Starting March 1, India will extend its Covid-19 vaccination drive to the general population. Everyone over 60 years of age – that adds up to not less than 10 crore people – and those over 45 with comorbidities will be eligible.

While the Union health ministry’s initial operational guidelines charting out the blueprint of the vaccination program mandated pre-registration to receive the jab, it now appears walk-in facilities would be available too. With the registration software prone to glitches, there had been vocal demands for a walk-in option.

Those with comorbidities would have to submit a prescription by a registered doctor.

The entry of the private sector

Unlike the first phase of the inoculation program intended at healthcare and frontline workers, the private sector will play a key role in the second phase.

The vaccines will be administered at private hospitals in addition to the government centres. In fact, the private centres would outnumber the government ones: 20,000 to 10,000, according to Union minister Prakash Javadekar who made the announcement on February 24.

The vaccine will continue to be given free of cost at the government institutes, but at the private centres, users will have to pay. It is not immediately clear how much, but news reports indicate it is likely to be anywhere between Rs 300 and Rs 400 per dose. The two vaccines in India’s armoury at the moment cost the government Rs 200 and Rs 295 per dose.

As with much of the government response to the pandemic, the decision to rope in the private sector has elicited strong reactions. While some believe the move is “exciting” and will help accelerate the pace of vaccination, others say it is a “disaster in the making” as it will lead to wrongful exclusions of eligible people and jumping of queues by people with the means.

Given the yawning global supply-demand mismatch of Covid-19 vaccines, involving the private sector would invariably lead to black-marketing resulting in a large section of poor needy Indians being deprived, said Indranil Mukhopadhyay, a health economist who teaches at the OP Jindal Global University.

Centralised procurement

The government’s way of dealing with this problem seems to be preventing direct procurement by the private hospitals.

Health officials of three states confirmed as much to the Centre would purchase the vaccines from the manufacturers and distribute them among the private hospitals, currently restricted to the only those empaneled with the government’s flagship health insurance scheme, Ayushman Bharat Pradhan Mantri Jan Arogya Yojana.

Some public health experts believe this is indeed a good tactic. “By not allowing the private people to directly put their hands into the vaccine kitty, the government has planned it well so far,” said Prabir Chatterjee, a doctor currently based in rural Bengal, who has spent several years working in the government’s pulse polio and other routine immunisation programs.

Diversion of doses to private?

But that still left room for manipulation, argued Mukherjee. “In a public system, there would be logic to this distribution – we know for example how many people a primary health centre serves,” he said. “But no one knows which private facility will cater to how many people. So how do you do need-assessment?”

Sandhya Srinivasan, a Mumbai-based public health researcher, expressed similar apprehensions about vaccine availability in the public sector going down as a result of doses being diverted to the private sector.

A medical worker prepares to administer a dose of the Covid-19 coronavirus vaccine to a municipal worker at a vaccination centre in New Delhi on February 22, 2021. Photo: AFP

Uneven spread

The fact that the private centres outnumber the government ones was also a cause of concern, according to some public health experts. It could lead to the concentration of vaccine delivery points in urban areas, they said.

“I hope that the government ones are increased, especially in rural areas where there is a shortage of facilities which can provide vaccination,” said Anant Bhan, a researcher of global health, bioethics and health policy.

This was particularly important, Bhan said, since there was likely “a larger proportion of population with susceptibility to infection in rural areas”. Bhan’s contention flows from the idea that urban areas have seen more infections so far.

‘Big win’

Prashant Yadav, a health care supply chains expert at Harvard Medical School, was much more enthusiastic about the move in general. Calling it “exciting”, he said an effective way for governments to utilise the capacity of the private sector without compromising on public health principles was by providing it “with key inputs like vaccines and supplies, but ensuring that data about vaccine administration, any adverse events, and health outcomes can feed back into an integrated national health data infrastructure.”

“If data reporting infrastructure for private providers who are vaccinating can be solved systematically, and price and quality issues can be carefully monitored, it will be a big win,” he added.

Profiteering concerns

But few people acquainted with India’s public health system are optimistic that will happen. “It’s good that no direct procurement would be allowed, but that does not translate to what would happen at the facility level – especially since walk-ins, etc. are allowed,” said Bhan. “There might be an official cost, but regulation would be needed to ensure no further charges are levied on patients.”

Like Bhan, Srinivasan also feared that the “private sector will be allowed to charge whatever it wants, if not for the vaccine, through ‘admin costs’”. “Which is treating a public health crisis as another opportunity, just as it happened with [Covid-19] tests and treatment,” she said.

Others believe asking the public to pay for vaccination is itself questionable. “People are coming forward not just to protect themselves, but to contribute towards the larger goal of herd immunity,” said Malini Aisola of the advocacy group All India Drug Action Network.

None of the two vaccines available in India, Aisola pointed out, have full-proof data on their efficacy. “So, to commercially sell them raises ethical questions,” she said.

Srinivasan agreed. “It’s not right for a vaccine company with government subsidies, emergency authorisation, inappropriate response to questions of safety to be making a profit here, or for private hospitals to be doing the same,” she said.

Weakened screening and surveillance?

But concerns about the private sector’s involvement go beyond profiteering. For one, would pre-vaccination screening for contraindications – pre-existing medical conditions that could potentially adversely react to certain drugs or vaccines – and post-vaccination surveillance for adverse events become laxer?

Chatterjee said he expected private hospitals to be more rigorous about pre-screening because “their reputations would be at stake”. “The private sector doesn’t like noise,” he said.

Not everyone agrees. India’s existing mechanisms for counselling, screening and surveillance left a lot to be desired and it was unlikely the private sector was going to fare any better, said Srinivasan. “We can expect worse,” she said.

Aisola tended to share Srinivasan’s cynicism. “It is clear we don’t have the systems in place yet, and we are opening out to the private sector,” she said.

In fact, even Chatterjee agreed that post-vaccination surveillance was going to suffer. “The private sector will say it’s not their job and they don’t have the resources for it,” he said.

What in case of adverse events?

Aisola asked if the private hospitals were going to offer free treatment in case of adverse events. “Currently, in the case of adverse events following immunisation there is a clause that allows for free treatment in government facilities,” Aisola pointed out. “Now that more people are potentially going to get vaccinated by the private sector, will they offer free treatment? The rules of engagement need to be clear.”

All in all, the involvement of the private sector, Srinivasan said, may not be a bad thing per se given the “enormous burden this vaccine campaign will put on the existing [government] services”.

“But it should be regulated, and definitely not be for profit,” she said.