Starting Monday, every adult in India will be eligible for a free vaccine paid for by the federal government. The new policy, announced by Prime Minister Narendra Modi last week, ends a complex system introduced just last month of buying and distributing vaccines that overburdened states and led to inequities in how the shots were handed out. India is a key supplier of vaccines around the world, and its missteps at home have led it to stop exports of shots, leaving millions of people around the world waiting unprotected. Only about 3.5% of Indians are fully vaccinated and while supporters hope the policy change will make vaccine distribution more equitable, poor planning means shortages will continue. Here’s a look at the changes to India’s vaccine policy and what they mean. THE EARLIER POLICY India has vast experience in running large immunization programs, and each year it distributes 300 million shots to infants and mothers for free. For these programs, the federal government is in charge of buying the vaccines and then works with the states to figure out how best to distribute them. But the scale of the COVID-19 vaccination campaign is unprecedented. And a massive surge in March pushed India’s health system to the breaking point. As hundreds of thousands of people became infected each day and hospitals overflowed with patients gasping for air, the states complained they weren’t getting enough shots from the federal government and clamored for more control over how the vaccines were distributed. Also read: To launch J&J Covid shot in India, Biological E begins talks with govt lab to test vaccine So, starting in May, the federal government agreed to buy just half of all vaccines produced for use in India and continued to give them out for free to health care and frontline workers and those over 45. The other half became available for states and private hospitals to buy directly. These vaccines were destined for people between 18 and 45; they were free if obtained from the states, but cost money if obtained privately. WHY IT DIDN’T WORK The states had never bought vaccines before and a limited supply meant they were competing with one another as well as with private hospitals. They were forced to pay higher prices than the federal government could have negotiated, said Dr. Chandrakant Lahariya, a health policy expert. “That essentially makes it inefficient,” he said. Private hospitals passed that cost on to people, and amid shortages at government centers, people had to either pay for a vaccine, or not get a shot. The change in policy also expanded eligibility to all adults. Expanding the criteria despite shortages meant shots weren’t always going to the groups the federal government initially said it would prioritize: those with essential jobs and the elderly. Since May, more people younger than 45 have received their first shot than those older than 60. More than 74 million people over 60 remain unvaccinated. Modi said these decisions were taken to satisfy the states’ demands, but the fractured response may have cost lives, said Dr. Vineeta Bal, who studies immune systems at the Indian Institute of Science Education and Research in Pune city. Also read: After Black & White: First case of Green Fungus reported in India WHAT HAS CHANGED NOW? The federal government has now decided to buy a larger portion of vaccines — but it’s still not returning fully to its original policy. It will buy 75% of all vaccines made for use in India and likely renegotiate prices. These shots will be given to states and will continue to be distributed for free. Private hospitals can buy the remaining 25% at prices that have been capped and can charge for them. States will receive vaccines based on their populations, disease burdens and how many people have been vaccinated. They will be penalized for wasting doses. But supply remains a challenge. Delhi Chief Minister Arvind Kejriwal said: “Where will the vaccines come from is a big question.” India has placed orders for vaccines still in development, but for the moment it will continue to rely on existing, overstretched suppliers like the Serum Institute of India.

India’s economy, pummeled by the coronavirus pandemic, contracted by 7.3% in the 2020-21 financial year, just before the country was hit by another catastrophic surge in infections. The economy grew at a 1.6% annual rate in the January-March quarter, according to figures released Monday by the government, but that recovery was stifled by a resurgence of infections in March. Daily new cases set global records, spurring many states to announce widespread restrictions and lockdowns. New cases and deaths recently have begun to decline, but much of the country is still under some form of a shutdown, with many industries and businesses unable to resume work. In January, a government survey estimated the economy -- previously one of the fastest growing among major nations -– would bounce back, expanding 11% in the current fiscal year, which began in April. But some ratings agencies say growth is likely to slow to about 10% due to the most recent surge in COVID-19 cases. Read: COVID-19 might leave adverse impact on Indian economy On Monday, India registered over 150,000 new cases and more than 3,000 deaths. Overall, the country has the second highest total number of infections, after the United States, with more than 28 million confirmed cases and nearly 330,000 deaths. Both figures are believed to be vast undercounts. After registering a daily peak of over 400,000 new cases in May, experts say infections seem to be easing, especially in the capital, New Delhi, and Mumbai. But there is concern the virus may still be rampant in the poorer countryside, where access to health care is more limited. Even though many states and cities remain under lockdown, a few have started to ease curbs on some types of economic activity. New Delhi Chief Minister Arvind Kejriwal has extended the current lockdown to June 7, but announced that manufacturing and construction activities can resume from Monday with health measures in place. “We have to maintain a balance between controlling the spread of COVID-19 and allowing economic activities,” Kejriwal said at a virtual news briefing on Friday, according to the Press Trust of India news agency. Kejriwal said the lockdown will be gradually lifted, with an emphasis on helping the most vulnerable, such as day laborers and migrant workers, many of whom work in factories and construction sites. Many such workers were left unemployed overnight when the government imposed a sudden lockdown in March last year, causing huge distress. India’s economy grew at a 0.4% annual pace in the October-December quarter, after two consecutive contractions pushed the country into a recession last year.

