason, amongst others, that vaccines are considered a ‘public good’. The consensus is that a ‘public good’ should be provisioned through governments and paid for collectively through taxation (in other words, people should not be made to pay for them). As the world is fighting a deadly pandemic, the vaccines are more relevant than ever. It must be this thinking that is behind the US, which has one of the most privatised and expensive healthcare systems, choosing free vaccinations for all citizens. This is a sort of first in their healthcare system.
After licensing of two Covid-19 vaccines, India launched its nationwide vaccination program on January 16 this year. In the first phase, three crore health and essential services workers were targeted for vaccination. Starting March 2021, everyone aged 60 years and above, and those older than 45 with comorbidities will receive the vaccines. In this new phase, those getting vaccines at a private facility will have to pay. However, the vaccination will be free of cost at government facilities.
India is entering into this new phase with a recognised challenge of vaccine hesitancy. Five weeks into vaccinations, though there is higher vaccine acceptance, the challenge persists. In this coming phase — interplay of hesitancy with the need for payment for vaccines — will play out and its effect on coverage will be known in the weeks ahead.
In this phase, there is also a ten-fold increase in vaccination sites in the private sector from the existing 2,000 to 20,000 and a marginal increase from 8,000 to 10,000 in government facilities. Twice the number of vaccination sites in the private sector than in government means three-fold higher access to vaccination for those willing to pay. Considering that a large proportion of the vaccination group comprises people 60 years and above, and most of them do not have any fixed source of income, for them, a government facility will be the only option. As more people are likely to choose government facilities which are less in number, the time to get them vaccinated could be longer. This will create a vaccine inequity, where even with the equal need, people with higher purchasing capacity are likely to have easier access to vaccines.
The other option for those older than 60 could be that, some earning member in the family covers the cost (of vaccination) in the private sector. This transfers the power to decide their own vaccination in the hands of someone else. Both scenarios put the elderly at a disadvantage. The government provisioning Covid-19 vaccines as a public good and covering the cost of vaccines, irrespective of the site of vaccination — public or private — would have been the right approach.
Essentially the approach to vaccination is very similar to private sector engagement for Covid-19 testing and treatment services in the early period of pandemic in India. Soon after, there were reports of nonadherence to standard operating processes for testing, unaffordably high price for testing and treatment, and refusal to cater to some patients. The Covid-19 vaccines have similar situations of more demand than supply. Vaccines being a medical product, challenges faced in sourcing in ‘investigational therapies’ and ‘repurposed drugs’ also need to be recalled. There were reports of non-availability, overcharging and black marketing etc. After initial few weeks, these challenges were tackled with government interventions such as price capping, stringent monitoring and regulation. The learnings from each of these experiences would be helpful in the vaccine rollout. Yet, these measures should not result in unnecessary harassment and excessive reporting burden for private sector facilities.
It is widely acknowledged that government spending on health in India is one of the lowest in the world. Often the limited absorption capacity (for additional funds) of the health sector is lamented. The government funding for Covid-19 vaccines was not only the right thing to be done in a pandemic but was also an opportunity for the government to spend.
India has a vast private sector, and its involvement in Covid-19 vaccine delivery is a step-in the right direction. Government footing the vaccination bill on behalf of the people, even at private facilities, could have been a powerful private sector engagement with public purpose. That would have created equal access for all, irrespective of paying capacity.
In the last one year, a few Indian states such as Kerala, Bihar, Madhya Pradesh and a few others had announced free Covid-19 vaccines for eligible beneficiaries. It is to be seen whether these states will keep their promise. The policy interventions of Union and state governments and promises made and kept during the pandemic period will determine the future of health care in India.
( Dr Lahariya is a public health expert and co-author of ‘Till We Win: India’s Fight Against The Covid-19 Pandemic’)