What lessons can be learned from COVID-19 vaccine rollout in Africa?

By Iain Macleod Briongos, PhD

The deployment of COVID-19 vaccines from 2020 onwards represented an unprecedented global effort, surpassing all previous vaccination campaigns in speed and coverage. In this post, we note the successes and failures of the COVID-19 vaccine campaign in Africa and how these lessons may be applied to the ongoing malaria vaccine rollout.

COVAX and vaccine procurement

The COVID-19 Vaccines Global Access (COVAX) program led by Gavi, the WHO, CEPI, and UNICEF was established to guarantee fair and equitable access to vaccines, diagnostics, and therapeutics worldwide. The program served multiple functions. Primarily, it acted as a collective bargaining tool for vaccine acquisition for 78 higher-income countries. These countries also provided funds, through voluntary donations, to 92 low- and middle-income countries, including 50 in Africa.¹ While, in principle, the idea was sound, many developed countries also signed bilateral agreements with vaccine manufacturers, undermining COVAX’s purchasing power and in some cases stockpiling more doses than required to fully vaccinate their national population.² This contributed to dose shortages in low- and middle-income countries, where only 819 million doses of a targeted two billion were delivered by the end of 2021,³ albeit doses that may otherwise not have been allocated to those countries.

Intellectual property and manufacturing

As pharmaceutical companies control pricing strategies for their products, vaccine procurement in each country was constrained by intellectual property rights. For example, Colombia was reported to be paying US$12 per dose⁴ and South Africa US$5.25 per dose as compared to US$2.16 by the European Union⁵ for the same vaccine. COVAX reported that for the first 1.3 billion doses they received, they paid an average of US$5.20 per dose;⁶ however, the lack of full transparency over the details of vaccine deals makes pricing for specific vaccines unclear. Regardless, the disparity in price per dose potentially represents a failure in the collective bargaining power of COVAX. Intellectual property rights, while a powerful tool to encourage innovation, also represent a hurdle to equitable access to vaccination.

Despite these challenges, one notable success was the use of multiple licensing agreements to boost vaccine production. For example, Oxford/AstraZeneca licensed production of their COVID-19 vaccine to the Serum Institute of India, increasing production by 70 million doses per month.⁷ However, reliance on one or few manufacturers can pose challenges – when COVID-19 cases spiked in India, exporting was reduced to meet local needs,⁸ leading to shortages elsewhere. Likewise, China has a high production capacity, having produced almost half of the global number of doses by late 2021.⁹ Both manufacture licensing and intellectual property waivers could be powerful tools in reaching the target number of R21 vaccines quickly and at low cost.

Vaccine delivery and uptake

A study of African countries that received vaccines from COVAX revealed a significant disparity in full vaccination rates, ranging from 0.13% in the Democratic Republic of the Congo to 44% in Botswana by the end of December 2021.¹⁰ With the vaccines that were delivered, many countries struggled with logistical and operational limitations such as preplanning, community outreach, and post-vaccination surveillance. ¹¹¹²

The training of additional healthcare workers to cope with an increase in demand was complicated by the requirement for social distancing and remote training over more successful practical and hands-on experience.¹³ Due to the limitations of the COVAX system outlined above, the unpredictability of both the vaccine supply dates and the number and type of vaccines being supplied also contributed significantly to low vaccination rates. Different vaccines have different characteristics – their required dosage, temperature resistance, stability, and expiry timelines – that countries might not have prepared for.¹⁴

Conversely, some countries managed to effectively integrate COVID-19 vaccines into existing routine health services, along the lines of Zambia’s integration of the COVID-19 vaccine roll-out with other vaccinations and family planning services.¹⁵

Public trust and misinformation

Misinformation and fear of adverse effects from the vaccine contributed to vaccine hesitancy and distrust in many countries. To combat this, some countries took to community-driven strategies, such as in Côte d’Ivoire, where community influencers and religious leaders were enlisted to address vaccine hesitancy.¹⁶ Countries also developed various strategies to improve communication and engagement, such as through multi-channel campaigns, social media efforts, and toll-free call centers. However, misinformation, especially via social media, and authorities’ inadequate response to it were significant obstacles. Surveys and focus groups in several countries aimed to understand public perceptions and adapt messaging, but vaccine hesitancy remained a concern,¹⁷ underlining the requirement for culturally sensitive and community-driven outreach strategies.

Applying lessons to malaria

While certain aspects of the COVID-19 vaccine rollout do not apply to the R21 vaccine, such as competition for doses with high-income countries, there are several relevant lessons that can be learned. Global collaboration can help to ensure access to the R21 vaccine, which could save thousands of lives per million vaccinated (for more discussion, see our blog post). By encouraging intellectual property waivers and ramping up manufacturing through multiple licensing agreements, dose production could be increased significantly and costs could be lowered. Beyond this, both securing funding from governments and philanthropic organizations and streamlining regulatory processes – for example, adopting a rolling process for Gavi application reviews and expediting vaccine batch testing –would help to meet the urgent distribution needs.

Vaccine delivery and uptake can be improved by tailoring strategies at a country-specific level to understand and adapt to unique cultural, healthcare, and infrastructure challenges. This should include pre-planning, training, community outreach, post-vaccination surveillance, and other logistical and operational considerations to maximize the efficacy of the vaccine rollout.

To limit the impact of mistrust and misinformation, multichannel engagement with the community is necessary. This includes limiting misinformation and supplying accurate information on both social media and traditional media, as well as direct engagement through community-driven outreach programs such as working with community leaders and religious figures.

The lessons learned from the COVID-19 vaccine experience offer valuable insights that can be applied to ensure a more successful rollout of the R21 vaccine and improve vaccination efforts worldwide.