Why India's COVID-19 vaccination strategy must be decentralised

Why India's COVID-19 vaccination strategy must be decentralised
Recently, the Union government refused to let the Brihanmumbai Municipal Corporation (BMC) go door-to-door to vaccinate the elderly and disabled residents of Mumbai for COVID-19. According to reports, this is because the Union government doesn’t have a policy for door-to-door vaccination. In Chennai meanwhile, many young people have received a COVID vaccine, despite rules about age restrictions and co-morbidities. Informal sanitation workers who do scavenging are not considered frontline workers, and have reportedly been denied the vaccine in places like Delhi. There seems to be a gap in understanding who is ‘vulnerable’ and who is less vulnerable when it comes to vaccine delivery.  All of these vaccination glitches bring us to the question: Is the COVID-19 vaccination strategy in India effective? And is there a more effective way of safeguarding the population against the virus? First, some facts. ‘Public health’ is a subject on the state list in Schedule 7 of the Indian Constitution. This means that the state governments in India have exclusive rights when it comes to making laws about public health. However, ‘prevention of the extension from one state to another of infectious or contagious diseases’ is a concurrent list subject — which means both the state governments and the Union government have powers to make laws to prevent the spread of say, coronavirus. This ambiguity means that even if Mumbai city wants to go door-to-door to vaccinate people, the Union government effectively can shut down the idea — either for political reasons, or because they don’t want to allow this in every state because of other concerns.  This kind of centralisation means that a state like Tamil Nadu, which sees a lot of in-migration, and has been at the forefront of public health measures in the country — and was one of the first states to eradicate smallpox and polio much before other states — will have to follow the same vaccination strategy as a state like Uttar Pradesh, that sees a lot of out-migration, and has a population that is thrice as large as Tamil Nadu’s. Can the strategy for Mumbai, which has a population density of over 20,000 people per square kilometre, be the same as for Bengaluru, whose population density is around 4500 people per square kilometer? Should we follow the same strategy for Kerala — where 12.6% of the population is above 60 years of age — and Delhi, where people above 60 make up 5.9% of the population?  In a country like India, where the demographics change from state to state, city to city, and even from one neighbourhood to another, a highly decentralised approach — where local governments can decide how to vaccinate the people they govern — seems most logical. The Union government should bow out of the vaccine delivery field, and assist state governments when asked, instead of taking decisions for Kanyakumari while sitting in Delhi. The next question is — who should get priority when it comes to the vaccine? There are several debates about some younger people in Chennai getting vaccinated even as phase 2 is reserved for those above 60, and those above 45 with co-morbidities. Who is more vulnerable — the elderly, or the working-age population who are most likely to go out and contract the virus? Essential service providers? Whose life is ‘more important’ — and who should we vaccinate first in order to contain the spread of the virus? The answer perhaps lies in universalisation. We don’t pick and choose who to vaccinate. We systematically vaccinate everyone — and we do it fast, like Israel, where over 50% of the population has been vaccinated already.  For the COVID-19 vaccine, it’s important that we go on campaign mode and ensure that the vaccines are made available to every single citizen. If door-to-door campaigns are the chosen method of delivery, vaccinate everyone in each household in one effort. If neighbourhood camps are to be set up for vaccination, invite everyone to come in and get the jab — and ensure that these camps and campaigns happen not just in the ‘posh’ and ‘middle-class’ neighbourhoods, but are also accessible to poorer residents and migrant workers. Though that may sound like the beginnings of an expensive logistical nightmare, such a vaccine drive isn’t without precedence. In 2014, India eradicated polio — and while the battle lasted six decades, the win came after governments decided to hold pulse polio camps several times a year, created awareness about the vaccine, and made sure every child in the required age group was given polio drops. This despite the fact that the polio drops need to be administered multiple times until a child is five years old. And the governments did not do it on their own — voluntary organisations like Rotary Club were roped in to ensure the vaccines are delivered in every nook and corner of the country. There is of course the question of whether we have enough vaccines, and shouldn’t the limited quantities be saved for the most vulnerable. It’s a difficult question undoubtedly — but perhaps the answer lies in India’s experience with the Universal Public Distribution System versus the Targeted Public Distribution System followed in various states. Various studies have proven that universalisation of PDS — like in Tamil Nadu — has been more effective, and has led to less exclusions, than a targeted PDS system. A paper by the UN Department of Economic and Social Affairs concluded, “A well-functioning universal public distribution system can be the means to ensure adequate physical access to food at the local and household levels. These proposals—for a universal public distribution system, for universalization of ICDS with quality, and for a mid-day meal to all primary and secondary school children—are likely to require higher food subsidies. In the choice between fiscal restraint and basic food security, if the former is chosen, the result will be a very high welfare cost to the majority of our people in this and the next generation.” Drawing a parallel to the COVID-19 vaccination question — universalisation will be more expensive. But it’s also likely to be more effective in containing the spread of the virus, and ultimately, protecting the lives of citizens. When India is looking to be a global leader and finding ways to give vaccines to other countries, producing sufficient quantities for our own citizens is a problem to which we can find a solution. Ragamalika Karthikeyan is Editor — Special Projects & Experiments at The News Minute. She was formerly a Legislative Assistants to Members of Parliament fellow at PRS Legislative Research. Views expressed are the author’s own. This piece was first published on Here's the thing, an exclusive newsletter for TNM Members.

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