Vaccinating 2 billion and beyond in India

Barriers to last-mile service delivery, not vaccine hesitancy, will be the main challenge to reach the next billion COVID-19 vaccine doses

On January 7th, India reached a remarkable milestone as the 1.5 billionth dose of a COVID-19 vaccine was administered, less than one year since the launch of the national program in January 2021. From the efforts of frontline workers to the roll-out of an innovative technology platform, the vaccine campaign has been an impressive all-round achievement to protect India's population from the virus. But the arrival of the Omicron variant has added greater urgency to COVID-19 vaccination efforts worldwide, and so it will be even more important to sustain the momentum achieved so far.

Reaching 2 billion doses and beyond could prove more challenging than the first billion. To help track progress of the ongoing campaign and generate evidence for implementation, some questions on COVID-19 vaccination were added to an ongoing panel survey implemented by the Center for Monitoring the Indian Economy of over 100,000 Indian households across 24 states beginning January 2021. Topics included vaccine hesitancy, coverage rates, and potential barriers to access. Here we present a few highlights based on data collected up to August 31st and offer some reflections on the road ahead.

At the national level, 96% of households with at least one member vaccinated reported that it was received free of charge, highlighting the predominance of public sector delivery. At the state level, there is wide variation in the equity of coverage expansion across both lower-income and higher-income states.

Vaccinating the next billion people will require reaching out to underserved populations.

First, the findings suggest that vaccine hesitancy is no longer a major constraint, if indeed it ever was. The share of households stating that they were not willing to receive a COVID-19 vaccine if it was offered free of charge by the government declined from 14% in January to less than 3% by August. The sharpest monthly decline followed immediately after the second wave during which COVID-19 cases and deaths had peaked across the country. Moreover, while there were clear socioeconomic differences in vaccine hesitancy at the start of the year - the richest quintile was almost twice as hesitant as the poorest - these differences have now disappeared, with hesitancy now almost equally low across the welfare distribution. However, the highest rate of vaccine hesitancy remains among the Schedule Tribe population, at over 9%. Overall, and consistent with previous cross-country studies (see here and here), vaccine hesitancy in India appears to be a smaller problem than elsewhere in the world.

Second, the survey findings highlight the impressive expansion of India's COVID-19 vaccine campaign but also some gaps that remain. The share of households reporting that at least one member had been vaccinated quadrupled from 17.5% in April to 70.4% in August. Consistent with administrative data, there are significant differences in vaccination rates across states. At the national level, 96% of households with at least one member vaccinated reported that it was received free of charge, highlighting the predominance of public sector delivery. At the same time, there is evidence of significant inequalities in vaccine coverage that have persisted since the early stages of roll-out. Coverage of the lowest quintile is 43%, compared to 66% of the highest quintile. At the state level, there is wide variation in the equity of coverage expansion across both lower-income and higher-income states. Interestingly, the socioeconomic gaps in COVID-19 vaccine coverage are almost identical to those observed for routine childhood immunization (% of children aged 12 to 23 months that are fully immunized) as captured by the NFHS-4 survey in 2015-16.

Third, while vaccine hesitancy does not appear to be a major issue, the findings point to other potential barriers to wider vaccine access. There are significant gaps in vaccine coverage between urban and rural areas (66% vs. 52%) and between those with and without mobile internet access (59% vs. 51%). Although not required, online registration is the most common entry point for vaccine access. And while 77% of all respondents reported that they knew of a specific location where they could avail of a COVID-19 vaccine, this was the case among only 58% of the unvaccinated. In fact, awareness of where to get a jab was lowest among the unvaccinated poorest quintile, of whom less than half knew of a location where they could be vaccinated.

India has made extraordinary progress on COVID-19 vaccination in a short period of time. But vaccinating the next billion will require reaching a poorer segment of the population, for whom the main barriers to vaccine access may include knowledge, awareness, proximity and convenience. A greater focus on these aspects of last-mile service delivery may offer the key to bringing the pandemic one step closer to its conclusion.