India has a vaccine hesitancy challenge

Written by Himanshu Arora

India launched the world’s largest Covid-19 vaccination programme on January 16, 2021, to vaccinate its 900 million eligible population. An estimated 30 million healthcare and frontline workers were to be vaccinated in phase 1. The subsequent phases covered the majority of the population, starting with the elderly and those with co-morbidities, people in the age cohort of 45-60 and 18-44 beginning May 2021. Despite logistical hiccups, India surpassed the USA in administering the maximum number of doses in the world. As of June 30 2021, India administered 33.2 crore doses to 27.4 crore individuals. However, only 4 per cent of India’s population is fully vaccinated compared to 45 per cent in the US and 48 per cent in the UK.

Much of the public discussion regarding the slow pace of vaccinations has centred around the supply-side barriers like shortage of vaccines, lack of infrastructure, logistics and equitable access to vaccines. The demand-side barriers like vaccine hesitancy fuelled by lack of trust, fear of side-effects, and concerns regarding safety and efficacy of the vaccines are less debated. Even before the emergence of Covid-19, WHO recognised vaccine hesitancy as one of the 10 leading threats to global health. In 2015, the WHO defined vaccine hesitancy as a “delay in acceptance or refusal of vaccination despite the availability of vaccination services”. In India, misguided hesitancy and fake information about vaccines are a substantial threat to the elimination of the pandemic and achieving herd immunity against the infection.

To get a complete picture of Covid-19 vaccine hesitancy and understand the trends, and reasons for hesitancy in India, I analysed the findings from ‘The Covid Symptom Survey’ (CSS). The CSS is conducted by Facebook, in partnership with the University of Maryland, in 200 countries, including India. The CSS, with its large sample size, ability to collect real-time information, and robust statistical framework, provides an opportunity to explore the trends in vaccine hesitancy in India. In India, CSS is using an active base of over 320 million Facebook users as a sample dataset.

The CSS survey asked the specific question: “If a vaccine to prevent Covid-19 were offered to you today, would you choose to get vaccinated?” The respondents were asked to respond with the following options: Yes, definitely; Yes, probably; No, probably not; No, definitely not. The survey findings reveal that a significant proportion of the population across states are vaccine-hesitant. The proportion of the population hesitant to Covid vaccines is highest in Tamil Nadu (40 per cent), Punjab (33 per cent), Haryana (30 per cent), Gujarat (29 per cent), and Andhra Pradesh (29 per cent). The proportion of the population hesitant to Covid vaccines is lowest in Uttarakhand (14 per cent), Assam (15 per cent), Jharkhand (19 per cent), Kerala (19 per cent), Odisha (19 per cent).

The CSS survey further probed the reasons for not taking the vaccine or delaying it among the naysayers. The top five reasons for not taking vaccine includes “waiting for others to get it first” (42 per cent), “other people need it more than me” (35 per cent), “fear of any side-effects” (34 per cent), “vaccines won’t work” (21 per cent) and “don’t believe in the vaccine” (11 per cent). Contrary to popular perception, the proportion of people choosing “high price of vaccines” and “religious belief” as reasons to opt-out remains minuscule.

Although 33.6 crore doses of Covid vaccines were administered in India, a larger proportion of the population continues to be apprehensive about them due to lack of information. The CSS survey collected this information by specifically asking respondents how informed they are about how to get a Covid vaccine. The state-wise findings show the proportion of the population informed about vaccines is lowest in Tamil Nadu (60 per cent), Andhra Pradesh (60 per cent), Punjab (60 per cent), Assam (60 per cent), Karnataka (65 per cent), and Haryana (65 per cent). The proportion of the population informed about vaccines is highest in Goa (90 per cent), Delhi (75 per cent), Odisha (75 per cent), Madhya Pradesh (75 per cent), and West Bengal (75 per cent).

Lack of trust in safety and efficacy of the newly developed vaccines, fear of side-effects, rumours about infertility and death after taking the vaccine, combined with the inconvenience of registration/booking slots, low-risk perception from Covid-19 and the absence of incentives for rural and urban poor etc. are fuelling high vaccine hesitancy.

Overcoming Covid-19 vaccine hesitancy will require a target-based approach focusing on the needs and concerns of individuals, groups, and communities. Behaviour science research shows that individuals are time-inconsistent, i.e., they are more concerned about the present as compared to some distant future event. The benefits of the vaccines will accrue in the future; however, the cost of vaccines, fear of immediate side-effects, inconvenience, time and money spent etc., have to be borne in the present. Therefore, the strategies to overcome hesitancy have to target the present through adequate incentives and timely information.

Active involvement of local influencers, religious leaders, traditional healers, local NGOs, local doctors, panchayat heads, etc., may encourage vaccine uptake. These leaders can be made to take the vaccines in open public sessions to spread the message regarding their safety; vaccination sites may be opened up at places trusted by people, such as temples and mosques, Election Commission offices, etc; public campaigns like “I am proud to be vaccinated” can create awareness and build momentum around vaccinations in regions with low uptake. Indelible ink, generally used in elections, can be applied on the fingers of vaccinated people. Such a campaign will create a sense of nation-building and can encourage participation. Given that a large proportion of the rural population works as daily wagers and fears losing a day’s income due to vaccination, workers may be given one-day MGNREGA wage for taking the shot. Small incentives, (1kg rice and pulses, 1 litre of cooking oil, etc) can be given to compensate people for the time and money they spend to get the vaccine and, finally, behaviour innovations like announcing prize money (lucky draw) amongst the people vaccinated in selected centres with low uptake can boost vaccination rate.

The writer is a health economist, previously worked with EAC-PM, GOI.