Ruchit Nagar and Saachi Dalal
Building the ship while sailing
Countries around the world are giving emergency approval to roll-out the long awaited COVID-19 vaccine. The Government of India is similarly gearing up for its first phase of roll-out in the coming 2 weeks.
A few days ago, we had a chance to participate in the National Orientation meetings for the roll-out plan hosted by the Ministry of Health and Family Welfare (MoHFW), along with the Rajasthan Department of Medical, Health and Family Welfare (DMHFW).
Our NGO, Khushi Baby works as the Nodal Technical Support Partner to the DMHFW for Rajasthan, with a specific focus on developing, integrating, and implementing digital health solutions for tracking longitudinal community health.
Through the trainings and now in the form of a 113-page blue-print, the MoHFW has described each aspect of this roll-out in painstaking detail: administration, training protocols, vaccine prioritization, cold-chain management, vaccine booth set-up, safe vaccine disposal, adverse events following immunization, IT platform, and intersectoral convergence.
This evolving effort will be complex with many moving parts.
As, Ms. Vandana Gurnani, Additional Secretary and Mission Director of the National Health Mission, aptly stated at the end of the training, “we are trying to build this ship as we are trying to sail it.”
There are key areas that need clarity. The first phase of vaccination prioritizes 30 Cr (300M) people across three groups: health workers, followed by frontline workers, followed by elderly and comorbid people.
The MoHFW has stated that it will follow a principle of only vaccinating those people who have been pre-registered. This makes sense. It ensures crowd-control and a smooth process on the vaccination day. It ensures appropriate staff and supply allocation. And it helps with tracking of unique and targeted beneficiaries receiving specific doses.
Registration is underway for both public and private health workers. District officials are bulk-uploading excel sheets with pre-set validations to the CO-WIN dashboard.
Templates to upload various categories of frontline workers across departments have yet to be released, but may follow a similar approach to that of health workers.
There is a concern, however, with the remaining 26 Cr (260 Million) people who are either 50 and above or having a medical comorbidity, who will need the vaccine in the first phase. With vaccine roll-out as soon as 2 weeks away, the central government has not provided specific recommendations on how this enumeration should take place, other than looking to recent electoral line-lists for those who are elderly.
This concern only grows when thinking ahead to the next phases of roll-out in which there will be attempts towards universal immunization.
The current CO-WIN app has a provision for self-registration of these beneficiaries using a web portal. The reality is that such a portal in a best-case scenario would only be accessible to the top 10% of India’s pyramid with knowledge and access to internet services. Aarogya Setu’s mobile app, despite strong central and state mandates across sectors and national-scale marketing campaigns, only reached 160 million out of an estimated 1.3 billion Indians. Common Service Centers across India and e-Mitra Kiosks in Rajasthan may be used to facilitate self-registration, but these facilities may only get us part of the way to the finish line.
A Digital Health Census
What we need is a digital health census to ensure equitable access of not just the vaccine, but future health services. Rajasthan is planning for just that.
Booth level officers (BLOs) under the Election Commission maintain neighborhood maps of all their electors. Our team has developed a mobile application for these officers to register beneficiaries in their respective areas in an offline manner. When internet connectivity is available, beneficiary data can be automatically fetched from the state’s Jan-Aadhaar database of 67 million residents. When unavailable, the surveyor can scan the beneficiary’s Aadhaar card QR code to auto-fill their registration details, or fill the details manually via the app, with the beneficiary’s consent. Then after selecting the beneficiary’s occupation, comorbidity, and pregnancy status, with the support of the local ASHA, AWW, or ANM, the surveyor can repeat the process for other family members and other houses. The surveyor can also geolocate the vaccination booth and other health facilities within the designated area.
While collecting data through the BLO teams, we are cognizant of future uses of the data by the health department. Accordingly database linkages will need to be built from the ground up so that ASHAs, ANMs, and Medical Officers can longitudinally track beneficiaries registered through the health census. In order to link these databases, seed data will need to be obtained from at least four separate departments, in what is expected to be a complex bureaucratic process, as certain state departments do not have direct ownership over their own datasets.
The mobile app platform, Mission Lisa, has been developed by the Khushi Baby team and was positively adopted by over 60,000 community health workers who have used it to already screen 1.3 Cr (13M) beneficiaries for COVID-19 and comorbidities over the last 5 months. Although the tool was initially used for screening, referrals, and follow-ups of vulnerable groups, now the same platform is being adapted for the purpose of the health census.
