Lessons from lower-income countries' Covid-19 vaccination efforts

There was a global sigh of relief when the World Health Organization declared in May 2023 that Coivd-19 was no longer a public-health emergency of international concern. But there is no room for complacency. The pandemic has represented an urgent warning about weak health systems and has served as an impetus to strengthen them ahead of a possible new variant or the emergence of a new pathogen.

The challenges of vaccine delivery, in particular, offered insights into what makes a successful health campaign. Specifically, lower-income countries demonstrated how to reach people where they are by using innovative and tailored approaches that often required collaboration among national governments, local organisations, and vulnerable communities. Their experience provides crucial lessons as the world prepares for the next pandemic.

Like their wealthier counterparts, lower-income countries had to vaccinate their adult populations against Coivd-19 as quickly as possible. That meant reaching broader population groups than their existing childhood-vaccination programmes could serve, while also targeting those in the greatest need: health-care workers, immunocompromised people, and the elderly.

But lower-income countries faced unique challenges. Owing to vaccine nationalism and other obstacles, many of them only accessed consequential amounts of doses much later than high-income countries, delaying their immunization campaigns. A dearth of financial resources, together with the weaknesses of national health systems, also hindered vaccine uptake. For example, countries with limited cold-chain capacity often lacked the ultra-cold storage facilities required for certain Coivd-19 vaccines. And many countries’ reporting systems could not provide decision-makers with up-to-date, in-depth data to adjust rollout strategies based on what was working and what wasn’t.

Despite these challenges, lower-income countries found ways to meet the needs of their communities. These initiatives included door-to-door outreach to vaccinate older people at home; female vaccination teams to encourage uptake by women; coordination between professional organizations and the private sector to reach people at the highest risk of getting very sick from Covid-19; mobile vaccination teams – on buses, motorbikes, camels, donkeys, and boats – to access remote or underserved areas; and vaccination sites in markets, along nomadic routes, and at major transit points, including bus stations.

Somalia is a good example of how to reach people where they are. The vaccine rollout occurred in the context of multiple overlapping challenges: years-long political instability and conflict; severe hunger caused by the worst drought in decades; and the displacement of several hundred thousand people by historic floods. But the country’s polio vaccination program had pioneered the use of locally informed “micro-planning” to find unvaccinated people, and these tailored strategies ensured that Somalia’s nine mass Covid-19 vaccination campaigns reached underserved populations, such as women and nomadic communities. In September-October 2022, for example, a phased campaign led by the Somali government reached 3.2 million people, achieving a 37 per cent primary series vaccination rate. Equally important was Somalia’s investment in cold-chain infrastructure and vaccine-delivery logistics, made possible with financial support from partner organizations.

The Solomon Islands, the South Pacific’s third-largest archipelago, also struggled to vaccinate people living in remote areas, given that most of the country’s resources are concentrated on Guadalcanal, the largest island. Government health workers responded by creating pop-up and informal clinics on outer islands, making it easier for isolated communities to receive the Coivd-19 vaccine and additional health services.

Meanwhile, in Sierra Leone, a country covered by grassland, savannah, and dense forest, many villages can be reached only by bike or on foot – a journey made even harder during the rainy season. But the country’s health workforce, together with community mobilizers, conducted mobile vaccination clinics in rural villages. Moreover, to address fears about the vaccine, local leaders took the jab and then promoted their vaccinated status within the community, creating a snowball effect.