With a new Covid-19 vaccine, many governments of low-income countries may find themselves unable to purchase sufficient doses of vaccine for their (usually large) population.

Recent efforts from rich nations, such as initiatives taken by European nations, Bill and Melinda Gates Foundation’s commitments worth of billions of USD, and many more provide some hope that immunization costs for poor countries can be somewhat reduced. But even then, these countries will still have to spend hundreds of millions of USD, if not billions, to buy enough doses of vaccines for their people.

“Many governments of low-income countries may not be able to pay the costs of deploying a new Covid-19 vaccine. They may, however, be able to pay in smaller installments over time. One way to provide this financing is a bond structure backed by OECD countries that would allow the money to be raised in capital markets. The OECD countries would make a legally binding commitment to pay investors in bonds over time.” (Rebecca Weintraub, Prashant Yadav and Seth Berkeley, Harvard Business Review).

Junior Mhlongo, the first South African to receive a trial dose of a Covid-19 vaccine

Two domestic structural bottlenecks

Having enough doses of the vaccine to vaccinate the entire population is a problem. Another hindrance facing developing country governments is related to the ability to implement a fair, inclusive and cost-effective domestic immunization program. To do this, these countries need to address two domestic structural bottlenecks: bureaucratic obstacles and infrastructure problems.

Countries affected by corruption may see the vaccine being made available to the top ranks long before it is made available to the rest of the population. Ineffective bureaucracy can also lead to poor management of immunization resources. For example, if the majority of resources go to a large city while the rural provinces heavily affected by the virus are ignored, this could cause dangerous consequences for public health.

National public health interventions: in this case, an attempt to vaccinate millions of people in middle and lower income countries also has to deal with inadequate infrastructure. Without road networks and the resources to mobilize air transport, vaccines will reach many parts of the population either too late, or not at all, and this will cause serious logistical barriers. These must be solved to offer equal access to vaccines.

Healthcare workforce is overloaded

The pandemic has overloaded healthcare systems around the world, and puts healthcare workforces at serious risk. Thousands of frontline medical workers have died from coronavirus, with more than 900 in the US alone. In developing countries, this is already a bigger problem given the much lower ratio of doctors to the population, meaning that not all coronavirus-infected patients are fully treated.

“This could be an especially big problem in low- to middle-income countries, where the depletion of health care workers’ ranks could also weaken existing programs to vaccinate people against other diseases. Investment in personal protective equipment and testing capacity is needed to protect the global frontline workforce.” (Rebecca Weintraub, Prashant Yadav and Seth Berkeley, Harvard Business Review).

Identify who needs the vaccine

Many citizens of developing countries lack official identities. The figure is estimated to be up to more than 1 billion. One way or another, this poses a great challenge for governments trying to reach all of their often dispersed populations. With no way to verify identity in an informal society, it is almost impossible for the authorities to know who has been and who has not been vaccinated. Initial supply will be limited; thus it is important to certify that each dose has been used for an actual patient.

“To address this problem, biometric digital IDs can be a game changer. For example, Simprints has deployed biometric IDs on health and humanitarian projects across 12 countries, which have increased health care visits and quality while preventing fraud. It is now partnering with Japanese telecom giant NEC to develop an affordable, interoperable, biometric solution for vaccines that can identify patients even in rural and offline settings. Using robust digital tools can help governments overcome identification barriers to ensure that everyone receives a Covid-19 vaccine.” (Rebecca Weintraub, Prashant Yadav and Seth Berkeley, Harvard Business Review).

Russia’s Covid-19 vaccine named Sputnik V. Photo: RDIF

Ensuring a fair strategy - COVAX

We cannot deny that a fair strategy for Covid-19 (if achieved) will be much different and potentially more challenging than HIV, since the virus is much more contagious. It is not like HIV where the majority of patient's daily activities do not present a risk of transmission. The coronavirus can be easily spread through droplets and respiratory surfaces.

To prevent vaccine nationalism from hampering global vaccination efforts, the World Health Organization and two other groups, Coalition for Epidemic Preparedness Innovations, and Gavi, a global non-profit group focused on vaccine delivery, have established a system to ensure equitable distribution and access to vaccines - the COVID-19 Vaccine Global Access Facility (COVAX). It calls on high-income countries to invest $18 billion in 12 experimental vaccines and ensures that early access is shared worldwide when effective doses of the vaccine are available.

COVAX seeks to lure rich nations by making them bet on an effective vaccine for different candidates, and if not funded, any of these 12 vaccines by COVAX probably fails.

As many as 172 countries have participated in COVAX. However, at a press conference on August 25, the WHO Director said that additional funding would be needed and more countries should make binding commitments to COVAX. The US, India and Russia have declined to join while China participated in the initiative. President Xi Jinping pledged that any effective vaccine developed by China would be distributed as a "public good" globally. However, some worried that vaccines coming from China may have quality problems after a 2018 scandal.

As Bill Gates wrote, "during a pandemic, vaccines and antivirals cannot simply be sold to the highest bidder"; instead, they should be readily available and affordable for those most threatened by the virus. On June 18, WHO released a "strategic allocation" plan for immunization, which will give priority to nearly 2 billion people worldwide, including frontline health care workers, people of over 65 years old and young people under 30 years old if they have a higher risk of Covid-19 infection because of underlying conditions such as cancer, obesity, diabetes or chronic respiratory diseases.

However, as richer countries continue to adopt the 'each-country-for-itself' approach, such an allocation plan is most likely to fail. Poorer countries will be left behind as prices rise - the result of an inevitable competition in dosage between countries that can afford it.

Experts are concerned that we may see a repeat of the last pandemic, where wealthy nations bought all available supplies of vaccines to fight the H1N1 flu virus in 2009-2010. Which countries get the vaccine and how much they are willing to pay for it will have consequences for international relations in coming years, with vaccines potentially becoming a leveraged tool in diplomatic affairs.

A fair distribution of doses around the world will be much more effective in pandemic control than in vaccinating entire populations in the richest countries. With unprecedented efforts around the world, we have come very close to an effective vaccine, and vaccine nationalism is a major hurdle that will need to be overcome to ensure that this effort is successful globally.

Pham Vu Thieu Quang (Leiden University, the Netherlands)

The dangers of vaccine nationalism

Success in developing a vaccine is one thing, but giving it to everyone in need is a completely different matter.