#3 Optimum Vaccine Delivery for COVID 19 - A Systems Approach
A systems thinking and behavioural economics perspective towards understanding the underlying vaccine delivery systems for COVID-19, and the key gaps that plague us even today.
Vaccine delivery for COVID-19 in India has affected people across all socio-economic backgrounds in India. With scores of India’s population yet to get its first jab, and with intense news coverage, a lot of friends and readers did approach me asking some really pertinent questions regarding vaccines. The most important question being, “Where are the vaccines, and why are we still struggling?”. To understand the implications of vaccine delivery in India especially on the public health system that caters to over 70% of India’s population, I thought it best to understand some of the nuances of this vast interconnected system from a first-principles perspective.
I decided to approach the question - “What should be the vaccine delivery system we aspire for in the public health system?”.
I used the outcome to compare it with our reality to highlight some of the key gaps, and the recommendations that form the bridge that narrows the wide gap.
Meta:
For inspiration, I went back to some of the roots of alternate models of analysis and decision making, finding refuge in the intersection of behavioural economics, game theory, and the systems thinking approach - some of which I have tried to integrate into this writeup.
This week I revisited the podcasts by Shane Parrish (The Knowledge Project) which showcase some interesting conversations with Atul Gawande (public health expert - founder and chair of Ariadne Labs, Lifebox) and Rory Sutherland (vice-chairman of Ogilvy UK). I found these two excerpts from the podcast a perfect fit to preface this edition of the newsletter.
“Finding the edges between things is often where I have something to add. You know, if you look at what I contribute in these spaces, it’s not genius ideas. A lot of them just come from digging in deep enough to understand the gap between what we’re aspiring for and the reality of what we’re doing, and then trying to figure out where the bridge is to a narrow that wide gap.”
— Atul Gawande
“The problem of economics isn’t only that it’s wrong; it’s that it’s incredibly creatively limiting because it tends to posit a very one-dimensional view of human motivation. Therefore, if you wish to change human behavior, the only two ways you can do it are basically by bribing people or fining them.”
— Rory Sutherland
Let me take you through the journey to the edges of intersecting spaces in the context of the optimum vaccine delivery systems.
Vaccine Delivery Systems.
The basic model of vaccine delivery works on a fairly complicated system that is illustrated in the diagram below:
R&D becomes the starting point for any vaccine system. Scientists engage in R&D to study the properties of a particular pathogen, understanding its composition, structure, and the chinks in its armour. After multiple trials and controlled studies which are then published in peer-reviewed journals, the technology is finalised for mass production. This is done by the organisation undertaking the research as well as the corporate or governmental organisations funding the research. A step before this is to get the drug regulator’s approval (specific to the country), which when received initiates the process of mass production.
The next cog in the flywheel is the component of vaccine manufacturers. The vaccine manufacturer allocates resources and installs the necessary capacity of equipment, machinery, and human resources required to produce the vaccines on a mass scale. This equipment and the process is a specialised one. Not every pharmaceutical company in the business has the means and the capability of manufacturing vaccines, even though they are in the business of drug manufacturing and distribution. However, there is some interoperability in manufacturing various kinds of vaccines through existing vaccine manufacturers who have the specialised capacity and the capabilities.
The rate of production of vaccines is a function of the inherent capacity of the manufacturing process (equipment + human resources), and the availability of raw materials for both production and post-production activities. This, in turn, is the function of the demand generation (number of vaccines ordered), and the financing avenues to support the vaccine production (debt and equity means of financing).
Outbound Logistics of Vaccine Manufacturer and inbound capacity of Procurement Agency: Based on the demand generation numbers obtained by the vaccine manufacturers, the vaccines are then sent to the procurement agencies who ordered the doses in the first place, on a first-come-first-serve basis. Most vaccines, including the COVID-19 vaccine in context, require cold-chain facilities (about 2 degrees to 8 degrees Celcius) for effective transportation and storage, both at the manufacturer side as well as the procurement side.
From Procurement to Health Service Delivery Mechanism: Once procured, it gets transferred to the health service delivery institutions at various levels, which can be both private sector institutions as well as the institutions of public health. Once it enters the health service delivery, it follows a complex system of interconnected loops which support the vaccine delivery.
Some of the feedback loops highlighted in this illustration include
Funding Loop: The loop that entails programme funding to technology and infrastructure updation to health-service delivery to immunisation.
Immunisation Awareness Loop: The loop that entails programme funding to immunisation campaign to mobilisation to immunisation awareness to the level of participation to actual conversion of adults into immunisation.
Awareness - Participation Loop: The loop between the increase in immunisation awareness leading to an increase in the participation of adults in immunisation.
Trust in the Healthcare System Loop: The loop between the trust in the healthcare system leading to higher immunisation participation which leads to higher immunisation.
Key Gaps
Some of the high-level gaps currently existing in the system even after months of debate and discussions include:
Lack of public sector funding for centralised vaccine procurement and delivery: The union budget allocated a sum total of INR 35000 Crores for vaccine delivery in India, with the caveat being it was allocated under the budget head of “transfer to states”. Although technically accurate (as the central government only stored buffer stocks of vaccines, and only state governments procure vaccines through State Vaccine Stores), the central government could have taken charge of vaccine procurement and delivery.
Price differential at Central vs State Level - Two different pricing mechanisms hurt the government in the ever-expanding fiscal deficit and create political and socio-economic signalling that vaccines are expensive at INR 350/600 a dose, thereby contributing to vaccine hesitancy.
Levels of Health Worker Motivation: Some of the key contributors to this element of health worker motivation are - workload, safety, and remuneration. We are terrible at ensuring optimum levels of all three contributory factors.
Levels of Participation in Vaccination: We have a rather complicated system for vaccine registration that does more for exclusion than inclusion, all in the name of showcasing a folly of digital technologies. With that comes additional hurdles of turnaround times, vaccination throughput, distance to health centres, and loss of daily income for a majority of the population.
Technology Transfer: A rather opaque and cumbersome process, the inefficiencies has reached newer heights as the government only allowed three public sector enterprises to take up independent vaccine production, which is far away from the ideal situation.
Media narrative of Vaccine Efficacy vs Levels of Participation: The media narrative of discussion pertaining to vaccine efficacy is doing more harm than good, quickly spreading through social media channels and word-of-mouth.
Vaccine Registration vs Slot Booking: An interesting example of the current problems of the vaccine registrations came in the form of the following tweet
When the technology does not work or fails in terms of OTP drops or captcha errors, it contributes to vaccine-hesitancy and contributes negatively to the level of participation.
Way Forward
Through this, I wanted to present a rather holistic view of the interconnected systems that exist in vaccine delivery for COVID-19. Having a better understanding of the interconnected feedback loops and factors that affect the system in a positive and negative way, we look at solutions in a new light. In this particular case, the solutions go beyond economics, and enter the realm of behavioural economics and involve a nash-equilibrium perspective as well.
For instance, the reason Moderna refused to apply for the global tender floated by the Punjab state government is not just because of the problem of State vs Centre, it is also because of the risk management associated with liability and financial security only available through central governments of a particular emerging economy. This enables Moderna to not push for vaccine sales in small and economically struggling countries in Africa, South America, and South-East Asia (a nash equilibrium point of attainment).
Best solutions come when we understand the problem in depth from multiple perspectives and having a deep systems approach. Standalone has neither been the default, nor will be the status quo. It is time we take a hard look at things and help those underserved to get access to vaccines as soon as possible.