Public Health

Waning Protection from Covid in the Wake of Low Takers for the Booster Dose

Till covid struck, a one -time vaccination or a pre-defined number of doses of vaccinations usually meant a full-stop to the disease. Covid has ensured that even vaccinations are not for ever and require citizens to resort to regular jabs to ensure immunity.

On June 11, 2022 there was a single-day rise of 8329 fresh COVID-19 cases was recorded in the country, pushing India’s infection tally to 4,32,13,435, while the count of active cases jumped to 40,370. The active covid cases showed an increase of 4103 cases in just one day. According to the MOHFW, the daily positivity rate on the same day was 2.41 per cent and the weekly positivity rate at 1.75 per cent. [1] At the time of publishing this article on 25th of June 2022, the daily positivity rate had gone up to 3.94 per cent and the weekly positivity rate to 2.90 per cent. [2] Vaccinations however continue to make progress with the MOHFW reporting that India’s cumulative vaccination coverage has crossed 196 crores as on 25th of June 2022.

These statistics of increasing covid cases worrying as they are, are also highly under-reported simply because of very low testing in laboratories. It is often difficult to distinguish between covid and the flu resulting in most people not bothering to test themselves. Those who do may just end up taking the home test, the results of which also they may not upload on the Cowin Site. Most people have taken it in their stride although many of them have reported that a bout of Covid has lingering common after-effects in the form of fatigue, cough, and pain in the limbs ranging from weeks to months. Some others have complained of far more serious after-effects and those are now being described as suffering from ‘long covid’

The surge of cases in India as also in other parts of the world is being identified as caused by the new Omicron sub variants BA.4 and BA.5 which spread faster than other circulating variants — mostly BA.2, which caused a surge in cases at the beginning of the year.  As per new research published in the New England Journal of Medicine, “The levels of neutralizing antibodies that a previous infection or vaccinations elicit are several times lower against the BA.4 and BA.5 subvariants compared with the original coronavirus.” [3] This suggests that these variants will allow them to escape pre-existing immunity from vaccination and infection. Further even if one was infected with Delta, that does not mean he or she is safe. Immunity whether by infection or vaccination wanes over time and needs to be bolstered. Therefore an overall vaccination number does not indicate whether the population is adequately covered or not.

Based on projections of population by Census 2011, there are an estimated 138 million people above 60 years of age, which means that there are still around 12.2 million people in the age cohort yet to receive a single shot. This means that there is sizeable elderly population which is yet to take their first dose.[4]

Further as reported on 10th of June 2022, 95.3 million people are yet to take their Second dose of the Vaccine. This includes 21 million in 12-18 years age group and 74.3 million adults. What is worrisome is that 78.1% of those who are eligible for a 3rd dose or better understood as booster dose or precautionary dose have failed to take it implying that the immunity coverage for a large section of population is waning. [5]

The government has recently arrived at an agreement with the two private producers of vaccine that is Bharat Biotech and Serum Institute of India to push down the vaccine price to only Rs 225 per dose. The government took on the responsibility of being the sole buyer of vaccines for empanelled hospitals which are affiliated to CGHS and PMJAY. In these hospitals it is supplying the same at a price of Rs 150 while these empanelled hospitals will be able to recover a maximum of Rs 250 per dose from the patient, leaving Rs 100 for them as a fee for storage, disposables, and manpower. For the private sector, the procurement price of the vaccine was a fixed Rs 225 but were allowed to charge a maximum of Rs 150 as service charge. Along with service taxation, a single dose at a private medical centre would cost you Rs 386-390. [6]

What it suggests is that the government would continue to provide free vaccinations at all its centres for the 1st and 2nd dose, there would be no free vaccination for the booster dose for adults in the age-group of 18-59 years. As per our knowledge, some states like Haryana and Delhi are providing free vaccination to all eligible population between the ages of 18-59 for the booster dose.  This practically means that for the most part, the private health sector has been handled the complete responsibility of henceforth protecting the country through administration of the booster doses.

Given the backdrop of a rising caseload and an increasing section of 80% population unprotected, would it lead to another public health nightmare. A further question that begs to be answered, is it the unwillingness of the private sector to work at considerably reduced margins or it simply a question of large-scale complacency that is responsible for the low uptake of booster doses.

