Anjela Tirki was vaccinated for Covid-19 at the Community Health Centre of her block in Chhattisgarh. An accredited social health activist or ASHA, part of the network of community health workers under the National Health Mission, she did not get any document stating that she had received the first dose of the coronavirus vaccine.
“The hospital people were doing a lot of documentation but I didn’t get any paper,” said Tirki, whose name has been changed to protect her identity. Neither was she aware that she had to take a second dose. She said: “I didn’t know that I would get another vaccine dose. I wasn’t told anything of that sort.”
India commenced the rollout of Covid-19 vaccines on January 16 amidst concerns about the lack of transparency around protocols, the approval of vaccines and adverse events in clinical trials. As of February 7, about 57 lakh healthcare and frontline workers have received the first dose of the vaccine across the country. The government of India has allocated a whopping Rs 35,0000 crore for vaccination in the latest budget. However, the plan for making the vaccine available free of cost to all people (after the priority population is vaccinated), especially those from lower socio-economic classes, is not explicit.
Moreover, going by the state and strength of our public health infrastructure, the vaccine roll-out is expected to have severe implications for routine health services. The government has announced that 1.54 lakh or nearly 65% of all Auxiliary Nurses and Midwives or ANMs employed by state governments will be involved as vaccinators, but insists that this will not have an impact on non-Covid health services, including routine immunisation.
Taking into consideration the existing ground realities and limitations of our health infrastructure, the government of India can perhaps take five concrete steps to ensure effective rollout of the Covid-19 vaccines.
1. Adequate preparation of the government health system for the rollout
The first step is the preparedness at different levels of healthcare facilities: it must include adequate physical infrastructure and health workforce, training of workforce, information sharing, and grievance redressal mechanism for participants in the vaccination rollout.
Vaccination centres should have fully equipped ambulances, adequate availability of cold chains and refrigerators, and continuous electricity supply so that refrigeration of doses is not disrupted. This has to be supplemented with basic facilities, including skilled staff, oxygen supply, emergency medicines, gloves, syringes and functional referral system to handle the side effects that may be immediate or within a few days to a couple of months after vaccination. A mechanism for regular inspection of the sites is also needed.
Equally important is the adequate training of doctors and nurses who will be administering the vaccine, as well as of ANMs and ASHAs who will be playing a crucial role in community awareness and mobilisation. The guidebook on Covid-19 vaccine communication strategy published by the ministry of health states that physical block level training and sensitisation workshops of local health providers should be planned before initiation of vaccination drive, but this is not happening everywhere.
Staff nurses of a government hospital in Harda district of Madhya Pradesh said they had received video clips and some posters on Covid-19 from the district officer followed by oral instructions to study them before Covid-19 vaccination. In many states, no training whether online or in-person had been given to ASHAs and anganwadi workers.
Access to accurate information about the vaccines, training for administration, safety, efficacy, adverse events reporting mechanism, cold chain and bio-waste management are important for their effective functioning. The sanitation workers, who have an important role in disposing medical waste, should also be regularly trained on the disposal protocol in an easy-to-understand language and be equipped with appropriate gear to handle the waste.
During the pandemic, ASHA workers have experienced extra working hours, loss of pay and social apathy. ASHAs, particularly who are designated as volunteers, are not paid adequately and regularly for their services.Their workload has been increased which should be adequately compensated with regular and extra wages and other social security measures. Since health workers were in the first line to receive the vaccines, their health concerns should not be neglected.
2. Ensure effective communication and information
Effective communication and information to the public that enables autonomy in decision-making is the second step. This decision making should not be limited to the decision to be vaccinated, but also to choose which vaccine should be administered.
The protocols and procedures for taking consent should be followed with everyone, including with the healthcare and other frontline workers who are currently being vaccinated. This has not been happening everywhere. As an ASHA from Sindhudurg district of Maharashtra said, “We got to know that our names had been submitted [for vaccination] when we asked the medical officer. They didn’t bother to ask us or inform us before sending the names. They took us for granted.”
The administration of any Covid-19 vaccine must be preceded with detailed counselling with information leaflets in local languages describing Covid-19 symptoms, details of the vaccine, side effects and relevant contact numbers for assistance and reporting in case of an adverse event. The importance of completing the prescribed dosage should be reiterated including by paying home visits if necessary.
