R S Sharma, Chairman of Empowered Group on Vaccine Administration and CEO of National Health Authority talks about using learnings from Aadhaar to ensure speed, inclusivity in vaccination, says vaccine wastage is a management issue, notes that supply, capacity, demand will determine vaccine coverage, and explains risks in home vaccination. The session was moderated by Senior Correspondent Prabha Raghavan
PRABHA RAGHAVAN: As chairman of the Empowered Group on Vaccine Administration (Co-WIN), what specific modifications did you make to meet the country’s vaccination objectives?
I was given this responsibility on January 8-9 — the honourable Prime Minister launched the vaccination programme on January 16 — and, at that point in time, what I inherited, so to say, was an application. We were covering healthcare and frontline workers from January 16 to February 1. We had collected the list of all the frontline and healthcare workers from the states and, (through the application), we were essentially slotting these workers for vaccination at particular health facilities. We were sending them messages saying that you can come to this facility on this date to get yourself vaccinated. But what I observed was that, because the data itself was not very clean — like on many occasions the phone numbers were not correct — many people were not getting the messages. Also, at times, even if the message reached them, they could not come on a particular day because of the nature of their job, which required them to travel. So we realised that the supply-driven approach resulted in lower efficiency of vaccination centres. Let’s say a centre had planned for 100 vaccinations, but only 20 people turned up, so there is underutilisation of manpower. We decided that this approach is not going to work, especially when it is applied to the general public. The first change that we made was to make our approach demand-driven. That was one fundamental change.
Earlier, we were also saying that the second dose should be given at the same centre to ensure that the person gets the same vaccine. But, suppose somebody is in Delhi and has to make a trip to Trivandrum to visit his family. Now, we cannot ask him to travel to Delhi only to get his second dose. So, the second change that we made was to give more flexibility in booking the second appointment at any centre. The only thing we said was that you will be able to view (on the Co-WIN platform) only those centres which are delivering the same vaccine which was given to you the first time.
Then, we created open APIs. It’s a future-proof application. Say tomorrow the hospitals decide to have their own vaccine appointment system, and (it is felt that there) is no need for a centralised appointment system, then that will be possible. The hospitals can then create their own systems and just plug into this (Co-WIN). So having an open API is the third part. It is an extremely important policy because it ensures innovation on top of the existing system. We want to connect with various players in this digital space…
And lastly, scalability is very important. We designed the system for a scale of 10,000 concurrent users (per second). Then, the other aspect was making it easy for people to register. For that, we let four people register from the same mobile. It made the system more inclusive.
PRABHA RAGHAVAN: Are there any learnings from the process so far that you want to take forward or improve upon in the future?
Certainly. The vaccination certificate can probably become one of your health records… With consent, we can issue unique health IDs to the person (getting vaccinated), and he has ownership of the record. Going forward, this can become one of the digital health applications.
Another thing is about aligning with global standards. The World Health Organization is actually creating a standard for digital certification of vaccination and we are aligning with them. As soon as they come up with their standards, from day one we will be aligned with it. So our certificate will be interoperable and anywhere in the world you can just digitally verify it.
The other learnings that we applied were from the Aadhaar days to ensure speed, inclusivity, interoperability, open APIs, open standards, and open source. All these principles have been incorporated to design the vaccination application.
PRABHA RAGHAVAN: How has the public response to vaccination evolved in the past month?
While more than 80 million registrations and appointments are taking place on the system, we are seeing that a majority of the people are just going to centres and getting themselves vaccinated… Now, we are promoting (getting registrations and appointments in advance) from the perspective of crowd management and people not getting disappointed… say, a centre has the capacity to vaccinate 100 people and 200 people land up there… Therefore, the appointment system, in our view, is a better system from every angle, but that’s not happening. However, we have a walk-in system and it does not compromise on any attribute… People should not think of it as some kind of shortcut.
ANIL SASI: How are we bringing down vaccine wastage? It has come down from 13% to 6% now. Also, how much of a challenge is the second shot?
Vaccine wastage is really something which we should eliminate as much as possible. Now, let me give you some idea as to why vaccine wastage takes place. So, let’s say a centre has a capacity for 100 vaccinations and about 81 people arrive at the centre, including both with appointments and walk-ins. A vial consists of 10 vaccines. Now after 80 people get vaccinated, a new vial will have to be opened for the 81st person. Now you can either ask the person to return, or the healthcare worker thinks that let me give this one shot and then others may also trickle in. But what if you give the 81st dose and then no one turns up. So, nine vaccine shots get wasted. Nine out of 81 is essentially about 11% wastage. This is unacceptable, right?
So, what can be done? One option is to have larger centres… For example, if a centre has capacity for 1,000 vaccinations and 991 take place, then only nine shots will be wasted, which is less than 1%. The issue of wastage is a management kind of issue, not so much a technology issue. And management is common sense.
Then, there is the second shot challenge. In the case of Covishield, the window is of six to eight weeks… Now, why should I restrict a person’s choice to only one particular day in the window by giving him an appointment. So, we stopped that (giving appointment for second dose). We are saying, alright, you got your first dose, there’s a window of six to eight weeks in which you should get the second dose and you can make appointments later. And then say after five weeks, we start sending messages… If the person has already made an appointment somewhere, we are fine… If he has not made an appointment, we send a message to him to make one. We send three to four SMSes to him. We are actually nudging him, again and again, to ensure that he gets vaccinated. But that’s all we can do. We can’t force (them)… We will also have a figure as to how many people did not take the second jab and maybe we can again send out a message to them.
TABASSUM BARNAGARWALA: You have spoken about the role of technology in building health infrastructure. India relied on a new software to run an adult mass vaccination programme. In January and February, we saw huge delays in administering vaccination due to multiple glitches. Do you think using the new software was a big risk that we took?
