India’s immunisation roadblock: Beating vaccine hesitancy through equitable access

Written by Himani Rathore

Robot wearing a VR set

July 5, 2021 | Mark Chataway and Aman Gupta in Voices, India, TOI

How can India vaccinate a population of 1.3 billion people, of which a majority is rural? As the country lives under the shadow of the second wave, the focus has shifted to preventing a third one.

India has an enormous logistical challenge on its hands. It should focus almost all of its energies on that: the global experience is that widespread vaccine hesitancy does not survive contact with a population in which the vaccinated are safe while the unvaccinated continue to fall ill.

“My neighbour fell sick after she was vaccinated by her employers and never recovered. No one from our village wants to get vaccinated now as it risks falling sick and losing jobs.”

A brief conversation with a houseworker in Delhi NCR went quite unexpectantly the other day.

Despite the recent rural spread of COVID-19, she refused to get herself vaccinated fearing she’ll fall sick and never recover. Evidence from other places in the world suggests that she will change her mind as those around her get vaccinated, but can we speed the process up?

Communications can play an important role in nudging people into accepting vaccines faster than they might otherwise at every one of the three levels that characterise every immunisation campaigns. While COVID-19 has accelerated many processes, the COVID vaccine is not that different from other vaccines when it comes to the actual rollout.

Tier one is figuring out the logistics. One of the greatest lessons the world learnt from the flu vaccination campaign across North America and Europe was that the more difficult and complicated it is for someone to get the shot, the lower the coverage rates. Simplify the process and coverage rates soar to 70-80% of the target population. Thus, 90% of the attention needs to be focused on making it easy for people to get vaccinated by implementing systems that fit into people’s lives; to the extent that people can work 10 hours a day, look after their families, do what they have to do and still get vaccinated. Communications is key to telling people how the vaccine system works and how to access it easily.

Tier two is dealing with people who are a bit reluctant or “hesitant”, as the terminology has come to be. Literature shows us that engaging with those people in an argument does no good. It funds people like us, communications agencies, because it’s good for business, but it doesn’t have any tangible effect. What has an effect is nudging them into it. If you want to go back to the gym, the market, on the bus or train, you’re going to need to show proof of immunisation. This is probably enough to get to 90 percent of the population. Tiny San Marino claims to have vaccinated every one of its 34,000 inhabitants with the Russian Sputnik vaccine, using only persuasion. Almost 90 percent of Israelis over the age of 50 had received a second vaccine dose by mid-April, despite some controversy over nudges that were more like a shove.

Then you’re left with a small percentage who really have a problem with the vaccine. For that group you use different techniques, but where the discourse goes wrong is that the focus is usually laid on convincing this tiny minority. The focus needs to be on the first two tiers of this equation instead. India currently faces the issue of equitable access which is clubbed with hesitancy. Even for those with access, the process isn’t easy. It involves hours of waiting, a trial and error and fastest finger first online slot booking mechanism which is counterproductive. Moreover, it defeats the purpose and amplifies the divide – the urban population versus peri urban, rural or rural dark.

The Indian Government claimed that it will get 100% of its population vaccinated by December 31, 2021. The realistic implementation of that is a cause of worry keeping in mind the above-mentioned factors. Only San Marino seems to have got it completely right so far, but the guiding principle that’s emerged through all of it is to have multiple routes to get vaccinated.

India might have to follow Israel’s footsteps and nudge people into getting the vaccine in order to achieve its mark. It’s a mechanism where while it is not mandatory to get vaccinated, your day-to-day, basic movement gets severely affected without it. In conjunction with the Arogya Setu App, this could be a workable solution in the days to come. The idea of implementing something of this nature would at large mean ensuring a form of mini herd immunity. A herd immunity within the people sitting and watching a cricket match, walking in a mall or sitting inside a theatre.

The European Union is now introducing what’s called a vaccine passport which will have a QR code in it which can either be printed out or simply reflected on the phone and will scan back to a central database. It will allow free travel throughout the Union and, in some countries, access to non-essential venues such as sports events or concerts. India absolutely has the capacity to do this, and multiple recent examples have shown that India must think about implementing something of this nature in a way that isn’t intrusive on privacy.

It is pertinent to note here the role of civil society organizations in facilitating a successful immunisation drive. They bring in a level of trust within the community and government should look at adopting mechanisms to work closely with them to ensure equitable access and beat hesitancy. While sourcing and procurement of vaccines could be central, India’s civil society which is widely spread at the grassroot level must be brought in to ensure equitable distribution and access. At the moment, the process of allocating vaccines in India is complicated. There’s a quota for the central government, one for the states and one for the private sector. This needs to be simplified and the central government should take responsibility for 80% of the vaccine stock and implement a transparent mechanism for its distribution. If there is a role for civil society, it should be integrated into some kind of public sector delivery system in order to vaccinate a large rural population. India has a much more sophisticated distribution infrastructure as opposed to African countries, wherein these systems can be smoothly integrated.

The private sector does play a big role too. Recently one of India’s largest food distribution company Zomato got all their frontline delivery boys vaccinated at one go. This plays a critical role as big corporates and conglomerates can actively ensure that not just the working population but even communities in which they operate get access to vaccines. This also goes a long way in beating hesitancy. One of the most distinctive facts to have emerged through immunisations drive till date is that hesitancy disappears when people you live around and work with have taken the shot. Thus, if you’ve got a corporate site employing 10,000 people and they look around and see that 8000 of them have been immunized, it is highly likely that the remaining 2000 will be up for taking the jab too.

Another key aspect to really driving this change through is effective communications. Australia used an aggressive communications strategy that showcased benefits of getting the vaccine and initiated larger conversations in the communications circumspect about public health with regard to rumours and misinformation. In a country like India where more and more people are using social media, misinformation spreads rapidly through channels like WhatsApp, Twitter and Facebook. Over a period of time, such rumours can create a certain kind of a mindset amongst a growing population and there seems to be an urgent need for building a communications campaign that focusses on reinforcing trust. The known strategy for overcoming this is to dumb down the discussion.

Moreover, communications strategies need to be moulded as per geography and flexible in its key focus areas depending on the population it is targeting. However, it needs to be part of the thought process from the beginning and not something which is brought in as an afterthought.

The counter narrative does exist though where one relies on the fact that as the vaccine rollout progresses, the distrust in vaccines drops. While this has worked in western countries, it is yet to be seen whether this strategy would work in India.

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