We failed to recognize community and country needs in rolling out COVID Vaccines.

We can learn from these mistakes.

There are two popular meta-narratives on the failures of Global COVID-19 vaccine rollout: “multi-national capitalist pharma companies didn’t make tech transfer available, and that leaves the most vulnerable behind” and “countries were not ready to deliver vaccines and had to destroy and reject doses.” While each of these narratives have some truth to them, they both divert attention from systemic failures in the highly complex and aging global health architecture’s setup of mechanisms that seek to “prioritize equity” in delivering essential medical products to where they are most needed.

These narratives deflect responsibility for issues that take place too far upstream in vaccine supply and downstream in last mile delivery, when there’s also a convoluted and messy middle that exacerbates problems. This messy middle is unfortunately perpetuated across many global health processes, incorporating sometimes arcane guidance that is irrelevant and counterproductive in the face of new, fast-moving developments such as those we’ve experienced in the global COVID pandemic. It is important to have mechanisms of international support and solidarity for equitable vaccination and I’m proud to have contributed to these efforts. My experience researching plans for the 92 countries eligible to receive vaccinations from COVAX, the global vaccine fundraising and distribution mechanism, and tracking their outcomes gives me a unique vantage point to make a constructive critique of the global COVID vaccine rollout.

There were obviously unforeseen issues, such as which vaccines would be available first, which would face production delays, and which countries would ban exports. Given the unprecedented nature of the global pandemic, many institutions with lofty public expectations and limited mechanisms to control and enforce global production and supply faced steep crisis response learning curves. I want to acknowledge the hard work and tireless effort from individuals in the global health field who gave so much to the pandemic response, often at great personal sacrifice, to help deliver billions of vaccines to protect the world.

Here are six key lessons along with recommendations on low-cost ways to address similar challenges in the future.

1.

Targeting recommendations for priority groups to reach with vaccines, including health care workers, must emphasize the importance of dialogue and consultation with leadership of key industry, civil society, and/or union groups being targeted. This lack of engagement likely contributed to hesitancy and skepticism by target groups, e.g., health care workers and teachers. Just 1 in 3 health care workers in Africa are fully vaccinated, almost a year after vaccines were made available to them, and only 1 in 5 adults over 50 years old are vaccinated. Most priority group targeting plans were abandoned early on by ministries of health to increase the speed of uptake. While it is wholly necessary to prioritize the most vulnerable, if the most vulnerable do not have a say in the prioritization or understand the rationale for being vaccinated first, this can create issues and resentment of health authorities. This can be especially true in places where adult vaccination is not the norm. As the Bolivian delegation from the health ministry shared in a project ECHO webinar in the fall, “confidence among these target communities is key, and not a given.” Countries which meaningfully brought union leaders into the planning process at early stages saw higher degrees of implementation success early on, and countries such as Kenya and Bolivia that learned from their mistakes made great strides.

To make sure early target groups accept vaccination, vaccination plans must be co-created with leaders of target groups representing health care worker and teacher unions. Prioritization frameworks should be written with comprehensive, inclusive engagement strategies as a precondition for country governments when making delivery plans that target the most vulnerable. This would help prevent assumptions of compliance or acceptance without adequate consultation by taking time to listen to and address community needs.

2.

Practical barriers to immunization, such as insurance coverage, inability to miss work, and childcare responsibilities, must be considered in the design of vaccination plans. In regions where economies were hit hard and incomes dropped, the need to take a day or more away from work to wait in line for COVID vaccination or dealing with side effects can pose significant risks to employment. Difficulty leaving school or work was cited by 1 in 4 unvaccinated South Africans as a barrier in January 2022 according to data from the John’s Hopkins COVID Behaviors Dashboard. The UNHCR appealed for states to remove barriers to access COVID vaccines. Where there are inadequate worker protections and paid medical leave, a day away can mean wages and income lost. In regions where adult vaccination is uncommon, these barriers are harder to overcome.

New and more effective livelihoods-based interventions for vaccine delivery must be tested and deployed across low- and middle- income countries (LMICs). Vaccination sites at workplaces and schools, as well as policies that protect formal and informal workers for essential medical leave should be piloted to determine what works to reduce practical barriers to adult immunization.

3.

