Vaccinating Africa: Countries struggle to deliver the few shots they've got

The first shipment of long-awaited coronavirus vaccines finally arrived in the Democratic Republic of the Congo on March 3. One month later, they’re still sitting in a warehouse in the capital, Kinshasa.

Why it matters: Africa is at the back of the global line for vaccines, and most countries only expect enough doses to cover a fraction of their populations this year. But in some cases, even those limited supplies may not be fully deployed before they expire.

Zoom in: The DRC has received 1.7 million Oxford/AstraZeneca doses from the global COVAX initiative. The government delayed the rollout, citing health concerns stemming from the AstraZeneca rollout in Europe. But the challenges don't end there.

• Health workers in the provinces haven't yet been trained to administer the vaccine due to funding shortfalls, says Freddy Nkosi, DRC country director at VillageReach, which is advising African governments on vaccine distribution.
• A digital data collection system designed to guide the vaccination campaign is also not yet operational, Nkosi adds.
• Once the rollout begins, it will be difficult to transport doses even to nearby provinces because of poor roads, he says. Other provinces in the giant country of 86 million people will only be reachable from the air.

Assuming the shots do arrive at distribution centers and health workers are prepared to administer them, there may not be much demand.

• “There are so many rumors circulating around the vaccines, and that’s also contributing to so many people, even among the health workers, being very hesitant to receive the vaccine,” Nkosi says.
• VillageReach is involved in a public engagement campaign to inform people about the vaccines and their eligibility for them.
• But the DRC is on the clock. Those 1.7 million doses will expire in three months, Nkosi says. If large quantities go unused, that will not only set back the first wave of vaccinations, it will undercut appeals for further shipments.

The state of play

The DRC isn’t alone. In Ivory Coast, where a slow rollout could cause thousands of shots to expire, health officials are blaming “a kind of systematic refusal of the vaccine,” per the Washington Post.

• While Rwanda has distributed nearly all of the vaccines it received last month and Ghana isn’t far behind, most African countries that received vaccines through COVAX are moving very slowly (or, like the DRC, not at all).
• The ticking clock and the distribution challenges could further exacerbate inequity if governments elect to prioritize capital cities like Kinshasa, or allow the well connected to cut in line.
• In Kenya, as all over the world, wealthy people seem to be having a far easier time getting access. The government is now moving to shut down a secondary market in which private clinics are selling the Sputnik V vaccine for around $80 per shot, AP reports.

The funding gap

Countries had to submit distribution plans to receive doses through COVAX, but funding to help implement those plans has been slow to arrive.

Breaking it down: CARE, the global anti-poverty charity, estimates that for every $1 invested in procuring the shots themselves, $5 will have to be invested in distribution — much of it to pay, equip and train health care workers.

• Other major costs include improving health infrastructure like cold chains and conducting public outreach to people who would likely have to travel long distances to get a vaccine they might not trust.
• But while COVAX has received most of the $11.1 billion it sought to procure vaccines for lower-income countries, rich countries have donated just $565 million of the $9 billion required to prepare health systems, says CARE’s Emily Janoch.

• “Resources follow the attention,” she says, "but the goal isn’t to have vials of vaccines, it’s to have vaccinated people.”

What to watch: The World Bank is now ramping up funding for distribution, and the Biden administration may soon get involved as well.

The road ahead

Even with sufficient funding and vaccine supply, this might still be the greatest supply chain challenge ever, says Ron Cruse, CEO of Logenix International. His company moves medical supplies around Africa and is preparing to transport coronavirus vaccines as well once the U.S. starts exporting.

Cruse says the challenges are clear just by looking at sub-Saharan Africa’s two most populous countries, Nigeria and Ethiopia.

• “We have trouble running malaria nets around Nigeria. Any trucks that go from Lagos to Abuja have to be guarded,” he says, including to ensure that authorities don’t seize supplies for local use.
• Meanwhile, Ethiopia is a “tinderbox,” Cruse says, noting that millions of people live in conflict areas in the north and west of the country.
• Around the continent, the challenges will also include government corruption and a looming rainy season that could make some roads impassable for weeks at a time.

Cruse thinks it simply won't be possible to deploy the Pfizer/BioNTech or Moderna vaccines at scale in Africa, as they require ultra-cold temperatures.

• The COVAX rollout to date has been based almost entirely on AstraZeneca, but that vaccine is facing challenges of both supply and demand.
• Johnson & Johnson's single-shot vaccine is a promising alternative, but supply is just now ramping up. That leaves a big role for vaccines from Russia and China.

What's next: Supply to Africa should increase significantly in the second half of this year, particularly as the U.S. starts exporting and manufacturing ramps up in South Africa.

• But once vaccines arrive on the continent, the distribution struggle begins.