Data Dive: The astoundingly unequal global COVID-19 response

Over two years into the COVID-19 pandemic, we have a growing arsenal of tools to fight the virus. But we are still lacking a truly global and equitable response to help find a way out of the pandemic.

Safe and effective vaccines have been available for over a year, so why aren’t vaccination rates increasing everywhere in the world? It comes down to three factors: supply, distribution, and last-mile logistics of getting shots into arms.

Rich countries bought the majority of the initial supply of vaccines, leaving low- and lower middle-income countries out of the market for over a year. The global supply of vaccines has only just begun to meaningfully increase — one year after they were made available in high-income countries.

So, now that the supply of COVID-19 vaccines has increased, efforts to vaccinate the world should be easy, right? Wrong. For low- and lower middle-income countries to get shots into arms, supply must remain predictable and available. And  high-income countries need to meaningfully follow through on their promises to help end the threat of COVID-19 everywhere.

Omicron challenged the way the world responded to COVID-19. First, it was a wake-up call that COVID is not over, even as news cycles and funding priorities started to move on. Second, it highlighted the importance of other pillars in the global response, including “test and treat” strategies. But even with the increasing importance of scaling up access to tests and treatments, vaccination remains the best tool to tackle COVID globally.

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    The key numbers

    As of 7 August 2022, 12.4 billion vaccine doses have been administered in the world:

    • 208.9 million doses in low-income countries
    • 4.4 billion doses in lower middle-income countries
    • 5.2 billion doses in upper middle-income countries
    • 2.6 billion doses in high-income countries

    African countries have administered 599.7 million doses. That means 21.1% of the population of the continent is fully vaccinated.

    To date, 61.7% of the world’s population has been fully vaccinated. But only 17.5% of people in low-income countries have been fully vaccinated. Lower middle income countries have fully vaccinated 55.2% of their people. That’s a huge difference compared with 74.4% in high income countries, and 77.3% in upper middle-income countries.

    Tracking progress against global vaccination targets

    In September 2021, world leaders aligned around the target of vaccinating 70% of the population in all countries by September 2022. By the end of 2021, wealthier countries had already met the target.

    Based on current trends, low-income countries don’t stand a chance to meet the 70% vaccination target in 2022.

    Here’s another way to look at it: Over half of the people on Earth live in the world’s poorest countries, but only 37.0% of vaccines administered so far have gone to people in these countries.

    When vaccination campaigns started, over 90% of doses were administered in high-income countries. Now, the majority of doses are being administered in upper middle-income countries, a group which includes China.

    Low-income and lower middle-income countries will need to administer doses to vaccinate 70% of their population with two doses by mid-2022.

    How is the rollout going in Africa?

    In African countries, 27 in 100 people have received at least one dose of a COVID-19 vaccine, as of 7 August 2022. Only 21.1% of the population is fully vaccinated.

    Until early on in 2022, supply had been the biggest constraints to scaling up vaccines in Africa. Most African countries have done relatively well at administering the low quantities of doses delivered.

    As supply continues to increase and become more predictable, the logistics of getting doses into arms and building vaccine confidence are becoming the biggest barriers to increasing vaccination on the continent.

    Why has the vaccine rollout been so unequal?

    Early in the pandemic, high-income countries had the purchasing power to be first at the negotiating table with pharmaceutical companies. This allowed them to monopolize the supply of vaccines for their own use. At the same time, high-income countries were slow to support mechanisms like COVAX that were created to purchase and distribute doses to lower-income countries.

    As a result, high-income countries have purchased 2.7 times more doses than COVAX, even though COVAX is serving a population three times the size of that in high-income countries. Similarly, high-income countries have purchased more than 20 times more doses than the African Union’s COVID-19 Africa Vaccine Acquisition Trust (AVAT), even though they are both serving populations similar in size.

    This situation created a lot of unpredictability and unreliability in supply to low- and lower-middle-income countries, making it difficult for countries to mobilise resources and plan for the long term distribution of vaccines. In order to address issues of unpredictable supply, COVAX, AVAT, and Africa CDC released a joint-statement in November 2021 with guidelines on how to create more predictable supplies.

