It's So Near, Yet So Far: Access to COVID-19 Vaccines in Africa

THE RACE ACROSS THE POND INITIATIVE ‘Women of Color in the Healthcare System’ Series

IT’S SO NEAR, YET SO FAR: Access to COVID-19 Vaccines in Africa Rumbidzai Ndungwani, Dr. Mellany Murgor, Saara Bouhouche, and Laetitia D.K. Diatezua July 2, 2021 The news of approval by the World Health Organization (WHO) for the newly developed vaccines against COVID-19 brought with it a sigh of hope and relief; the long months of anxiety surrounding fears of COVID-19 contraction were coming to an end. However, the luxury of some COVID-19 immunological protection is one that a majority of citizens from African countries will not enjoy, at least, for the foreseeable months. The Women of Color Advancing Peace, Security, and Conflict Transformation (WCAPS)’s Race Across the Pond Initiative (RAP Initiative) calls on all global leaders, private sector, and involved actors to step-up their engagement and cooperation to ensure resource-constraint countries in Africa and beyond have equitable access to vaccines and are able to contain dramatic scenarios.

Months after the ongoing approvals of the COVID-19 vaccine, countries across the globe continue to buzz with activity in trying to get the last milestone to receive at least one of the approved vaccine types. In the process, pre-existing health care disparities have become more glaring. Logistical challenges from the COVID-19 pandemic exposed several inequalities in healthcare systems worldwide, especially in resource-constrained countries. Initially, the issues were mainly related to the testing capacity, both technical and resource wise. Today, within the context of the African continent, and more particularly Sub-Saharan Africa, the vaccine distribution has come with its great load of supply-chain challenges. This article highlights some of the key issues experienced during the acquisition, distribution, and administration of the COVID-19 vaccine within the African continent.

As of June 28, 2021, 5,461,165 confirmed cases and 141,518 deaths have been officially reported for the African continent; though global data suggests an under-reporting of

Women of Color Advancing Peace, Security, and Conflict Transformation The Race Across the Pond Initiative: Women of Color in the Healthcare System Series

COVID-19 death cases. As of May 2021, only 1% of the 1.3 billion vaccines had been administered in Africa. Over 40 of the continent's countries depend on the COVAX initiative, which partially stalled between April and June 2021 in exporting vaccines due to the surge in the number of COVID-19 cases in South Asia. As a result, several countries halted the administration of the vaccines having run out of commodities.

Those that continued inoculating are now in short supply of COVID-19 vaccines.

Strengths in Supply Chain The redistribution of vaccines for countries with low consumption rates have proven to be a success. A good example is the Democratic Republic of Congo, which returned unused vaccines to UNICEF for redistribution. Positively, Rwanda has enhanced its cold chain system with five new ultra-cold refrigerators and, along with Ethiopia, is one of the countries that has been able to fully utilize the first batch of the supplied AstraZeneca vaccine. Additionally, the coordinated acquisition of discounted vaccines through COVAX facilitated resource-constrained countries to procure additional doses, beyond those donated by China, the United Arab Emirates, and other states. However, given the short planning and preparation time for the COVID-19 vaccines roll-out, most countries leveraged their existing vaccine storage cold chain equipment, transport system and vaccine distribution system, including those operated by the public and private sectors.

Challenges in Supply Chain In Africa, most countries acquired the majority of their vaccines through COVAX (most of which were Oxford/AstraZeneca) - vaccines that were mainly supplied by the Serum Institute of India (SII). In May 2021, SII abruptly stopped the AstraZeneca exports as it tried to mitigate its own rapidly rising COVID-19 morbidity and mortality cases. Sadly, this left most African nations at risk of running out of the initial COVID-19 vaccine supplies. In May 2021, the WHO advised most countries to administer the 1st dose to as many people as possible. While this guidance might have been fueled by the fear of having vaccines expire, most countries have used the bulk of their stockpile and face the danger of inadequate number of vaccines to inoculate a second dosage, particularly for the AstraZeneca vaccine. Conversely, some countries are struggling to increase vaccine uptake since February 2021. Vaccine hesitancy, weak health infrastructure and health staff have been some of the major barriers faced. The WHO estimates that nine in ten countries in Africa will miss the vaccination targets.

