India can learn a lot from its experience in managing cash—getting a billion people what they need can be planned effectively
A vaccine for Covid-19 is expected to come sometime over the next few months—hopefully in this year. Once a vaccine is available, getting it to India’s billion-plus people is a logistical challenge with many moral and ethical questions attached. How should India plan for the vaccination programme?
Before we go there, let us recognise that a few very important questions still remain to be answered. What shape and form the vaccine will be, remains to be seen: it is expected that it will be intravenous, and hence, may require skilled or trained practitioners to administer. It is also not clear whether there will be only one vaccine or many competing ones, and how effective each might be. All of this will feed into the number of doses that might be required—whether a single shot would do or multiple jabs may be required. Hopefully, India will develop its own vaccine; however, if vaccines are available from other countries, how soon can they come to India?
Given all these imponderables, one may be tempted to push back the planning till there is more clarity. With fast-paced changes taking place in this field, it is possible that many of these questions will be responded to rather quickly. It will be useful, hence, to have the policy framework for the delivery of the vaccine in place.
Make it flow like cash
A vaccine is a good with significant positive externalities: the more the number of people who take the vaccine, the better it is for everyone in the society. Ideally, if everyone is inoculated, then everyone is safe. There are a few providers (or maybe even one), and everyone is a buyer. All citizens in the country will queue up to get a vaccine, as and when it is available.
Cash is a similar type of good. There is only one supplier (the government), and everyone needs it: all are required to have the same type of cash when they transact with each other. All citizens in the country queue up to get the notes as required.
India has recent experience of ensuring the wide availability of a good like cash to all its citizens. Unlike in the case of demonetisation, where the announcement was sudden, the expectation of a vaccine has been building up for some time—this allows us the opportunity to draw upon our experiences. The re-monetisation process lasted only around 50 days: similarly, we need to think of timeframes in days and not years as we think of our vaccine delivery.
The three As
Availability and training: There is an implicit government assurance to all citizens that they will all have the notes in their wallets when they want them—this has been perfected over years of experience. As RBI’s annual report of 2017 says, “…during a short span from November 9 to December 31, 2016, the Reserve Bank pumped in 23.8 billion pieces of banknotes into circulation aggregating Rs 5,540 billion in value”. Assuming that every transaction meant the final customer picked up 24 pieces from a bank, it meant a billion transactions, similar to the number of vaccine doses that may be required.
The availability of the new notes was made across all branches of the banks: more than 125,000 centres. A similar size and scale need to be brought to bear to the vaccination programme, which should be available across all primary and secondary healthcare units with appropriate training for administration. We note that there are 0.9 mn Accredited Social Health Activist (ASHA) workers and many private medical care professionals in the country. The training for administering intravenous vaccines, if not already done, should be started now—even before the vaccine has been finalised. Similarly, the logistics and cold storage facility plans should be thought-through now.
Access and prioritisation: As we plan to roll-out the vaccines, access to every citizen has to be assured. Unlike in the case of cash, where there were concerns on hoarding, there should be a limited concern that a citizen would want to take multiple shots when a single dose would suffice. Anyone who presents himself/herself should be offered a shot without concerning too much on whether the person has received a shot earlier.
The government should invest its energies in getting the doses, not in administering the system that administers the doses. If an elaborate system of maintaining records is kept, it can lead to undue bureaucratic delays and hold-ups. Anyone who wants to take a vaccination shot should be allowed to without the need to show any documents. The crisis is not the time to create a health registry or a digital health id.
The issue of who gets the vaccine first remains. The frontline health-workers, other essential workers, and senior citizens have a natural claim to be the initial recipients. The most effective way in which this can be practically and morally be addressed is if the other citizens know that their turn will come soon. This is a key reason why the target for overall vaccination has to be measured in days—not months or years.
Affordability and pricing: An important component of access is the price at which vaccines will be available. In the case of the vaccine, a low price coupled with the solid expectation of availability-on-demand will remove most of the incentive to hoard. The government can give an assurance of supply (and hence keep prices in check) by contracting capacity for many hundreds of millions of doses. The government should use the powers at its disposal to grant licences to make the vaccines to a large number of players. It should consider and resolve whether India can invoke a process patent instead of a product patent in this case.
There should be a pay-out to ASHA workers or other health professionals who administer a dose. A local, social audit should be powerful enough to determine whether the vaccines were actually administered and not just stored or wasted away. Public announcements of when and what quantities of medicines reach the health centres should be periodically made.
A vaccine shot to heal them all
Once vaccines are ready, we should aim to reach as many of our citizens as quickly as possible. The Indian pharma industry has proven to be a world-beater in manufacturing large scale doses. As we saw with the prices of ventilators and PPE kits, a large supply almost inevitably results in low prices—the government should use the scale to keep vaccine prices low.
A quick dose of vaccination will lead to a quick restart of the lives of the citizens and the economy.
The author is with Axis Bank
Views are personal