In October 2021, the World Health Organization (WHO) announced a target of fully vaccinating 70% of each country’s population against Covid-19 by the end of June 2022. At the time, while many high-income countries had already surpassed this goal, Covid-19 vaccination programmes in developing nations, particularly in Sub-Saharan Africa, had barely begun. The key barrier that stymied vaccination rates was supply – countries in the African Region (a WHO region that excludes countries in north Africa like Morocco and Egypt), with a combined population of one billion people, had received just 200 million doses.
But as vaccine supplies increased in the following months, the number of administered doses did not. In October 2021, just a quarter of the doses received by countries in the African region were waiting to be administered. Ten months later, that figure now stands at 37%.
Now, despite an increased availability of vaccines, immunisation rates have begun to slow in many African countries. For example, South Africa, which administered 41 doses per 100 people in the second half of 2021, has used just 14 doses per 100 people so far in 2022. In total, across the African Region, 82 million doses were administered from March to May, compared to 128 million in the previous three months.
Covid-19 vaccine delivery strategies need to be nimble
Vidya Sampath, director of the healthcare delivery nonprofit VillageReach’s Covid-19 vaccine delivery plan, says that maintaining the momentum of immunisation programs would have been easier if African countries had received vaccines earlier. “In 2021, the global movement lost the prime opportunity to cater to a surge in demand [in Africa] by not having the vaccine ready and available. Now in 2022 there’s ample supply but the risk perception has greatly diminished.”
Despite successive waves of Covid-19 across the continent, the impact for many, particularly young Africans, has been relatively low. The WHO estimates that just 8% of global excess deaths due to Covid-19 during 2020 and 2021 occurred in Africa. In contrast, Africa is home to approximately 16% of the global population.
Sampath says that the reduced demand for vaccines in Africa has often been mistaken for vaccine hesitancy. Adam Bradshaw, an advisor for the Tony Blair Institute for Global Change specialising in Covid-19 policy, agrees. “Lower risk makes people more apathetic, and it’s more complex than just conspiracy theories.”
With citizens less willing to sacrifice time and endure costs to receive vaccines, the onus has fallen on governments to deliver vaccines directly.
Bradshaw says one way that African countries are doing this is by combining Covid-19 vaccination with other points of contact with the health service. “The idea is integrating health services to make the most of the limited resources that are actually available,” Bradshaw says. “If someone attends a clinic for their kids’ vaccination or for an adult health checkup, they are being encouraged to get a Covid-19 vaccine.”
Sampath says that in Ghana and the Democratic Republic of Congo, vaccines strategies have shifted to focus on bringing doses to vaccine-ambivalent individuals “right where they’re standing”. Bradshaw says that in response to low immunisation rates in rural areas, many programmes have started utilising mobile vaccinations strategies, where healthcare workers travel to villages to offer vaccines.
Resource limitations force African countries to adapt delivery models
According to Sampath, staff shortages have been one of the biggest barriers limiting vaccination rates in Africa. In mainland Africa prior to the pandemic, the number of physicians and nurses per 1,000 people ranged from 4.2 in Eswatini, formerly known as Swaziland, to just 0.2 in Chad, according to data from the World Bank. In comparison, the European Union has 14 physicians and nurses for every 1,000 people.
African countries also spend far less than high-income nations on healthcare. According to assessments by the charity CARE, the average “tarmac-to-arm” delivery costs for a single vaccine dose is $9.97 in South Sudan, equivalent to 40% of the country’s per capita pre-pandemic expenditure on healthcare.
According to Sampath, restricted funding and fewer healthcare employees has meant African countries have been unable to redeploy staff to work at mass vaccination sites that were common in richer nations. “Mass vaccinations sites for just a single city cost millions of dollars for a four-to-six-month effort. That type of funding is just not available to African countries,” says Sampath.
In response, Ghana has borrowed successful strategies from other immunisation campaigns, like those for Polio, and instituted a National Covid Vaccination Day. Ghana also implemented two mass vaccination drives – one-week periods where healthcare staff were temporarily diverted towards the Covid-19 vaccination effort before returning to their normal responsibilities.
Our index of “pre-pandemic healthcare readiness” – which ranks countries based on their healthcare spending, the size of their healthcare workforce and inoculation rates for other diseases including Tuberculosis and Hepatitis B – shows that existing healthcare infrastructure has been critical to vaccination progress. In general, the African Region countries that have struggled to scale up vaccination programmes are those with the least prior investment in their healthcare operations.
For instance, on average, the five African Region countries with the highest vaccination rates spent over 10 times more on healthcare per person than the five countries with the lowest vaccination rates, and employed six times more physicians and nurses per capita.
