Can Direct Cash Transfer Incentivize Vaccination In India?

What comes free with a Covid-19 vaccine?

A bumper draw, gift cards or a gold pin!

Making a statement, supporting the cause and, encouraging people to get vaccinated are businesses, communities, and governments across countries. Really a paradox where, while on the one hand are countries like Serbia, Israel with surplus vaccines convincing people to get a jab, on the other are those like India coping with stretched vaccine supplies to reach the shifting vaccination targets.

With the supply of doses expected to ease by July-August with an estimated 10 million doses available per day, can we also follow their lead?

May not be easy.

For India to meet its ambitious target of vaccinating at least all its near 945 million adult population by the end of 2021, the country needs to administer minimum 1.88 billion doses in total, of which nearly 89% are yet to be given. Simply put, an approx. 238 million doses every month from June ’21 onwards which only swells up to 359 million doses per month if one were to include those below 18 years. Surely, a tall order considering some of the vaccines are still in phase 1 and their availability may take time. Besides, as per CoWin data itself, the fastest rate at which India has vaccinated so far is 3.8 million doses per day (based on seven-day rolling avg). Therefore, even if 5 million vaccinate per day from July onwards, it will be only April next year for adult population & October ’22 for everyone to be vaccinated.

It is not just the supply side but the distribution, and behavior dynamics also affect the vaccination uptake in the country. With more than 12 billion vaccine doses announced by all manufacturers for release in 2021 subject to clearance, an inclusive and efficient distribution of safe vaccine will be imperative to protecting lives. While the good news may be the recent increase in the vaccination pace, but this is largely due to the intensity of 2nd wave. And, even here, a large rural population is still unattended especially in the wake of the virus now hitting these areas. How does one handle vaccine supply which is anyway skewed towards urban areas? How do we push the rural population largely driven by factors like willingness, perception, trust, norms before they decide to take a jab? As of mid-May just about 15% were vaccinated outside urban areas and the case load in rural areas was more than 60%!

We seem to be moving ahead.

The government’s recent decision to clear applications to import and supply COVID-19 vaccines approved for restricted use by US FDA, European Medical Agency (EMU), UK (Medicines & Healthcare Products Regulatory Agency (MHRA), Pharmaceuticals and Medical Devices Agency (PMDA) Japan or which are listed in WHO Emergency Use Listing (EUL) in three working days is a welcome step. The decision will not only provide quicker access to such foreign vaccines by India, encourage imports including import of bulk drug material, but also accelerate the vaccine manufacturing capacity and total vaccine availability within the country. With a third wave expected to hit children, talks with Pfizer are on to vaccinate them as quickly (possibly from July). State governments are also doing their bit in rural India with information campaigns, target messaging, and opening of more sites.

But, is this going to be enough?

A more participative and collaborative public-private partnership can be a gamechanger. For instance, with an accelerated vaccination drive, a huge number of inoculators will also be required. The private sector can fit in well here to meet the manpower resource gap. They can complement government efforts and help create new vaccination sites, mobilize workers/volunteers for an accelerated drive and leverage on technology like blockchain and IoT to ensure a smooth last mile delivery.

With the 2nd wave waning and the next one staring, leveraging on the frontline workers like trained army doctors, AYUSH doctors & ASHA/Aanganwadi workers can work greatly towards the accelerated rural push. One can take a cue from the success story of polio eradication mission in the country. The state of Uttar Pradesh alone had nearly 65% of global polio cases in 2002 with a high vaccine hesitancy. UNICEF aggressive engagement with social mobilisers and celebrities greatly helped mitigate this fear.

A simplified vaccine registration process to bridge the rural-urban divide, push towards behaviour change which has the potential to overcome vaccine hesitancy, training of frontline workers coupled with a more stringent watch over curbing vaccine wastage in the country that stands at nearly 5% versus the global average of 1% could be some added measures.

Learning from the global experiences

Incentive for inoculation? Yes, Israel’s Green Pass Program gave access to gyms, hotels & restaurants and Belgrade offered gift cards to the first 100 in their walk-in centres at a shopping centre, many states in the US have also incentivised vaccination after their numbers started plummeting. New York’s Vax & Scratch Program could win someone a whopping $5 million; California’s Vax for the Win Program (touted as the biggest in the country) offered a huge $116.5 million as incentives; Ohio’s Vax a Million could land someone a four-year full-ride scholarship!

Back home, India’s goldsmith community from Rajkot in the state of Gujarat also offered 45+ women and men gold nose pins and hand blenders respectively for getting a jab at their vaccination camp.

Can we not borrow from these examples?

It may be worthwhile to consider the option of a direct cash transfer scheme to the beneficiaries of government welfare schemes in the country. The transfer could be conditional and given either in parts with every jab or at once after the person is fully inoculated. This could be a timebound and conditional cash transfer. Taking an example here is that of a successful cash transfer program called Bolsa Familia (Family Allowance) in Brazil where the government transfers cash to poor families only if they agree to send their children to school, healthcare centre and vaccination. The cash transfer could also give a minimum income in the hands of people to help them live with dignity. Something that NREGA is already doing. With a reverse migration and dipping family incomes due to the pandemic, already about 25.6 million households have demanded work under NREGA in the month of April 2021, which is about 91% more than the number last year.

While critics may say that providing cash for jabs is like giving a candy to children, it is to be noted that the concept is not new. There are payment incentives given to participants for clinical trials, plasma donation or stopping unhealthy behaviour. Some may also say that in the context of rural India where people anyway do not trust vaccines may think that payment is a reconfirmation of its unreliability.

But, the spirit behind the cash transfer scheme for a jab is to incentivize vaccination in the country and contribute towards attaining a herd immunity. At the global level, close to 100 targeted cash transfer schemes have been launched where 50 are new and, specifically in response to Covid-19 in countries like Ecuador, Peru, Iran and Italy. No doubt, every incentive must come with the right checks and balances. It is here that data transparency and education on vaccine safety becomes critical for an evidence-based approach to achieve the desired results.

We are in the slog overs. The call is to up our game. Word of mouth helps but, money can be a motivator.