CO-WIN

Fighting the inevitable

What is CoWIN?

CoWIN is a cloud-based application developed by the Government of India (GOI) for the Covid-19 vaccination drive in the country. Beneficiaries looking for vaccines can register on the CoWIN site by uploading a valid photo identity proof document. The CoWIN application also has the provision for the creation of Department Users (administrators and supervisors) and implementing the inoculation process. It is an open-source, modular, open standard channelled, robust, secure, scalable, interoperable and evolutionary process automated engine. It is operating system agnostic. All we need as a user is a browser to access and operate the application modules. For administrators, a quick deployment and easy data migration make for fast adoption of Co-Win.

The Monster numbers of Covid

The number of cases affected by Covid are colossal. Total number of covid cases as on 26th June 2023,15.30 hrs was – 4,49,88,426
Number of people recovered are-4,44,50,404,Number of death ares-5,31,854

The inevitable need for massive immunisation

The only means to protect the people was through immunisation. The role of immunisation division of Ministry of Health & Family Welfare was very critical. They got designed the Co-WIN portal with technical help of UNDP and this was built on the lines of an already existing

immunisation portal. The portal was launched to register the people for immunisation from 16 ^th

January 2021.The vaccines introduced were Bharat Biotech’s Covaxin and Serum Institute’s Covishield. The immunisation was carried out in different phases according to top priority to Health care professionals and staff and then according to age groups. The figures of those vaccinated are a whopping 220 crores plus which by any standards are huge even on a global scale.

As on 2 ^nd Sept’23, 2 pm, the number of immunised people was as follows-

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People immunised with 1st dose of vaccination = 1,02,74,16,885

People immunised with 2nd dose of vaccination = 95,19,84,536

People immunised with precaution dose of vaccination = 22,73,39,149

Number of people who are fully vaccinated (1st,2nd and precaution dose) = 220,67,40,570

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Pre-existing ground prepared by experts

The Government of India established and developed the CoWIN platform with experts, who had already contributed to rolling out digital public goods such as Aadhaar, UPI, and Digi Locker, providing technical expertise and as well as overseeing the development. The same partners had also collaborated on the design and implementation of another flagship digital health service, eVIN, which was later built upon as they constructed a tool to address problems specific to COVID-19. CoWIN will be expanded to include the Universal Immunization Programme and connected with the building blocks of Ayushman Bharat Digital Mission, which intends to combine all health-related digital interventions under one digital umbrella.

Public-Private Partnerships

The government of India initiated early and proactive steps in formation of the following groups to oversee COVID-19 vaccination and technology platform:

• Task Force for Focused Research on Corona Vaccine . This group was established in April 2020 to encourage domestic research and development of drugs, diagnostics, and vaccines, headed by the principal scientific advisor to the government of India.
• National Expert Group for Vaccine Administration for COVID-19 . This high-level inter-ministerial task force was established in August 2020 to centralize decision making for the full COVID-19 immunization process. Representatives from 19 ministries and 23 departments at the national, state, and district levels made up the National Expert Group for Vaccine Administration for COVID-19, which was formed to identify and express tasks and responsibilities for administrators at all levels, removing bottlenecks and redundancies.
• Empowered Group on Vaccine Administration for COVID-19 . This group was established in January 2021 to facilitate optimal use of technology to make COVID-19 vaccination inclusive, transparent, simple, and scalable.
• The United Nations Children’s Fund (UNICEF ) and other civil society organizations donated their expertise in communication and social mobilization, particularly when it comes to addressing vaccination hesitancy and related difficulties, to the development of the CoWIN platform.

• Bill and Milinda Gates Foundation (BMGF) for various components
• The United Nations Development Program – The eVIN system has been repurposed to develop the CoWIN application in collaboration with GAVI and United Nations Development Programme (UNDP).
• The UNDP in turn has partnered with Mumbai-based IT company Trigyn Technologies to develop Co-WIN.
• A call centre firm was also outsourced for 24×7 toll free line-1075
• WHO- For technical and operational aspects of vaccination, gaps between doses and precautions and guidelines and protocols about health, hygiene and safety.
• Global Alliance for Vaccines and Immunization (GAVI)- As per Team Leader , Health Strengthening Systems, United Nations Development Programme (UNDP) , eVIN was introduced by GOI in collaboration with GAVI (Global Alliance for Vaccines and Immunization) in 2015. Budgets were also allocated by GAVI for Co-WIN.
• Amazon Web Services (AWS)- These were used to host the database. These were selected over NIC’s Meghdoot Cloud Services.
• PayTM, Jio ,Whats App ,Apollo Hospitals, IIT BOMBAY were also selected as partners among others.

The Pre-existing Enabling Environment

According to Director, Immunisation, Ministry of Health and Family Welfare, India’s ongoing commitment to digital infrastructure traced back to the fact that critical digital health tools were already in place across all states and union territories of India.

In 2015, the United Nations Development Program had rolled out the eVIN smartphone application to address existing inequities in vaccine coverage and digitize the Universal Immunization Programme, one of the largest public health programs that targets children and pregnant women in India aligning it with the reproductive and child health (RCH) mission of the Ministry. The eVIN application managed the end-to-end vaccine delivery supply chain of at least 12 vaccines, including the measles vaccine and the BCG vaccine for tuberculosis. SAFE-VAC is the online reporting software for directly capturing any adverse events following immunization.

