‘Centre and states are collaborating all the time … the vaccine stock government procures is only for states’

India’s administrative system has borne a heavy burden during the second Covid-19 wave. PK Mishra, principal secretary to the prime minister, puts it in context to Pradeep Thakur:

What is the Centre’s strategy to ramp up the country’s health infrastructure?

Over the last one year, there has been an unprecedented ramping up in terms of infrastructure as well as human resources and capacities in the health sector. At the beginning of the last year, there was only one lab with a capacity of undertaking a few hundred tests per day for Covid-19. Today, India has conducted nearly 32 crore tests in total through 2,500 plus labs, hitting a global high – on May 11, 2021 – of 20 lakh tests per day. There is similar exponential increase in the availability of ICU beds, ventilators, PPEs, and N95 masks. The production capacity for liquid medical oxygen has been expanded more than ten times, from a pre-pandemic 700MT per day to over 9,000MT per day in May, accompanied by similar increase in cryogenic tanks in hospitals, and oxygen cylinders, oxygen concentrators and PSA oxygen plants. And this expansion is still continuing.

Many of these life-saving emergency measures have been implemented by repurposing capacities from other sectors such as industry, railways and defence. Government has come out with an incentive scheme for doctors and paramedics to increase their availability. More than 50 lakh patients have been served remote doctor consultation by the National Telemedicine Service (eSanjeevani) through the pandemic starting from April 2020. Over the medium term, the Prime Minister’s comprehensive vision for improving universal access to health services has many dimensions. It includes a holistic approach to health, and a robust multi-tiered system, that provides protection to the poorest.

 Why does the Centre avoid imposing nationwide lockdown despite more than 4 lakh daily cases?

In the current wave of the pandemic, the daily caseload of infections is peaking at different times in different parts of the country. We know more about the virus and specific containment measures than one year ago. Now it is more effective and appropriate to take a micro-containment zone, and where required district-specific approach to lockdowns. An evidence-based and real-time dynamic approach to lockdowns adopted by many states is already showing results. The Centre has a key role in providing the overall guidance to states, as is done by the ministry of health and the ministry of home affairs from time to time. Based on this, states are empowered to implement their own measures.

 Retrospectively speaking, could we have managed the second wave of the pandemic better?

There is always scope for improvement. We were extremely concerned by the rapidly increasing scale of the second wave and the unprecedented impacts it has had on the lives and livelihoods of tens of thousands. Particularly, for a week during the second wave, the distress due to scarcity of beds and oxygen was of grave concern to all levels of the government.  We had been keeping an eye on the infections. There was constant dialogue and review with states, particularly with states where we saw an early trend of rising number of infections. There were at least half a dozen meetings at the official level to monitor the situation from mid-February to mid-March. We expected an increase but we did not anticipate such a steep rise. None of the models predicted this. Our emphasis on vaccinating health workers and frontline workers early in the year was a part of our preparedness for the second wave. The health workers have been doing a heroic job.  On some other aspects, even with rapidly scaled up capacities, we fell short but these are being addressed now. Major disasters bring surprises, and new lessons.

Millions have been displaced and lost jobs. Any evaluation made by the government on the last one year of the disaster?

This is a dynamic situation. Unlike any other disasters such as a cyclone or a flood, the pandemic is not a discreet event that you can undertake a one-time assessment of the impacts. It is also not a linear disaster with a fixed pattern of impacts. Many sectors are affected at different times in different ways. And it is still ongoing. For India as well as for the rest of the world, we do not yet have a full picture of its unfolding impacts. The central and state governments have been responding to the anticipated and unfolding impacts of the pandemic through a variety of measures announced since May last year. The RBI has also been acting to alleviate the impacts. Providing protective measures to the most vulnerable is the top priority.

India is a leading manufacturer of vaccines, yet we are currently facing a shortage. Where did we go wrong?

Eighteen crore vaccinations have been done in India, the third highest globally in quantity, and the fastest in speed. This is not an ordinary number by any standards, equivalent, in terms of population, to half of USA, 1 Russia, 2.5 times UK, 7 times Australia, 35 times New Zealand.  Vaccinating 130 crore people is a big undertaking, not just in terms of scale and speed, but also in terms of ensuring efficient and sustained last mile delivery across complex supply chains and varied local constraints. We must recognize that Covid vaccination is under emergency use authorization, requiring vaccination supply chains, local infrastructure and equipment, trained medical manpower and links with Adverse Events Following Immunisation (AEFI) reporting.  This is not akin to the door-to-door immunisation programme we are now familiar with for long known diseases such as polio.