Global donors need to understand and prioritize country ambitions for COVID- vaccine delivery, especially coverage targets for youth. Blanket 70% coverage targets for the general population on short timelines are unrealistic given population structures in LMICs, especially when considering many vaccines that have only been recently approved for youth (within the last 6 months). Nigeria’s target is to reach 70% of adults by the end of 2022. DRC aims to reach 45% of their population by the end of 2022. Ethiopia plans to reach 80% by the end of 2023. Most messaging has implied that COVID vaccines are necessary for the elderly, health care workers, and the immunocompromised. As youth make up more than 50% of citizens in LMICs, they are a woefully neglected audience for COVID vaccine messaging and need to be centered if the world’s ambition is to reach anywhere near a 70% target. Surveys show lower vaccine acceptance in young people across Africa, which is worrisome given the sheer size of this group. What’s more, an unpopular vaccination program risks undermining confidence in the government’s ability to deliver other health services. Today’s youth will be tomorrow’s mothers and fathers of the children in need of life saving routine vaccinations; a campaign for COVID vaccination whose value and ambitions is not clearly communicated nor understood could erode public trust in immunization programs in general.

Global health leaders must take time to listen and understand ambitions from country immunization programs. Local health officials have the best context and understanding of the trade-offs needed to secure their nation’s public health and their ambitions need to be supported.

4.

It is essential that countries know when and how many doses will be arriving to forecast and plan for human resources and budget COVID vaccination campaigns. Countries were forced to wait and see when deliveries would arrive, creating a sense of limbo in health systems. Immunization programs were expected to adapt to the priorities and timelines of global donor institutions instead of their own, out of fear of letting COVID vaccine doses expire on their watch. This uncertainty created misalignment of priorities, improper incentives, and took away focus from other disease control programs, routine immunization, and primary care. Even though just 1% of doses have been wasted in Africa, governments have faced criticism for negligence.

Transparent delivery schedules should be worked into contracts with manufacturers and dose donors. A recent MSF critique of COVAX lists several additional recommendations for donors, including monthly distribution schedules and stricter requirements for public disclosure of contracts.

5.

High-income countries should donate recently produced surplus doses, rather than doses that are months old. Many of the COVID vaccine donations from Europe to Africa in Fall 2021 came with less than three months of shelf life. When doses are close to expiry, it’s harder to convince an already weary public that vaccination is safe and effective. Funds were not available for many countries to deliver vaccines until months after doses arrived. Doses getting to countries so close to expiration causes unnecessary investment in rapid distribution on tight timelines. This leaves more opportunities for inadequate management of adverse effects and risks a backlash from workers who are not compensated on time for surge activities that campaigns necessitate. Countries publicized destruction of doses to assuage the public that their COVID vaccination campaigns did not sacrifice safety.

Global standards are needed for the shelf life of immunization dose donations. With less urgency, countries will be able to more adequately staff up to deploy vaccines and reassure the public that vaccines are safe and effective.

6.

Country delivery funding from donors must be easier to access, better coordinated and more quickly disbursed. Donor funds for COVID vaccine delivery arrived months after initial shipments of doses, and reasons for delays were not well communicated. It took 2.5 months for GAVI to disburse early access funds to its 60 applicant countries, all of which were promised funds in less than 30 days. After funds were disbursed, countries were asked to submit yet another application within months to access additional funds, on top of requests to apply for COVID vaccine delivery support from the World Bank, Global Fund, and European Investment bank. Many major donors did not yet have systems in place to effectively share data in real time on programs they were financing in priority countries. When the vaccine delivery money finally arrived, we see evidence that countries used it effectively, at or above expectations outlined in applications. After an infusion in funds, Ethiopia’s campaign in February 2022 was a huge success, reaching 2.5 million people in a single day. Cote D’Ivoire’s vaccination drive in December 2021 ramped up dramatically after its loan from the World Bank came through.

There need to be shorter, less complicated, and fewer applications for countries to access funds for delivery of products, and the money must get out to countries, states, and communities much faster. A single application for vaccine delivery funding that is endorsed by global health donors and high-income country governments would facilitate faster access, reduce duplication, and minimize competing priorities.

This critique is a challenge to those of us working within the system to reflect on fundamental questions of inclusion, equity, transparency and more in the context of the COVID-19 response.

It’s easy to criticize these failures, and some were inevitable given the necessary speed of response during a crisis and lack of experience in a global pandemic, with many global health and donor institutions not set up for success in emergency response. This critique is a challenge to those of us working within the system to reflect on fundamental questions of inclusion, equity, transparency, and more in the context of the COVID response. The stakes cannot be higher if we hope to avoid the same mistakes the next time the globe needs to act quickly and in unison to respond to a health emergency. The common aim should be to provide great service to and with the most vulnerable communities, while respecting autonomy and agency. In the words of Mike Ryan, WHO’s executive director of the Health Emergencies program, at a Project ECHO webinar in December 2021, global health leaders must “make sure [they’re] not responsible for making the barriers to successful vaccination.” We can do better. We have to.