The Government of India could address the specific circumstances of the COVID-19 pandemic by building on its pre-existing capabilities to perform disease surveillance and monitoring and to manage technology, people, and processes across the vaccine supply chain. CoWIN integrates eVIN and SAFE-VAC along with other pre-existing infrastructures and digital solutions and functions as a comprehensive tool for managing India’s COVID-19 vaccination campaign.

PROCESSES-The way Co-WIN worked

The Co-WIN application was developed with five modules:

1. The orchestration module – CoWIN administrators create logins at national, state, and district levels. They assign roles to users like vaccinators and verifiers. Vaccine stocks are managed in databases and accordingly states supply vaccines to districts, who then
2. distribute them to vaccine facilities. District administrators confirm receipt by uploading batch numbers in the application.
3. The vaccination cold chain module – It used data from eVIN and was built natively into CoWIN to enables status updates of daily vaccine distribution at the national, state, district, and regional cold storage levels.
4. The citizen registration and scheduling module – Enabled citizens to register themselves for the vaccination program, either through the CoWIN website or through other government applications, such as Aarogya Setu or UMANG. Offline registration at vaccination centres was also facilitated for the people.
5. The vaccinator module – Used by vaccination officers, verifiers, and supervisors at the vaccination centers to update the status of vaccinations in the backend.
6. The certificate, feedback, and adverse event following immunization reporting module – provided a feedback mechanism for vaccinated people to report and fix errors and also provided the vaccination certificate

Each module fed information into the next one, which minimised user labour and redundancies. The CoWIN application has various modules. One of the most important modules is the ‘Citizen Registration’ module that is aimed at registering for a vaccination session, finding a nearby vaccination center, booking a slot as per availability, and rescheduling an appointment in case the slot or vaccination location is not convenient for the beneficiary.

The Pre-existing processes in e-VIN

The Electronic Vaccine Intelligence Network (eVIN) is a smartphone and cloud technology-based app that digitises information on vaccine stocks and temperatures across all cold chain points. There are around 29,000 cold chain points present in India currently. e-VIN was already implemented in 733 districts of 36 districts and Union Territories in India.

Cold chains are common in the food and pharmaceutical industries and also in some chemical shipments. One common temperature range for a cold chain in pharmaceutical industries is 2 to 8 °C (36 to 46 °F).

As Abhimanyu Saxena, Directot ,Health Strenthening Systems,United Nations Development Programme (UNDP) puts it in an interview with the author, The eVIN was introduced by GOI in collaboration with GAVI (Global Alliance for Vaccines and Immunization) in 2015.

Issues faced in Vaccine logistics

According to an UNDP report on e-VIN assessment, the following issues emerged in vaccine logistics –

• lack of real-time visibility of stock levels and temperatures overstocking and stock- outs of vaccines occurs.
• monitoring the temperature of Cold Chain Equipment (CCE) heavily relies on dedicated human resources at the cold chain points (CCPs). However, this manual system maintenance leads significant challenges for accurately recording, reporting, and monitoring the temperature of CCEs.
• Poor record keeping methodologies that leads to lack of visibility of vaccine stocks that are available.
• No records of returned vaccines are kept.

The Vaccine Supply Chain through e-VIN

The figure 1 that follows shows the supply chain behind vaccine reaching it’s end users and a detailed explanation of the steps has been given below followed by the image.

The steps involved in supply chain of vaccine are as follows

• Vaccine manufacturers supply vaccines to Government Medical Store Depots (GMSDs) and State Vaccine Stores (SVSs).
•  SVSs are located in different parts of the country: North, West, East, and South. SVSs receive vaccines directly from the manufacturer and also from GMSDs. Some states have multiple SVSs located outside the state headquarters.
• SVSs then distribute vaccines to Regional Vaccine Stores (RVSs).
•  From RVSs, vaccines are sent to the District Vaccine Store (DVS). If there is no RVS, vaccines are directly sent from SVS to DVS.
• Finally, the vaccines are distributed to Community Health Centers (CHCs), Primary Health Centers (PHCs), Urban Health Centers (UHCs), or the last cold chain point.

Vaccine supply chain works on ‘Push and Pull’ mechanism. Vaccine stocks are generally pushed down from higher to lower levels (Manufacturers to GMSDs and SVSs) . However, in case of additional vaccine requirements at lower levels, a demand is raised from the lower level to the higher level. Vaccines are then pulled out from the buffer stock at the GMSD level and supplied to the respective state. There are four GMSDs present in India at Karnal, Mumbai, Chennai and Kolkata.

Bracing up for future: the U-WIN (Universal Wellness Immunization Network)

The Director (Immunization), Ministry of Health and Family Welfare, sounds very enthusiastic and ambitious ,in an interview with the author on 19th July’23, U-WIN is a program to digitalise India’s Universal Immunisation Programme (UIP) and the target is to immunise 2.5 Crore infants and 3 crore pregnant women every year with full vaccination. The government came up with this concept after the huge success of CoWIN platform, as a ‘visionary’ and ‘scalability’ change. It uses the same technology that was used in CoWIN, in a better way. The idea is to spread it over the entire country and make 11 vaccines available to the people. As of now, it has been implemented in 65 districts of the country and it will be expanding in 700+ districts in the coming months.

Technology

As Dr. Ram Sewak Sharma, National Health Authority chief executive officer and chairman of the Empowered Group on Vaccine Administration for COVID-19 puts it,

Realizing our honorable prime minister’s vision, it has been a privilege to roll out CoWIN to cater to the vaccination needs of a billion plus Indians. Adding to the array of India’s successful digital public goods like Aadhaar, UPI [Unified Payments Interface], and DigiLocker, CoWIN has served as the digital backbone for COVID-19 vaccination in India. No other platform in the world has scaled so swiftly in such a short period of time. The credit for this is attributable to CoWIN’s open and interoperable architecture.

