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Where India's COVID-19 Vaccination Strategy Went Wrong

Apr 17, 2021 8:01 AM 7 min read

Even as the Second Wave of COVID-19 infections engulfs India, the country’s faltering vaccination drive threatens to make a bad situation worse.

As the world’s largest vaccine maker, India’s vaccination drive was supposed to be the light on the horizon. Not just for its own pandemic response but also for several other countries, particularly low- and middle-income ones, which relied on India’s pharmaceutical expertise to flatten their COVID-19 curves.

But after a delayed start and due to several missteps, India’s vaccine strategy has found itself derailed. Vaccination targets are off-track, supplies are dwindling, some inoculation centres have shut down altogether, and manufacturers are struggling to make enough doses for the country, let alone the rest of the world.

Where did it all go wrong?

The Partnership that Delivered: What India Should Have Done

When the pandemic struck, governments the world over showered pharmaceutical companies with funds and eased regulatory requirements in order to fast-track vaccine development.

The development of the first COVID-19 vaccines - those of Pfizer, Moderna and AstraZeneca - in less than a year was a testament to both efficient government intervention and private sector competency.

Now, the governments that led the charge in supporting vaccine research - particularly the US and UK - acted both as sponsors and buyers. Even before the Pfizer vaccine passed clinical trials, the US government placed an order for 100 million of its doses with an option to purchase 500 million more. Uncle Sam signed similar deals with Moderna, Johnson & Johnson, Novavax and AstraZeneca for more than 500 million doses.

This helped both sides: for the governments, pre-orders placed them at the front of the line for purchases, and for the pharma companies it meant more capital to accelerate R&D.


A Saga of Gaffes: What India Did Instead

Coming to India, the Government took a different approach - that of dragging its feet.

For starters, vaccine makers like Serum Institute (SII) had to largely rely on their own capital or approached investors. In August, for instance, SII raised $150m from the Bill and Melinda Gates Foundation and invested $100m of its own money to expand its facilities. (Recently, citing “very stressed” vaccine production timelines, SII appealed to New Delhi for a ₹3,000cr ($400m) lifeline. One week on, the latter is yet to respond publicly.)

The bulk of the Indian Government’s direct investment since last year had to do with vaccine distribution (for instance, the ₹35,000cr ($4.67bn) Budgetary allocation) rather than vaccine manufacturing, which was largely left to the private sector.

The second blunder was limited investment in vaccine storage both before and after the pandemic hit. We’ve already discussed the woeful state of India’s cold storage industry. This was a pre-pandemic problem, but even throughout 2020, while other countries ramped up storage capacities, the Indian Government dropped the ball in SII’s court. This is why the vaccine maker could only store 50 million doses because its own storage capacity was limited + it couldn’t afford to expand at a short notice due to the above-mentioned gaffe #1.

The third mistake was the delay in placing orders. The Government inexplicably waited till January 11th to place its first purchase order - and that too for only 11 million jabs initially. The Government spent months debating the price per dose and to this day has not committed to a long-term supply schedule, relying instead on ad-hoc purchases.

The fourth error was in the delayed vaccination roll-out itself. On December 8th, the UK became the first country to launch public vaccinations. Pfizer and Moderna received emergency authorisation in a slew of countries in December itself. The Oxford vaccine aka Covishield received regulatory approval in the UK on December 30th. Covaxin received the same in India four days later.

But India’s vaccination drive only began on January 16th, one whole month after some other countries. Two weeks after Covishield and Covaxin were given a regulatory green-light. And only five days after placing its first order with SII.

One might argue that vaccinations are a delicate business and it’s best to be late rather than sorry. But public health emergencies demand swift Government action. Particularly when your country is among the worst-affected. Especially if haste could be shown in approving Covaxin without publishing phase III trial results.

The fifth oversight was not accounting for raw material shortages. The US constricted the export of key equipment and raw materials so that they could be used for its own vaccination drive. This included vials, chemicals, bags, tubes, cell culture media etc. This hurt the Indian vaccine makers’ outputs.

