(CNN) Pakistan is in a tight spot: Covid-19 cases are surging during a third wave, hospital beds are filling up, and the government vaccination program is progressing slowly due to delayed deliveries and limited supplies.
So last month, it became one of the few countries to allow the private sector to import and sell vaccines.
Initial sales of the Russian Sputnik V vaccine in the first weekend of April caused a frenzy, with crowds rushing to vaccination centers and queuing for hours for their shot.
Several centers sold out in days. Others that had initially allowed walk-ins switched to online sign-ups after being inundated with people. Many online booking systems have since been paused, as clinics slowly work through a backlog of inquiries.
One major importer is private pharmaceutical company AGP Pharma, which has received 50,000 doses of the two-shot Sputnik vaccine. Other companies and private hospitals are in the process of applying and placing orders.
The government has received 2.56 million doses of vaccines, all from China, according to local reports citing the health ministry. About one million people have been vaccinated with those shots since February, mostly in priority groups such as health care workers and those above age 50 -- leaving a huge percentage of the country's 238 million residents left waiting, according to official figures.
The private vaccines, however, are open to everyone -- and many people, otherwise ineligible for the government's program, are now hoping to secure a slot in private clinics.
"It's good that it's available privately, I have no idea when our turn will come through the government," said Anushka Jatoi, 35, who got the vaccine with her family at a private hospital in the southern city of Karachi.
But the private sales have also raised concerns about pricing and accessibility, and highlighted the country's deep-rooted social inequality. Most private sales are in large cities, such as Karachi and Islamabad, and remain inaccessible to residents in more rural areas -- and the price remains beyond most of Pakistan's population.
The Sputnik vaccine currently costs 12,000 Pakistani rupees ($80) for two doses, according to the Drug Regulatory Authority of Pakistan (DRAP).
That's four times the international market price, which is less than $20 for two doses, according to the vaccine developers. And it's about 30% of an average household's monthly income, at $273.2 (41,545 rupees), according to the most recent available data by the Pakistan Bureau of Statistics.
Pakistan has only approved a handful of vaccines for emergency use, including three Chinese vaccines, Russia's Sputnik V, and the Oxford-AstraZeneca vaccine. So far, it has largely relied on donations from other countries -- chiefly China, which has provided more than a million doses of Sinopharm.
Pakistan is set to import three million more doses of China's CanSinoBio vaccine this month. Russia also announced in April that it will soon supply Pakistan with 150,000 doses of the Sputnik vaccine. It's not clear if the Sputnik and CanSinoBio vaccines are donations or purchases.
And Pakistan is still awaiting more than 17 million of doses of vaccines allocated by COVAX, a global vaccine-sharing initiative with discounted or free doses for lower-income countries.
With long delays in the COVAX program, and vaccines arriving from Russia and China relatively slowly, Pakistan's government has allowed the private sector to step in. Companies and private hospitals must fill out an application to the country's regulator, DRAP, to receive a No Objection Certificate (NOC) -- the document which allows them to import and sell vaccines.
There are some rules, however, including around the prohibition of selling the vaccine on the retail market; private institutes and clinics can only administer the vaccine on their premises and under the supervision of healthcare professionals, according to DRAP. Private clinics must also have their facilities assessed by the provincial director of general health.
Leaders at AGP, the pharmaceutical company supplying the private Sputnik shots, have argued that Pakistanis are running out of time as the outbreak worsens. By sharing the burden between the state and the private sector, more people can get inoculated faster and get the economy back on track, they say.
Pakistan has recorded more than 721,000 cases and more than 15,000 related deaths, according to data from Johns Hopkins University, and is currently in the middle of a third wave.
"We were cognizant of the fact that with 113 million (adults) in Pakistan, vaccination by the public health care sector will be a huge challenge," said AGP CEO Nusrat Munshi. "Someone had to rise to the challenge."
