Thursday, November 26, 2020

Vaccination rollout in India- are we ready? We need a BIG Information System to succeed..

Vaccination program has many components - Vaccine development; manufacturing vaccine, storage and distribution of vaccine and finally administering the vaccine to the subjects by trained personnel.

At present (as of 25-Nov-20) what is clear is that multiple Vaccines will indeed by ready (available for buying by Governments) in a month or two. Nothing else is clear in India, at least it is not in public domain. This note is about the type of Information System we need. Without a very good Information System, we will incur big costs and continuing grief!

WHO reports over 100 vaccines under trial. Only COVAX program is committing supplies to all countries - this is a joint initiative of Governments and Private Organizations and individuals (notably, Bill Gates). Rich countries have cornered multiple doses (Canada has ordered 9 doses per person). Poor countries haven't made any acquisitions yet. India has not made public any Vaccine acquisition budget nor the price or quantities it will provide to its citizens.

Vaccination program will require an integrated national application involving big data and AI programs - its stake holders will be everyone living in India, Vaccine manufacturers, Cold chain distribution & logistics providers, Healthcare centres and its personnel, Testing Labs and various authorised personnel who will manage the vaccine program. It must contend with multiple vaccines with different protocols (e.g. 1/2 dose followed by 1 full dose after 28 days in case of Vaccine A may differ from 1 + 1 at an interval of 40 days in case of Vaccine B) and different requirements of storage temperatures at central warehouse vs. transportation temperatures etc. and different regions with varying Ro (R naught is a measure of infection Reproduction rate - 1 or below 1 means pandemic will die down, higher figure means pandemic is going to increase the numbers of infected persons). Priority lists must be made regionwise and Vaccine and personnel made available in adequate measures regionwise - and this will need to be dynamically adjusted based on Ro, numbers of persons according to priority categories in target areas and Vaccine & personnel availability. So, by any measure, the proposed online application will be one of the biggest information systems project anywhere in the world, with the exception of China. India's Arogya Setu, AB-PMJAY applications can help give the proposed Vaccine Management System (lets call it VMS), a head-start.

Vaccines are being introduced in the fight against CoVid-19 with a crashed development schedule, therefore, it is vital to monitor their claimed "safety" and "efficacy". 100% safety means no one administered the vaccine suffered any adverse side effects (one may allow and manage minor side effects - for e.g. low grade fever). 100% efficacy means not a single person given the vaccine got infected afterwards in the planning horizon - the time over which a particular Vaccine is going to be effective should also be a performance measure but this is at present not being reported by any Vaccine manufacturer because the observed time horizon has been too short. 

Few key measures that will help the Government create a successful VMS:

