New Delhi has heralded a liberalised inoculation strategy for the country amid cries for oxygen, medicines, vaccines, and a better healthcare infrastructure. Hoping to bring the pandemic-ravaged country back on track, the government has opened up the Covid-19 vaccination drive making all those above 18 years eligible, beginning May 1. It has also thrown open the private market in the country, where each dose may cost up to five times its existing price.

According to the government’s official statement, vaccine manufacturers will supply 50% of their production to the central government while the rest can be sold to the state governments and in the open market at predetermined prices. Imported vaccines will be used entirely outside the central quota.

Sangita Reddy, joint managing director, Apollo Hospitals Group, believes that opening up vaccination to all above 18 years is a turning point in India’s battle against the pandemic. “With our current rate of 45 lakh doses per day, it would take us one year to reach herd immunity. Post May 1, we can expect upward of one crore doses per day. Long journey ahead but we will win,” a confident Reddy tweeted on April 19.

Industry officials, however, believe that the demand will continue to outstrip the supply even after the existing vaccine manufacturing capacities are expanded. At present, Serum Institute of India (SII), world’s largest vaccine manufacturer by volume, makes 2.4 million doses of Covishield a day, according to a spokesperson. Bharat Biotech (BBIL) refused to give their daily numbers, but said their existing annual capacity for Covaxin is 200 million. Their maximum daily production doesn’t exceed 0.6 million doses. So, the existing combined capacity is around 3 million doses a day while the demand is already 10 million. Neither the government nor the manufacturers have made public the daily vaccine production figures.

In a quick reversal of its policy stance, the government on April 19 also approved a payment of about ₹4,500 crore as advance to the two leading vaccine makers, against their future supplies. This follows a months-long demand by them for financial support to ramp up their capacity. As per the fresh deal, Serum will supply 200 million doses and BBIL, 90 million doses to the government by July at a pre-agreed rate of ₹150 per dose. Serum will get ₹3,000 crore in advance and Bharat Biotech about ₹1,500 crore. In the private market, vaccine makers are likely to sell each dose for around ₹1,000.

Big challenge ahead?

Bhramar Mukherjee, a biostatistician and a professor of epidemiology at the University of Michigan, says she was a little surprised by the government’s announcement. “Right now, only 1.3% of the population has received two doses and 8% at least one dose. We have a long way to go. When you have a shortage of supply, increasing the demand base immediately may not be wise,” she tells Fortune India.

“I know of some cases where the second dose vaccinations of elderly citizens have been postponed due to issues with the vaccine supply. We need to make sure people get their second dose within the allowable time frame. India already has issues with vaccine adherence. If scheduling second shots for elderly becomes even more complicated when younger people are eligible, that will be detrimental to protecting the most vulnerable,” says Mukherjee.

A week ago, India opened up the vaccine market by approving all international vaccines already endorsed by the World Health Organisation (WHO) and European/American regulators. But it is yet to sew up any supply deal from abroad. “I do not think beyond Sputnik V (Russian vaccine), there is a concrete promise of a given date of delivery. Given the astronomic surge in cases, a proactive alliance will be needed to generate and garner support for this dire situation. Even with all the efforts, it may take time to get copious supplies and inoculate 800 million adults,” argues Mukherjee.

The health infrastructure of many states in the country are crumbling right now. “The states are busy and overwhelmed with securing oxygen, ventilators, and medicine. States that are hard hit will need support from the central government and international organisations to manage both immunisation and Covid-19-care streams. Huge investments in public health and healthcare infrastructure are needed right now. We have to deal with variants, viruses, and vaccines for the foreseeable future and we have to be more prepared and agile with our strategies and policies,” Mukherjee adds.

As on April 20, India reported 2,94,115 fresh cases, a new peak, accounting for nearly 36% of the total cases reported across the globe. Its daily death toll has gone to 2,020 on April 20 with the total tally moving above 1.83 lakh since the pandemic began a year ago.

The government’s move comes with a liberalisation of the pricing of vaccines that the two leading vaccine makers had sought a few months ago. According to the press note, private vaccination providers shall transparently declare their self-set vaccination price. Analysts and health activists have raised concerns that this manufacturer-determined price will most probably be the base price from which states will have to bid to procure vaccines. They are worried that the relaxation will let vaccine firms make super profits in the midst of the pandemic.

Will the move lead to a scramble among the state governments to buy vaccines at higher prices, leaving poor state governments in a dire situation?

Brinelle D’Souza, a senior faculty at Centre for Health and Mental Health, School of Social Work, Tata Institute of Social Sciences (TISS), who is also co-convener of Jan Swasthya Abhiyan (JSA)-Mumbai, a non-governmental organisation working in the public health sector, finds it surprising that, on one hand, the government says that there are huge vaccine shortages, while on the other, they are now expanding the rolls to everyone who is 18 and above.

“Vaccines and Covid-19 medicines must be viewed as public goods especially now given the health emergency we are facing. The government should have used compulsory licensing provisions under the Indian Patents Act 1970 for the two vaccines so that other pharmaceutical companies with capacity in the country could be involved in the production. This measure would have not only addressed shortage in the country but also made it possible to export vaccines to poorer countries. India has a robust generic industry and the government could have controlled the prices as it is doing now,” says D’Souza. She believes that in the absence of price control, the state governments and citizens may have to bear the burden of cost.

Existence of adequate stocks is another challenge. According to Aldon Fernandes, vice president, R&D Biologicals, Bharat Serums and Vaccines Ltd., India, at this moment, simply does not have necessary stocks.

“Although we can easily ramp up production capacities, our drawback is that multiple raw materials need to be imported and the process itself takes up to six months. This will also put a severe strain on resources for manufacture of other drugs in terms of manpower and resources. The pharma companies won’t put their money all at one go. Unless they are provided financial support, they will keep manufacturing at a slow pace to ensure they do not end up with stock piles,” says Fernandes.

The weeks following the May 1 opening up will have many answers.

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