Of the total vaccinations happening in all the states, except for Ladakh, there was hardly any state which had achieved a coverage of more than 4% for booster as a percentage of total vaccinations. This includes states of Delhi and Haryana which allow for free vaccinations at government establishments. This implies a strong element of complacency among the population. A conversation with a medical practitioner went like this, “People are just unconcerned and plain irresponsible.” There is also a certain section which feels that vaccinations have no role in protecting people against covid.  The low number of hospitalizations seemed to have lulled the public into a general complacency even for wearing of masks. Only those who must travel abroad or have some medical procedures to be taken are probably the ones who are more serious about it. At best, those who have some underlying serious medical issues or have a greater sense of self- preservation instinct seem more likely to take it. What people seem to miss out is that vaccinations while does not prevent people from contracting covid, definitely reduces the severity of it including preventing of hospitalizations. As a leading medical professional puts it, “I don’t think there should be any argument or debate on the efficacy of the vaccines. When it comes to the booster, everyone should take it.”[7]

As we look at the data, as coverage of the population increases, the daily vaccination slopes booster doses should have been a rising one instead of the tapering one that we see right now given that more people have become eligible for the booster dose. Taking an average of the last 30 days as on 11th of June 2022, the breakup for the vaccinations carried out was 16% for the 1st dose, 64% for the 2nd and only 20% for the precautionary/booster. Rudimentary check of the Cowin site for your district would show that only a handful of medical centres would be showing options for scheduling for booster doses. Within that also there would be very limited slots. This suggests that medical establishments within the district are simply not opting to schedule vaccinations and rely mostly on walk-in registrations for the same.  Some hospitals may also not be buying stock. One also needs at least 10 persons before a vial of vaccine is opened otherwise it leads to a loss. Obviously, wastage of even a single dose cannot be tolerated given that there is a dead loss of Rs 225 per dose. The service charge may not be enough to compensate for the loss due to wastage.

Whether it is complacency, or it is the lack of financial incentive for private healthcare institutions, the fact remains is that if we leave a high percentage of population unprotected, we may be inviting another deluge on our fragile health systems.  The government needs to step up messaging and encourage people to go in for vaccinations including for the booster dose. If demand picks up, then volumes will ensure that the private sector may do its bit in increasing coverage for vaccination. This is a delicate pricing game where you need at least that volume to cover the fixed costs plus some incentive. It is high time that the Government takes immediate stock of the situation and carry out a massive health communication campaign for vaccinations. It may also need to send in a delicately worded advisory to the private sector to up its game in vaccinating people.









What Changed: Ramblings of a Covid Touched Life

Life is never going to be the same, at least not for a long time. Roads are still empty, factories are only partly working and life dotting the roadsides has gone back to the village. I hesitate to press the doorbell of my neighbor, to walk out in the open, to occupy a public utility, to travel in public transport. My shadow is perhaps a 3X factor of my physical self and both of us struggle to locate spaces that will accommodate us both. The combing of my hair and the creaming of the face is now perfunctory in front of the physical mirror as I am more preoccupied with the mirror in my soul.

The doorbell now waits for the whole day just to be rung up once by the housekeeping staff to collect garbage. The anticipation of opening the door for the morning newspapers, daily deliveries and for my help is a thing of the past. Day and night seem indistinguishable except for the color of the sky. Silence has draped the world much like dark colored curtains on the windows. Imagine asking the computer what date and day it is.

Chat conversations are peppered with spelling and grammar gaffes and so what. Those are minor compared to the ones that have resulted in millions taking to the streets and dead bodies sharing space with living ones. Aspirations of making it big and taking on the world downsized to just staying alive and getting home somehow. Climbing mountains was not important, nor winning trophies, the greatest achievement just boiled down to how many you could feed so that they did not sleep hungry.

Sales of vanity causing products tanked, but so did the faith in political processes and leadership. All that was empty, so was the likes and hearts on narcissistic posts. All you wanted or who you followed was the one who could get you help or gave you correct information and perspective. The bubbles of religion, caste, race, and class, nation got burst, you realized nothing gives you immunity because the virus was egalitarian, it did not differentiate. The mind pendulum oscillated constantly, based on the sentiment of information that waded and invaded through social media and personal networks.

The heroes were neither the politicians nor the celebrities but just the ordinary folks, who dug into their pockets, spent millions in minutes and hearts trying to feed and ferry.  For the first time, we were not fighting trolls, we were fighting power, privilege, ignorance, inefficiency, apathy, and insensitivity. Peddling religion and caste became secondary, securing jobs, cash flow, health and attendant facilities became paramount.

Civil society, health and sanitation workers, professionals, intelligentsia, long neglected by politicians became the harbingers of hope and positivism and the leaders with a purpose. They had their feet on the ground and their hearts and minds aligned and that was what was required to fight the crisis.  Writers and journalists joined the fight and reported and wrote with a purpose to tell as it is, so you did the thinking and not others for you.

