Several years ago one of us had the good fortune of meeting Dr DA Henderson, the smallpox ‘General’, and then Dean Emeritus of the Johns Hopkins School of Public Health, United States, who was widely credited with eradicating the scourge from the planet. When asked about the experience for India, one of the last countries to eradicate the disease, his frank answer was that it was a tough one. Yet, despite the odds, we succeeded in reaching down to the last village.
At the same time, it’s increasingly clear that vaccinating our entire population will take several months despite our best efforts. In the meantime, the virus will continue to mutate and strike those who are not protected. Sound management practices dictate that in a resource-constrained scenario, we should go in accordance with the powerful Pareto Principle which states that 20 per cent of the risk, if identified properly, can ensure 80 per cent of the solution. There are simple methods involving indicators such as socio-economic, demographic, health, Covid-19 cases, deaths and vaccinations. With the top 100 districts prioritised by this methodology, almost 70 per cent of India’s Covid-19 vaccination challenge is addressed. Fortunately, NITI Aayog has already identified 112 aspirational districts. Many of the 100 prioritised districts would coincide with this list. These need vaccination of the entire 18+ population immediately. A landmark experiment from Serrana, Brazil, has shown the dramatic impact of mass vaccination in bringing down Covid-19 incidence and severity of infection.
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For the remaining districts, prioritisation needs to follow the operational guidelines that the Government of India had originally released in December 2020. Besides healthcare workers and frontline workers, this envisaged vaccination of those above 60 years first, followed by those above 50 years, followed by those with comorbidity in the below 50 years category. In addition, parents of children below 12 need to be vaccinated on priority, particularly keeping in mind the possibility of a third wave affecting children adversely. Unlike adults, children require caregivers at the health facility. Hence, they would be at increased risk. Uttar Pradesh is a State which has shown the feasibility of such an initiative.
Notwithstanding the prioritisation, sound public health principles dictate that the equity dimension should be first and foremost. These groups include but are not limited to those below poverty line, tribal populations, hard to reach communities such as those in flooded or hilly area, urban & peri-urban poor and the like. They need to receive the vaccine before others while carrying out the vaccine drive within broad demographic categories as mentioned above. Often these ill-informed individuals are pushed into a risk abyss since they either do not have access to health or IT facilities or are unable to afford it, if at all they are available. The safety net of the vaccination is critical since for them it is not just a question of lives but livelihoods and catastrophic health expenditure too. The government has already allocated 25 per cent of the vaccine to the private sector. Hence, all the more reason that the remaining vaccines be first given to those who need the safety net of the State.
Further, the role of the private sector for a country as big as India to fulfil its vaccination commitment is crucial. While private hospitals are playing an important role in the vaccination drive, along with pharma companies which are developing the vaccines at an accelerated pace, the role of the MedTech industry as a major contributor in healthcare-related activities gained prominence. Leading medical devices companies ramped up the required capacity at an unprecedented speed and scale, rising to the challenge. Early last year saw India in short supply of public health infrastructure. But with the entry of the private MedTech industry, the country witnessed an unprecedented scale-up in not only testing equipments and kits, but also availability of critical Covid-19 care items. According to the Association of Indian Medical Device Industry (AiMeD) before the outbreak of Covid-19, there were only 20 firms manufacturing 62 lakh PPE kits per year, but within two-three months, the number of manufacturers increased to 140 firms with 25.55 crore annual capacity. Similarly, Indian firms manufacturing ventilators, masks, sanitisers, gloves, goggles and the like have shown a quantum leap. The ‘second wave’ further boosted the need to look into granular medical devices like oxygen-related equipment, ventilators, ICU beds, infusion pumps, high flow nasal cannulas, etc. Today, leading industry and MedTech companies are providing extended technical support to strengthen supply chains, cold-chain equipment, storage, and last-mile logistics, especially in places without reliable electricity and refrigeration and assisting governments to speed up the entire process right from the stage where vaccine is procured to the time it is delivered and further in partnering on outreach campaign to combat misinformation. These campaigns must involve an ‘all of society’ approach, including religious leaders and celebrities.
The world watches us today in our sink or swim moment. Every small step in a rationally-driven national vaccination program is a giant leap for the global Covid-19 endgame. To vaccinate a billion plus lives, time has come to develop a new PPP model that calls for a “Partnership for a Public Purpose”.
Nitish Dogra is an Indian public health physician and recipient of a Community Hero Award from the Johns Hopkins University. Rajiv Chhibber is a healthcare communications expert