Why India's digital divide is hampering vaccine access

In the first week of May, Pralay Sagar Das wrote the names, ages, phone numbers and identity card information of his family members on a piece of paper and handed it to a local facilitator in his home town of Govindpur, a remote village in Odisha, on India’s eastern coast.

Das, 21, doesn’t have a laptop, and his low-end smartphone can't support the official app Co-WIN, which Indians aged 18-44 have been required to use to book vaccine slots since May 1. The facilitator registered the family on the app.

“I registered offline, it was easier,” the engineering student said, refusing to confirm if this was a paid service. Writing down names and arranging a fixer to use the app on your behalf is one thing; yet actually securing a slot has so far proven to be difficult. Of Das’ list of 5 people, even his mother — a health care worker — still hasn’t been able to get the COVID-19 vaccine.

The Das family are among the 70 million people who have registered on Co-WIN and are scrambling for unavailable vaccines.

India’s 940 million adults will require roughly 1.9 billion doses of the vaccine. While the government says 2.16 billion vaccines will be available by the end of 2021, India’s daily vaccination rate has fallen to 1.6 million a day from 3.6 million in April—  and with a population of almost 1.4 billion, that means around 230 people jostle for a single injection.  At the current vaccination rate it will take 2.4 years to inoculate everyone, and epidemiologists believe the virus will mutate, possibly to resist existing vaccines, before then.

The second wave of the pandemic is ravaging India’s remotest corners, with nearly 25.5 million cases and 283,248 deaths recorded so far. Amidst vaccine hesitancy and lack of jabs, only 2.97% of the country — under 40 million people — is fully vaccinated. Now 600 million 18-44 year-old Indians, nearly twice the population of the United States, can access vaccinations via online booking.

But a deep digital divide means vulnerable communities, the rural population, and the digitally illiterate have been left out of this new vaccination process.

“Digitization adds a thick layer of exclusion. It benefits only the privileged, educated, and urban populations,” Sulakshana Nandi, national joint convener of Jan Swasthya Abhiyan, or People's Health Movement-India, told Devex. Data shows there is a huge gap in inoculation: Urban districts get 1.7 times more vaccines than their counterparts in rural India, where 65.5% of the population lives.

Where vaccines don’t reach

The virus has reached remote parts of the country such as Tamil Nadu’s Sittilingi Valley. Dr. Regi George, a community doctor who runs the Tribal Health Initiative, attends to 20,000 Indigenous residents spread over 25 remote villages. Cases have been spiking and health care is often inaccessible, George said.

He feared the community would be left out of the new vaccination drive; with the digital dependency exacerbating problems caused by lack of access, vaccine shortages, and hesitancy on the part of the elder population.

“We have such poor network signal here. People still use feature phones, and the phone numbers they need are set on speed dial,” explained George. “How do you expect them to use Co-WIN?”

Around 550 million Indians continue to use feature phones, which means they cannot access digital apps. While India had 450 million smartphone users as of 2019, only 25% of its rural citizens had a device. Only 4% of Indians in rural areas and 23% urban areas had access to computers. Internet connections aren’t universal either — just over 34% of Indians have one.

The disconnect between India’s reality and the government's scheme has prompted criticism over the Co-WIN app’s efficacy. George said: “They make policies in the cities and think the entire country runs on apps.”

As pointed out by Oxfam India, India’s vaccination plans are missing detailed district plans and social mobilization strategies to reach vulnerable communities.

Inequitable policy and planning

The inequity begins with the central government’s policy and spills across all stages from procurement, supply, pricing and the access to the vaccine itself, Nandi explained.  

As of February, India had ordered vaccines sufficient for just 4% of its population, whereas many other countries had placed sufficient orders to vaccinate their citizens many times over.

The central government, which had been handling procurement and supply of vaccines, adopted a “liberalized” vaccination policy on April 23. States could procure their own supplies, and were given just over a week’s notice to make arrangements.

“States were told: Go forth, multiply, procure, compete with each other and get your own vaccines,” said Anjela Taneja, who leads the work on inequality at Oxfam. Most states later announced free vaccination drives, but the taxpayers are still paying for it.

“They are forcing the states to make a choice, the implication is they will go broke,” Taneja said. The central government continues to set the prices for vaccines even as it purchases them from manufacturers for a lower rate than the states, some of whom will have to spend over 30% of their health care budget on vaccines alone.

Taneja compared this with the early days of the pandemic when American states were in a bidding war to access critical medical resources: “It was a lesson that procurement has to be centralized. India went about the whole thing in reverse.”

Vaccines from Serum Institute of India and Bharat Biotech, which produce Covishield and Covaxin respectively, are currently priced between $2 and $20 for a single dose, depending on who procures it and where a citizen gets the jab. The Russian vaccine Sputnik V was rolled out last week at $13. Some states offer free vaccines at government facilities, but private hospitals can charge from $8 to $18 for a single shot.

This is unaffordable for most Indians, over 134 million of whom live on an income of less than $2 a day. At least half of these were pushed into poverty by the pandemic, according to Pew Research Center.

“The current policy doesn’t deliver on socioeconomic justice,” Nandi said.

Jumping through hoops

Activist Pallabi Ghosh has seen this injustice play out at vaccination centers in Assam’s Lumding, a railway town nestled amid lush rainforests in India’s northeast corner. Starting at midnight, serpentine queues of people thinking they can register for a vaccine form — and in the morning, they are turned away, told they have to book a slot, or that there aren’t enough doses.

“Some think you can register and show up at the vaccination centre,” Ghosh said, highlighting the lack of communication around the process.

India has 22 official languages, but Co-WIN is currently accessible only in English, a language which only a few speak — just over 12% of Indians in urban areas and only 3% in rural areas. Nearly three weeks after Co-WIN was made mandatory, and four months after its launch, the government announced that it would be available in 14 other languages soon.

For over a fortnight, Ghosh herself has spent several hours each day peering into the Co-WIN app without any luck. “The saying in Lumding goes, getting a vaccine slot is like meeting the prime minister. It’s not possible,” she said. At a time when the working class can’t afford to lose a day’s wage, spending weeks to book a slot is a luxury most people can’t afford.  

“Why should we jump through hoops to get a vaccine, is the question we should be asking,” Taneja wondered, adding that digitization will exclude those with disabilities, homeless, and pavement dwellers, sanitation workers, wage laborers, and even teachers.

In Uttar Pradesh, nearly 1,600 teachers who were assigned work at polling booths during the state’s election died due to Covid this year, and 37% of India’s 30-million strong health care workforce were fully vaccinated by April.

Some states have chosen a different system. Chhattisgarh, for example, where the population was over 30% Indigenous in the last census, and which has 40% living in poverty, has done away with Co-WIN. The tribal communities, and other vulnerable categories have been prioritized at community-level walk-in vaccination drives. Over 70% of the state’s elderly population have been vaccinated, apart from several vulnerable tribal groups.  

“None of these groups will be vaccinated if left to Co-WIN,” Nandi said. “Now, the first ones to get vaccinated are those who work from the comfort of their homes and have access to health care.”