Only a handful of other countries have allowed the commercialization of vaccines. India has allowed some private facilities to distribute doses, though prices were regulated by the government. Colombia decided in early April to allow private imports, but mandated that the shots must be free for consumers. Indonesia has launched a private vaccination program, where companies can buy state-procured vaccines for their employees. And Kenya had allowed private sales for a while, but shut it down on April 2, citing fears that counterfeit vaccines might enter the private market.
Pakistan's decision to allow private sales has ignited a debate around the ethics of commercializing vaccines during a pandemic -- and a legal battle between the government and AGP over pricing.
At first, the government had allowed an exemption on price caps, meaning private firms could import and sell vaccines for whatever price they wanted. Critics argued this encouraged companies to profit from desperation, and could edge out the poorest and most vulnerable residents while benefiting the privileged few.
Jatoi acknowledged her privilege, describing the private hospital where she got vaccinated as being "like a hotel," with complimentary snacks and croissants in the waiting area. "We're lucky to be be in this position," she said.
Transparency International Pakistan, the national branch of the international anti-corruption non-profit organization Transparency International, wrote to Prime Minister Imran Khan last month, urging the government to ban private imports and sales. The commercialization of vaccines would essentially allow the wealthy to cut the line and exacerbate existing inequality, said the letter.
"The selling of this vaccine is just unethical, and too bad for the community," said Dr. Tipu Sultan, former head of the Pakistan Medical Association. "Only few people who are moneyed are going to buy it. The bulk of the population cannot afford it."
Eventually, the government reversed its decision and DRAP announced it would set a price cap -- prompting AGP to take the government to court. Since 50,000 doses of Sputnik vaccine had already arrived, the company was granted an interim order allowing it to sell the vaccines at $80 for two doses until the final pricing is decided.
Munshi, the CEO, defended the cost of the vaccine. There are many additional fees included in the process, including the cost of international shipping, government taxes, border clearing charges, warehouse costs, national supply chains, and specialized storage to keep the vaccines at the required minus 18 degrees Celsius, she said.
The company had used DRAP's recommended pricing formula to reach their final, "plausible" price, she added. "At this point in time the availability of the vaccine is far more important than the price."
But critics say even the current price of $80 is too much, out of reach for much of the public.
"This should not be more than 1,000 rupees or 1,200 rupees ($6.6 or $7.9)," said Sultan. "It is the duty of the state to provide vaccination for every citizen. And if they start selling it, then obviously it will be costly."
Everyone in Pakistan is now waiting -- for more vaccines to arrive, for registration at private clinics, for the government to reach a decision on pricing.
But the process of getting a privately sold shot has numerous complications, even for those who can afford it.
"I'm super frustrated because I have to travel for work, and I'm unable to get my vaccine," said Maha Mussadaq, a content lead at Foodpanda Thailand, who has been stranded in Islamabad. She tried all week to sign up for the vaccine, but has not been able to confirm a time slot, she said. She went online to register, and was told she would receive a phone call with more details, but was given no indication of when it might come.
"There's no system in place, and there's no definition of a timeline," she said. All of her travel plans for work are dependent on whether she can get the first dose, but with news of the vaccine selling out, she is quickly losing hope of that happening.
And even those who got their first shots are worried. "I'm afraid there's no guarantee that we'll get the second dose, what if supplies run out?" said Jatoi. "There's a lot of uncertainty."
Meanwhile, authorities are bracing for the Ramadan events that will start on Tuesday. During the Muslim holy month, devotees typically observe fasts and gather in mosques for daily prayers. At the end of the holy month, called Eid al-Fitr, friends and families gather to celebrate with feasts, festivities, and special prayers.
It's one of Islam's biggest holidays -- and it poses a Covid-19 risk. Around this time last year, countries around the world were experiencing devastating first waves, and imposed lockdowns that saw at-home and virtual Ramadan events.
But this time around, many of those lockdowns have lifted. In Pakistan, mosques will be allowed to remain open and hold services, albeit with rules such as mask-wearing, social distancing, and disinfection requirements.
The government warned last week that if the outbreak worsens during Ramadan and cases surge, it could revise and tighten restrictions again.