Based on the success seen in India, we are now diversifying this platform to repurpose it for the Universal Immunization Programme and other digital health care services. We are also working on taking CoWIN global to let other governments benefit from such an efficient and transparent system.” ( Source; Dr Ram Sewak Sharma on exemplars.health)

Technology and Architecture of Co-WIN

CoWIN’s five components are extremely adjustable both together and independently, enabling them to quickly evolve to meet new and changing requirements. The platform’s open-source design enables third-party developers to integrate it into their own applications and platforms, extending its functionality and potential. CoWIN can also connect to and exchange data with other digital systems in India and around the world, allowing the government of India to market it as a digital public good.

CoWIN, short for COVID Vaccine Intelligence Network is an extension of India’s indigenous system called the Electronic Vaccine Intelligence Network (e-VIN) system. The e-VIN was introduced by GOI in collaboration with GAVI in 2015. The purpose of e-VIN was to enable the real-time visibility of vaccines provided to the states for different diseases and check the temperature across various cold chain facilities across the country. The idea behind e-VIN was to make vaccine utilization more efficient, avoid stock-out events and reduce wastage.It should also be noted that-

1. The eVIN system was re-purposed and scaled-up to develop the CoWIN application in collaboration with GAVI and United Nations Development Programme (UNDP).
2. UNDP in turn, partnered with Mumbai-based IT company Trigyn to develop CoWIN.
3. For cloud services, Amazon Web Services was chosen over National Informatics Centre’s (NIC) Megh Raj cloud platform

What the policy makers have to say

Some observations the Policy makers shared in the Immunisation division of the Ministry as well as by Health Systems Strengthening, division of UNDP, New Delhi, are as follows-

i. While e-VIN only took care of the logistics. With CoWIN they wanted to bring everyone’s data on a digital platform, record the vaccination status of status easily and to smoothen the process of vaccination drive. The coverage and scope has been very wide in the sense that 97% of the population have received the 1st dose of vaccination and 90% have received 2nd dose of vaccination. This has been world’s largest vaccination drive
ii. The Leadership was provided from- Additional Secretary, MoHFW and CEO,NHA through discussion of an empowered group. The Project Management Unit (PMU) was composed of members from – MEITY, NHA, Doctors, NeGD(National e-Governance Division), MoHFW, CoWIN Developers.

They all worked to develop CoWIN as a very successful platform.

iii. It was first time doing adult vaccination and there was no foresight of how long the pandemic would last. Various ministries were involved, huge number of registrations were needed to be done and also the vaccinators (front line workers) needed to be trained.

iv. Outsourcing was done at three steps-

(a) Development of the new module by a software development agency

(b) Hosting of the system a MieiY empaneled cloud service i.e. Amazon Web Services was selected over NIC.

(c) Call centre for CoWIN services (specifically technical)

v. The Changing Scope of Co-Win; Initially the policy was- 1^st round vaccination of FLW and HCW, Next higher age group (above 60) vaccination followed by 45+ and the 18+.The policy kept changing as time progress depending upon the requirements. The technology was in sync with the policy change. The platform was being developed on a regular basis to make it as user friendly as possible. All the request and complaints from the end users was being looked into. Initially there were issues but later they were fixed. Later offline registration facility was also provided. 

Plans of the department were laid out for the future, as follows-

1. visionary changes-Developing UWIN from CoWIN
2. scale changes -Spread it in the entire country and complete immunisation.
3. scope changes planned -12 vaccines will be made available via this platform.
4. Full vaccination of school children.
5. Complete elimination of Measles and Rubella, as pointed out by

Head, Immunisation Division.

vi. Implementation of UWIN will have 12 vaccines. Vision is to vaccinate 2.6cr children and 2.9cr women annually. Pilot was going on in 65 districts as in July’23, and by August end, it would be expanded to 700+districts (all over India).

1. The budget for Co-WIN was taken care by the government and some part of it was also supported by GAVI fund. ‘Budget was not an issue’, says a senior official of the Ministry. Lots of money was saved due to the digitalization.
2. Video training was provided to workers.
3. Digital documents were sent which saved the expense of paperwork.
4. Virtual communication.

vii. No studies reportedly have been done by the government on impact assessment. Private studies might have been done but they don’t have any record of it.

viii. Adoption of Best Practices ;

Digital certificate having QR code, developed as per WHO standards have been adopted.

This was required in view of international travel. There was a constant guidance from WHO. Global standards rolled out by WHO, internationally recognized certificates which was valid in 95+ countries.

There were several partners that brought international guidelines which were planned and followed-

(i) WHO supported in technical and operational component.

(ii) UNICEF supported in communication component.

(iii) BMGF (Bill and Melinda Gates Foundation) on various components

NHA looks after CoWIN for its international use. CoWIN is mediated as digital technology tool through CoWIN Global outreach program.

ix. The sustainability aspect;

A mission mode kind of implementation was carried out fo design and development of Co-WIN and its applications.The model of CoWIN has been sustainable as it is user friendly and it has been used in UWIN. CoWIN helped save expenses of paperwork as digital documents were used and transmitted. Gloves were not used.No adverse impact on environment has been there but as Abhimanyu Saxena puts it, it has certainly impacted the over-worked health workers and

logistics like the vaccine truck drivers.Relevance to SDG was rather direct i.e. to protect health of people.(SDG 3-Ensuring good health and well-being of people). x. The SWOT Analysis– Policy makers identified following parameters of SWOT.