  1. The specifications of VMS must be the responsibility of a multidisciplinary team comprising - Vaccine Scientists & Manufacturers, Doctors, Epidemiologists, Public-health experts, Economists, Data Scientists, Top Solution Architects and Large Scale Delivery Managers (of the calibre of Nandan Nilekani).
  2. VMS must contend with political and legislative issues, therefore, PM's stewardship is mandatory- for e.g. priority of vaccination policy of Centre must not conflict with State's points of view, Aadhaar linking must be mandatory with necessary legislative support (as Aadhaar was passed as a Money Bill, SC has limited its applications).
  3. Arogya Setu must be broadened to include Testing results input by authorised personnel. 164.7 million users are having the Arogya Setu App on their smartphones. Surprisingly, there is no Testing data point- for e.g. I took an Antigen Test (RAT) administered by Ahmedabad Municipal Corp. at our residential complex about two months ago and last week a RT-PCR test at a private lab because I had come in contact with a friend who became Corona positive - the Arogya Setu is blind to these data points - authorised personnel of AMC and the private lab could have updated my record in the Arogya Setu App by using my Aadhaar number which was requested (but not demanded) by all three transactions - i) while registering with Arogya Setu, ii) AMC RAT and iii) RT-PCR test at private lab.
  4. AB-PMJAY Aushman Bharat - PM Jan Arogya Yojna has issued e-Cards to 126.8 Million individuals- this application has even got family members data. I am not sure if it has Aadhaar number of each family member- if it has, it would be of great help in VMS.
  5. Aadhaar link is mandatory for VMS to succeed- why? VMS can pull data from Arogya Setu and AB-PMJAY databases and create a non-duplicate data of people- it can assign each member of VMS a Health ID (which may be administered by National Digital Health Mission). Data can also be pulled using Aadhaar ID from various other lists that must be uploaded into VMS by Medical Associations and Health Care service providers from across the country. Without Aadhaar link, none of this is possible. Building an online database of 1.36 Billion Indians is out of the question without Aadhaar link. If the Government doesn't realise the importance of legislative support, it is bound to hit a wall before long, due to expected legal challenges to mandating Aadhaar disclosure for enrollment into VMS.
  6. VMS must provide APIs - Application Programming Interface - for coupling other applications already running in multiple places so that an individual's health status can be updated. It is vital for tracking the health status of each vaccinated person - at least in the first few months - any side effects? any infection (test results must be updated) and all this must be allowed to be done by authorised persons (organizations) who are treating or testing the individual anywhere in the country (or the world).
  7. VMS must analyze the available data and the state of research and accordingly generate advisories or SMS followup action in terms of further tests to be performed or treatment to be taken for each member. It can of course also generate advisories regionwise for the type of vaccines to use, the intensity of tests (RAT or RT-PCR) to do etc. which will immensely help local Governments.
  8. Every individual does not have a smartphone. Therefore, VMS should generate SMS and also accept inputs from SMS replies. And it must support vernacular languages as per individual member's preference.
  9. Government must not place its bets only on one vaccine- it must use VMS to measure safety AND efficacy performances of multiple vaccines - introduced in the SAME region - to rule out influence of geographical differences- of people or climate.
  10. Government has invested much in building brand awareness of Arogya Setu and AB-PMJAY which it must encash- it may run campaigns to say that VMS will assign priorities and determine the schedule of giving you vaccine based on your data in these respective applications- therefore, please provide your latest data in these Apps, and please help your family and friends to register soon.
  11. Government has lost the opportunity of creating a great health information infrastructure when the Corona pandemic broke. Under the pressure of avoiding CoVid-19 infection, everyone would have been inclined to i) prepare and pass data protection Act; India can use a ready-made template of General Data Protection Rights (or the health related sections of GDPR - of EU/UK), ii) pass Aadhaar applications bill through Lok Sabha and iii) get citizens to provide the minimum required data, provided the benefits of free or subsidised testing, treatment and vaccines were publicized. At the very least, GOI should have provided tests free or at discounted rates on a massive scale. The funding for development of tests was grossly inadequate - it should have been at least two magnitudes higher. This failure to fund massive testing has cost us dearly. We have lost at least 10% of GDP and 134K lives. Tens of millions have been rendered jobless and pushed down the abject poverty line. At least 75% of both these costs, monetary and non-monetary, could have been avoided with a smarter strategy of massive testing and locking down infected individuals rather than the whole Country,  States or Cities. Only recently, has testing been scaled up and instead of locking down whole cities, we are locking down "micro-zones" which is somewhat closer to "individual level lockdown" that is (and was) the ideal solution, pending an effective vaccination program roll out or the discovery of a treatment of CoVid-19.


26-Nov-20 ET Each State asked to submit priority list of people to be given vaccine first

What is eVIN

IE eVIN and CVBMS rolled out. NEGVAC formed to oversee the Vaccine rollout plan by GOI. No sign of a single integrated application- this portends suboptimal utilisation of resources. 

24-Nov-20 COVAX latest news - this program is working with global cooperation- Governments + Private Individuals and organizations.

23-Nov-20 Livemint - The global cooperation is missing so Vaccine distribution and administration is not likely to be equitable.


