NEW DELHI - When Serum Institute of India (SII) head Adar Poonawalla fled India for London after claiming he had received threats from people desperate to source for Covid-19 vaccines, it brought into sharp relief India's vaccine procurement policy.
The Indian national is chief executive officer of the world's largest vaccine maker by the number of doses produced.
The 40-year-old told The Times that he left the country with his wife and children because of the threats and "aggression", and because he was having trouble managing expectations.
Mr Poonawalla has indicated he will return to India in the coming days even as British Prime Minister Boris Johnson announced on Monday (May 3) that SII is set to invest £240 million (S$446 million) in facilities in Britain.
The Indian government late last month had changed the vaccine policy, from being the sole entity procuring vaccines to allowing states and private hospitals to source 50 per cent of the vaccines directly from manufacturers.
India is using the SII-produced AstraZeneca vaccine and Indian firm Bharat Biotech's Covaxin in the Covid-19 fight.
Russia's Sputnik V has also been approved but is not yet available in India.
Experts say India's vaccine policy is complex, and adds to the current chaos caused by vaccine shortages, with several states unable to ramp up their inoculation drive.
"Traditionally, vaccines are acquired by the Centre (federal government) and distributed among the states based on their needs or other criteria.
"Having a single point of vaccine procurement has been recommended by the National Expert Group on Vaccine Administration for Covid," said Ms Anjela Taneja, who leads the work on education, health and inequality at Oxfam India.
"It is difficult to understand the advantages of forcing India's states to compete with each and against private hospitals, thus fracturing India's bargaining power and lowering the scope of negotiating bulk, centralised procurement."
The Supreme Court on April 30 raised such questions as well, and called on the government to relook its procurement process.
The court noted that states are paying more - between 300 rupees (S$5.40) and 400 rupees per dose - while the federal government is paying 150 rupees.
It noted that poor and marginalised citizens may not be able to pay for the vaccine. Some states, but not all, have announced that they are giving the vaccine free.
Experts say states could end up spending more on vaccines, to the detriment of healthcare infrastructure financing, at a time when the pandemic has already reduced revenues.
"What will happen to states that need vaccines more and backward states that do not have the most efficient procurement system and are not able to negotiate well?" asked Associate Professor Indranil Mukhopadhyay at private university O.P. Jindal Global.
"It's going to be extremely difficult for poorer states to manage procurement and that is one concern... There is going to be a lot of chaos."
Professor Amar Jesani, independent researcher and editor of the Indian Journal Of Medical Ethics, called the procurement policy "too complicated".
He said that the government should have followed its highly successful National Universal Immunisation Programme, where the federal government procures and then distributes vaccines.
India is in the midst of a Covid-19 crisis that has seen it become the second most-affected country in the world.
A second wave has resulted in 382,315 cases and a daily record high of 3,780 deaths in the 24 hours up to Wednesday.
India has over 20 million cases, which has put an inordinate amount of pressure on the healthcare system.
The government has said that the vaccine procurement policy was finalised following inputs from the states, which had wanted to negotiate directly with the manufacturers.
"In any battle, time is of the greatest essence. While the dreaded disease is spreading like a tsunami, it was critical to ease the controls and allow a free hand to the state governments as well as the private sector," said Health and Family Welfare Minister Harsh Vardhan.
As the country tries to ramp up production of the Covid-19 vaccines, the government has been forced to defend itself over claims that it was slow in ordering doses.
It denied an Indian media report which claimed that the government had not placed any recent orders, revealing it had ordered 160 million doses of both vaccines to be delivered from May to July and is expecting 23 million doses from a previous order.
Mr Poonawalla, who said shortages could last two to three months, said ramping up vaccine capacity is not easy.
His company can produce up to 70 million doses a month.
He said vaccine manufacturing is a specialised process, adding that it is not possible to ramp up production overnight.
"We also need to understand that the population of India is huge and to produce enough doses is not an easy task," he said in a statement. "Even the most advanced countries and companies are struggling."
Still, many including former prime minister Manmohan Singh have suggested that a solution would be to open up vaccine production.
Ms Taneja noted that Brazil had approved a temporary breach of patents for the greater good.
"The government needs to bring in all available manufacturing capacity to ensure availability of the vaccine. It may consider temporarily allowing pharma manufacturers to produce generic versions of patented medicines for the larger public good," she said.
Some believe the crisis over vaccine production will stabilise within two months.
"With all gates open for public and private participation... Vaccine has moved into the realm of hope but will take at least two months to make it a reality at scale," said Ms Shobana Kamineni, vice-chairman of Apollo Hospitals.
"Once India gets 20 per cent of its population vaccinated, we can start to believe we will turn this tide."