Strength-

1. Digitalization
2. Security aspects

Weakness–

1. Training of users
2. IT illiteracy of the users
3. Absence of ID card

Threats-

1. Hacking of data
2. Unavailability of funds

Opportunities 

1. Potential to become a portal for mass immunization for different vaccines
2. Potential to become a portal for global adoption for immunization.
3. Upgradation of Technology; Currently Co-WIN 2.0 is being used. Interestingly, as Abhimanyu Saxena of UNDP puts it, there have been 141 releases or updates to the CoWIN. Policy related changes were incorporated in the CoWIN from time to time.

Improvements done were as follows-

• Gap interval between 1^st and 2^nd dose reduced on technical advice.
• Foreign nationals vaccinated
• Certificate provided digitally

xii. Information tracked (Track and trace)

Only a certain minimal, critical, essential data were captured. The data captured were of-

1. Name
2. Gender
3. Year of birth
4. Type of ID
5. ID card number

xiii. Integration with other Government e-Initiatives-

Co-WIN initiative critically links with other e-governance initiatives of different ministries of Government of India e.g. ABDM (Ayushman Bharat Digital Mission), and Reproductive and Child Health (RCH) portal.

 The Co-WIN is linked to major e-Governance APIs* like –

MyGov, UMANG, Digilocker, Arogya Setu. Aadhar can be used for generation of ABHA (Ayushman Bharat Health Account). The ABHA id can be linked with RCH ID also. Passport can be added can be linked to certificate to facilitate international travel.

xiv. Other functionalities-

• As Abhimanyu Saxena of UNDP puts it, the Co-Win also enables ‘online indentation’ by HCWs (Health Care Workers). HCWs numbered 29,500.
• It provided registrations through a variety of identity cards and even without id cards through NGOs..

What the users of Co-Win Medical Professionals have to say

The author captured responses on various aspects of CoWIN from 31 vaccine administrators from 19 vaccinating centres through google forms but followed up by personal visits and phones.

1. Planning, budget and scheduling adequate resources, professional staff and equipment for vaccination as per the number of people registered and scheduled for vaccination at the respective hospital was done- 72.8% respondents rated it as significant to great extent.
2. The degree of real time synchronisation and data update regarding scheduled /re-scheduled appointments /centres and slots between Co-Win portal and the doctor’s respective hospital/centre/dispensary was- 66.7% respondents rated it as significant to great extent.
3. Facilities by National Health Authority (NHA) /MoHFW/State department of Health for provision of resources including IT infrastructure for up-linking with Co-Win and other Govt department portals, and other infrastructure like storage and logistics of vaccine under controlled conditions at the respective hospital was rated significant to high by 66.7% of respondents.
4. A significant to high level of communication, coordination and collaboration, facilitated mainly by Co-Win, with following percentage of respondents-
   • Local Civil administration – 65.3%
   • Health & FW Department – 70%
   • Other vaccination centre – 50%
   • Logistics and transportation – 56.6%
5. A significant to high importance to role, effectiveness and service level of Co-Win application portal in administration of Covid Vaccination program through their respective hospital /dispensary/vaccination centre was assigned by 83.3% of respondents.

*API stands for Application Programming Interface. In the context of APIs, the word Application refers to any software with a distinct function. Interface can be thought of as a contract of service between two applications. This contract defines how the two communicate with each other using requests and responses.

What the Users have to say

The author captured responses of 515 vaccine beneficiaries registered on CoWIN using Google forms . Of these,86.5% had themselves registered on CoWIN portal while 13.5% did not do it directly but through someone in family/friends circle. The responses are as follows (as given in Annexure IV).

1. 68.1% say that there is easy and good access and navigation to the Co-WIN website.
2. 55.2% respond that the website was operated reliably, and the services and links provided, operated flawlessly and were available all the times.
3. 62.2% say that the Co-WIN website was responsive enough as per the needs in terms of requirements for appointment scheduling etc.
4. 60.7% responded that Co-WIN site reflects competency of the staff involved in design and delivery of services through website.
5. 76.6% respond that Co-WIN reflected upon courtesy of staff and its demonstration at the vaccination centre.
6. Around 70% responded that the CoWIN portal gave an assurance, hence credibility in terms of information and services, it delivered.
7. 61.4% responded that the website provided a sense of security, processing of information and validation of facts in a secured manner.
8. 48.4% observed that the Co-WIN website was well-linked /integrated with other resources it may need.
9. 60.5% responded that the Co-WIN site communicated /educated with, adequate and updated information in a clear manner
10. Around 60% responded that Co-WIN seemed to understand user’s needs and requirements in a clear and predictive manner and offered various choices as per needs of the registrant.
11. 76.9% said that as per the expectation of user, overall the services offered by the Co-WIN site, met expectations and 17.1% said that Co-Win exceeded their expectations. In totality, an impressive 94% respondents said that CoWIN either met or exceeded their expectations.

Specific comments by end users –

From the feedback the author received from end users, it was found out that most people appreciated the Co-WIN website initiative.

“I feel that it is one of the most crucial e-governance infrastructure projects which has been successfully undertaken by GOI. Vaccinating huge number of people in a country like India is commendable”

“It was a great saviour during the global pandemic and helped handle such crisis situations in an efficient manner. Quality with such a sense of urgency is something that is the need of the hour.”