    Since the pandemic began, cooperation efforts have largely fallen flat, and governments continue to look inward with their planning and policies. Efforts to share essential COVID-19 vaccines began increasing in earnest in August 2021, once high-income countries had already vaccinated much of their population with two and, in some cases, three doses.

    Wealthier countries have commitments to share over 2.7 billion doses with low- and lower middle-income countries through 2022. So far, as of 7 July 2022, G20 countries have delivered 1,512 million of these doses.

    Addressing today’s barriers to vaccine rollout

    As vaccine supply becomes increasingly stable, barriers to getting “shots in arms” have led AVAT to seek a pause in COVID-19 vaccine donations until later in 2022. This will provide countries the opportunity to address other challenges slowing vaccine uptake. Remaining challenges include:

    Logistics: Global and in-country last-mile delivery efforts and plans to get shots into arms must address and budget for infrastructure and logistical challenges. These include cold storage capacity at vaccination sites and the availability of needles, syringes, and disinfecting swabs.

    Low demand and vaccine hesitancy: Many initiatives to improve vaccine confidence and address misinformation on COVID-19 vaccines in Africa are already underway:

    • The #MythOrVax campaign launched in 2021 in partnership with ONE, UNICEF, the African Union, African celebrities, and TikTok is back for part two this year. Using online quizzes and interactive mythbusting on TikTok, the campaign aims to dispel myths, challenge misinformation, and raise awareness for COVID-19 and COVID-19 vaccines.
    • Ghana’s Misinformation and Rumour Management Taskforce has been working at the national and regional levels to address false claims.
    • Senegal’s toll-free call centers provide facts to people who are uncertain about receiving a vaccine.
    • Botswana surveyed its population to understand risk perception and launched a social media campaign called #ArmReady to increase public demand for vaccinations.
    • The Africa Infodemic Response Alliance (AIRA), hosted by WHO, brings together African fact-checking organizations, big data, AI and innovation bodies, and other organizations to share facts about COVID-19 and vaccines.

    Lack of resources: Understanding and addressing the demand side challenges of getting shots into arms will require significant and urgent funding for countries to help in-country and global initiatives respond to these challenges. Countries need at least US$52 billion to fund the overall global pandemic response in 2022. This includes funding for vaccines, therapeutics, diagnostics, and health systems strengthening.

    Grant financing by donor countries accounts for at least US$27.7 billion, or 53%, of this. ACT-A estimates that at least US$6.8 billion is needed to support in-country delivery costs of getting shots into arms. As of June 2022, US $5.8 billion has been committed by donor countries both bilaterally and through ACT-A across all pillars for the 2021-2022 funding cycle.

    COVAX raised US$4.8 billion in April 2022 through donor pledges, innovative financing mechanisms, and from multilateral development banks. Though the fundraising effort fell just short of COVAX AMC’s ask of US$5.2 billion, the financing will help kick start COVAX’s efforts to help countries boost vaccinations. It will also support the creation of a Pandemic Vaccine Pool to help participant countries procure future doses should they be needed.

    The amount committed to date is just a drop in the bucket compared to what is needed for  vaccines, therapeutics, diagnostics, and health systems strengthening. Donors must act quickly to fill the funding gap in 2022 to sustain progress in the fight against COVID-19.

    COVID-19 wasn’t that bad in Africa, right?

    We have known little about the pandemic’s true impact in African countries, due to low testing and reporting. Only 1.9% of COVID tests since the pandemic began have been conducted in African countries. We lack access to hospitalization data for most countries, and mortality statistics can lag for many years.

    But the impact is likely much worse than what is seen in official reporting. A number of serological studies that measure the presence of antibodies are reporting that high percentages of the population in Africa have been exposed to or infected by some strain of the coronavirus. A recent WHO study suggests that up to 65% of all Africans have been infected by COVID-19. This would put true infections on the continent 97 times higher than reported confirmed cases over the same time period.

    While the official cumulative death toll due to COVID-19 in Africa is 256,163, the Economist’s excess deaths model estimates over 2,737,301 cumulative deaths due to COVID-19. If these projections are true, COVID-19 killed more people in Africa in 2020 than malaria (602,000), HIV/AIDS (460,000), and tuberculosis (379,000).

    Is ‘test and treat’ the new way forward?

