The stark reality of the failure of COVAX and its implications for Africa

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Aidspan

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Article Number: 5

And the Global Fund is also running out of COVID-19 Response Mechanism funds

ABSTRACT The first 18 months of COVAX distribution of COVID-19 vaccines to developing countries have not gone as hoped. As richer countries roll out booster shots, 98% of people in low-income countries remain unvaccinated. The astoundingly unequal COVID-19 vaccine rollout has seen 84.3% of vaccines go to upper-middle- and high-income countries, while just 0.4% go to the world’s poorest. The ambitious COVAX program has contributed just 5% of all vaccines administered globally and recently announced it would miss its two billion target for 2021.. However, even if vaccines are made widely available, African countries still face infrastructure and public perception challenges that will need to be overcome for national roll-out plans to be effective.

The Bureau of Investigative Journalism (BIJ) has published a damning article on the failure of the much-heralded COVAX facility to provide COVID-19 vaccines as promised, failing both in terms of delays and quantity. This coincides with the publication of other reports, none of which paint COVAX in a good light, plus the grumblings of countries who feel let down. Delays in countries’ receipts of vaccines have fuelled conspiracy theories and this will have undoubtedly contributed to vaccine hesitancy.

COVAX is the vaccines pillar of the Access to COVID-19 Tools (ACT) Accelerator

The ACT Accelerator is touted as a ‘ground-breaking global collaboration to accelerate the development, production, and equitable access to COVID-19 tests, treatments, and vaccines’. COVAX is co-led by Gavi, the Vaccine Alliance; the Coalition for Epidemic Preparedness Innovations (CEPI); and the World Health Organization (WHO). Its aim is to accelerate the development and manufacture of COVID-19 vaccines and to guarantee fair and equitable access for every country in the world. In this respect, it has not been fit for purpose.

A shabby state of affairs

In Sub-Saharan Africa, according to WHO, the first (COVAX) vaccine doses were administered on 1 March 2021 in Côte d’Ivoire and Ghana. Kenya followed closely with its first batch of COVID-19 vaccines (AstraZeneca) arriving on 3 March, heralding a much-needed ray of hope in a dismal pandemic situation. Since then, vaccine donations have picked up a bit in Africa, although not nearly enough. Currently, barely 4.5% of the African population is fully vaccinated. According to WHO, African countries have received 201 million doses by now, a mere 2.4% of the world’s distribution.

Conceived at the start of the pandemic, COVAX pursued majestic goals, promising fair access to COVID-19 vaccines for every country worldwide, and free-of-charge to the poorest. For richer nations, COVAX said it would act as an insurance policy. For poorer ones, salvation.

But the first 18 months have not gone as hoped. As richer countries roll out booster shots, 98% of people in low-income countries remain unvaccinated. COVAX, described as “naively ambitious” by one expert, has contributed just 5% of all vaccines administered globally and recently announced it would miss its two billion target for 2021.

WHO believes 70% vaccination target is possible – but only if wealthy countries make way for COVAX and Africa

Health Policy Watch reports that WHO believes that it is possible to get 70% of the world vaccinated against COVID-19 by June 2022 – but only if wealthy countries redirect their doses and vaccine orders to poorer countries that are lagging behind.

“Eleven billion vaccines are needed to reach the 70% target”, said WHO Director-General Dr Tedros Adhanom Ghebreyesus at the launch of the global body’s Strategy to Achieve Global COVIDd-19 Vaccination by mid-2022. “More than 6.4 billion doses have already been administered globally, and one-third of the world’s population is fully vaccinated against COVID-19. Contracts are in place for the remaining five billion doses, but it’s critical that those go where they are needed most, with priority given to older people, health workers, and other at-risk groups. We can only achieve our targets if the countries and companies that control vaccine supply put contracts for COVAX, and the African Vaccine Acquisition Trust (AVAT) first for deliveries, and donate doses.”

Tedros added that there was “horrifying inequity” as high and upper-middle-income countries had used 75% of all vaccines produced so far while low-income countries have received “less than half of 1% of the world’s vaccines”.

Earlier this year, WHO had set three global vaccination targets to end the pandemic: 10% of the world’s population vaccinated by the end of September, 40% by December, and 70% by next June.