The sixth misstep was underestimating the pandemic. The country staged a miraculous escape from the First Wave, and this made people and politicians overconfident. The Union Health Minister declared that India had reached “the endgame” of its battle against the pandemic on March 7th (ironically, mere days before the Second Wave struck). Even the RBI added to this premature optimism, saying that the COVID-19 curve has been bent “like Beckham” and that “soon the winter of our discontent will be made glorious summer”. Complacency bred carelessness, which sparked a rise in infections. This was aided by super-spreader religious gatherings, massive political gatherings and dangerous new variants of the virus


It Pays to Be Prepared (and Rich)

Incidentally, in March 2021, the Indian Government formed an inter-ministerial panel to suggest ways to ramp up vaccine supply. The panel suggested measures like early orders and more capital infusion into manufacturing companies - things that were being done by other countries since early 2020. It would have been less costly to learn from these countries’ examples last year rather than scramble to learn from our mistakes today.

As for countries that invested well and planned ahead, their efforts paid off.

The developed world is racing ahead with its vaccination drive, with many Western countries slated to inoculate the majority of their populations by mid-2021. Because they placed orders and flushed pharma firms with cash early on, they were able to stockpile doses. In fact, by the end of 2020, rich countries (just 14% of the world’s population) had bought 53% of the most promising vaccines - enough doses to vaccinate their entire populations three times over.

FYI: Vaccine-hoarding is no doubt unethical and even counterproductive, because if poorer nations are not vaccinated the virus will continue to mutate and spread and the pandemic will continue to rage on, regardless of the inoculation successes of developed countries. But that is a topic for another day.


Missed Targets

India’s stated target is to vaccinate 300 million people (23% of the population) by the end of July. (Presently only frontline workers and those above 45 are eligible to get vaccinated.)

The exact herd immunity threshold for COVID-19 is not known, but preliminary data from Israel, Seychelles and the UAE shows their infection curves declining after 40% of their populations were vaccinated. At its current pace, India will take close to eight months to vaccinate 40% of its population.

As of April 14th, more than 111 million Indians have been vaccinated. The pace of vaccination is the world’s fastest - last week, it averaged 3.8 million doses/day. But due to the sheer size of the population and the seriousness of the Second Wave, the pace needed to cover the vulnerable population alone in 2-3 months is nearly 7-10 million doses/day.

That’s a speed problem. But there’s a supply crunch looming too. Either due to the aforementioned missteps or due to the sheer surge in infections, many states are reporting a severe vaccine crunch. Many are ringing alarms saying they have enough doses for only a few more days while some districts have shut down vaccine administration centres altogether due to lack of doses.

FYI: Before 2020, SII, Bharat Biotech and Biological E had an annual manufacturing capacity of c. 2.3 billion doses. Of this, SII's existing capacity alone is c. 1.3-1.5 billion doses.

International Ramifications

India’s failure with coming up with a successful vaccine strategy may sour its attempts at vaccine diplomacy + delay recovery in many other countries.

Between January and March, 64 million doses were shipped abroad by India. So far this month, only 1.2 million doses have been sent out. As the country struggles to flatten its relentlessly climbing COVID curve, it has moved to curb exports. Officials have said that Indian demand would determine how many doses would be exported.

This bodes ill for the developing world. SII had inked a deal with COVAX to deliver Covishield doses to 64 lower-income countries. This has now been delayed. AstraZeneca had inked a deal with SII for 1 billion doses, and earlier this month sent the latter a legal notice over supply delays. And it’s not just poor countries feeling the squeeze - the UK’s vaccine rollout has slowed because of supply crunch from India.


An Escalating Crisis

As of April 15th, India reported 14 million coronavirus cases in total, overtaking Brazil as the second-worst hit country by the pandemic. Given that testing is not universal and data from rural areas may be underreported, the actual toll is likely to be even higher.

With daily new cases touching new highs every day, the body count steadily rising, and the health system teetering on the edge, the worst of the pandemic is yet to come.

Presently, only Covishield, Covaxin and Russia's Sputnik V have received regulatory approvals in India. To ramp up vaccine availability, the Government recently announced that it would grant an emergency licence for vaccines that have been approved by the US, the UK, Europe, Japan, or the WHO.

This is a step in the right direction. But challenges remain. Unlike the US or the EU, India does not offer pharmaceutical companies indemnity protection. Cold storage and logistical issues remain. And the Second Wave is escalating by the day, making matters worse for the vaccination drive.

How long the current crisis will last is anybody’s guess. But had there been the will for better political planning and regulatory foresight, and had there been less general apathy and reckless self-congratulations, India’s vaccination drive would have been one worthy of India’s vaccine industry.


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