“Co-Win clearly serves its purpose, kept me informed and facilitated easy booking of vaccination slots and certificates as and when needed”

Though the platform received a lot of appreciation, there were few feedbacks that we could take into consideration while developing it for future uses-

“ Sometimes there were issues with vaccine slot booking ”

“Like most websites, the mobile interface has clipping in text and graphics, and can be improved.”

“With the high volume of visitors during the time it was needed, it could not handle it.”

“The UX (User Experience) could be smoother and more intuitive.”

“System robustness is missing, many times it was seen that people registered on specific contact is unknown. Secondly during peak uses it’s performance were inconsistent.”

Challenges in Implementation and Scaling of Co-WIN

The government’s strategic goal has been to provide equitable vaccination at universal scale & transparent distribution for all citizens as also to inclusive distribution to align stakeholders and remove information asymmetry. CoWIN plays has played a key role in this strategic direction and intent however, there are a few barriers to overcome.

Need for financial and operational support or global adoption:  Co-WIN was recognized as a digital public good for responding to COVID-19 in July 2021, and the Indian government encouraged other interested countries to use the platform. However, adopters have not committed to providing critical financial and operational support though countries like Bhutan, Bangladesh, Maldives and Guyana showed the interest.The ability of CoWIN to develop an ecosystem of partner organizations that can give this support is critical to its sustainability at global level.

Requirement for global recognition of Co-WIN certificates as vaccine passports:  CoWIN’s ability to issue online certificates after each immunization dose is one of its most useful features. The government of India has been working to ensure that they are accepted in all countries. Currently, it is being accepted in 95 countries.

Need for a responsive technology and architecture; A key challenge is to respond to evolving needs in times like pandemic. It would entail maintaining resource commitments as new variants emerge, modifications at system level for booster dosages; increasing therapeutic evidence and responding to requirements by new stakeholder groups, such as child registration and privacy issues with minors’ data.

The issue of Data Privacy and Security and Hacking of Data

As pointed out earlier, the issue of data privacy and hacking of data has been always looing large over the Co-Win portal and the policy makers and implementors have been very much concerned over it and considered it as a top threat in a kind of SWOT analysis done at strategic management level in the MoHFW,as pointed out earlier.

As Dr Bhupinder Singh Khanuja, a senior IT consultant in Covid Cell of Immunization Division of MoHFW, responded ,the MoHFW has taken several measures to counter the threat of cyber security of the portal e.g.

1. Co-WIN portal of Ministry of Health & Family Welfare has complete security measures and adequate safeguards for data privacy with Web Application Firewall (WAF), use of Anti-DDoS (Distributed Denial of Service) use ,SSL (Security Sockets Layer) /TLS (Transport Layer Security) .The SSL/TLS certificates allow web browsers to identify and establish encrypted network connections to web sites using the SSL/TLS protocol. The IT People regular carry out vulnerability assessment and Identity & Access Management of the Co-WIN portal.
2. To ensure safety of the personal and biometric data of the citizens on the Co-WIN App/Portal following measures have been taken:
   • Beneficiary can access vaccination details by registered mobile number through OTP authentication only. 
   • Mobile Numbers, Aadhaar Number & other Photo ID Card numbers of beneficiary are masked. Only last 4 characters are visible to users (service providers) of Co-WIN.
   • Complete Co-WIN database is encrypted using “Encryption Algorithm” Key to protect citizen data and data integrity has been maintained for all vital information.
   • Two factor authentication feature (Password and OTP) while login by the users (service providers) is in place restricting unauthorised access on Co-WIN.

Can Blockchain Technology be panacea for all

Blockchain is perhaps one of the biggest technology buzzwords in recent times. Blockchain in its simplest form refers to a list of records maintained in a digital ledger stored over a peer-to-peer network. These records are called blocks and each block is linked to its previous record or block using a cryptographic hash thus forming a chain. Apart from the cryptographic hash value, a block also comprises the timestamp and the transactional data. All the nodes (computer) in a blockchain network carry a copy of the digital ledger. Whenever a new transaction is made, the network participants validate the transaction using complex algorithms. Once the transaction is verified, it gets appended to the list of other verified transactions as a new block and gets copied to all the nodes in the blockchain network. Blockchain technology is thus decentralized and highly transparent. All participants in a blockchain network can view the entire chain. Data manipulation is virtually impossible as the information is timestamped and any attempt to tamper with data will require all the copies of the blockchain to be altered simultaneously.

However, In India, operation of cryptocurrency is an issue. Also, the Bitcoin transactions make the transactions slower i.e. reduce speed to only 4.6 transactions per second. So ‘scalability’ and ‘speed’ could take a back seat in block technology thereby defeating the very purpose of Co-WIN portal . There are network connectivity issues in many parts of India. Under such circumstances, an application built on blockchain technology may not see success. As the number of blocks grow in a blockchain, scalability gets adversely impacted. Additionally, there would also be a significant level of incompatibility with use of legacy and other systems already in use for a significant time and particularly those achieved stability. Hence to implement such technologies, a complete overhaul of the infrastructure and systems would be required that may also require huge investment.

How Blockchain can address CoWIN Issues?

During the challenging times of the COVID-19 pandemic, Jeevan Pramaan played a pivotal role in providing relief to pensioners. The digital platform proved instrumental in ensuring pensions continued and hassle-free disbursement, even amidst lockdowns and restrictions. With the conventional methods of physical documentation and in-person verification being disrupted, Jeevan Pramaan emerged as a savior by allowing pensioners to submit their life certificates online.