On Co-WIN glitches, I can concede that… when we started working on that, there were already some applications which were there and we did not have time to re-engineer or overhaul that application. So, in the initial days when the software started, we did have some glitches (like OTPs not getting delivered). However, we actually plugged these glitches in a few days. By January 19 or 20, the software had become stable. Also, the problem was not with the software; the problem was with data. For example, we had collected the names of frontline and healthcare workers in Excel sheets. Now those names were there with the phone number, etc. As the Excel sheet did not have any validation, there were phone numbers that had nine digits or started with 00 (wrong phone numbers)… So, because of the data, we could not send messages to those people… So, there were more problems with the data than with the software that we were using… I completely disagree with the hypothesis that Co-WIN delayed the vaccination programme. It has no role to play in delaying or accelerating the vaccination programme. It is only an enabling platform which records the vaccinations and facilitates the vaccination programme. Speed is not really in the hands of the software; it is a function of multiple (factors).
SUNNY VERMA: Have you done any assessment internally or otherwise on how long it would take for the entire population of the country to get vaccinated?
I am not really in charge of these aspects. I think it will be interesting to look at dashboard.cowin.gov.in. It gives a real-time snapshot of the vaccination done, day, gender, centre, state, district etc. It’s a good overview of the vaccination programme and one can drill down to district or whatever level one wants. It also reports AEFI (Adverse event following immunisation), which is basically adverse effect numbers. It’s a comprehensive information system. But with regard to the actual estimates — how much time it will take (to vaccinate the entire population) — there are three variables which actually work in deciding these numbers. The first variable is the vaccine supply. The second variable is capacity to vaccinate, and the third variable is the demand — how many people turn up at the centres. The numbers will be a result of an interplay of these three variables.
SANDEEP SINGH: If there is a rush for vaccination today, will we be able to handle it?
Co-WIN is an extremely scalable platform. We are very confident of it and we will be able to handle the load that comes. Also, the team which has worked tirelessly on this is very competent… We have complete ownership of this thing (Co-WIN). It’s not as if we have outsourced it to somebody. We are very confident that we will be able to scale it up.
We have the infrastructure at the backend as well as safety and security policies in place. We are also going to release the Co-WIN implementation strategy… The tech backbone is absolutely scalable, safe, secure. It has all the attributes of a software which is easy and inclusive… We have learned in our 10 years of experience with Aadhaar, UPI (Unified Payments Interface) and other kinds of frameworks that for any technology to succeed in our country, it has to have the following attributes: data collection must be minimum — we are not even collecting residential addresses, we are just collecting age, name and gender; and it has to be easy and inclusive. This inclusion has been ensured through Aarogya Setu… Any smartphone can be used for it (registration) and you can also do it through the portal. And we will be opening it up for other third-party apps also.
We have designed it on open APIs. It also has to serve India’s diversity. So, we are also giving certificates in local languages. So, from a tech standpoint, it’s a fairly robust product.
RAJ KAMAL JHA: Given the surge, many more vaccines will have to enter the system. How prepared is the Co-WIN platform to handle that?
Absolutely. Suppose tomorrow we have Sputnik V, and day after tomorrow, we have some other vaccine. We don’t have to change anything in the software. We just add another input. They are all data points and you just plug that in… The data points for a vaccine are batch number, the vaccine name and of course the recommended gap (between shots) etc. These are the data points which you plug into the software and it starts dispensing… It’s fairly scalable and we are very sure that we will be able to implement any policy which the government may decide. It will be compliant… I am very clear that it is the policy which directs technology and not the other way around. We are following that principle.
KAUSHIK DAS GUPTA: In future, Covid vaccine will be available in the open market. Is the Co-WIN app suited to take care of such an eventuality?
Absolutely… Typically people think that this is something which has been built to serve only the government, it is regulated stuff… Currently, vaccines are in emergency use authorisation. They are not available in the market and they cannot be priced and sold in the open market. But tomorrow, suppose that happens (availability of vaccines in open market). Now, the application that we have built has components. One is reservation, which deals with appointment and scheduling. Now, in an open market situation, that is irrelevant. You don’t require that. Similarly, vaccination happening in an open market situation, you are not required to record that much stuff… However, you may still require a certificate… to say that a person has been vaccinated with a particular vaccine. Now, the way in which we have designed these things is that all these components can work independently in some sense. You can discard the first component of appointment… and directly connect with the certification model… So the certification components (of the Co-WIN app) can be useful for issuing certificates that are digitally verifiable.
SHUBHAJIT ROY: What have we learnt from Covid vaccination programmes from across the world?
Many of these learnings will be replicable and applicable here, but many of them may not be. For example, in the US, when vaccination takes place, they issue certificates on a piece of paper. Now, in the US, it may not cause much of a problem because it has that kind of literacy levels and awareness is much higher. In India, literacy is low and people are not that aware. We need to have a solution which is appropriate for our diverse environment. If technology can make the vaccination programme more efficient, then I think we must leverage technology… Frankly, I am not aware of such a digital backbone (like India’s) in any other country. We are quite busy in our endeavour to ensure that our application is stable.
ANURADHA MASCARENHAS: Is home-based vaccination feasible in the future?
The government has enabled vaccination at workplaces. Wherever you take the vaccination, you must ensure a couple of things. There has to be adequate space so that the vaccination centre doesn’t become a point of infection. Most important is to have a doctor… So that in case of any adverse reaction, you can immediately take care of it. In case there is an adverse reaction and the vaccination is being done at home, there can be serious issues. So I think that is one of the reasons why we are restricting it to places where you have easy accessibility or at least you can take care of the adverse reactions in time.