India has done a remarkable job on COVID-19 vaccination, administering 2.01 billion doses in just 18 months, vaccinating 98 percent of its adult population with one dose and fully vaccinating 91 percent of its adult population.
“This is a staggering achievement for a population as large as that of the African continent; with a federal structure requiring the Centre and States to work hand in hand; and with the complexity of planning and logistics involved,” says Ms Anuradha Gupta, Former Deputy CEO, Gavi, the Vaccine Alliance.
According to her, “Given India’s population density, overcrowded cities and initial shortages of masks and sanitisers, the virus could have gotten out of hand. Quickly, India overcame this, and the manner in which the country organised itself and its vaccination drive during an unprecedented crisis is exemplary – especially given the expanse of geographical and linguistic diversities.”
Following are excerpts from an interaction with her:
The Government of India repeatedly said that it has employed a “whole of government” and “whole of society” approach while rolling out the vaccination drive. What is your take on these strategies?
Effective response to a pandemic of this proportion would inevitably require a “whole of government” and “whole of society” approach. India evolved a data-driven response mechanism for real-time management of the pandemic, and was able to establish planning and monitoring structures that brought in stakeholders from across the federal government. Similar coordination mechanisms at the state, district and block levels ensured seamless collaboration across ministries and departments, reducing the government’s reaction time, keeping it agile and adaptive in its response.
Proactive communication to inform and educate people about COVID-19 vaccines, benefits, eligibility and availability went a long way in garnering broad support. The government and technical experts spoke with one voice – this helped in keeping vaccine confidence high and dispelling rumours or misinformation.
You have been a former Additional Secretary of Health in India and are now playing a key role in ensuring global vaccine equity. From that vantage point, how do you perceive the role of the government in the way it has carried out the vaccination drive?
I led the National Rural Health Mission, and I expanded it into the National Health Mission by bringing urban health in scope. With sustained government investments in health systems, rural areas had begun to show improvements in health outcomes. However, health infrastructure in urban areas fell woefully short, especially for the poor. Equity meant bringing a laser focus on marginalised populations who suffered from a disproportionate burden of disease and deaths. The role of government in public health financing is essential to expand access and address inequities. Through the National Health Mission, India took ownership of its own public health agenda, allocating domestic budgets.
During COVID-19 vaccination, past investments in the National Health Mission proved to be of immense value and utility. Public sector vaccine administration, along with a supportive private sector, enabled an increase in vaccination points. While the public sector provided 97 percent of COVID-19 vaccination free of cost, the private sector offered vaccination at affordable, pre-determined prices to complement government facilities. A major achievement was to offer vaccination in every part of the country including remote areas, helping avoid urban-rural and rich-poor divides and disparities. Few countries have achieved systematic, equitable vaccination in this manner.
You handled the Universal Immunisation Programme (UIP) and National Health Mission for decades. What learnings do you think India best applied from UIP in COVID-19management?
The Universal Immunisation Programme (UIP)’s extensive logistics and reach provided a ready platform for India’s COVID-19 response. Under UIP, more than 29,000 cold chain points have been set up to store vaccines in refrigerators. But more importantly, India’s existing army of grassroots health care workers gave it an added advantage in this gigantic vaccination drive. More than 2.88 lakh Auxiliary Nurse Midwives (ANMs) conduct regular vaccination for more than 26 million live births every year – mainly through outreach sessions in villages and community settings. ANMs may walk several miles with vaccines on their backs so children receive timely vaccination against deadly diseases.
Under the National Rural Health Mission, one of the most impressive achievements was the creation of one million Accredited Social Health Activist (ASHA) workers. ASHAs have played a major role in connecting their communities with – and spurring demand for – health services. Over the years, India has made sustained, systematic investments in ASHAs’ capacity. During COVID-19, ASHAs sustained community trust in vaccines, helping address concerns about adverse events following immunisation (AEFI). UIP has also made steady investments in a robust AEFI monitoring system, which also helped identify and address community concerns relating to COVID-19 vaccines.
Another strong enabler was the National Technical Advisory Group on Immunisation (NTAGI) established for UIP; it proved very useful in fighting COVID-19, because it offered timely guidance such as on vaccine products, doses and use.
Thanks to the large domestic demand for UIP vaccines, India became a major vaccine manufacturing hub. During the pandemic, India strengthened and enhanced its manufacturing capacities, and did not have to look to other countries to secure access to COVID-19 vaccines.
Do you think the Indian experience has lessons for the world in the way it carried out the vaccination drive?
The COVID-19 pandemic has been a wake-up call for most countries to realise that public health and economic growth are inextricably linked, and the value of public health infrastructure to sustained demand for immunisation. India’s very compelling model is now discussed in African countries – from domestic ownership and domestic financing, to investing in frontline health workers.
What stands out is India’s fantastic use of technology. Under UIP, a transformative shift occurred when the Electronic Vaccine Intelligence Network (eVIN) was designed with the support of Gavi in 2014. The technology gave India the confidence to immediately build and roll out the Co-WIN (Winning over COVID-19) platform, which has emerged as the pivot of the country’s COVID-19 vaccination drive. A beneficiary module was built on it to streamline the process, record vaccination and issue certificates for each beneficiary. Gavi is proud to have supported this initiative.
Be it registration, phased prioritisation of eligible groups for vaccination or session planning, Co-WIN ensured that VIPs couldn’t game the system to their advantage. Despite initial teething troubles, the digital platform ensured transparency and real-time monitoring. Control rooms at the national, state, district and block levels ensured data became the basis for iterative planning and course correction. Clearly, India’s approach was focused on the prioritisation of vulnerable populations. The science-driven vaccination drive focused on both safety and speed.
For this, India’s systems were already in place, but the way they were augmented for pandemic response is a success story in itself.