Monday, July 20, 2020

Does the fix for India's well-being lie in controlling its population growth?

I think that the real problem is not the population growth rate, rather it is the management of the ratio of GDP to Population ( Per capita GDP = GDP/Population) which is one of the important determinants of the standard of living. Population growth is declining rapidly in India, and in almost all countries across the world. Every country strives to give it's people a rising standard of living, ensuring at the same time that no one is left below the subsistence level or hungry (India ranks near the bottom in the Hunger Index - behind all its neighbours). If the "average standard of living" goes up but the very poor remain very poor, it is not a sustainable or an acceptable outcome. Goal#1 out of 17 SDGs is for the world to wipe out abject poverty (UN / World Bank defines it as an income of 1.9 International Dollar per day) - most likely India will achieve this goal before the target date of 2030.

Population and GDP growth both need to be looked at together over the recent past for India and China which have similar size of populations.

India's per capita GDP = 2.3K USD p.a. (nominal) or 9.0K USD p.a. (PPP)
China's per capita GDP = 8.3 K USD p.a. (nominal) or 16.1K USD p.a. (PPP)

India's population growth rate is approaching the replacement level, so it will soon not be the most important problem to fix!

India's current TFR (Total Fertility Rate) is < 2.3  
Replacement level TFR is ~ 2.1 (TFR below 2.1 means population will decline; Lancet is about to publish a report which shows India's population will decline to 1.09 Billion at the end of the century)

TFR in 13 States has already dipped below the replacement level of 2.1!

Notice that many Muslim population dominated States have a low TFR (Kerala & erstwhile J&K) - this is because they are having a better per capita income or the number of those living in abject poverty is lower than many other Hindu dominated States (e.g. UP and Bihar which have lowest per capita income and highest TFR)! TFR has more to do with well-being than caste or religion. (State wise per capita income:

Could it be that China being a Dictatorship need not worry about it's population growth (denominator) because it is confident of growing the GDP (numerator)? India being a Democracy (a functional anarchy) cannot expect to grow GDP like China, therefore, it must treat the population growth as the more important factor (denominator) to manage?

The above argument can be easily resolved. India is indeed growing it's GDP, though not as rapidly as China. It has lifted hundreds of millions in the new millennium above the poverty line - and that has resulted in TFR to drop. This massive reduction of people living in abject poverty was done through direct benefits and entitlements to the poor, besides achieving GDP growth at the second highest rate, after China. These measures included - MNREGA, FOOD SECURITY ACT, RIGHT TO EDUCATION during UPA and SBM during NDA.

There is ample evidence, across all countries of the world, the TFR drops when people are lifted above the subsistence level. 

The phenomenon of TFR reduction due to poverty reduction is best explained by Dr. Hans Rosling his video and few stunning graphs..

There is a direct correlation between poverty reduction and population growth reduction. Rather than focusing or directing resources on "family planning - family size reduction", which was the thrust of Indian Government few decades ago, it should instead focus on targeted measures, including Direct Benefits Transfer, to the poorest segment of the population. The idea of Universal Basic Income (UBI) could easily be modified and more targeted delivery of benefits can happen with today's digital infrastructure - what Modi calls the JAM (Jandhan Account, Aadhaar and Mobile) enablement.

If you wish to dig deeper:

POLITICS and POLICIES arising out of misconception or intentional exploitation of religious differences

If you don't have the picture of the phenomenon of TFR linkage to poverty in your head, you will come up with the wrong prescription for India's priorities. You will give precedence to "population explosion" instead of targeting poverty alleviation. This is exactly what the PM prescribed in his last independence day address (15-Aug-19). This bogey has a sex appeal in India, which PM has milked in the past elections.

Modi's infamous speech, "Ham panch hamare pachees" resonates till today with many Hindus who neither understand TFR nor the fact that Muslims constitute disproportionately larger share of the abjectly poor population.