Why are low-income countries still behind on Covid-19 vaccinations?

In Memory of Matthew Bramley

“I’m in a dilemma which I never imagined to be in,” admitted Adar Poonawalla, head of the Serum Institute, the world’s largest vaccine producer, in December 2021. His problem? Making too much covid vaccine.

Throughout 2021, low-income countries struggled to get enough supply. The African Union’s envoy for vaccine acquisition evoked a famine in which “the richest guys grab the baker”. Pharmaceutical companies prioritised rich countries that paid inflated prices and signed contracts before regulatory approval. Some vaccine-producing countries blocked exports. Others opposed proposals by the World Health Organisation (WHO) to waive intellectual property rights on the vaccines, preventing more firms from producing them. Donated vaccines came slowly and often had short shelf-lives.

But supply is no longer the problem. Wealthier countries have now largely completed their vaccination programmes and production has been scaled up. In December 2021, Mr Poonawalla’s Serum Institute stopped production because it had a 200 million dose surplus. Last February, low-income countries requested less than a quarter of the doses available from Covax, the international vaccine-sharing scheme. More than one-third of vaccines supplied to Africa have gone unadministered. And even though richer countries have few people left to jab, they continue to administer more daily doses than poorer countries. Why are low-income countries still behind?

The problem for low-income countries is no longer supply, but distribution.

Some areas, especially rural ones, are difficult to reach because of bad roads. Fergus Drake, the CEO of Crown Agents, a development NGO, has seen “whole articulated lorries lost in some of these mud craters” in South Sudan. In Kenya, half of adults have been vaccinated in the capital, Nairobi, compared to just 10 per cent in Mandera county, near the border with Somalia. Ghana has been deploying drones and motorbikes to reach some areas. In conflict areas it is trickier still. The WHO vaccination campaign in rebel-held parts of Yemen has faltered.

Administering vaccines is also expensive. It requires workers, training, freezers, transportation, and commodities such as vials and syringes. According to CARE, a charity, each dollar’s worth of vaccine costs $5 to distribute. The World Bank estimates it will cost a further $12bn to vaccinate enough people in Africa.

Unsurprisingly, health systems have struggled to scale up. Many do not have information on people’s location, age and comorbidities, making it hard to know who to prioritise. And when administrators are forced to choose, Africa’s young population and high levels of prior covid infections mean that other diseases such as yellow fever and measles often take priority. That does not mean covid is mild in these countries. The Economist’s model estimates over 150 excess deaths per 100,000 in low-income countries.

Low uptake can also be blamed on vaccine hesitancy and misinformation. In a public opinion poll in 2020 by the Africa Centre for Disease Control, 43 per cent of respondents believed that Africans were being used as guinea pigs in vaccine trials. In Niger and Liberia almost 90 per cent of respondents considered prayer to be more effective than vaccination. Underlying this hesitancy is a lack of trust in government. In an Afrobarometer survey of 15 African countries, fewer than half of people trusted their government to make sure the vaccines are safe. In West Africa, those who did not trust their governments were five to 10 times less likely to want to get vaccinated.

Low-income countries must now find ways to turn vaccines into vaccinations. 

Image Description: Covid-19 Vaccine Vials