This not only eliminated the need for pensioners, especially the elderly, to visit government offices physically but also contributed to the overall safety and well-being of the vulnerable population during the pandemic. Jeevan Pramaan’s relief in remote life certificate submission helped maintain the regular flow of pension funds, ensuring financial stability for retired individuals.

In response to the COVID-19 pandemic, the government extended the deadline for submission of life certificates to provide relief to pensioners and safeguard their health. The initial extension was granted until December 31, 2021, and was subsequently extended to February 28, 2022.

The adaptability and efficiency of Jeevan Pramaan in the face of unprecedented challenges underscored its significance as a resilient and technology-driven solution, providing much-needed support to pensioners during a critical period.

1. Managing Vaccination and Streamlining Processes
   Blockchain can help in tracking vaccines right from the point it is manufactured in the production facility to the point where the beneficiary receives it. Timestamp information can be entered for the vaccines at each phase on the blockchain so that data cannot be tampered with by anyone. The agencies can also track the number of vaccine doses manufactured as well as the number of doses administered. The beneficiary can also access the information about vaccine storage to see if the dose he is going to receive, has been safely handled.Blockchain can streamline the current process for registration of beneficiaries, booking of the slots, and ensuring a smooth vaccination at the health care centers. The process can be made fool proof to a large extent without any kind of manual intervention.

2. Tackling Data Privacy
   The blocks in a blockchain are secured through cryptography. The participants in a blockchain can access the information only using their private keys. Since the blocks are stored in decentralized manner on various nodes and not on a central system, there is no single point of failure. It is extremely difficult for hackers to tamper with the blocks on each node that is part of the blockchain.
3. Counteracting the menace of Automation BOTs
   Automation BOTs create a kind of frustrating experience of trying to book a slot from user’s end. These BOTs are automated scripts that constantly keep pinging the public APIs of the CoWIN platform for the availability of slots. This makes the server slow and many a times, it
   results in the delay in getting OTPs. Some of the BOTs are programmed to book the slots as soon as they become available bypassing the CoWIN captcha verification. To counteract such BOTs, data science/machine learning technologies can be coupled with blockchain technology. System recognizing legitimate clicks or scroll behavior on the page as well as prompting the users to input private keys to confirm their identity on the Co-WIN application before booking an available slot can handle these BOT issues.

Integrating Co-WIN with other e-Governance APIs

Co-WIN has been well integrated with various Application Programming Interfaces (APIs) like-

i.   MyGov, UMANG, Digilocker,  ArogyaSetu.  Aadhar can be used for generation of ABHA (Ayushman Bharat Health Account) through ABDM (Ayushman Bharat Digital Mission) . The ABHA id can then be linked with RCH (Reproductive and Child Health) portal ID also. Passport can also be added to certificate to facilitate international travel.

ii.  As the Team Leader of UNDP puts it, the Co-Win also enables ‘online indentation’ by HCWs ( Health Care Workers).HCWs number around 29,500.

Analysis

Though detailed cost-benefit analysis or impact assessment has not been undertaken by any agency on CoWIN as per available information, however, an assessment study was carried out on e-VIN by UNDP and published in December 2018 just a few months before Covid struck India. In case of CoWIN,many a costs were highly reduced e.g. cost of paper, cost of communication and training. The benefits have been mainly intangible and immense in terms of saving the lives of human beings which is beyond any direct estimation. The budget for Co-WIN was taken care by the government and some part of it was also supported by GAVI fund. ‘ Budget was never an issue , says a senior official of the Ministry. The budget involved in the entire vaccination process was 35,000 crores.As MoHFW officials expressed, lots of money was saved due to the digitalization as video training was provided to workers, digital documents were sent thereby saving the expenses of paperwork and mostly virtual communication was followed.

Estimating Costs of Scaling up e-VIN/CO-WIN; Some insights by UNDP

According to a MoHFW report on techno-economic assessment of e-VIN, e-VIN was initially implemented in 12 states and an estimation was made on the amount of investment required for scale up. As per UNDP statistics, it has been implemented in 733 Districts spread over 36 states covering 29000 CCPs (Cold Chain Points) with vaccine service availability level of 99% and 80% reduction in vaccine stock-outs.

As per assessment carried out by MoHFW,there would be some fixed costs that would be similar across states, e.g. e-VIN software development and management, training of trainers, communication materials and personnel at the national level for supervising all activities. Based on the UNDP data, an estimated investment was suggested to be about INR 8.42 crore per state for a period of three years. It was assumed that the implementation in a state will be in a phased manner and the expenditure to incur will be gradual over a period of 2-3 years. The operational expenditure in states for mobile phones, temperature loggers, printing and stationery, accessories, and trainings would depend on the number of cold chain points (totalling then 27000;now 29000) in the respective states. Based on the expenditure pattern of 12 states on e-VIN, it was estimated the average amount required per cold chain point to be INR 36,087 taking it to be only a financial cost.It does not include the time cost required to implement the programme. Cost of human resources costs were not calculated as the government pay scale will be different than the figures received from UNDP. It is expected that the existing cold chain handlers at cold chain points will be managing the system also in the future and there will probably be no additional hiring of staff for e-VIN implementation. Training costs would be highly minimised ;however about 50% of temperature loggers, mobile phones and accessories and would need replacement reducing operational expenses and personnel hours to half. It is expected that the existing cold chain handlers at cold chain points will be managing the system also in the future and there will probably be no additional hiring of staff for scaling of CoWIN to U-WIN implementation.