Those who are vaccinated should also be told how vaccination does not mean complete protection, and the need to continue following the Covid-19 related protocols and taking requisite precautions such as using face masks and maintaining physical distance must be emphasised.
As the health system prepares for extending the rollout to the general population, the health machinery and the district administration should provide correct and scientific information using various forms of communications, such as infographics, posters, audio-visual media, community radio, phone helplines, print, electronic and social media and phone helplines in easy to understand formats and local languages. This will be important to ensure that people can make an informed decision about getting vaccinated.
3. Ensure follow-up and no-fault compensation
The third important step is to establish an effective and accessible health grievance redressal mechanism with toll-free state level complaint helplines. This information should be widely disseminated and prominently displayed at the vaccination centres and public places.
Vaccination cards must be provided to those who are vaccinated. All state governments must put in place a robust system to record any adverse event following immunisation within 24 hours and put in place a mechanism for immediate treatment and medical management. Provision must be made to allow adverse event reporting manually, through printed test reports, email or SMS messages, and make the findings related to them available in the public domain.
Given that the short-term and long-term effects of the vaccines are yet to be known, those who have been vaccinated must be followed up with for a few years, as against three months that is being suggested in the fact sheet for Bharat Biotech’s Covaxin.
The procedure to avail compensation in the event of serious adverse events must be clearly laid out to those vaccinated and they must be paid no-fault compensation within prescribed timelines. No fault compensation is a mechanism providing immediate compensation to the affected party without the need to establish causal relationship between the effect and medical intervention. This is important particularly in light of reports of the vaccine manufacturers pushing for indemnification from liability in case of adverse events following vaccination.
4. Avoid technology overdependence
The Covid-19 vaccines Operational Guidelines issued by the ministry of health indicate that the Co-WIN app would be used for registration of individual beneficiaries, and recording the successful vaccination at the time of conducting the session. The complete reliance on Co-WIN for providing vaccination related information had an impact on timely relay of information on the first day of vaccination, when the application reported glitches in several sites. Maharashtra had to suspend the first phase of vaccination drive briefly due to these technical glitches.
Despite strict instructions from the government for mandatory digital registration in the app for vaccination, states such as Maharashtra and Chhattisgarh, are having to undertake offline and manual registration due to technical and network issues. Therefore, as an important fourth step, it is critical that traditional forms of communications and follow-up are continued, and training given on the same.
5. Opportunity to expand and strengthen the government health system
Over the last several months, the focus of the health system on the Covid-19 pandemic has led to neglect of other health services. One of the main reasons for this is a struggling public health system weakened due to decades of neglect, under-funding and privatisation.
The Covid-19 vaccine rollout must be taken as an opportunity to expand and strengthen the public health system and address the issues within the health system that were exposed during the pandemic. The healthcare industry’s push to get involved in the vaccination rollout through Public Private Partnership arrangements needs to be taken with caution. Previous experiences both in India and abroad have shown that outsourcing of such core public health tasks is inefficient, leads to high costs and exclusion of the poorest.
As a fifth step, the government must develop and make public a clear plan in terms of human resources, budgets, transport, drugs and schedules for Covid-19 and other immunisation programmes. At the same time, active planning is required to strengthen and adequately finance the government healthcare systems to ensure access to healthcare for all with availability and fair access, not only to vaccines but also to diagnostics and therapeutics.
The government has allocated funds in the Union Budget 2020-’21 to vaccinate 500 million people in one year. This means, to give two doses of vaccine, it will take around 83,000 two-person teams, vaccinating (including counselling and documentation) 50 individuals per day, working for 240 days to complete the task. Considering that the existing health workers are already involved in the routine healthcare tasks this would require recruiting about 1.5 lakh more health workers (ANMs, nurses, paramedical staff).
Increasing public employment would not only help in addressing the current unemployment crisis but will help in improving public services quality and access in the long run. Therefore, the central and state governments should see this as an “opportunity” to expand and strengthen the public health system, by recruiting more health workers, especially ANMs, nurses and ASHAs, investing on health infrastructure and improving the referral system, especially at the primary healthcare level.
The authors are public health practitioners and would like to thank Sarojini Nadimpally for her suggestions and inputs.