Lahaul & Spiti (Himachal Pradesh): Among those vaccinated when vaccines were made available in this remote Himalayan district was David Raj, 36, a German, who lived in a rented cottage in the tourist town of Manali.
Raj travelled 45 km northeast to Lahaul and Spiti where he was vaccinated in what he described as a “very comfortable” experience. It was an experience that his landlady, Santosh Kumari, 55, did not share.
When she travelled to Manali from her village of Jalma, which has no Internet connectivity or mobile signal, to get vaccinations for her children, aged 19 and 24, she could not get an appointment.
That required mandatory registration for those aged 18 to 45 on the Covid Vaccine Intelligence Network (CoWIN) portal application, which is difficult in Lahaul and Spiti, a remote district in the north Indian state of Himachal Pradesh, where more than half of its 30,000 people are electronically cut off from the rest of the world.
The district lies more than 300 km to the north of state capital, Shimla, and no network provides a signal at an altitude of over 10,000 ft. Yet, when the local administration opened online booking for the first Covid-19 vaccination drive on 17 May 2021 through CoWIN, all the slots were booked within minutes.
On 17 May, over 50% of the jabs were taken by those situated on the luminous side of the digital divide, instead of the natives. Most of them were tourists from far off states such as Rajasthan, Punjab, Delhi and Maharashtra. One, Raj, was from Germany.
“There were only 100 slots available,” said Pankaj Rai, district commissioner of Lahaul and Spiti. “Out of those, around 60 were taken by people outside the district.”
“It was clear to us—to win the war against Covid, bypassing the online booking was the only way if we had to vaccinate our vulnerable rural population in this remote geography,” said Rai.
A day after the 17 May vaccination drive, Rai's office sought state government permission to begin offline vaccination booking in the district, developing a method that could be used nationally.
In rural and remote geographies of India, there are around 200 million smartphone users, but there isn’t the connectivity to support those devices, a problem that has attracted the notice of the Supreme Court of India.
No Internet Access
A three-judge Supreme Court bench headed by Justice D Chandrachud on 31 May observed that the use of CoWIN to organise India’s vaccination drive, could potentially imperil the constitutional right to equality and the right to health.
“It is the marginalized sections of the society who would bear the brunt of this accessibility barrier,” the court said.
As of 8 July 2021, no more than 5.1% of India’s population, or 70.31 million, was fully vaccinated; 16% had at least one vaccination. Himachal Pradesh was ranked 22nd in the number of both doses administered, with 11% fully vaccinated and 45% with at least one dose. CoWIN statistics were not updated after 9 July, but it is clear India’s pace of vaccination was slowing.
Article 14 research, based on the latest available data, puts numbers to the “accessibility barrier” that the Court referred to: 1.04 billion of 1.38 billion Indians have no access to smartphones required to access the CoWIN app.
On 18 May, Lahaul and Spiti’s chief medical officer, in a letter to the director of the national health mission (NHM), Shimla, pointed to the possible effects of exclusion. “If the same trend (of online registration) keeps going in later sessions, the district might face a situation of local resentment,” he wrote.
Challenges Of Offline Registration
On 19 May, the Himachal Pradesh government allowed the Lahaul and Spiti administration to reserve 80% of slots for offline booking, leaving 20% for CoWIN registrations.
Amitabh Awasthi, health secretary, Himachal Pradesh, told Article 14, that the approval was immediate.“We knew that in these areas this was the only solution,” he said.
But the Lahaul and Spiti administration faced other challenges. “On-the-spot registrations meant crowding at a time when social distancing is a norm,” said Rai.
Registration on the CoWIN application was mandatory to avoid such crowding in the centers, according to R.S. Sharma, the chief of CoWIN portal.
Since Rai’s administration was bypassing the application, they needed to find a way to ensure Covid-19 appropriate behaviour.
After the Supreme court’s 15 June order, it was no longer mandatory to register on CoWIN for walk-in vaccination drives. However, walk-ins are rarely conducted in India, given the vaccine shortage.
Rai came up with his version of an app that helps villagers get a slot using a mix of Google form, WhatsApp and physical paper sheets.
In Lahaul and Spiti, areas are divided into three zones based on Internet availability. Villages in a 30-25 km radius from the district headquarters in Keylong have full connectivity. Some areas in the interior have 2G connections, while areas more than 100 km away with no network are called shadow spots.
Villagers without Internet access can fill a paper form with their name, date of birth, phone number and ID proof and drop it into a ballot box in every village.
Those who can access the Internet but do not know how to use CoWIN can WhatsApp details to the local administration. Google forms in regional languages are also open during limited hours of the day to book a slot.
To educate people about vaccination, the local administration created tutorials on using WhatsApp and Google forms in regional languages. The new policy is advertised on social media and panchayats are tasked with spreading the word.
Every morning, village panchayat officers collect forms from the ballot boxes, via WhatsApp and Google forms before selecting beneficiaries.
“Initially we used to call civil society members to pick chits through which randomly slots were distributed, like a lottery system,” said Rai, the district commissioner. “However, now we have devised computerised randomisation, which leaves no scope for partiality.”
Administrative staff type the details of the beneficiary on the CoWIN portal. “Once the data is fed to the CoWIN portal manually, the vaccination certificates are generated which are handed over to beneficiaries,” said Awasthi, the health secretary.
Replicable But What About Vaccines?
On 29 May, Himachal Pradesh government announced that the offline mode would be adopted for other remote areas of the state.
The state government had also requested the union ministry of health and family welfare on 26 May to allow it access to the CoWIN portal for flexibility in vaccination. It was decided that all the slots would be distributed offline in Himachal's tribal and remote locations, bypassing CoWIN.
Even if CoWIN is bypassed, universal immunisation is still a distant dream, said some experts.
“What Lahaul Spiti did fixes one end of the problem, that is vaccine distribution,” said Srinivas Kodali, a researcher working on Internet, data and governance. “The other end is vaccine shortage. Vaccine shortage is not a distribution issue.”
Despite the odds, the overall rate of vaccination in Lahaul and Spiti, at 23%, is more than four times that of the national rate of vaccination in India, according to latest statistics from Our World In Data.
Kodali said universal vaccination was “very hard” without a constant supply of vaccines. Lahaul and Spiti figured out how to strategically vaccinate the more vulnerable population in their limited capacity. “I hope the government will too,” said Kodali.(Srishti Jaswal is an independent journalist.)