The fight is long, there are going to be miles of suffering to be undergone, and the road to recovery is going to be a very steep climb. Everything will fall into place if hearts, souls, minds and priorities are in place. Let none of us forget that.


The Implications for Simultaneity in State and National Elections: Empirical Findings

The Background

The ruling dispensation in the last 5 years or so has on multiple occasions advocated simultaneous holding of state and national elections with the ostensible objective of reducing administrative and financial cost incurred on holding elections at staggered intervals. Recently the proposal has once again surfaced after the new BJP government has come to power.

Reasons for Supporting Simultaneity

There are substantial number or arguments that have been put forward in support of the same. A report on “Feasibility of Holding Simultaneous Elections Lok Sabha and State Legislative Assemblies’ advocated it on three grounds which included policy paralysis that results from the imposition of the Model Code of Conduct during election time, impact on delivery of essential services and burden on crucial manpower that is deployed during election time. [1]

The other major argument that is often quoted to support simultaneity is the sheer volume of arrangements and resources that is needed to conduct an election in India. In 1952, the size of the electorate constituted 173 million voters, by 2014 it had gone up to 863 million and in 2019, there were 900 million voters which included an estimated 130 million first time voters. [2] The expenditure incurred by the Election Commission of India (ECI) on conducting national elections however went up from Rs 10.52 crores in 1952, to Rs 3870 crores in 2014, that is 367 times[3][4][5], which roughly translates into a YOY growth rate of 6%. Figures spent on the 2019 elections by the ECI could not be accessed by the author. The funds spent by ECI is however only a fraction of the total money that is spent by political parties. As per a study by the Center of Media Studies, political parties and candidates spent nearly Rs 60,000 crore in India’s recently concluded general election of 2019, making it twice the amount spent in 2014. It is argued that enforcing simultaneity would substantially reduce the expenditure by political parties since it would reduce duplication on state and national elections. [6]

Implications of enforcing Simultaneity

However there are certain implications that might result in the enforcement of simultaneity. Experts suggest that it may well open the backdoor to situations like the 42nd Amendment Act. Enforcing it may also require increasing or decreasing the term of Parliament and State Assemblies which detracts from the constitutional provision of a full five- year term of legislatures. The Natchiappan Committee made the suggestion of holding elections in two phases, one synchronized with the end of the Lok Sabha and the other sometime during the midterm of Lok Sabha to resolve this practical problem.

The fact of the matter is that lengthy election schedules appear to be unavoidable even during the recently concluded parliament election which was conducted in 7 phases from 11th of April to 19th of May, 2019. Even during this more than a month long jamboree, there were concerns voiced, that it gave enough time for manipulation of later phases of voting. Simultaneous election of state governments will simply imply that the elections will be one long one year instead of being spread over 5 years. There will therefore be continued practical challenges of ensuring the required administrative and logistical arrangements which however was not considered as an insurmountable problem as per a discussion paper by Niti Aayog. [7]

The Impact on Federalism

However, there are far more powerful implications as regards the democratic federal structure of the country that could be impacted by this move. In the last couple of years, the landscape of Indian politics has considerably changed. The dominance of the Indian National Congress (INC) has been considerably diluted to see the emergence of another powerful alternative, the Bhartiya Janata Party (BJP). This has also simultaneously coincided with the emergence of many regional parties and satraps that require all national parties to frequently align with them either explicitly or through other non-tacit agreements especially during the state and local elections.  There has also been a phenomenal increase in money muscle power and use of carefully orchestrated media coverage through all mediums to influence perception and image of parties and their leaders. Winning elections in India therefore, not only requires a poll manifesto that aligns with the aspirations of the Indian voter but also needs in great measure, ingredients of substantial political funding, organizational acumen, well-crafted strategic alliances, careful selection of political aspirants with the accompaniment of a well-designed intensive and intrusive media campaign. In a bid to gain power, political parties apart from the ostensible development agenda also factor in calculations and equations based on caste, creed, religion, language, economic status, nationalistic rhetoric and topographical features while topping it with generous infusions of money and media power. 

Simultaneity in national and state elections with attendant powerful political campaigns can therefore put the voter in a decision conundrum of choosing between state and national issues for which he or she may not be sufficiently informed or even empowered. The partisan role played by the media can sufficiently throw the voter off-balance. There is thus a high possibility of state elections mirroring national elections or vice -versa. This can throw up fractured mandates in national elections if state issues are more dominant in the minds of the voter or more powerful national parties that evict local and regional parties should voters vote more on national considerations.

