CoWIN in India: The Digital Backbone for the COVID-19 Vaccination Program

Introduction

In late 2020, the government of India initiated preparations for one of the world’s largest vaccination programs at an accelerated pace, with the objective to reduce vaccine-preventable deaths, ease strains on the health care system, and pave the way for a return to normality. Within a span of months, the government of India delivered a platform at scale that housed end-to-end workflows from the manufacturer through each step of the vaccination process. This task required consensus building and coordination with a multitude of senior stakeholders, while employees also adapted to a new reality of physical distancing and working remotely.

One of the key steps in this effort was the creation of the National Expert Group on Vaccine Administration for COVID-19, which has guided all aspects of vaccine introduction in India. The National Expert Group on Vaccine Administration for COVID-19 effectively established high-level coordination with 19 ministries at the national level, 23 departments at the state and district level, and numerous developmental partners, laying the foundation for a cohesive and coordinated effort.

The Indian government required an end-to-end solution that captured each step of the vaccination process to optimize resource utilization, maximize efficiency, and ensure each person had access to COVID-19 vaccines. Prime Minister Narendra Modi launched the COVID-19 Vaccine Intelligence Network (CoWIN) on January 16, 2021, to achieve this goal. CoWIN serves the functions of registration, appointment scheduling, identity verification, vaccination, and certification of each vaccinated community member—encompassing end-to-end workflows required for universal vaccination coverage. To expedite the development of this platform, several existing and proven digital assets were leveraged, such as:

• Electronic Vaccine Intelligence Network (eVIN), which has served as a robust supply chain solution in India since 2015
• Digital Infrastructure for Vaccination Open Credentialing (DIVOC), to support digitally verifiable certificates
• DigiLocker, a cloud-based platform for storing, sharing, and verifying documents and certificates
• Surveillance and Action for Events Following Vaccination (SAFE-VAC), to effectively track adverse events following immunization

CoWIN now serves as an open-source, multilingual application ecosystem that allows administrators to manage and update vaccine status along with inventory databases, while enabling recipients to book vaccine appointments.¹ The platform is modular and interoperable. CoWIN meets needs specific to COVID-19, such as the need for portable, user-friendly proof of vaccination.

While the presence of over 800 million internet subscribers² and 600 million smartphone users³ in India sped the adoption and scale of CoWIN, the platform evolved rapidly and in an agile manner to meet the next set of challenges while vaccinating a population of 1.3 billion. To enhance accessibility, several features were introduced, accompanied by requisite policy reforms such as allowance of walk-in vaccinations, and registration of up to four family members under one account. With over 940 million registered users (as of January 2022), the platform has been able to quickly deliver an accelerated vaccination program as 1 billion doses were administered within a span of nine months. CoWIN’s scalable architecture made it possible to vaccinate over 25 million people in one day. CoWIN offers valuable lessons for the use of digital health tools to support COVID-19 vaccinations.

What Does CoWIN Do?

CoWIN connects stakeholders across the health care value chain to enable a seamless vaccination delivery program including cold storage points, administrators, vaccinators, and verifiers (who check identification of people to be vaccinated); public and private vaccination facilities; and vaccine recipients.⁴ Users can access the platform via desktop, tablet, and mobile phones, and they can use it to meet a variety of needs. The following figure illustrates some of the ways in which different stakeholders use CoWIN.

CoWIN’s open APIs enable interoperability with other existing systems and enhance innovation. For quick adoption, CoWIN’s developers integrated it with other government mobile applications, such as Aarogya Setu,⁵ a digital solution designed by the government of India for contact tracing that identifies hot spots and assists in curbing the spread of infection, and UMANG,⁶ a platform that enables all Indian citizens to access government services.

India’s vaccination drive was rolled out in a phased manner, where phase 1 focused on vaccinating health care workers and frontline workers, phase 2 focused on vaccinating people aged 45 and above, and phase 3 focused on vaccinating people aged 18 years and above⁷; in January 2022, India started vaccinating people ages 15 years and older, and began administrating precaution doses to health care workers, frontline workers, and people ages 60 years and older.