A data-driven COVAX vaccination campaign
After data collection, the goal is to cross-reference the comorbidity status of beneficiaries against existing data sets from existing databases including: Rajasthan’s Mission Lisa Database, Pregnant Woman and Child Tracking System (PCTS) Database, Health and Wellness Centers Non-Communicable Disease Database, Nikshay Tuberculosis Database, and the Ayushman Bharat Mahatma Gandhi Rajasthan Swasthya Bima Yojana Insurance Database. After validation, the data may be uploaded to the Center’s CO-WIN backend through APIs.
Now assuming that the CO-WIN backend is able to handle (validate and deduplicate) the hundreds of millions of records uploaded from non-frontline beneficiaries, the next task is left to District Collectors — to assign facilities, schedule sessions for each facility, and assign vaccinators and target beneficiaries to each scheduled session. This responsibility will likely be delegated down to the Block Program Managers, Block Chief Medical Officers, and other supporting managerial staff.
On the day of the vaccination camp, up to 100 beneficiaries will go through a standard process. These beneficiaries will first be verified, then proceed to be vaccinated, and finally observed, before being sent home. If they have registered phone numbers, they will receive an SMS reminder prior to their first camp and prior to the second camp for the follow-up dose. After completion they will receive a link to a digital certificate of their full COVID-19 immunization completion.
Making CO-WIN a winner
The existing CO-WIN platform however may face challenges. Currently the platform is designed to be only available when internet connectivity is present and the app only has English language support. Representatives from multiple states noted on the orientation call that they would face difficulty in using the application in connectivity-poor pockets.
Assuming verification can take place, the option to authenticate the beneficiary and enroll them into the new Universal Health ID program appears to be another feature added without detailed attention to how it may affect the ground operations. Each modality again requires internet connection. The fingerprint scanning option would require provision of biometric modules and a method of sanitation. There is no current provision for biometric module procurement. OTP-verification could be feasible, provided that the beneficiary brings their correct mobile phone and SIM. Demographic verification seems to be repetitive given that in the prior verification step in which the name, gender, and date-of-birth fields are already marked.
In some urban settings a contactless biometric solution could be feasible and more efficient than the existing multi-step process which requires 5–8 inputs between the verification and authentication screens. The Government of India’s UIDAI has piloted facial biometrics with the National Payments Council of India in four banks using Aadhar’s backend database. Results have yet to be published on the experience.
Again, an offline modality should be considered, given the field situation that the majority of Indian’s will experience. Biometrics can be captured, deduplicated, and stored offline, and securely, in the phones of the vaccine officer during the pre-registration process and used for 1:1 offline authentication on the day of the vaccination camp. Offline matching accuracy may be lower and require more initial data at the time of registration.
Khushi Baby has devised a way for the biometric to be stored offline on an NFC card owned by the beneficiary. Admittedly, this would require vaccinators to have access to NFC-enabled phones and for procurement and distribution of health cards to be launched in sync with the beneficiary registration drive. The card could also serve as the physical and digital vaccination certificate, but with the timeline ahead, such ambitions seem unrealistic. In any case, Khushi Baby will be conducting contactless biometric pilots for offline authentication in Udaipur in the coming month, and we hope to better understand feasibility and accuracy of this modality for the later phases to come.
CO-WIN has other gaps. An adverse event can only be reported after the session has been marked as completed, even if the event took place during the observation period. And after the referral is made, there is no mobile interface for the medical officer who will be required to conduct a follow-up visit.
This is another opportunity for the Mission Lisa model to be adopted. AEFI data can be down-synced to medical officers tied to specific Primary Health Center geographies, where they can take follow-up and similarly be connected with the corresponding ASHAs and ANMs who will also find the relevant alerts on their user-specific modules. CO-WIN would benefit from opening APIs for reporting of vaccination and AEFI outcomes for native applications developed by states, such as Mission Lisa.
More clarity is needed and there is more work ahead, particularly on the health-IT side of this complex process to get 1.3 billion people in India vaccinated against COVID-19.
- How will we register people with comorbidities for prioritized vaccination?
- How will we ensure equitable access to the vaccines?
- How will we track vaccine distribution in connectivity poor pockets?
- How can we leverage this moment to strengthen our community health system for the future?
Some key questions remain unanswered, but Rajasthan is on the leading edge to seek out solutions. We look forward to seeing how state-driven innovations can be adopted into the central government’s overall framework.
Ruchit Nagar, MPH, is the CEO and Co-founder of Khushi Baby. He is also a final year candidate at Harvard Medical School. Saachi Dalal is the CSO at Khushi Baby. Khushi Baby is serving as the Nodal Technical Support Partner to the Department of Medical, Health, and Family Welfare for the Government of Rajasthan for community health IT-interventions.