The ROI analysis was carried out using only the government perspective and not social perspective. Only, the cost of illness that was averted as a result of missed opportunity was considered. Because of considering the only reason of low-cost saving as missed opportunity only, the amount of saving was found to be insignificant. The cost of illness information is difficult to be available in the Indian context for vaccine preventable diseases. The benefits associated with societal perspective would include savings from premature mortality or productivity loss due to impacts of disease i.e. covid here. If the cost of illness/pre-mature mortality that can be avoided by vaccinating for Covid is included, the estimation of saving would be more realistic and obviously greater; and the savings from productivity loss and premature mortality and the benefits from Co-WIN implementation like even for e-VIN or in future, U-WIN will be overall much higher.

Can a realistic estimation of RoI be made for CoWIN?

Return on Investment can be defined as the amount of return (in terms of money) obtained by investing one unit of money in any programme or activity. Total return includes the sum of net savings from all aspects due to e-VIN or now CoWIN and the total investment would be the sum of all expenses related to e-VIN or now CoWIN. MoHFW report on implementation of e-VIN in 11 states based on availability of data, found RoI to be 1.41.

In case of CoWIN , it would take some time and efforts to estimate the costs and returns. Incidentally, the latter is challenging and limiting because of estimation of benefits or returns due to government perspective only and not social perspective. The long term projection for RoI in e-VIN was projected by UNDP to be 2.91for each rupee invested at national level. A separate study thus needs to be conducted for the same in light of expenditures and returns from using CoWIN wherein leads can be taken from earlier study carried out on e-VIN.

Environment and Sustainability; Linkage to Sustainable Development Goals (SDGs)

As Dr Veena Dhawan, Director, Immunisation stated , gloves were not used in the vaccination process. A good biomedical waste management system was used. No adverse impact on environment has been observed there. Abhimanyu Saxena, Team Leader, Health Strengthening System at UNDP puts it, it has certainly impacted the over-worked health workers and logistics like the vaccine truck drivers who worked continuously.

Dr Dhawan very vehemently points out that the relevance to SDG was rather direct i.e. to protect health of people. According to her, the implementation of Co-Win caused no harm to the environment. The linkage to sustainability goals is directly through goal SDG 3 i.e. good health and well being. This is to ensure healthy lives and promote well-being for all at all ages. The initiative can also be linked with SDG 17 i.e. partnerships for the goals. This is to strengthen the means of implementation and revitalizing the global partnerships for sustainable development.

The MoHFW and NHA entered into global partnerships with UNDP, WHO and companies like Meta for WhatsApp and Astra Zeneca through Serum Institute of India. The initiative can also be linked to some extent to even SDG 11 making the cities and human settlements inclusive, safe, resilient and sustainable.

Conclusion

The Co-WIN has been hugely successful in mass scale vaccination to the tune of more than 220 crores of the Indian population across length and breadth of country covering 92.66% population. A proactive and collaborative decision making was done by the government and its partners; The platform’s success can be attributed to enabling factors like the adaptation of pre-existing technology and architecture for quick integration, scale and widening the scope for different segments of society.

Modular designs of the platform that can be quickly modified to meet emerging needs in a rapidly changing pandemic context have contributed significantly to the success of Co-WIN. Co-WIN well demonstrates India’s ongoing commitment to expanding and improving its digital health infrastructure in general and making any ‘digital public good’ in health accessible to all. However,

1. More streamlining and integration of processes is required, may be by use of block chain technology. It is yet to be explored. AI can also be used for intuitive design of portal. Bots appearing on portal must be avoided as these slow down the app.

2. Creating a more robust and high capacity architecture is require
3. Issues of data privacy and cyber-security should be given priority by giving still high level of encryption and security levels as data security, has been expressed as a threat by policy makers.
4. Sustainability of use of the portal with varying change in scale and scope should also be kept reinforced.
5. Quality of outsources and their credentialing should also be intensively ascertained and verified time to time.
6. A constant touch with community at large is desirable.

Overall, Co-WIN has been rated significant to high rating by most of the vaccinators and users.

References

1.MoHFW Report on Techno -Economic Assessment of e-VIN ,Immunisation Technical Support Unit (ITSU), Ministry of Health & Family Welfare,New Delhi,Dec.,2018.

2. Immunization Division, Ministry of Health & Family Welfare, Government of India.  Comprehensive Multi-Year Plan 2018-22. MoHFW: New Delhi,2018.

3. Immunization division, Ministry of Health & Family Welfare, Government of India.  Handbook for vaccine & cold chain handlers. MoHFW: New Delhi,2016.

4. World Health Organization. Systematic review of missed opportunities for vaccination (MOV),2013

Web-Resources

1.www.cowin.gov.in

2.www.undp.org

Annexure-I

Table 1: The age wise total vaccination registrations done through Co-WIN –

(Source- https://dashboard.cowin.gov.in/ )

Table 2: Vaccines received by different age groups as on dashboard of Co-WIN

(Source- https://dashboard.cowin.gov.in/ )

(Source- https://dashboard.cowin.gov.in/ )

Annexure-II

The factors that helped e-VIN solving the vaccine logistics are-

• All cold chain handlers are provided smartphones with the eVIN application which allows for the digitization of vaccine inventories.
• As a routine task, every cold chain handler enters the net utilisation for each vaccine in the standardised registers at the end of every immunisation day.
• This is simultaneously updated in the eVIN application and uploaded on a cloud server which can then be viewed by programme managers at district, state and national level through online dashboards.
• In addition to providing real-time information on vaccine stocks, the system also helps to track storage temperature of vaccines.
• SIM-enabled temperature loggers attached to the cold chain equipment capture temperature information through a digital sensor placed in the refrigerator.
• Temperature data is recorded every ten minutes and updated at an interval of sixty minutes on the server via General Packet Radio Service (GPRS). In case of temperature breach, the logger alarms and sends email and SMS alerts to responsible cold chain technicians and managers.