At the beginning of each of these phases, CoWIN’s developers augmented the platform to tailor features enabling ease-of-use for different user types. For instance, in phase 1 the entire registration process was online, because health care workers had reliable access to the digital infrastructure. In subsequent phases, however, the platform incorporated provisions for both online and offline registrations (typically via physical registration centers known as common services centers) to ensure the inclusion of all citizens—even those from remote areas and those without access to digital tools and the knowledge to use them. Furthermore, due to the nature of their jobs, at times health care workers and frontline workers were not able to attend their vaccination appointments as they were required to travel to locations they had not chosen. This supply-driven approach resulted in lower efficiency of vaccination centers, resulting in underutilization of human resources. CoWIN data illustrated that this approach would not work, especially when it would be applied to the general public. This resulted in the first fundamental change in the vaccination policy—demand-driven distribution. The government can make vaccines available, but individuals have to choose to take them.

CoWIN application has five modules: the orchestration module; the vaccination cold chain module; the citizen registration module; the vaccinator module; and the certificate, feedback, and adverse event following immunization reporting module.

Each of these five modules functions independently from the others, which minimizes dependencies across the modules and makes it easier to fix technical issues. At the same time, each module feeds information into the next one, which minimizes user labor and redundancies.⁴

Through the orchestration module, CoWIN administrators at the national, state, and district levels create unique logins to register on the platform. Administrators can assign roles to other system users, such as vaccinators and verifiers. Using the databases of vaccine stocks and sites, state authorities supply vaccines to the districts and districts supply them to the vaccine facilities. District administrators can acknowledge the receipt of vaccine stocks by uploading the batch number of the stocks received through the application.⁸

The vaccination cold chain module,⁸ which used data from eVIN and was built natively into CoWIN, enables status updates of daily vaccine distribution at the national, state, district, and regional cold storage levels. It also enables the documentation of receipt of stock, including faulty stock.

The citizen registration module enables citizens to register themselves for the vaccination program, either through the CoWIN website or through other government applications, such as Aarogya Setu or UMANG. Registered citizens can select their preferred date, time, and vaccination center. To circumvent the lack of digital access, the platform enables four members to be registered using one user login.⁹ Additionally, people may walk into vaccination centers, where workers can register them on the platform. Registered users receive automated text messages on their registered mobile numbers with vaccination appointment information, second dose reminders, and links to digital vaccination certificates.⁹

The vaccination module is used by vaccination officers, verifiers, and supervisors at the vaccination centers to update the status of vaccinations in the backend.

Lastly, the certificate, feedback, and adverse event following immunization module helps administrators issue proof of vaccination. The module provides a feedback mechanism for vaccinated people to report and fix errors. It also enables reporting of adverse events following the vaccination using SAFE-VAC, a surveillance system integrated with CoWIN.^{8 ,9}

Enabling Environment Before COVID-19

India’s ongoing commitment to digital infrastructure meant that critical digital health tools were already in place across all states and union territories of India.

In 2015, the United Nations Development Program 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. The eVIN application managed the end-to-end vaccine delivery supply chain of at least 12 vaccines, including the measles vaccine and the Bacille Calmette-Guérin 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 preexisting 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 preexisting infrastructures and digital solutions (detailed in the Adapting to a New Challenge section) and functions as a comprehensive tool for managing India’s COVID-19 vaccination campaign.

Adapting to a New Challenge

In July 2020, the Ministry of Health and Family Welfare of the government of India established that this new platform would need to play multiple roles simultaneously to provide end-to-end support for COVID-19 vaccination delivery nationwide. Consequently, the CoWIN platform was developed with integration of databases of health care and frontline workers, hospitals, COVID-19 vaccination centers, and other administrators. Existing infrastructures and plugins were incorporated to ensure the individualized tracking of community members mandated by the ministry.

For instance, developers added the biometric digital identity tools Aadhaar and DigiLocker into the system as part of the citizen and vaccinator modules. Similarly, developers leveraged open-source software DIVOC, DigiLocker, and SAFE-VAC to create the certificate, feedback, and adverse event following immunization module. CoWIN has its own API policy, which has helped in integrating with third-party applications to render vaccination services to the community members through various platforms (e.g., Paytm and MakeMyTrip).

The development of the platform was accompanied, in parallel, by preparations for its implementation. Databases of health care workers and frontline workers were created by the state governments and collated centrally, COVID-19 vaccination centers and primary health care centers were outfitted with cold storage facilities and digital tracking devices; standard operating procedures were codified; training materials––primarily online––were prepared and circulated among administrators, vaccinators, nurses, and other health care staff; hands-on training of staff was carried out for two days; and community outreach and social-mobilization programs were launched.