So a phased approach was adopted based on scientific and epidemiological protocol as well as global best practices, prioritising those needing it the most – the essential group of health and frontline workers who are our primary protectors against Covid, followed by the vulnerable group of all above the age of 45 years, accounting for 90% deaths from Covid. Vaccinating everyone as soon as possible is our goal and we will leave no stone unturned in achieving it. We have developed an indigenous vaccine in record time, and are manufacturing another one under license agreement. We are looking into several strategies for scaling and diversifying production, and encouraging new vaccines that are approved elsewhere. Our teams are in regular touch with manufacturers, domestic and international, on a daily basis. We are confident that we will achieve the goal of vaccinating all adults by the end of this year.

The vaccine strategy of the Centre to let states and private hospitals directly procure them from manufacturers has suddenly brought down the daily inoculation. Is there any rethink?

The decrease in daily inoculation is not because of change in policy and less production. In the early phase of vaccination, we had through regulatory approvals allowed stockpiling from before the vaccination began. That is why we were able to inoculate more people per day as delivery capabilities were systematically ramped up. The change in strategy will lead to increased availability through higher domestic production as well as import of vaccines. While kicking in with a time lag of a few months, the supply is slated to increase from 7 crore per month in April to 16 crore in July, and 25 crore in October.

It is important to highlight that the stock that the Government of India procures is only for the states. Twenty crore such vaccine doses have already been provided free of cost to the states. In collaboration with the states we are continuously improving the last mile delivery as we encounter new challenges and learn new lessons. We are working closely with the civil society organisations and the private sector to ensure equitable and comprehensive access to vaccines.

Is India going to miss the UN’s sustainable development goals’ target of 2030?

It is not a question for India alone. There will be challenges in achieving some of the SDGs and there is certainly a temporary setback.  However, there are possibilities that there can be a post-pandemic boom and if we put our minds together and streamline our efforts, the next ten years can be years of unprecedented progress. I also expect that there will be global solidarity to meet these challenges. The world has the wherewithal to bounce forward from this. Particularly SDG 3, aimed at ensuring healthy lives and promoting wellbeing for all at all ages, will receive more attention. Resilience of Infrastructure – particularly digital infrastructure – is likely to receive renewed emphasis in the post-pandemic world. India has already been working with the international community in this area through the Coalition for Disaster Resilient Infrastructure.

The Centre-state relations, are they somewhere affecting pandemic management?

On the contrary, there is a lot of collaboration and dialogue between the Centre and the states – at the political as well as administrative level. Over the last year, on an average, the PM has met and consulted with the CMs more than once a month. This is in addition to bilateral discussions with states facing specific problems. Cabinet secretary has met with state chief secretaries more than 30 times over the last one year. Health ministry has conducted over 100 interaction meetings with states. Everyone – at the Centre as well as in the states – recognizes that we have to work together.  We are collaborating all the time. It is very intense and is manifest in all aspects of the response. Unfortunately, the regular intensive collaboration between Centre and the states, and among states, does not get covered enough; but the one-off stories of relatively minor differences in perception that are far fewer get much more focus.

 India has released over Rs 30,000 crore to states towards disaster relief management in the last one year. How much of this you believe will go towards ramping up health infrastructure?

Resources are being released from several sources not just from the National Disaster Response Fund which is mainly for immediate response. In fact, last year Rs 15,000 crore was provided for ramping up health infrastructure. For vaccines Rs 35,000 crore is made available. In the medium term, it is envisaged to provide over one lakh crore rupees for health infrastructure; it includes the fund available for the National Health Mission. The response to the pandemic can lay the ground for longer term investments towards making the health infrastructure more robust in the medium and long term.

Actions being initiated to deal with a possible third wave of Covid?

There has to be continuity between the actions we take for tackling the second wave and improving our preparedness for a possible future wave or sudden spurts in specific locations. As we learn lessons and gain new insights, we have to continuously improve our pandemic response system. We have to continue to follow a swift, decisive, inclusive and scientific evidence-based approach to managing this pandemic.