    The rapid spread of the Omicron variant changed how the world responds to COVID-19. While vaccination remains the strongest tool, Omicron demonstrated that countries need to adopt “test and treat” strategies to more quickly detect and address infections.

    With more testing, safe and effective oral therapeutics can be used more widely to prevent severe health outcomes from COVID-19. Oral therapeutics can be self-administered and provide a more cost-effective option, if distributed equally around the world.

    But greater access to diagnostics and therapeutics is needed for this approach to be scaled globally.

    Access to affordable and effective testing is also extremely limited and selective in most countries. Following the Omicron wave, testing rates fell by 70% to 90% across the world.

    Current trends suggest that oral therapeutics will not be available equitably across the world. That is a problem given that many countries have begun to adopt the test and treat strategy.

    Even before regulatory authorisations are granted, high-income countries are already dominating the market for the two most promising drugs for preventing severe infection — Pfizer’s Paxlovid and Merck’s Molnupiravir.

    While production and delivery have not ramped up yet, there are early signs of an equity gap in access to therapeutics. African countries are being left out of pre-purchase agreements. Global mechanisms that are leading the ACT-A therapeutics pillars have only been able to purchase a small fraction of the available supply of treatment courses.

    The US has secured most of the Paxlovid courses purchased by high-income countries, spending over US$500 per course when generic versions could have a production cost of US$20 per course. But generic production will not be available to low- and lower middle-income countries until the end of 2023 at the earliest.

    Why does equitable access to COVID-19 tools still matter?

    The world will continue experiencing waves of infections, which are opportunities for the virus to mutate. There are thousands COVID-19 variants, and some – such as Omicron and Delta – proved to be more transmissible than other strains. Various sub-variants of Omicron are already spreading and could spark a new wave.

    As of 7 August 2022, there were 3,214 daily confirmed cases in Africa (-41.2% in the last week), and 19 daily confirmed deaths (-40.5% in the last week)

    The longer the virus remains unchecked anywhere on the planet, it will continue to mutate, breach borders, and wreak havoc on communities and the global economy:

    • Unequal vaccine distribution could cost the global economy a total of US$5.3 trillion over the next five years.
    • Developed economies could bear 34% of the global economic loss between 2022-25 if vaccine inequity continues.

    Vaccination remains our strongest tool to prevent new and possibly more dangerous variants from emerging. Increased global vaccine access should be used together with diagnostics, treatments, and other measures that help lower and manage the risk of infection.

    World leaders must continue cooperating, working across borders, and taking the “global” part of this pandemic seriously. Otherwise, we risk being stuck in an indefinite cycle of booster shots and uncertainty.

    What needs to happen?

    World leaders have agreed to work towards vaccinating 70% of the world’s population in all income categories by September 2022. But the global response to the pandemic has slowed. The virus has not yet transitioned into an endemic phase. And as such, efforts to vaccinate the world and end the threat of COVID-19 must not be abandoned.

    We are calling on world leaders to take immediate and urgent action to:

    1. Deliver the funding needed to dismantle barriers to getting shots into arms, and increasing access to therapeutics, diagnostics, and health systems strengthening by the end of Q2 2022.
    2. Prioritize the equitable expansion of test and treat capacity, particularly in low- and lower middle-income countries, alongside support for country led efforts to get shots into arms.
    3. Ensure a sufficient supply of doses to achieve the 70% vaccination target is available and predictable over the long term. If additional doses are needed, they must be made available in a timely, coordinated, and transparent manner.
    4. Support efforts to scale up regional production of vaccines, therapeutics, and diagnostics, including providing the funding, information, and partnership needed to regional manufacturing and production capabilities. Bilateral and multilateral partners that have entered into agreements with local manufacturers should ensure they follow through on their commitments, be it on funding, timeline, or domestic vaccine delivery.

    We have all the tools needed to beat this virus, end the threat of COVID-19, and kick start a global economic recovery. We just aren’t using them and sharing them equitably across borders. And while that remains the case, we prolong the lifetime of this crisis and increase the threat to people in every single country.

    How can I learn more and stay informed?

    ONE’s Africa COVID-19 Tracker provides the latest reliable figures, commentary, and analysis on the health, economic, and social impacts of the pandemic on the continent. Sign up for our weekly email Aftershocks and follow @ONEAftershocks.