Failure to meet 10% target

Fifty-six (56) countries, mostly in Africa and the Middle East, flunked the 10% target last month. However, WHO’s Dr Kate O’Brien, head of vaccines and immunisation, said that around 200 million vaccines were needed for all countries to reach 10% coverage – less than a week’s production, as around 1.5 billion vaccine doses are being produced every month.

Bruce Aylward, Tedros’ special adviser, added that 40% of people were already fully vaccinated in North America, South America and Asia, while the Western Pacific was close to this.

“Of course, the problem is in Sub-Saharan Africa,” said Aylward. “There’s enough vaccine in the world, but we have a distribution and delivery problem. If we can’t solve that problem in 12 weeks, that speaks poorly for the urgency we need to end the pandemic.”

He challenged every country with over 40% coverage, saying that if they were not prioritizing support to lower-income unvaccinated parts of the world and COVAX then “they’re simply not doing enough to help achieve global equity”.

COVAX has not met its promise to vaccinate the world

The Bureau of Investigative Journalism (BIJ) has reviewed confidential internal documents and spoken with officials from more than two dozen countries, many of whom described confusion and frustration with COVAX. Although appreciative of the intent behind the initiative, they say they’ve struggled to get information from COVAX personnel and been left in the dark over when, if ever, deliveries would arrive.

Countries have received supplies months late or with little notice, throwing vaccination campaigns into chaos and sometimes delaying people’s second doses. In some cases, short-date vaccines were returned or thrown away after governments were unable to distribute them in time. Countries and regions with the financial means to do so then scrambled to make deals with vaccine manufacturers directly but found themselves at the back of the queue.

The side-effect of vaccine hesitancy

“Because the vaccines were delayed, conspiracy theories became more widespread”, says Dr Faisal Shuaib, Nigerian Ministry of Health. This has probably contributed to vaccine hesitancy in many African countries such as Zimbabwe.. But reluctance to be vaccinated is also a roadblock in the Democratic Republic of the Congo (DRC). A study commissioned by the African Centres for Disease Control (CDC) on COVID-19 perceptions in 15 African countries found that only 59% of respondents in the DRC were willing to be vaccinated for COVID-19.

Vaccine hesitancy has proved to be a particular challenge in many African countries, including among healthcare workers. In the Africa CDC survey, 20% of the respondents said that they would not get vaccinated. The study revealed that across most of the African countries surveyed, respondents tended to view COVID-19 vaccines as less safe than other vaccines. In addition, more than half of the respondents felt that the threat from the coronavirus was exaggerated and that it did not pose a significant health risk.

In response, churches throughout the region, including South Africa, are using parish structures to ‘address vaccine hesitancy and dispel myths’.

Sidelining stakeholders, including the poorest, in decision-making around vaccines

COVAX has been accused of sidelining the organizations that represent the interests of poorer nations in its high-level talks, denying a voice to those who were most desperate. The BIJ spoke to several officials who wish to remain anonymous, worrying that openly discussing their experiences with COVAX could harm their relationships with the organization.

Some countries’ COVAX supplies did not reach the people who were the intended beneficiaries. An article in the International Health Policies Newsletter (COVID-19 vaccinations in Kenya: What’s the current state of affairs?) notes that the original roll-out of the COVAX vaccines in Kenya originally targeted health care workers, some other frontline workers, people over the age of 58, and those with certain medical conditions. The initial vaccine roll-out also included other vulnerable populations such as those living in informal settlements. Everyone else had to wait. However, although this strategy had been agreed in advance, not everything went according to plan: in March 2021, when the first COVAX vaccines arrived, the government allowed vaccination of the foreign diplomats before the frontline staff or the elderly. This is not COVAX’s fault, of course, but adds to complaints about why the ‘world’s first global allocation mechanism based on principles of equity and fairness’ is being distributed unfairly once it reaches the country.

Globally, 34.7% of the world population have been (fully) vaccinated by now. It is woeful that Kenya’s vaccination rate is nowhere near: it currently stands at 1.7 % with 3.8 million doses given and 929,000 fully vaccinated. Kenya was one of the many countries in Africa that missed WHO’s target of fully vaccinating 10% of the global population by 30 September. To look at it differently, Kenya is still struggling to vaccinate populations at high risk while many developed nations have already inoculated all their adult populations (and even some of their teenagers).

COVAX’s umbrella organisation commissioned a review and the BIJ was able to see the draft version.