India’s surge in coronavirus cases is having a dangerous effect on neighboring Bangladesh. Health experts warn of imminent vaccine shortages just as the country should be stepping up its vaccination drive, and as more contagious virus variants are beginning to be detected. On Saturday, health authorities said that for the first time, a coronavirus variant originally identified in India was detected in Bangladesh, without providing further details. For weeks, South African variants have dominated the samples sequenced in Bangladesh. There are concerns that these versions spread more easily and that first-generation vaccines could be less effective against them. Experts say that declining infections in Bangladesh over the last two weeks compared to March and early April — for reasons that aren’t fully understood — provided the perfect opportunity for the nation to scale up vaccinations. Also read: Bangladesh detects first case of Indian Coronavirus strain “This is the time to vaccinate, keep infections low and make sure that new variants don’t emerge here,” said Senjuti Saha, a scientist at the Child Health Research Foundation in Bangladesh, who is also sequencing the virus. However, India has banned the export of vaccines as it grapples with the crisis at home. The country’s Serum Institute was supposed to supply 30 million vaccine doses — 5 million doses a month — to Bangladesh by June. But the institute has only supplied 7 million doses and has suspended further shipments since February. “It’s caused a real problem,” said Dr. A.S.M. Alamgir, a scientist with the government’s Institute of Epidemiology, Disease Control and Research. Also read: Border with India to remain shut for another 14 days Fearing shortages, the government late last month stopped allowing people to register for a first vaccine dose, and the administration of second doses is also being hampered. The densely-populated country of 160 million is desperately seeking new avenues for vaccines other than India, and is attempting to produce Russian and Chinese vaccines at home by bringing technology from both countries. Bangladesh is expecting 500,000 doses of Chinese vaccines next week as a gift from Beijing, and has also sought help from the United States. Dr. Mustafizur Rahman, a scientist of the Dhaka-based International Center for Diarrheal Disease Research, said threats from new variants remained a big concern, especially when vaccines are not available. Also read: Covid-19: Bangladesh sees 45 more deaths with 1285 new cases Although the border with India is closed to people, goods continue to cross. Virus sequencing in Bangladesh, like other countries including the U.S., has been scant. This means there could easily be blind spots. “We can’t rule out that the Indian variant would not make a new wave in Bangladesh. We have a porous border with India,” Alamgir said. Since March of last year, when the first COVID-19 case was detected in Bangladesh, the country has reported 770,842 confirmed virus cases and 11,833 deaths. Also read: India's surge hits southern states, prompts more lockdowns A nationwide lockdown has been extended until at least May 16, but many businesses, markets and local transportation remain crowded. Although inter-city travel is banned, tens of thousands are expected to leave the capital of Dhaka for their home villages to celebrate next week’s Muslim holiday of Eid al-Fitr. “If we fail to maintain safety procedures across the country, the virus will make its natural progression, that’s for sure,” he said.