The development of the platform started in full scale on January 8, 2021. It was launched January 16, 2021, for frontline and health care workers, and by March 2021 for citizens.

This phased rollout was particularly useful in identifying both the technical limitations of the CoWIN platform and the programmatic limitations of the vaccination drive. In response to technical issues,¹⁰ and duplications due to data entry errors, CoWIN’s adaptable design enabled the technology team to quickly build new, key features that enabled users to search pin codes and choose their vaccination centers. Furthermore, the government invited third-party application developers to integrate their APIs with the CoWIN platform, enabling these applications to provide a variety of value-added services such as booking appointments.¹¹

For those without access to digital devices or infrastructure, developers introduced a toll-free helpline number for citizens to book vaccination appointments¹² ; eventually, vaccination centers established walk-in registrations. Developers addressed language barriers by integrating 16 local languages into the platform. Lastly, concerted efforts have also been directed toward including women and marginalized groups, so far excluded, into the vaccination drive. For example, vaccine centers created special sessions to enable registration of persons without prescribed identity cards.

The following map highlights the uptake of CoWIN across the nation (assuming the place of vaccination is the same as the place of residence of the community member).

Impact

There has been no formal impact evaluation of the platform and its modules. However, platform engagement metrics offer one way to track the impact of the platform, and they have risen consistently. By the end of December 2021, the platform had reached 900 million registered users and helped administer 130 million doses of the COVID-19 vaccine.¹³ Since CoWIN is supplemented by offline modules, this number does not imply that all registrations were completed by end users through direct engagement with the platform. Given that many people in India do not have access to a smartphone, or have low literacy, the registrations on CoWIN were carried out on their behalf by family members, mutual aids, or third-party service providers (e.g., nongovernmental organizations).

CoWIN also provides real-time dashboards—created both by the government¹⁴ and by private organizations such as Sattva¹⁵ —and data visualization tracking metrics such as the number of doses administered with a bifurcation of dose 1 and 2; vaccine type; and the gender, age, and regional distribution of vaccination.

Administrators have used this data to study vaccination trends and facilitate their efforts across the country. For example, by comparing data on the number of vaccines manufactured and transported to a given COVID-19 vaccination center with data on the number of people vaccinated there, administrators can assess the extent to which vaccines are being wasted and take corrective actions when necessary.

CoWIN also enables administrators to evaluate the performance of vaccine drives via user feedback. The Rapid Assessment System, designed by the National e-Governance Division of India has been integrated with the CoWIN platform to gather feedback on the vaccination process.¹⁶ Since mid-January 2021, 97.35 percent of 0.7 million people surveyed expressed satisfaction with the vaccination process in India.¹⁴

Finally, the impact of the CoWIN platform can be estimated from the interest other countries have demonstrated in adopting the platform for their own COVID-19 inoculation drives. Representatives from 141 countries attended the CoWIN Global Conclave on July 5, 2021, where officials announced that India would offer the CoWIN platform to the world as an open-source digital public good.

The Path to Scale and Sustainability

Health care personnel and vaccine recipients would have had to rely on offline infrastructure and discrete digital tools during the COVID-19 pandemic if there had not been a complete digital health platform. This might have led to data reporting communication gaps, delays, and even inaccuracies. CoWIN streamlined its functionality by combining all components of the vaccine process into a single platform, enabling India’s vaccination program to scale quickly.

India’s health care infrastructure has been fully integrated with the CoWIN platform, which meets a national goal under the country’s digital health plan, according to the Ayushman Bharat Digital Mission, overseen by the National Health Authority, Ministry of Health and Family Welfare. Officials and developers can adapt the underlying platform to manage other health care programs in the future: the CoWIN system, for example, has already generated 110 million unique health IDs and databases for all health care professionals and health facilities, as well as longitudinal electronic health records.

CoWIN’s development and growth in India necessitated multiagency coordination. The government of India convened the National Expert Group for Vaccine Administration for COVID-19 in August 2020 to handle communication and coordination among many ministries and make strategic decisions relating to the administration of the end-to-end vaccination process.