All these steps combined solve the problem of real-time stocks visibility, record keeping methods and temperature maintenance at the cold chain points.

(Reference- https://www.vikaspedia.in/health/health-care-innovations/health-system-strengthening-1/evin-project-of-health-ministry )

Co-WIN HOSPITAL/DISPENSARY/VACCINATION CENTRE ANALYSIS

An analysis of responses from 30 doctors from different hospitals in Delhi, and tried to get their views on CoWIN implementation at the Hospital/Dispensary/Vaccination Centres end. Hospitals from where the responses were collected of the doctors are a:

1. Bhagat Chandra Hospital
2. Seed Primary Urban Health Centre Nathupura
3. DGD Jharoda Majra Primary Health Centre
4. DGD Tank Road Dispensary
5. Seed Primary Urban Health Centre Jagatpur
6. M&CW Centre Bhai Parmanand Colony
7. Rajiv Gandhi Cancer Institute & Research Centre
8. Apollo Hospital
9. Primary Health Centre Badshahpur
10. Government Multi Specialty Hospital, Sector-16 ,Chandigarh
11. National Institute of Health and Family Welfare Clinic
12. Hindu Rao Hospital
13. Institute of Human Behaviour and Allied Sciences
14. Institute of Liver and Biliary Sciences hospital
15. Rajiv Gandhi Cancer institute
16. Telangana dispensary
17. Railway Hospital
18. ESIC Hospital Okhla phase 1
19. CGHS dispensary/Wellness centre R K Puram Sector -12

The observations are as follows-

1. The supply of vaccine to the hospital met the requirement as per scheduled appointments done on Co-Win-

60% doctors mentioned this was witnessed Always/to great extent.

 13.3% doctors mentioned this was witnessed Negligible/some extent

2. Planning, budget and scheduling adequate resources, professional staff and equipment for vaccination as per the number of people registered and scheduled for vaccination at the respective hospital was done-

56.7% doctors mentioned this was witnessed Always/to great extent.

20% doctors mentioned this was witnessed Negligible/some extent

3. The degree of real time synchronisation and data update regarding scheduled /re-scheduled appointments /centres and slots between Co-Win portal and the doctor’s respective hospital/centre/dispensary was-

46.7% doctors mentioned this was witnessed Always/to great extent.

3.3% doctors mentioned this was witnessed Negligible/some extent

4. Availability of space for registration, waiting area and in-house processing/treatment facility for the patients coming to respective hospital through Co-Win for vaccination was-

 53.4% doctors mentioned this was witnessed Always/to great extent

10% doctors mentioned this was witnessed Negligible/some extent

5. Percentage range of people, out of the total registration done for a day, that turned up physically for vaccination at the centre.

76.7% doctors mentioned that out of total registrations done 61-100% people turned up physically.

13.3% doctors mentioned that out of total registrations done 0-40% people turned up physically.

6.Facilities by National Health Authority (NHA) /Ministry of H &FW/State department of Health for provision of resources including IT infrastructure for up-linking with Co-Win and other Govt department portals, and other infrastructure like storage and logistics of vaccine under controlled conditions at the respective hospital was-

43.3% doctors mentioned this was witnessed Always/to great extent

16.7% doctors mentioned this was witnessed Negligible/some extent

7. On an average, the percentage of vials that were rejected or expired and were returned.

83.4% doctors mentioned that 0-upto 5% vials were rejected or expired and were returned.

16.6% doctors mentioned that more than 5% vials were rejected or expired and were returned.

8. Percentage of adverse event that occurred and was reported to the relevant authority.

90% doctors mentioned that 0- 1% adverse events occurred and was reported.

10% doctors mentioned that 1-1.5% adverse events occurred and was reported.

9.The level of communication, coordination and collaboration, facilitated mainly by Co-Win, with-

• Local Civil administration-

40% doctors mentioned this was witnessed Always/to great extent

13.3% doctors mentioned this was witnessed Negligible/some extent

• Health & FW Department

40% doctors mentioned this was witnessed Always/to great extent

13.3% doctors mentioned this was witnessed Negligible/some extent

• Other Vaccination Centres

26.7% doctors mentioned this was witnessed Always/to great extent

30% doctors mentioned this was witnessed Negligible/some extent

• Logistics and transportation, III party service providers (3PLs)

26.6% doctors mentioned this was witnessed Always/to great extent

53.3% doctors mentioned this was witnessed to significant extent/moderate extent

20% doctors mentioned this was witnessed Negligible/some extent

10 .Rating their hospital /dispensary/vaccination centre on the basis of-
Role, effectiveness and service level of Co-Win application portal in administration of Covid Vaccination program through their respective hospital /dispensary/vaccination centre.

63.3% doctors mentioned this was witnessed to highest/great extent

16.7% doctors mentioned this was witnessed to moderate/some extent