The index also identifies countries whose vaccination programmes have outperformed expectations, such as Mozambique and Rwanda.
Sampath describes Mozambique’s vaccine rollout as a “fantastic success story.” In the beginning , Mozambique administered vaccines in phases: first they vaccinated all health workers, then everyone aged over 65, then those over the age of 50 who had comorbidities. “They went looking for these very specific high-risk groups, and so they were able to manage their limited supply,” says Sampath. “This takes a lot of coordination and planning, and unfortunately many countries weren’t supported in order to do this.” The efficiency of Mozambique’s delivery strategy, combined with the regular championing of vaccines by elected officials, built trust in the programme which led to sustained demand.
Like Mozambique, government leaders in Rwanda have consistently emphasised the benefits of vaccines. Rwanda was also commended for its early planning on which vaccines to use in different areas – the Pfizer/BioNTech mRNA vaccine for example, which needs to be stored at ultra-cold temperatures – was only used in the capital Kigali, where refrigeration infrastructure could be maintained.
The successful rollouts in Mozambique and Rwanda offer a glimpse of what may have been possible throughout Africa if investment in vaccine development had been mirrored in vaccine delivery. “The global community took a risk and said it is okay to put our money into 50 research projects and only get five or six [positive outcomes],” says Sampath. “That same type of urgency and willingness to commit resources hasn’t been seen on the delivery side.”
Broad 70% target does not align with needs in Africa
Currently, the only two countries in the African Region to have fully vaccinated over 70% of their population are island nations: the Seychelles and Mauritius. A quarter of countries still have a vaccination rate below 10%. And as the WHO’s target date nears, low vaccination rates in Africa have prompted a debate about the appropriateness of a target that appears unachievable for many countries.
Recent research overseen by the Africa Centres for Disease Control and Prevention (Africa CDC) found that in Kenya, achieving 70% coverage across the general population was less cost effective than focusing vaccination programmes on inoculating the elderly. Achieving high immunisation among the general population was particularly cost ineffective in countries with young populations with high exposure to Covid-19, and prioritising vaccination for the elderly, pregnant women, individuals with comorbidities and healthcare workers provided the best value for money.
Commenting on those findings, Dr. Justice Nonvignon, Acting Head of the Africa CDC Health Economics Programme stated, “African countries may deliver greater health benefits to their citizens by investing in other more cost-effective health programs.” Nonvignon added, “There is no doubt that Covid-19 vaccines remain cost-effective under a number of scenarios. But it is equally clear that as the pandemic evolves, we need to be thoughtful about how we spend our time and money.”
Bradshaw says that the continued suitability of the 70% target depends on how the pandemic unfolds in future months. “If new variants emerge that are extremely deadly, transmissible and pose a bigger risk to people who are unvaccinated, even if they are young and healthy, then the pursuit of an aspirational goal like 70% would be really useful.
“But some countries, based on their current rates, won’t ever reach that target,” says Bradshaw. He says those countries’ efforts are better spent on integrating Covid-19 practices into essential immunisation programmes and focusing on the most at-risk groups.
“Changing the 70% target is definitely one option in front of us,” says Bradshaw. He says that once the June target date has passed, there is the possibility that regional institutions like the Africa CDC could work with the WHO to develop new region-specific targets.
Sampath warns that comparing vaccination rates in Africa to the 70% coverage target underestimates the progress of many of the continent’s vaccination programs. “[African countries] don’t have 70% of their population to vaccinate,” says Sampath. “In most countries in Africa, only people over the age of 18 are eligible for vaccinations, and so if you talk about how these countries need to vaccinate [only] 40% or 50% of their population, then it doesn’t seem like such an impossible task."
Evaluating vaccination rates without considering the eligible populations in each country can be misleading. For instance, if a hypothetical country had Kenya’s age-specific immunisation rate, but the United Kingdom’s population distribution, its overall coverage level would be 30%— almost double Kenya’s actual vaccination rate of 17%.
Kenya is one of the few countries in Africa reporting vaccination rates split by age group. This delineated data not only allows the Kenyan vaccine delivery team to measure progress against nuanced targets, but also allows them to identify gaps in coverage and assess the impact of targeted outreach strategies. Both Sampath and Bradshaw noted that if a more bespoke measure for reporting vaccination coverage in Africa is to become a reality, governments will first need to follow Kenya in developing data collection and reporting systems that are fit for purpose.
Sampath adds, "There has to be a global reframing, with an understanding that the broad 70% brushstroke really does not apply to Africa.”