Not only is the possibility of the voter being influenced either way, there is also the added possibility of the dominant party using both the national and state level machinery to influence state elections especially with state funding and certain projects dependent on central largesse. As such making a choice in favor of simultaneity of holding elections sans the necessary check and balances of enforcement of transparency in political funding, expenditure limits, and models of election conduct can further harm the edifices of a vibrant and independent democratic tradition in the country

Empirical Evidence

The impact on federalism has been corroborated by research studies as well. A study conducted by the IDFC institute and reported by Hindu concluded that there was “on average, a 77 per cent chance that the Indian voter will vote for the same party for both the State and Centre when elections are held simultaneously”. This analysis was done for four rounds of electoral data for 4 rounds of Lok Sabha elections of 1999, 2004, 2009 and 2014 wherein state elections coincided with that of national. They noted that the “trend of choosing the same party has gone from 68 per cent in 1999 to 77 per cent in 2004 to 76 per cent in 2009 and 86 per cent in 2014.” [8]

A similar study was done by Jagdeep S. Khokhar and Sanjay Kumar using figures from 1989 elections onwards found, that when simultaneous elections for the Assembly and the Lok Sabha were held, it was found that in 24 elections, the major political parties polled almost a similar proportion of votes both for the Assembly and the Lok Sabha, while only in seven instances was the choice of voters somewhat different. [9]

Analysis by us using only 2014 election results

A similar analysis was done by the author of this article but using only the 2014 elections which was unique at many levels as it gave rise to the hegemony of the BJP. One found that there were 9 states where state elections were held after the May 2014 general elections within the 0-9- month period constituting 1148 assembly constituencies and 151 parliamentary constituencies. For the purposes of doing this analysis, all BJP allies (Shiv Sena, Telugu Desam, Shiromani Akali Dal, Sikkim Democratic Front etc.) were taken to be part of the winning NDA party combination and similarly all the other parties besides NDA were clubbed as non-NDA.

Out of the 151 parliamentary constituencies that subsequently went for state polls, BJP and its allies had won 96 seats or approximately 64% of the contested seats in 2014.  These 151 parliamentary constituencies translated into 1148 state constituencies. This  implied that at the central level the NDA won 737 seats but in actual state level was down to 501 seats whereas for non-NDA, it translated into 411 seats at the central level but increased its tally to 647 state level seats. Bifurcating Telangana and Andhra Pradesh as two separate states, the NDA won 6 out of 10 states having lost Delhi, Orissa, Telangana and Arunachal Pradesh that subsequently went for elections post 2014 within a 9- month period.

Schedule of State Elections Held in the 0-9 month period post May-2014 General Elections

Percentage of Seats Won in the State Elections by NDA and non-NDA compared to National elections in the corresponding constituencies

Building the Model

To arrive at estimates for probability of winning at both national and state level, a logistic regression model was used. The data for constructing the model was taken from the Election Commission Site, whereas party affiliations were adjusted for after going through the site of Some of the other variables that was used to construct the model was the total voting percentage, the age of the candidate, the time duration from the period when the elections were held, and the type of the constituency. Since most of the candidates were male, sex of the candidate was not found to be a statistically significant variable in the model.

Results of the Model

The results of the model were astounding. The results seemed to suggest that other variables being constant, the party that wins at the center would have a winning log odds ratio of 8.23 : 1 for state elections. Even after adjusting for state level differences, the log odds ratio of winning the state elections would still be approximately 5.16 : 1 should the same party wins at the center. More important, the duration of the interval between the central and the state level elections was an important variable which seemed to suggest that the greater the duration between the two elections, the probability of the winning party at the center also winning elections at the state would considerably decline.

Using this model without adjusting for state differences and using a 0-9-month window period, it appears that should a ruling party win at the center, keeping other variables constant, there is an average 60% probability that it will win the corresponding state elections as well. This probability however varies with the probability being 72.2% if the elections in the state are held alongside the center elections, comes down to 56.2% for state elections held after 5 months, to 49.2% for after 7 months and 42.2% after 9 months.


It is often said that politics and politicians are both fickle. Election results too are equally uncertain. To rule the roost even for 5 years, the stakes are high, and therefore the investment too can be very high. In this process, there are innumerable factors that come into play which can range from money power, perceptions, political and development agenda, caste, religion, socio-economic status, prowess of the candidate, political alliances, percentage of women and young voters, ant-incumbency factor, to even number of parties and participants in the fray. Therefore, any statistical model would never be able to account for all factors given the high degree of variation within each constituency.

Nevertheless, there appears to be strong evidence that national elections do have a high probability of affecting results at the state level as well. For a vibrant federal and democratic set up, that may not be very healthy to have dominance of a party both at a national and state level. As such the proposal to have simultaneity in both state and national elections needs to be examined far more rigorously for its repercussions on the overall democratic foundations of the country.