In hopes of taming a monstrous spike in COVID-19 infections, India opened vaccinations to all adults Saturday, launching a huge inoculation effort that was sure to tax the limits of the federal government, the country’s vaccine factories and the patience of its 1.4 billion people. The world’s largest maker of vaccines was still short of critical supplies — the result of lagging manufacturing and raw material shortages that delayed the rollout in several states. And even in places where the shots were in stock, the country’s wide economic disparities made access to the vaccine inconsistent. Also Read: India: 18 die in fire at Covid hospital Only a fraction of India’s population will be able to afford the prices charged by private hospitals for the shot, experts said, meaning that states will be saddled with immunizing the 600 million Indian adults younger than 45, while the federal government gives shots to 300 million health care and front-line workers and people older than 45. Also Read: India grieves 200000 dead with many more probably uncounted So far, government vaccines have been free, and private hospitals have been permitted to sell shots at a price capped at 250 rupees, or around $3. That practice will now change: Prices for state governments and private hospitals will be determined by vaccine companies. Some states might not be able to provide vaccines for free since they are paying twice as much as the federal government for the same shot, and prices at private hospitals could rise. Since state governments and private players compete for shots in the same marketplace, and states pay less for the doses, vaccine makers can reap more profit by selling to the private sector, said Chandrakant Lahariya, a health policy expert. That cost can then be passed on to people receiving the shots, increasing inequity. “There is no logic that two different governments should be paying two prices,” he said. Concerns that pricing issues could deepen inequities are only the most recent hitch in India’s sluggish immunization efforts. Less than 2% of the population has been fully immunized against COVID-19 and around 10% has received a single dose. Immunization rates have also fallen. The average number of shots per day dipped from over 3.6 million in early April to less than 2.5 million right now. In the worst-hit state of Maharashtra, the health minister promised free vaccines for those ages 18 to 44, but he also acknowledged that the shortage of doses meant immunization would not start as planned on Saturday. States say the paucity of shots is one reason why immunizations have declined. India thought the worst was over when cases ebbed in September. But mass gatherings such as political rallies and religious events were allowed to continue, and relaxed attitudes on the risks fueled a major humanitarian crisis, according to health experts. New variants of the coronavirus have partly led the surge. Deaths officially surpassed 200,000 this week, and the true death toll is believed to be far higher. The country’s shortage of shots has global implications because, in addition to its own inoculation efforts, India has promised to ship vaccines abroad as part of a United Nations vaccine-sharing program that is dependent on its supply. Indian vaccine makers produce an estimated 70 million doses each month of the two approved shots — the AstraZeneca vaccine made by the Serum Institute of India and another one made by Bharat Biotech. The federal government is buying half of those vaccines to give to states. The remaining half can then be bought by states and private hospitals to be given to anyone over 18, but at prices set by the companies. The federal government is buying shots at 150 rupees each, or $2. The Serum Institute will sell the shots to states at 300 rupees each, or $4, and to private players at 600 rupees each, or $8. Bharat Biotech said it will charge states 400 rupees, or less than $5.50 for a shot, and private players 1,200 rupees, or more than $16. By comparison, the European Union paid $2.15 per dose for the AstraZeneca vaccine. The company says that price is discounted because the EU contributed to the vaccine’s development. The strain is mounting on the Serum Institute, which in addition to being India’s main supplier is also a critical supplier of the U.N.-backed initiative known as COVAX, which more than 90 countries are depending on. The institute paused exports in March. “The urgent demand for vaccines in India is bad for the rest of the world,” said Ravi Gupta, a professor of clinical microbiology at Cambridge University. Some experts warned that conducting a massive inoculation effort now could worsen the surge in a country that is second only to the United States in its number of infections — more than 19.1 million  “There’s ample evidence that having people wait in a long, crowded, disorderly queue could itself be a source of infection,” said Dr. Bharat Pankhania, a senior clinical lecturer specializing in infectious diseases at Britain’s University of Exeter. He urged India to first stop the circulation of the virus by imposing “a long, sustained, strictly enforced lockdown.” Pankhania cautioned that immunization efforts alone would not help immediately stem the current spike of COVID-19, since shots “only start to bear fruit in about three months’ time.” Vaccination would help prevent future waves of infection, he said. India is also importing shots from the Russian makers of Sputnik V. The first batch was due to arrive Saturday. Another 125 million doses of Sputnik V will be distributed by an Indian pharmaceutical company later this year. Given the urgent need for vaccines, some experts said rationing available doses is critical. “Vaccines need to be delivered to the areas with the most intense transmission,” Gupta said, explaining that vaccines should be used as “emergency control measures” in specific regions of India rather than offering doses to all adults across the subcontinent. Pankhania said the widely seen images of Indian virus patients gasping for air and smoke billowing from makeshift funeral pyres should spur rich countries to share their vaccines more freely. He criticized the approach taken by many Western countries that are attempting to vaccinate all citizens, including younger people at low risk, before sharing any doses. “It is better globally to immunize all the (vulnerable) people that need to be protected rather than to immunize entire populations in only some countries,” Pankhania said.

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