In hopes of taming a monstrous spike in COVID-19 infections, India opened vaccinations to all adults Saturday, launching a huge inoculation effort that was sure to tax the limits of the federal government, the country's vaccine factories and the patience of its 1.4 billion people.
The world's largest maker of vaccines was still short of critical supplies — the result of lagging manufacturing and raw material shortages that delayed the rollout in several states. And even in places where the shots were in stock, the country's wide economic disparities made access to the vaccine inconsistent.
The country's ambitious effort was also partly overshadowed Saturday by a fire  in a COVID-19 ward in western India that killed 18 patients, and the death of 12 COVID-19 patients at a hospital in New Delhi after the facility ran out of oxygen for 80 minutes.
Only a fraction of India's population will be able to afford the prices charged by private hospitals for the shot, experts said, meaning that states will be saddled with immunizing the 600 million Indian adults younger than 45, while the federal government gives shots to 300 million health care and front-line workers and people older than 45.
So far, government vaccines have been free, and private hospitals have been permitted to sell shots at a price capped at 250 rupees, or around $3. That practice will now change: Prices for state governments and private hospitals will be determined by vaccine companies. Some states might not be able to provide vaccines for free since they are paying twice as much as the federal government for the same shot, and prices at private hospitals could rise.
Since state governments and private players compete for shots in the same marketplace, and states pay less for the doses, vaccine makers can reap more profit by selling to the private sector, said Chandrakant Lahariya, a health policy expert. That cost can then be passed on to people receiving the shots, increasing inequity.
"There is no logic that two different governments should be paying two prices," he said.
Concerns that pricing issues could deepen inequities are only the most recent hitch in India's sluggish immunization efforts. Less than 2% of the population has been fully immunized against COVID-19 and around 10% has received a single dose. Immunization rates have also fallen. The average number of shots per day dipped from over 3.6 million in early April to less than 2.5 million right now.
In the worst-hit state of Maharashtra, the health minister promised free vaccines for those ages 18 to 44, but he also acknowledged that the shortage of doses meant immunization would not start as planned on Saturday. States say the paucity of shots is one reason why immunizations have declined.
In a positive development, the country on Saturday received its first batch of Sputnik V vaccines, which it is importing from Russia. Moscow has signed a deal with an Indian pharmaceutical company to distribute 125 million doses.
India thought the worst was over when cases ebbed in September. But mass gatherings such as political rallies and religious events were allowed to continue, and relaxed attitudes on the risks fueled a major humanitarian crisis, according to health experts. New variants of the coronavirus have partly led the surge.
The country's shortage of shots has global implications because, in addition to its own inoculation efforts, India has promised to ship vaccines abroad as part of a United Nations vaccine-sharing program that is dependent on its supply.
Indian vaccine makers produce an estimated 70 million doses each month of the two approved shots — the AstraZeneca vaccine made by the Serum Institute of India and another one made by Bharat Biotech.
The federal government is buying half of those vaccines to give to states. The remaining half can then be bought by states and private hospitals to be given to anyone over 18, but at...