India faces a record wave of the pandemic, but has vaccinated barely 2 per cent of its citizens. Immediate rapid deployment of vaccines is essential to reduce the prevailing suffering and death and alleviate the pressure on the healthcare system. This is not just morally imperative, but time critical. Many epidemiologists think that we have a year or less before the virus mutates making the majority of existing vaccines ineffective and creating the need for new or modified vaccines. Delaying vaccine access will increase inequality and the social and economic costs of the pandemic.

Jumping the line for the vaccine

Failing to put the most vulnerable at the front of the line for COVID vaccines risks exacerbating the gaping wealth, racial and ethnic disparities that have characterized the pandemic. While India has seen many reports of out of turn COVID vaccination, this was taken very seriously in other countries. Peru’s health and foreign ministers and its former president was placed under criminal investigation after reports of officials receiving vaccine doses before the national immunization program began. Argentina’s health minister had to resign after reports that he used his connections to get ineligible VIPs vaccinated. The World Bank threatened to pull support for Lebanon’s vaccine in the face of MPs receiving the vaccine out of turn. Instances of ineligible people receiving vaccines have been reported in India without concrete action taken.

Failing to vaccinate the vulnerable

India has until now prioritized vaccination of essential service providers and vulnerable groups for which the central government continues to have responsibility include healthcare workers, frontline workers and those above 45. Ensuring a second dose of the vaccine for them needs to be prioritized. This list, however, excludes many vulnerable groups including teachers, banking staff, journalists, migrant workers and those directly involved in the current response (eg crematorium workers). Teachers’ vaccination is not prioritized despite over 700 teachers dying on election duty in Uttar Pradesh alone.

We are yet to finish vaccinating the already identified vulnerable groups. Only 37 per cent of India’s 30 million health and frontline workers are fully vaccinated. Only 38 per cent of people over 60 have received even one shot of the vaccine. The expanded vaccination mandate and shortages should not compromise the focus on these groups. The rationale behind the decision to jump directly to opening vaccination to another 600 million people irrespective of vulnerability and without ensuring adequacy of vaccine supply is unclear.

Leaving India’s women behind and not maintaining records of coverage of the poor and marginalized India is lagging in immunizing its women. So far, 52.2 per cent of those vaccinated are men, while 47.8 per cent are women. About 0.01 per cent of the vaccines have been administered to transpersons. No records are being maintained of people vaccinated disaggregated by income or social group. This would be critical to ensure India’s poor and marginalized groups are not excluded from access of lifesaving vaccines.

Opening geographic inequalities Vaccine coverage has been highly unequal till now. While some 20 per cent of the population of Himachal Pradesh has received the vaccine, only 4.67 per cent of Uttar Pradesh received the shot. It is critical to prioritise vaccination in areas with higher COVD prevalence rates, but releases of vaccines to the states do not appear proportionate to the eligible population or the number of cases and deaths.

An online-only vaccine enrollment strategy that excludes

India needs to reconsider the vaccine enrollment strategy. Successful vaccination drives are rooted in detailed district plans and social mobilization strategies to reach vulnerable communities; these are missing this time around. The near complete reliance on on-line appointments for vaccination without providing for even walk-in facilities tends to exclude those who lack internet access, the elderly living alone, those with disability and populations such as homeless and pavement dwellers and those in institutions. Only 15 per cent rural households have access to the Internet and only 24 per cent of India’s population has smartphones.

Absence of decentralized vaccination

A more targeted bottom up approach is needed to ensure vaccination nearer to peoples’ habitations, especially in high coronavirus prevalence areas. It is also unclear why alternative options of vaccination of the vulnerable, including door to door vaccination, has not been adequately explored. This strategy has been the backbone of India’s successful polio vaccination drive and could be explored for the COVID vaccine.

What is to be done

India needs to ensure that the vaccines continue to be provided free of charge to all, are procured through large scale centralized vaccine procurement at low regulated prices and ensure these are allocated in a way that is fair. Vaccination must prioritize at-risk groups, be sensitive to the existence of the digital divide and reach the vulnerable where they live and work.