Face-off: Is pay-for-jab the best model for India?

FOR: Private sector is essential to reach the most vulnerable in the shortest span

Dr Ashok Seth, cardiologist and chairman of Fortis Escorts Heart Institute

Just when we thought that we had Covid under control, the number of new cases across the country has started climbing again. Because we cannot resort to lockdown this time, there is greater potential for the second surge to be more deadly and overwhelm our healthcare infrastructure. Clearly, the only real weapon we have against this threat is vaccination.

In India we are lucky to have two vaccines available, manufactured in our own country in large quantities. Exemplary coordination between the Central government and state agencies have led to approximately 1.25 crore healthcare and frontline workers being vaccinated. Daily vaccination numbers are expected to grow further as teething troubles are fixed and vaccine hesitancy decreases. This is commendable, but it may not be enough. To protect India from the real threat of a dangerous second wave, the main strategy has to be to vaccinate the maximum number in the shortest period of time.

This is a formidable task for a population of 130 crore. Out of the healthcare and frontline workers and the vulnerable population who were to be vaccinated by July 2021, only 4% have been vaccinated with the second shot till now. Even if we were to double these numbers, it could take more than a year to vaccinate a mere quarter of the population, by which time this virus and its variant strains could wreak havoc.

It is time to exponentially augment our vaccination drive which is only possible with the participation of the private sector. Let us face it, India’s successful fight against Covid in India set an example of what the government and private sector can do if they join forces.

Whether it was ward beds, ICU beds, or ventilators, the government relied heavily on private providers. After first deciding to test only in government labs, we were only able to get the pandemic under control after private labs joined. And all this happened with a sense of duty as the government-mandated reimbursements were often just about meeting the costs of services.

The atmanirbhar agenda which has created a surplus of PPE and N95 masks in India is also a clear example of public-private partnership. The biggest example of this partnership is our vaccine programme — in a few months we could have five vaccines researched, developed and manufactured in India, making it the Covid vaccine hub of the world. Clearly, the trust and bonding between the public and private sector is stronger than ever.

This is the right time to leverage this partnership to augment the vaccination drive given that the initial logistics have been sorted out and vaccination centres are already being run in private hospitals according to government’s norms. Oversight, social responsibility and public confidence have been established now that more than a crore have been vaccinated through government agencies.

Every day I get at least 50 queries from my patients as to when the vaccine will get to them. They are all vulnerable and fearful and I hate to say to them: perhaps in six to twelve months.

Private hospitals and healthcare providers have the ability and infrastructure to vaccinate a large number. The government should waste no time in defining a process of seamless registration through IT and non IT-based pathways. In consultation with private healthcare providers, it should define the price a patient would have to pay for the vaccine.

I can assure you that private hospitals are not looking at it as a way to increase revenues. Most see it as a national and social cause to keep patients safe and for a return to normalcy for the nation, which, at the end of the day, would be the biggest profit for all. The sourcing of vaccination would also have to be defined — whether it should be through the government or directly through the manufacturer at government-applied rates.

The great comfort is that there is no shortage of vaccines. In fact, there is unused stock which has allowed the Serum Institute of India to export. We need to prioritise our own vulnerable patients who urgently need it, eagerly want it and are willing to pay for it. Those concerned that this will not lead to equitable distribution should remember that vaccine distribution will remain with the government, which will lay down a process to be followed by all private providers.

Finally, the government has taken on a huge financial, social and moral responsibility to vaccinate for free. That is how it should be for health workers, frontline workers and those in the lower socio-economic strata. But those who can afford this vaccine should go to private centres and pay for it just as they did for Covid tests and treatment at government-approved rates. This will take the pressure off the government, in terms of finances and logistics.

AGAINST: People with more purchasing power are likely to have easier access to vaccines

Dr Chandrakant Lahariya, public health expert and co-author of ‘Till We Win: India’s Fight Against The Covid-19 Pandemic’

Vaccines come with positive externalities since the benefits extend beyond those vaccinated. That is, if enough people are vaccinated, even those who haven’t got the vaccine are less likely to contract the disease. It is this for this reason, amongst others, that vaccines are considered a ‘public good’. The consensus is that a ‘public good’ should be provisioned through governments and paid for collectively through taxation (in other words, people should not be made to pay for them). As the world is fighting a deadly pandemic, the vaccines are more relevant than ever. It must be this thinking that is behind the US, which has one of the most privatised and expensive healthcare systems, choosing free vaccinations for all citizens. This is a sort of first in their healthcare system.

After licensing of two Covid-19 vaccines, India launched its nationwide vaccination program on January 16 this year. In the first phase, three crore health and essential services workers were targeted for vaccination. Starting March 2021, everyone aged 60 years and above, and those older than 45 with comorbidities will receive the vaccines. In this new phase, those getting vaccines at a private facility will have to pay. However, the vaccination will be free of cost at government facilities.
India is entering into this new phase with a recognised challenge of vaccine hesitancy. Five weeks into vaccinations, though there is higher vaccine acceptance, the challenge persists. In this coming phase — interplay of hesitancy with the need for payment for vaccines — will play out and its effect on coverage will be known in the weeks ahead.

In this phase, there is also a ten-fold increase in vaccination sites in the private sector from the existing 2,000 to 20,000 and a marginal increase from 8,000 to 10,000 in government facilities. Twice the number of vaccination sites in the private sector than in government means three-fold higher access to vaccination for those willing to pay.

Considering that a large proportion of the vaccination group comprises people 60 years and above, and most of them do not have any fixed source of income, for them, a government facility will be the only option. As more people are likely to choose government facilities which are less in number, the time to get them vaccinated could be longer. This will create a vaccine inequity, where even with the equal need, people with higher purchasing capacity are likely to have easier access to vaccines.

The other option for those older than 60 could be that, some earning member in the family covers the cost (of vaccination) in the private sector. This transfers the power to decide their own vaccination in the hands of someone else. Both scenarios put the elderly at a disadvantage. The government provisioning Covid-19 vaccines as a public good and covering the cost of vaccines, irrespective of the site of vaccination — public or private — would have been the right approach.

Essentially the approach to vaccination is very similar to private sector engagement for Covid-19 testing and treatment services in the early period of pandemic in India. Soon after, there were reports of non-adherence to standard operating processes for testing, un-affordably high price for testing and treatment, and refusal to cater to some patients.

The Covid-19 vaccines have similar situations of more demand than supply. Vaccines being a medical product, challenges faced in sourcing in ‘investigational therapies’ and ‘repurposed drugs’ also need to be recalled. There were reports of non-availability, overcharging and black marketing etc. After initial few weeks, these challenges were tackled with government interventions such as price capping, stringent monitoring and regulation. The learnings from each of these experiences would be helpful in the vaccine rollout. Yet, these measures should not result in unnecessary harassment and excessive reporting burden for private sector facilities.

It is widely acknowledged that government spending on health in India is one of the lowest in the world. Often the limited absorption capacity (for additional funds) of the health sector is lamented. The government funding for Covid-19 vaccines was not only the right thing to be done in a pandemic but was also an opportunity for the government to spend.

India has a vast private sector, and its involvement in Covid-19 vaccine delivery is a step-in the right direction. Government footing the vaccination bill on behalf of the people, even at private facilities, could have been a powerful private sector engagement with public purpose. That would have created equal access for all, irrespective of paying capacity.

In the last one year, a few Indian states such as Kerala, Bihar, Madhya Pradesh and a few others had announced free Covid-19 vaccines for eligible beneficiaries. It is to be seen whether these states will keep their promise. The policy interventions of Union and state governments and promises made and kept during the pandemic period will determine the future of healthcare in India.

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