As more vaccine supplies finally become available to the world’s low-and middle-income countries (LMICs), the latent challenges that should have been addressed long before have emerged. Those include vaccine hesitancy and the ability of weak health systems to mount mass vaccination campaigns amidst other pressing health needs. Global policymakers need to shift their attention from focusing only on the sheer numbers of vaccine deliveries – to developing vaccines fit for purpose in LMICs, and building health systems capable of absorbing these life-saving health products.     

Thanks to a high vaccination coverage, rich countries have curbed down COVID’s death tolls and hospitalizations, and now some of them can afford to keep most services up running with limited restrictions even amid a COVID wave. 

COVID19 vaccination was so impactful that some experts suggest that the virus will soon become endemic – rather than the epidemic-cum pandemic that it has been for the past 20 months. 

Nevertheless, the low vaccine coverage in resource-constrained countries may lead to the creation of still more variants, slowing  the endemization process.  In that sense, the discovery of the Omicron variant was a timely reminder to the world that “no one is safe until everyone is safe” and that, in a better world, vaccines should be available for everyone at the same time.

The reality has been somewhat different 

Highly populated Asian countries have only fully vaccinated around 1 in 3 people. Coverage is 27% in Bangladesh, 27% in Pakistan, 35% in India, 39% in Philippines, and 38% in Indonesia,  leaving hundreds of millions with no jabs. 

Proportionally,  the situation is much worse in Africa (from only about 0.2% vaccination coverage in the Democratic Republic of Congo to about 2% in Tanzania, Burkina Faso, Niger and Madagascar. 

This  is far from all being safe at the same time.  And even as more doses finally become widely available in many African countries, the issues are  far from being resolved. Access to vaccines is quite complex and it encompasses technological, social, financial, and systemic dynamics. So in some countries, only a portion of available supplies actually end up being administered. 

Some countries hold off on more deliveries that they can’t absorb

Countries like South Africa, Namibia, and Mozambique have reportedly asked vaccine manufacturers and donors to hold off on sending more shots because they “can’t use the supplies they have”, according to a recent New York Times report. 

In manycountries less well-resourced, any vaccine campaign is likely to be  a real ordeal – even if health authorities have plenty of doses. 

Even the least demanding  COVID vaccines [e.g. AstraZeneca] require a refrigeration cold chain, while  the most effective mRNA jabs  require much lower temperatures  for long-term storage. 

Cold chain challenges will remain a barrier  – new types of vaccines are needed  

Just impossible for many countries with poor electricity coverage and basic logistics. Not to mention the number of health workers necessary to deploy mass immunization campaigns in countries with historical shortages of medical staff. 

That means that essentially, the existing available  COVID19 vaccines are effective and safe – but they are best fit for high-income countries’ contexts.

Massive investments should urgently go into transversal health system strengthening.  But in view of the time that will take, there is also a need to focus research on the development of a new generation of vaccines suitable for low-income countries. 

Much as resource constraints drove the development of rapid tests for HIV/AIDs and malaria, the same constraints should drive research into vaccines that are fit for purpose in health clinics with little access to electricity and few trained staff. . 

An ideal vaccine should be an oral or nasal spray one with a 12-month shelf life which requires no refrigeration nor the assistance of health workers. 

Out of the 137 vaccines in clinical development reported by WHO, less than 1 in 10 belong to a new generation. As their efficacy and safety still have to be proved, it is not clear how much public investment they receive compared to proven products already in the market. 

It will take years to strengthen poor countries’ health systems and years to develop new vaccines. COVID-19 pandemic made clear that these investments should not be punted down the field to another time. .

Vaccine hesitancy another barrier 

Additionally, vaccine campaigns suffer from hesitancy among people, and poor countries are not spared. The fact that vaccine hesitancy may be a potential threat to the achievements of traditional vaccination programmes in Africa has been well reported, even before the pandemic hit. 

Although one new survey suggests that in many African countries the willingness to get COVID vaccines is certainly far greater than availability, the picture is not uniform. South Africa has only reached a 26% vaccination coverage – despite comparatively wide vaccine access.  In places like the DR Congo, vivid memories also persist of vaccine coercion episodes or doubtful drug testing. Public awareness campaigns can counteract the distrust but, again, almost no investment has gone into low-income countries for vaccine promotion: education on vaccines is left to the social media. Certainly, this trust cannot be built by shipping close-to-expiration doses or second-class vaccines, as it has been repetitively reported in the media.

Government buy-in – at the price of other health priorities ? 

Finally, COVID19 vaccine campaigns are only partially endorsed by countries facing other pressuring health priorities. For example in Niger, half of the population is below the age of 15 and only 2% of the population is aged above 65, the life expectancy is around 62 years and almost 1 child in 10 dies before the age of 5 from preventable diseases. Burkina Faso, Mali, and many countries in Africa share a similar profile. What is the incentive for those countries to divert their scarce resources to a virus that is predominantly perceived to hit the elder?

International agenda has been too focused on supply numbers and not quality of delivery

Despite the complexity in deploying COVID vaccine campaigns, starting from the G20 in Rome and their reaffirmed commitment to the Access to COVID-19 Tools (ACT) Accelerator, the focus of the international agenda has been mainly about shipping as many doses as possible. In early November, a Task Force meeting on Scaling COVID-19 Tools was held among International Organizations including World Health Organization and COVID-19 vaccine manufacturers. 

The discussions were disappointingly limited on how to supply more vaccines, how to tackle trade-related bottlenecks, how to diversify manufacturing, etc. 

Agenda for strengthening health systems is too narrowly limited 

Although the latest Strategic Plan of the Act Accelerator  – the umbrella initiative for COVID  vaccination, treatment and testing, does include investment for health systems in the fight against the pandemic, it is narrowly limited to the “the technical, operational and financial resources to translate new COVID-19 tools into effective health interventions” (e.g.to set up ultra- cold chain infrastructure).

Even members of the civil society have recurrently called for more doses or a patent lift, as if it were a magic formula, while it is just a piece of a complex puzzle. 

In a recent opinion piece, Medicins Sans Frontieres’ director of operations Isabelle Defourny, rightly suggested avoiding simplistic views and pointed out the need for more holistic and localized responses to the pandemic. Similarly, the European Federation of Academies of Sciences and Humanities (ALLEA) in a December statement raised similar concerns that the current focus on a patent waiver may distract attention from other measures that are of fundamental importance in striving towards global vaccination. 

If the multiple barriers to vaccination are not surmounted in the first place, we will not reach vaccination for all at once, and no one will be safe. A genuine roadmap to end COVID19 should be inclusive of all countries and not driven by a few. It should consider all stakeholders involved and give voice to them. Failing to do so, the pandemic will likely last for longer.

About the Author:  

Riccardo Lampariello, head of Health Programme, at Terre des Homes, the leading Swiss relief agency for children’s aid, holds an MSc in Applied Statistics and an MBA. He has over 20 years of experience in Health: from Pharma – where he worked for 10 years in various positions in Clinical Development and Business Development – to International Organizations and International NGOs. He worked for GAVI Alliance, the Union of International Cancer Control and in May 2017 Riccardo joined Terre des hommes (the Swiss leading child protection agency improving millions of children’s lives worldwide) where he is Head of the Health division. With a focus on innovation, he drives the development and deployment of innovative projects (both disruptive and incremental), including one of the largest digital health solutions in Sub Saharan Africa. Twitter: @RLampa75 LinkedIn : www.linkedin.com/in/lampariellor

The opinions expressed in this article are the author’s own and do not reflect necessarily the view of Terre des Hommes.

Image Credits: WHO.