CoLose to CoWin: Improving Vaccine Delivery in India

The COVID-19 pandemic has caused loss of lives and livelihoods at a scale not seen since Independence. A return to normalcy can only be achieved with rapid universal vaccination. Thus, it is important to address the problems with the current vaccine distribution process and provide solutions to ensure rapid vaccination.

Current challenges

The current registration process relies heavily on the COVID Vaccine Intelligence Network (‘CoWIN’) system which is excessively centralised. Though well-intentioned, the app has raised several concerns about its ability to achieve a smooth universal adult vaccination rollout.

They can be summarised as follows:

Rural vs. Urban accessibility: Despite increasing smartphone penetration, not every Indian has either a smartphone or the requisite technical skills to sign-up for the app. In particular, the app penalises rural India, which lacks the broadband connectivity penetration and the speeds available to middle and upper-middle-class citizens in metropolitan cities. According to the telecom regulator’s metrics, there are 98.35 internet connections per 100 people in urban areas while it as low as 55.41 for rural areas.

Literacy: The government’s decision to make the app multilingual helps the majority of people not fluent in English access the app. In addition, the government must factor in the number of illiterate citizens who would also need to use it. The beauty of our electoral process is that it accommodates our vast population of illiterate voters, through the use of party symbols. The same principles must be applied to our vaccine registration and distribution process.

Income: A sizable portion of Indians live hand-to-mouth as they try to earn a daily income. It is therefore difficult for them to take hours out of their time to gather the required documentary proof, register on the CoWIN app and then spend several hours looking for appointments with spotty internet access.

Centralisation: With our large and diverse population, a centralised vaccine allocation and registration process creates a burden almost no single system can bear. While the ambition of the application is appreciable, a decentralised system of registration and distribution with greater autonomy for local health officials would achieve better and more equitable results.

Policy recommendations

The way in which the vaccination campaign is being done — people are expected to engage in a competitive and inaccessible registration process for what is supposed to be a public good — needs to be reversed. The government needs to employ grassroots-level health workers and volunteers to create a frictionless vaccine distribution system. This would entail the following.

(i) Identifying beneficiaries should be carried out by micro-mapping districts with the help of District Magistrates as well as local government health workers (Mallik S, Mandal PK, Ghosh P, et al. “Mass Measles Vaccination Campaign in Aila Cyclone-Affected Areas of West Bengal, India: An In-depth Analysis and Experiences”. Iran J Med Sci 2011;36(4):300-5). This can help delineate regions by population density and high-risk areas for transmission. This will ensure that vaccine supplies are in tandem with the needs of a particular demographic and that scheduling is managed according to the availability.

(ii) Existing databases of welfare schemes should be used for grassroots outreach and enrolment of vaccine beneficiaries (Tan LF, Chua JW. “Protecting the Homeless During the COVID-19 Pandemic”. Chest 2020;158(4):1341-42). Such a rooted mechanism of registration will particularly help reach marginalised groups and migrants that may lack the requisite identification documents currently required. Alternatively, low-tech forms of identification such as paper cards and symbols should be encouraged to serve as reminders for follow-up second doses.

(iii) The onus of registering on the CoWin portal must be shifted from the public to government workers, tackling the impediment posed by a lack of access to smartphones, an internet connection, literacy, or difficulties in navigating technology. This process must simultaneously be expanded to be more accommodative in leveraging best practices from India’s polio vaccination drive.

Local government health officials, auxiliary nurse midwives (ANM), accredited social health activists (ASHA); anganwadi workers (AWW); medical professionals and students; armed forces doctors; and regional as well as district health officers must reach out to the populations of their regions and register them via CoWin, using the app as a liaison while lifting the burden from the public.

Vaccine-specific booths must be expanded to all regions, especially those with otherwise low immunisation rates and that are difficult to access, and at transit points. Once vaccine supplies increase, these efforts should be supplemented with door-to-door visits (Shet A, Dhaliwal B, Banerjee P, et al. “COVID-19-related disruptions to routine vaccination services in India: perspectives from pediatricians” MedXRiv 2021) to further reduce hesitancy and increase uptake.

(iv) By supplementing a grassroots-level outreach with widespread information dissemination campaigns (through the radio, television, local speaker announcements, announcements by religious leaders and public figures, and volunteer outreach), locals can be informed of the status of vaccinations in their vicinity (Burgess RA, Osborne RH, Yongabi KA, et al. The COVID-19 vaccines rush: participatory community engagement matters more than ever. Lancet 2021;397(10268):8-10). This will help officials target their outreach more effectively, foster public confidence in the process, and help dispel any latent hesitancy. Efforts must also be made to educate the public about the side-effects of the vaccine and the provision of foodgrains or cash grants could help smoothen over any worries about a loss of income owing to post-vaccination side-effects.

(v) Tackling vaccine hesitancy must also go hand-in-hand with adequate incentivisation, according to the community's needs. For example, making a provision for small financial deposits for beneficiaries such as daily wage labourers, can accommodate larger sections of society as they may be averse to standing in long queues for the vaccine in fear of losing out on their wages.

-- Abhishek Dalal, Sanskruti Yagnik, Rishika Arora and Krithika Kataria