India's vaccine providers can charge $10 to $32 for coronavirus shots amid the country's unprecedented surge

• All adults in India can get vaccines starting May 1, but the shots may not be widely accessible.
• India's government allows vaccine manufacturers to charge fees at private hospitals.
• The cost could amount to $10 to $32 per vaccine - well above India's average daily income.

The Indian government announced last week that all adults will be eligible to receive coronavirus vaccines starting May 1. But there's a catch: The shots won't be free everywhere.

Healthcare workers, frontline workers, and Indians older than 45 can already get their shots through government vaccination centers at no cost. But under the nation's plan, the rest of India's adult population could be charged a fee at those same locations. Most Indian states have promised to waive costs for all adults at the sites, but that's not the case at private hospitals, which will continue to charge for vaccines. India's government has also given vaccine manufacturers permission to raise their prices in the open market.

The nation's two main coronavirus vaccines, known as Covaxin and Covishield, are each offered to the federal government at 150 rupees ($2) per dose - or 300 rupees ($4) to fully vaccinate one person. (Covishield is India's locally produced version of the AstraZeneca vaccine, while Covaxin is similar to China's Sinovac vaccine.)

But Covishield's manufacturer, the Serum Institute of India, said last week that the price would be different for state governments and private hospitals: The former will be charged 400 rupees ($5.35) per dose, and the latter 600 rupees ($8) per dose. And the maker of Covaxin, Bharat Biotech, announced Saturday that it plans to charge India's state governments 600 rupees ($8) per dose, and private hospitals 1,200 rupees ($16) per dose.

That's between $10 and $32 per vaccine at wholesale prices - well above the average daily income in India. Private hospitals could ultimately ask consumers to pay even more.

Charging for shots could prevent many Indians, particularly poorer residents, from getting vaccinated right away. That's especially detrimental given the country's devastating surge in coronavirus infections.

India reported more than 350,000 new cases on Monday - the world's highest-ever daily total. The four daily caseloads before that shattered world records as well. Deaths in India have skyrocketed to more than 2,300 per day on average - the highest of any country, aside from Brazil.

Even these unprecedented tallies likely underestimate the real number of cases and deaths, epidemiologist wager. Widespread testing shortages prevent India from quantifying the full scale of its outbreak - and a handful of doctors, local journalists, and relatives of the deceased have reported that the official counts don't align with the long lines outside of hospitals, nor the bodies piling up at crematoriums.

"If you ask me how many people are actually getting infected in India every day, I would say it's a least 1 million," Ashish Jha, dean of the Brown School of Public Health, said in a Monday webinar.

A slow vaccine rollout could mean even more death

More than any other country, India is in a race against the clock to get shots into arms. A model from the University of Washington's Institute for Health Metrics and Evaluation predicts that India could see another 572,000 deaths between now and August 1. According to the model, India's daily cases have likely reached their peak already - but daily deaths won't peak until next month.

The nation has thus far immunized less than 9% of its population since. Prabhat Jha, an epidemiologist at the University of Toronto, told Insider that the current rate, he estimates just 20% of Indians will receive their first dose by mid-June.

Rahul Gandhi, a member of the Indian National Congress, said last week that because private hospitals are charging for shots, long lines are likely at the vaccine sites where residents don't have to pay.

"Enough of discussion. Countrymen should get the vaccine free. Do not make India the victim of the BJP system," Gandhi tweeted on Sunday, referring to India's opposing political party, the Bharatiya Janata Party.

The BJP is the party of Prime Minister Narendra Modi, who has been accused of downplaying India's crisis. Modi held large election rallies and discouraged the implementation of more lockdowns as coronavirus cases surged this spring.

In a recent press release, India's Ministry of Health and Family Welfare suggested that charging for vaccines could give manufacturers more money to scale up production, or perhaps encourage new vaccine manufacturers to bring their shots to India.

But Bramer Mukherjee, an epidemiology professor at the University of Michigan, told Insider that India already has the resources to ramp up its own vaccine supply.

"India is the vaccination production magnet in the world," Mukherjee said. "They should be able to scale up and be able to do much better job at this."

A black market for vaccines?

Many of India's low-income residents have already had trouble getting vaccines: A lack of internet access can make it difficult to sign up for appointments, and government-run vaccination centers aren't always easily accessible to those living in urban slums.

Wealthy Indians, however, can purchase vaccines at private hospitals fairly easily. As of March, twice as many private hospitals were doubling as vaccination centers than government hospitals, Quartz reported.

"Vaccinating just the affluent and urban elites will not be as effective or equitable as more targeted distribution to social and geographic hotspots," Prabhat Jha said.

Already, Indian hospitals have price gouged medications like remdesivir, an antiviral drug that showed early promise as a COVID-19 treatment but appears less effective in recent studies. Although the government capped the price of remdesivir at 1,100 to 1,400 rupees (around $15 to $19) per unit, Indian police have arrested at least 14 people for selling remdesivir at higher prices on the black market, according to The Indian Express. In at least two of those cases, the drugs were being sold for 32,000 to 45,000 rupees (around $429 to $603) per unit.

"There's a huge black market for remdesivir, and I'm worried that might happen for vaccines now as well," Krutika Kuppalli, an assistant professor at the Medical University of South Carolina, told Insider. "If there's not enough supply and the demand keeps going up, then people start getting desperate."