On 24 May 2021, India exceeded 300,000 Covid-19 deaths. While nationally the number of confirmed cases of Covid-19 is now falling from its peak in early May, many Indian states are still experiencing a sharp rise in cases.

Several of India’s South Asian neighbours have also seen significant pressure placed on their health systems, partly because of the new B.1.617.2 variant, first observed in India, which has now been identified in 54 countries. On 21 May, UNICEF warned “there is a real risk of fragile health systems collapsing” in the region.

The International Red Cross says immediate international support is required to prevent a “human catastrophe” and Amnesty International has said urgent action is needed to address shortages of oxygen, medicines and hospital beds.

This Insight describes the current pressures on health systems in South Asia, the impact of the Indian Government’s ban on exporting vaccines on global vaccine provision, and UK Government support to the region.

Hospital capacity and access to oxygen

Since April, many hospitals in Nepal, the Maldives, Pakistan and India have exceeded their capacity, and there are fears of further surges in hospital admissions in Bangladesh, Nepal, Pakistan and Afghanistan. To date, Bhutan has remained insulated from the pandemic.

The UN has previously assessed Nepal, Pakistan and Bangladesh as amongst the top 20 most vulnerable countries in the world to the pandemic, based on their intensive bed capacity. South Asian countries, including India, are also among those who have struggled since March to obtain sufficient oxygen supplies.

Due to pressures on its own hospitals, in late April India halted exports of oxygen.

Cases and deaths are likely to be higher

Reported case and death totals for the region are likely underestimates, due to weaker testing systems. Nepal, for example, has limited free testing to those with symptoms or to people who have been in direct contact with someone who has tested positive. Over 44 percent of its Covid-19 tests are coming back positive, suggesting case numbers are higher than reported.

Reported case numbers are beginning to fall in Nepal and Pakistan, but they are now having an increase in deaths. In Sri Lanka, the Maldives and Afghanistan, both case numbers and Covid-19 deaths are continuing to rise. Bangladesh is seeing a fall in both.

Demand for vaccines and Covax

In March, India suspended vaccine exports to focus on vaccinating its own population. The proportion of the country who have received at least one dose has now reached 11 percent, up from two percent in mid-March.

According to the news agency Reuters, India’s export of vaccines is unlikely to recommence before October.

This has affected the Covax initiative, a global scheme for fair access to vaccines and which had aimed to provide 170 million free doses to 92 low and lower-middle income economies by May. It has fallen short, providing 72 million doses and predicts the shortfall to increase to 190 million in June.

The Serum Institute in India had been the largest manufacture for Covax, scheduled to provide 1.1 billion doses. While Covax has secured additional agreements for vaccines, these will not be delivered until the second half of 2021.

Many South Asian and African countries are eligible to receive vaccines from Covax to vaccinate up to 20 percent of their populations.

However, most South Asian states have vaccinated less than 10 percent of their populations and are waiting for further deliveries from Covax.

Share of population who have received at least one dose of Covid-19 vaccine (at 26 May)

Area Share of population
Bhutan 62.6%
Maldives 57.0%
India 11.3%
World  10.1%
Nepal 7.3%
Sri Lanka 6.7%
Asia  5.5%
Bangladesh 3.5%
Pakistan 1.9%
Afghanistan 1.2%

Source: Our World in Data, Covid vaccinations, accessed 27 May 2021

Covid-19 doses allocated by Covax (at 25 May 2021)

Country Allocated Doses shipped
Pakistan 14.7m 1.2m
Bangladesh 11.0m 0.0m
India 10.0m 10.0m
Afghanistan 2.6m 0.5m
Nepal 1.9m 0.4m
Sri Lanka 1.4m 0.3m
Maldives 0.1m 0.02m
Bhutan 0.1m 0.0m

Source: UNICEF, Covid-19 market dashboard, accessed 25 May 2021

Calls for richer countries to donate vaccines

India, alongside China and the African Union, had previously been a significant bilateral donor of vaccines to other states. By May 2021, they had collectively donated nearly 26 million doses.

In response to the crisis in South Asia and the global shortfall in doses delivered to Covax, the World Health Organization (WHO) and UNICEF have both called for richer economies to donate vaccines. UNICEF estimates that if G7 members and the “Team Europe” group of EU countries donate 20 percent of their vaccine supply from June to August 2021, 153 million doses would be available to Covax.

The UK has already provided £548 million to Covax to help distribute doses to lower income states. UK opposition parties have called upon the Government to support a waiver of intellectual property rights to allow more states to manufacture vaccines, to identify surplus doses for India and other countries, and to share expertise on testing. The Nepalese Government has also requested the UK to provide two million Covid-19 vaccines.

The UK Government has said the UK will “share the majority” of future surplus vaccines with Covax, but said in May it was too early to announce when this might happen. Seven European states, including France and Germany, have pledged to share a total of 100 million vaccines. By June, the United States also aims to share 80 million vaccines. The UK Government is currently in talks on an intellectual property waiver.

Support provided by the UK Government

For 2021/22, the Foreign, Commonwealth and Development Office has allocated £1,305 million of aid for supporting the global response to the pandemic and strengthening global health security. This includes commitments to Covax and the WHO.

The region has historically received a large amount of UK bilateral aid. In 2019, £961 million was given in total to India, Bangladesh, Pakistan and Afghanistan.

Since March 2021, the UK has also provided £4.7 million through the WHO to support Pakistan’s Covid-19 response. For India, the Government has sent additional ventilators and oxygen generators. An oxygen plant has been funded in Nepal. The Government had also raised concerns about the mandatory cremations for all Covid-19 victims in Sri Lanka, a practice which was ended in March this year.

A Ministry of Defence Team is currently in Nepal to assess the situation in-country and determine what further support the UK can provide.

Further reading

About the author: Philip Loft is a researcher specialising in international development at the House of Commons Library

Photo by Mufid Majnun on Unsplash

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