Strong partnerships between government agencies and partner groups have also contributed to the CoWIN platform’s continued growth. The United Nations Children’s Fund 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.

Finally, the rapid scale-up of CoWIN was aided by capacity strengthening for administrators and health care staff. While early training was blended (virtual and on-site), as the epidemic proceeded, instruction was relocated to virtual platforms (particularly where connectivity was not a concern) to meet with social distancing rules. Staff members have been given self-learning and instructor-led courses at the state and district levels, and some states have developed an online academy so that “anybody can seek refresher training or ask questions if required.” A sophisticated troubleshooting hierarchy and technical support system––including the installation of a technical helpline––enabled administrators and health care workers to resolve professional difficulties as fast as possible, in addition to e-learning programs.

The open and interoperable architecture of CoWIN were beneficial for its size and long-term viability, enabling third-party application developers to link its API into their own platforms and provide better services to users ranging from vaccine recipients to administrators and COVID-19 vaccination centers.

Key Drivers of Scale

Groundwork – designed by experts: The government of India established and developed the CoWIN platform with experts, who had previously contributed to rolling out digital public goods such as Aadhaar, UPI, and DigiLocker, providing technical expertise and overseeing the development. These same partners had also collaborated on the design and implementation of another flagship digital health service, eVIN, which they 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.

Partnerships – creative multiagency collaboration: 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 interministerial 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.

Technology and architecture – open-source, modular, and interoperable design: 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.

Operations – strengthening the capacity of administrators and health workers: India needed to engage in capacity strengthening before it could begin vaccinating its 1.38 billion people, especially when it comes to implementing the CoWIN platform at scale. Staff were introduced to the internal workings of the CoWIN platform through blended trainings (a combination of virtual and on-site), and a technical helpline allowed administrators and health care workers to swiftly troubleshoot any technological issues. The immunization program in India was carried out efficiently thanks to provisions for continual capacity strengthening of CoWIN administration and employees.

What Implementation and Scaling Challenges Remain?

The Indian government’s main goal is to provide digital health services to its entire population. CoWIN plays a key role in that effort; however, there are still a few obstacles to overcome.

Financial Health – requirements for global adoption: CoWIN was recognized as a digital public good for responding to COVID-19 in July 2021, and the Indian government has prepared a road map for other interested countries to use the platform. Similar digital solutions have not had substantial worldwide impact in the past because adopters have not committed to providing critical financial and operational support. The ability of CoWIN to develop an ecosystem of partner organizations that can give this support is critical to its worldwide sustainability.

Groundwork – certification and vaccine passports: CoWIN’s capacity to issue online certificates after each immunization dose is one of its most useful features. As economies open up, COVID-19 vaccine certificates have become more important, but the government of India is still working to ensure that they are accepted in all countries.

Technology and architecture – responding to evolving needs in the pandemic: Other obstacles include maintaining resource commitments as new variants emerge; system-level modifications for booster dosages; increasing therapeutic evidence; and responding to challenges of new stakeholder groups, such as child registration and privacy issues with minors’ data.

Way Forward

Within a short period of time, CoWIN has created an end-to-end ecosystem that integrates everyone from manufacturers to health care workers providing vaccines. Given the widespread reach and success of the program—along with a robust digital backbone offering functionalities that can be translated into other public health programs to improve performance—the CoWIN team is currently exploring integrations with blood bank management, routine immunization, and organ donation services.

These integrations will not only serve to improve program performance of existing public health programs in India, but also intend to facilitate interoperability with the vision of creating a fully integrated digital health ecosystem under the Ayushman Bharat Digital Mission. The envisioned state further aims at bringing the entire health care ecosystem including facilities, providers, and other ecosystem partners, such as manufacturers, within one umbrella.

Conclusion

Since its inception in January 2021, CoWIN has helped 90 percent of India’s population get vaccinated with at least one dose, as of December 2021. The platform’s widespread utility can be attributed to several key factors, including the adaptation of existing technology and architecture for quick integration and scale; proactive and collaborative decision making by the government and its partners; modular designs that can be quickly modified to meet emerging needs in a rapidly changing pandemic context; and India’s ongoing commitment to expanding and improving its digital health infrastructure in general.

This is a qualitative assessment based on the mHealth Assessment and Planning for Scale framework. To learn more about the framework, click here.