Additionally, many resource-constrained countries find it difficult to promote vaccine uptake against inadequate planning and preparation for vaccine arrival and distribution.

The hurried roll-out of vaccines has consequently put strong pressure on existing

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Women of Color Advancing Peace, Security, and Conflict Transformation The Race Across the Pond Initiative: Women of Color in the Healthcare System Series

struggling health systems. Despite the availability of 2 to 8 degrees Celsius cold chain equipment (CCE) for routine immunization in resource constrained countries, a huge gap for CCE exists. One fifth of the immunization facilities in the remote parts of the world do not have access to optimal cold storage conditions for vaccines. Even more so is the scarcity of ultra CCE - equipment capable of transporting and storing at temperatures of -80 to -60 degrees Celsius. Most African countries procured and received the AstraZeneca, Sinovac and Sinopharm vaccines, which can all be stored at temperatures between 2 to 8 degrees Celsius. However, transportation and storage of vaccines which require ultra and negative temperature CCE, like the Pfizer and Moderna ones respectively, are posing a serious challenge due to the unavailability of adequate CCE at the primary health care level.

The hurried response to address the needs has also put pressure on already-weakened health systems, notably in countries actively recovering from unrest and/or violence. In one such case, South Sudan, recovering from years of civil unrest and in the midst of rebuilding its health system, indicated that its AstraZeneca batch of doses expired as it was not aware of the near expiry dates during delivery. The Democratic Republic of Congo’s vaccine distribution is hindered by pre-existing weaknesses in its health systems, most glaringly a poor transport network hindering the delivery of vaccines to remote areas and harmful rumors on social media spreading misinformation.

Consequently, its uptake of the COVID-19 vaccine remains low.

The unavailability of data generation and reporting has revealed challenges on programmatic planning and forecasting for future needs. Data reporting, at primary health care level, is an ongoing challenge in most low to medium income countries on the continent, which are usually still using paper-based reports. While countries would like to track the number of people vaccinated against the number of vaccines used, limited data capturing and reporting makes this difficult. Furthermore, there has been limited visibility on the real time vaccine stock consumption as well as the actual number of COVID-19 vaccine beneficiaries.

Country Profiles Given the short life span of the COVID-19 vaccines, countries need to step up on planning activities for vaccine roll-out with strong monitoring and evaluation systems.

Strategic planning has proven effective in some countries like Rwanda, Ghana and Angola which managed to exhaust their vaccines stock, as expected within a short timeframe and averted expiries, particularly for the AstraZeneca batch which expired in April 2021. In contrast, other countries like Malawi and South Sudan have had to destroy

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Women of Color Advancing Peace, Security, and Conflict Transformation The Race Across the Pond Initiative: Women of Color in the Healthcare System Series

or return some AstraZeneca vaccines, as the expiry dates of received doses (April or June 2021) were too short to fit their vaccination roll-out capacity. Furthermore, South Africa has recorded the highest number of COVID 19 cases across Africa with 1,941,119 confirmed cases and 60,038 deaths (as of 28 June, 2021). Despite facing a devastating third wave, only 0.5% of its entire population have been vaccinated with an immunization rate remaining as low as 4.52 per 100 population (as per June 28, 2021), even with the government's accessibility to a variety of the vaccine types. There has been a gross mismatch in the acquisition, distribution and utilization of the COVID-19 vaccine. The lack of sustainability and uncertainty on the supply of the vaccine has left some countries, like Botswana, Rwanda, and others, to now administer more than one type of vaccine. While this idea improves vaccine coverage, it further compounds existing logistical challenges due to the special cold chain system required for each type of vaccine.

Action Needs To Be Urgently Taken We welcome the decision by the G7, and several countries, including the US and France, to donate vaccines for resource-constrained countries beginning this June 2021.

However, more can and should still be done to ensure faster, equitable and sustainable access to COVID-19 vaccines to all populations globally, and particularly on the African continent.

The Gavi alliance, WHO and other partners have released a joint statement urging action. This Call to significantly increase funding and facilitate by all means the full deployment of the global mechanism COVAX, needs to be supported by all member states, private sector, civil society and all non-state actors.

We join this Global Call and we urge all world leaders and stakeholders to act in solidarity and be change-makers by supporting the COVAX supply-chain and contribute to achieve the effective delivery of the initially planned 2 billion vaccines by early 2022.

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