Prime Minister Narendra Modi’s federal government has opened up vaccinations for some 960 million eligible Indians without having anything close to the required supply – more than 1.8 billion doses.
It has barely enough for two million jabs a day.
Everyone from age 18 to 44 now has to register on the government’s CoWin website to get vaccinated.
But hundreds of millions of Indians don’t have access to smartphones or the internet, without which it’s impossible to get a Covid-19 jab.
Poor planning, piecemeal procuring and unregulated pricing by Modi’s government has turned India’s vaccine drive into a deeply unfair competition, public health experts told the BBC.
It’s a puzzle how the world’s largest vaccine manufacturer, often dubbed the “pharmacy of the world” for generic drugs, ended up with almost no vaccines for itself.
“India waited till January to place orders for its vaccines when it should have pre-ordered them much earlier. And it procured such paltry amounts,” says Achal Prabhala, a co-ordinator with AccessIBSA, which campaigns for access to medicines in India, Brazil and South Africa.
Between January and May 2021, India bought less than 250 million doses of the two approved vaccines – the Oxford-AstraZeneca jab, manufactured as Covishield by the Serum Institute of India (SII), and Covaxin by Indian firm Bharat Biotech. At US$2 per dose, they were among the cheapest in the world.
Contrast that with the US or EU, who pre-ordered more doses than they required nearly a year before the vaccines became available.
“This guaranteed the vaccine manufacturers a market and gave them certainty to forecast supply and sales,” Prabhala says.
India has since ordered an additional 100 million doses of Covishield and 20 million doses of Covaxin, which are expected to be delivered by the end of July. But only about 36 million Indians have been fully vaccinated so far, and some 100 million are still waiting for their second jab.
Declaring that India had defeated Covid, Modi even took to “vaccine diplomacy”, exporting free jabs that eventually outnumbered those that were administered in India by March.
Another failure, according to Malini Aisola, co-convener of the All India Drug Action Network, was the decision not to enlist the vast swathe of India’s manufacturing capabilities that could have been repurposed into vaccine production lines.
Four firms have only recently been given rights to make Covaxin, while by early April, Russian developers of Sputnik V, had inked manufacturing deals with a host of Indian pharma companies to produce the vaccine.
As the sole buyer initially, the federal government could have held far greater leverage over pricing, Aisola says. “Centralised bulk procurement would have allowed the price to come down from US$2. Instead it has gone up,” she adds.
Since May 1, it has been up to individual states and private hospitals to broker their own deals with manufacturers.
States have to pay double – US$4 – the federal government’s rate for a dose of Covishield and four times as much for Covaxin – US$8. This was after the two companies lowered prices for states as a “philanthropic gesture”. States are also competing for scarce stocks alongside private hospitals, which can pass on the costs to customers.
The result is a veritable free market for vaccines that have been developed and manufactured with both public and private funding. At private hospitals, a single dose can now cost up to 1,500 rupees (US$20).
Several states have now announced their own plans to import other vaccines from Pfizer, Moderna and Johnson & Johnson. But India is yet to approve these vaccines, and no manufacturer is able to guarantee supply in the next few months.
Sputnik V has been approved, but it’s still unclear when the vaccines will be rolled out.
Some have accused SII and Bharat Biotech of “profiteering” during a pandemic, especially after receiving public funding. Others say they took substantial risks and that the fault lies with the government.
India is the only country where the federal government is not the sole buyer, and one of the few where vaccinations are not free.
But public health experts agree that SII and Bharat Biotech need to be more transparent about their manufacturing costs and their commercial contracts.
Aisola says SII needs to disclose how it spent the US$300 million it received from the international Covax scheme and the Gates Foundation, funding which was meant to finance vaccines for low-income countries. SII has failed to do so, partly because India banned exports. The company is also fielding a legal notice from AstraZeneca for defaulting on its promise to send 50% of its supply to low-income countries.
Public health experts are also calling for scrutiny of the Indian government’s contract with Bharat Biotech, especially since the Indian Council of Medical Research has said it “shares” intellectual property (IP) for Covaxin, which it developed along with the company. But the jab costs more – often double – than Covishield.
“They say they share IP but what sort of an agreement did they sign? Does it give the government the right to override any clauses in case of an emergency?” asks Dr Anant Bhan, a public health expert.
While India has supported waiving the patents on foreign-made vaccines, it has made no move to suspend patents for Covaxin.
Contrary to its international position, it has opposed suggestions from opposition leaders to invoke compulsory licensing and allow other pharma companies to manufacture the approved vaccines, saying these measures would prove “counterproductive”.
Bhan agrees that at this stage it would take time to transfer technology and build capacity in other pharma companies – but he also says it’s unclear why none of this was attempted earlier.
Vaccinating even 70% of India’s 1.4 billion people was always going to be a long exercise in planning and patience. But given the country’s strong record on immunisation, it was not an impossible task, Bhan says.
However, why the government chose to rely on just two companies who can now control supply and dictate prices is a question that is bewildering experts.