Amid the fevered speculation about which COVID-19 vaccine will be successful and when it will hit the market, there has been much less focus on a critical aspect of the equation: ensuring the right people get the right vaccine at the right time. Failure to do so will allow COVID-19 to remain at large, with those most in need living in low- and middle-income countries likely to lose out.
Countries need to start preparing to distribute a vaccine to the right populations at an unprecedented pace. Under the WHO ACT-Accelerator framework, countries will initially receive doses for 3%, then 20% of the population, ultimately scaling up to full coverage.
Although more detailed guidance is forthcoming on who the 20% should be, it will be up to individual governments to work out who and where the health workers and key at risk populations are.
A lack of robust and comprehensive health information systems in countries with less developed systems will make it difficult for many countries to work this out.
Planning for vaccine distribution and the identification of vulnerable populations needs to be transparent to ensure that access is equitable, and that citizens understand who will receive vaccines, and who won’t. Transparency is also key to ensure that access, or lack of access, is not used to the detriment of marginalized populations, or to foster political patronage — something that we’ve seen happening already in Bangladesh.
Distributing vaccines needs careful preparation and has never been done before at pace presenting an unprecedented global challenge. The COVAX Facility is designed to ensure there is equitable access to vaccines globally, but the demand is massive. Complicating things further, most national vaccine distribution systems are designed to ensure that children receive their full immunization schedule — not for large scale adult vaccination programs.
In addition, cold chain — refrigerated storage required to preserve the vaccine — requirements may also be different for the COVID vaccine.
Experts have welcomed interim efficacy data from the ongoing phase 3 clinical trial of Pfizer and BioNTech's COVID-19 vaccine candidate, but concerns around affordability and access remain.
UNICEF and others have begun to work on this, and plan to have 65,000 solar cold-chain fridges in place in lower-income countries by the end of 2021, but more work is needed if vaccines are to reach those in need in remote and difficult to reach locations like Nepal, or Sudan.
In many such countries the private sector is a — or the — major provider of health care. Working through who and where the best partners for delivering the vaccine will vary from country to country and inevitably will pose challenges.
The risks: Theft and corruption, weaponizing vaccines
Whilst most vaccines have little street value, initial limited supplies of a COVID-19 vaccine — compounded by a likely high demand from anxious populations — will make it a target for theft and diversion.
Many countries lack what the World Health Organization considers to be well-functioning and integrated medicines regulatory systems, making it more likely that substandard and falsified vaccines will appear on the market. The impact of these could be devastating, fueling skepticism and distrust, worsening the pandemic, and ultimately costing lives.
Add to this the real risk that vaccines will become a new weapon with which powerful states attempt to wield geopolitical influence. Over 30 countries have already expressed interest in receiving the Russian Sputnik V vaccine. The vaccine was approved by Russia in August, prior to phase 3 trials, in a move criticized by some as hasty, and motivated by nationalism rather than science.
Premature approval and deployment of any vaccine risks doing more harm than good, and not just to the recipient — a lack of transparency in the development and approval of vaccines gives room for sceptics to discredit vaccines. But the fact that so many countries expressed an interest in this vaccine — before details of its safety or efficacy were known — goes to show how worried governments are about not getting sufficient supplies or access.
How to get this right
There are many issues still to be resolved in what may shape up to be one of the biggest logistical challenges the world has ever seen. A lot rests on its success. Many LMICs have already been hit hard by COVID-19. Delays in distributing vaccines will only add to their citizens’ suffering.
While many countries have begun to plan for distribution, we need to ensure that this is done in a way which builds trust and consensus. National allocation frameworks and distribution plans should be developed in a transparent manner. National Immunization Technical Advisory Groups must also be transparent and engage with citizens to ensure that prioritization of vulnerable groups is fair, and does not leave room for corruption or manipulation.
Safeguards must be put in place to protect supply chains from theft and diversion to the black market. Support and innovation is urgently needed to prevent substandard and falsified vaccines entering the supply chain, distorting markets, and undermining trust in formal delivery mechanisms.
To do this effectively will require a range of strong oversight mechanisms to be in place before vaccinations are rolled out. Multiple options are available, from technology-based approaches such as blockchain — which would help prevent theft and assure the quality of vaccines — to campaigns to make communities aware of the dangers posed by black market or illegal sales, and the introduction of corruption reporting hotlines.
If we are to defeat COVID-19 it is critical that we get this right. With so much effort invested in developing a successful vaccine, we cannot afford to fail at the last mile.
A positive legacy of COVID-19 should be stronger, more transparent, and better performing health systems, and robust vaccine delivery chains, leaving the world better positioned to cope with future pandemics and health crises, ensuring that people, no matter where they live, have access to good quality health services — so that ultimately we can achieve Sustainable Development Goal 3 by 2030.