The review highlighted the ‘insufficient inclusion and meaningful engagement’ of low- and middle-income countries, civil society organisations and community representatives. It also noted concerns that COVAX isn’t doing enough to expand vaccine production through measures such as technology transfer, and that health systems will ‘need support’ in the coming months to roll out increased supplies of vaccines. However, COVAX told the BIJ that the initiative is breaking new ground in facilitating access to COVID-19 vaccines for all.

COVAX went on to say that estimates of the number of doses and availability are based on information received from manufacturers, and that ‘because of delays in the release of vaccines from manufacturers, it has not always been possible to notify countries a long time in advance’ about supplies. It acknowledged that ‘while the mechanism is now working at scale, volumes made available to it to date are unacceptable’. It calls on manufacturers and governments ‘to prioritize COVAX so it can urgently accelerate deliveries to countries that need doses most’.

COVAX has delivered some 330 million vaccines so far, yet now intends to distribute a massive 1.1 billion vaccines in the next three months alone. Some officials in poorer countries fear that the sudden influx of vaccines could overwhelm their health systems and lead to much-needed vaccines going to waste in countries such as the DRC, Malawi and South Sudan.

As a vision of solidarity to an operation based on charity, COVAX has failed to live up to its promise. Eighteen months since the initiative was launched, countries in the global south continue to face devastating COVID-19 waves and billions of people remain unvaccinated. Experts say that COVAX must reflect and learn from its mistakes to change the direction of this pandemic – and apply vital lessons before the next.

Meanwhile, the Global Fund is running out of COVID-19 money

On 8 October the Global Fund announced that, to date, it has awarded a total of $4 billion to more than 100 low- and middle-income countries to fight COVID-19, adapt HIV, TB, and malaria programs, and urgently reinforce fragile systems for delivering health services. This funding is on top of the over $4.2 billion a year the Global Fund provides to countries’ HIV, TB, and malaria programs.

Since March 2021, when new funding became available thanks to the support of donors led by the United States, followed by Germany, the Netherlands, and Switzerland, the Global Fund has awarded $3 billion for COVID-19 through its COVID-19 Response Mechanism (C19RM), created by the Global Fund in March 2020. This builds on the $1 billion funding the Global Fund approved for the COVID-19 response in 2020.

However, despite the progress countries are able to achieve with this support, the Global Fund will run out of C19RM funding this month. Without further funding, the Global Fund will no longer be able to support countries as they seek to protect their front-line health workers, scale-up testing to stop the spread of the pandemic and provide severely ill patients with life-saving treatments including medical oxygen.

“Since the Global Fund is the primary provider of financial support for many low- and middle-income countries for all the non-vaccine components of their COVID-19 responses, this means countries will need to scale back just when they need to be scaling up,” said Peter Sands, the Global Fund’s Executive Director.

As part of ACT-Accelerator’s overall appeal, the Global Fund is seeking to secure an additional $6.3 billion to respond to the most immediate and urgent needs in the global fight against COVID-19.

Conclusion

To defeat COVID-19, the Global Fund advocates for a comprehensive approach that brings together testing, treatments, vaccines and the health systems to make it happen – vaccines alone will not be enough. Until vaccines are made available worldwide and as variants of concern continue to emerge across the globe, the best strategy to fight COVID-19 is to test, trace, treat and isolate, which requires hundreds of millions of tests, effective new treatments, and training and personal protective equipment (PPE) for health care and laboratory workers.

In summary, the astoundingly unequal COVID-19 vaccine rollout has seen 84.3% of vaccines go to upper-middle- and high-income countries, while just 0.4% go to the world’s poorest. Access to vaccines, scaling up, and speed are key to any successful mass COVID-19 vaccination program in Africa. However, even if vaccines are made widely available, African countries still face infrastructure and public perception challenges that will need to be overcome for national roll-out plans to be effective.

Read the BIJ’s full report here.

Further reading:

• COVAX (who.int)
• COVID-19 vaccination climbing slowly in Africa | CIDRAP (umn.edu)
• How vaccine hesitancy affects COVID-19 containment – CNBC Africa
• UK Covid vaccine rules cause hesitancy – Africa health boss – BBC News
• In Africa, parishes work to overcome hesitancy about COVID-19 vaccines | Crux Now
• Why are COVID-19 vaccines going to waste in some African countries? | ONE