How splitting vaccines 50-50 has created new supply bottlenecks

THE distribution of Covid-19 vaccines across the length and breadth of the country had achieved a degree of cohesion and was more or less seamless despite supply constraints. But the Union government’s decision to decentralise vaccine procurement from May 1, has now presented fresh bottlenecks along the supply chain.

The two specific obstacles, according to company and government sources involved in planning the supply chain brass tacks, are: i) absence of scale now, compared with the earlier integrated hub-and-spoke model, and ii) logistical impediments faced by procurers such as individual hospitals or chains and different states.

This assumes significance because the private healthcare providers or corporates and state governments are now practically on their own in organising the logistics, in addition to managing procurement of vaccines, which is a rationed product today. New offshoots are being created in the journey of Covid-19 vaccines from manufacturing units to the recipient, translating into potential delays and higher costs for end-consumers.

The logistics prior to May 1 leveraged the state-owned universal immunisation programme (UIP) infrastructure, which had a solid network of around 29,000 cold chain points across the country to store the vaccines at recommended temperatures.

LOGISTICS EFFICIENCY BEFORE MAY 1

For the vaccine makers, prior to May 1, the exercise of shipping supplies began once it received an order. The only buyer then was the Central government.

Each half-millilitre Covishield dose used on the country’s priority groups started off from a 1-millilitre vial that AstraZeneca handed over to Pune-based Serum Institute of India (SII) in early May 2020. The cellular ingredient for the vaccine from this vial was then cultured in an almost two-storey-high bioreactor — metal tanks with a capacity of over 1,000 litres — used to culture the cells for the vaccines. Each bioreactor produced millions of doses in one go, and the vaccine thus extracted would be filled into 10-dose vials supplied by Schott Kaisha, one of the glass manufacturing companies that tied up with SII. Batches of these vials, packed in ice boxes and loaded onto refrigerated trucks, would be driven to the Pune airport and loaded on to different flights as per a distribution plan prepared in New Delhi on the basis of inputs from states and other population-based criteria.

Bharat Biotech, which grows, purifies and kills the Sars-Cov-2 virus for its Covaxin at four facilities in Hyderabad and Bengaluru, would also pack its Covid-19 vaccine into 10-dose vials before sending them out in a similar manner.

Before the Centre kicked off its immunisation drive on January 16, vaccines from SII and Bharat Biotech were carried in the cargo hold of commercial flights like IndiGo, SpiceJet, GoAir, Vistara and Air India. To cut costs — transportation by air is known to be more expensive, further shipments traveled by road using services of companies like the Transport Corporation of India that would carry the vaccines in refrigerated trucks to some of the Central government’s larger depots in key hubs like New Delhi, Mumbai, Karnal, Kolkata and Chennai.

These Government Medical Store Depots (GMSDs) or the “primary” vaccine storage facilities operated by the Directorate General of Health Services (DGHS) formed the hubs of the Centre’s hub-and-spokes system. The vaccines would travel from these GMSDs in refrigerated trucks or insulated vans to vaccine stores in various states. While the Centre’s job ended here, the hub-and-spokes model would continue down the chain. From the State depots, the stock would be divided and distributed to regional or district vaccine stores. The doses would further fan out to Primary and Community Health Centres as well as private hospitals, either to be administered there or further be carried by staffers in ice boxes to their eventual vaccination sites.

The larger depots are where the vaccines are stored for transportation to city centres nearby. Once the vaccine reaches the nearest city centre to its final destination, it is stored in another warehouse. Here, the quantities to be sent to primary and community healthcare centres are sorted.

This model allowed the vaccines to reach far-flung areas such as the Northeast. The vaccines would first reach the closest hub — Kolkata, in this case, to be further transported by regional flights. The government’s cold chain network was utilised till the vaccine vials were taken to their vaccination centres.

Considering that Covishield and Covaxin can both be stored between 2°C and 8°C, they are usually kept in regular refrigerators at these centres till they are administered.

THE POST MAY 1 CHALLENGES

Under the current phase of vaccination, the Centre will receive only 50 per cent of what the companies produce. It will allocate this to States and Union Territories “based on the criteria of extent of infection (number of active Covid cases) and performance (speed of administration)”, the Health Ministry has said. “Wastage of vaccine will also be considered in this criteria and will affect the criteria negatively,” it said on April 19.

Now, vaccine makers are expected to also meet orders being placed directly by states and private entities, which will not require them to significantly alter their logistical requirements, but will also be much more exacting. Experts believe the creation of this new offshoot could add to the complexities in the vaccine’s journey and hinder India’s inoculation drive.

According to CoWin dashboard data, there are 58,259 government sites and 2,305 private sites for vaccination.

For vaccines procured by the Centre and distributed to states, the hub-and-spoke model used earlier is expected to continue, but for order directly placed by states may no longer have the ease of starting off at a larger vaccine depot. These orders will also have to be calibrated in a way that the State depots are able to efficiently handle their storage at optimal temperature conditions to preserve the safety and potency of vaccines.

Private hospitals, too, will have to collaborate with vaccine makers as well as cold chain firms to procure and store the doses they will be administering — especially given that nearly 600 million people between 18 years and 44 years only are eligible to receive their jabs at private facilities for now.

Vaccine manufacturers already have arrangements with general sales agents to ship their products. Depending on factors like price, availability and timing, these agents decide the flights or other means of transportation, through which vaccines are to be shipped.

With the opening up of vaccines sales for manufacturers, states and private healthcare entities may no longer enjoy the cost effectiveness they enjoyed as a result of economies of scale due to centralised procurement by the Union government.

A top executive representing private hospitals said the Centre charged Rs 100-150 to private vaccination centres in logistical and administrative costs. “The private centres should be allowed to procure from the Central government, even if they have to pay for the doses. Let the government be in discussions with the vaccine manufacturer. Why should the manufacturer have the discretion to choose between two states or two private hospital chains, particularly because there is a supply shortage right now?” the person, who did not wish to be named, said.

The executive said with private centres left to procure supplies on their own, procurement has become a first-come-first-serve or a price bidding exercise. “While they have the logistics network, the costs of logistics do not match with what the Central government asked for when it managed the supply chain,” he said. It is unclear whether private cold chain companies are being roped in for this exercise. This depends on how many doses they have been able to secure from the vaccine makers, given the current shortage in supply. “It is not clear now… people are exploring various options,” said the executive of a private cold chain company on condition of anonymity.