Vaccine hesitancy not the main barrier to immunization in low-income countries

Reviewed by Emily Henderson, B.Sc.Oct 5 2022

Low vaccination rates in poorer countries have little to do with so-called “vaccine hesitancy” according to a study that examined access to COVID-19 tools across 14 low-income countries.

World Health Organization (WHO) show that only 16 per cent of people in low-income countries have received a single COVID-19 vaccine dose, compared to 80 per cent in high-income countries, some of which are already rolling out a fourth booster shot.

Some pharmaceutical companies have blamed a reluctance to accept the vaccine, rather than supply shortages, for poor vaccination rates, especially in less wealthy countries.

But the joint report by Matahari Global Solutions, the People’s Vaccine Alliance and the International Treatment Preparedness Coalition (ITPC) found that inadequate supply of vaccines and treatments, underfunding of health systems and poor adaptation to local needs were behind the low coverage.

Fifa Rahman, principal consultant at the global health research and policy group Matahari and lead author of the report, said there were several fundamental reasons why people were not accessing vaccines, not simply an outright distrust of the drugs.

“There is little doubt that the vaccine hesitancy narrative is rooted in racism and colonialism and the idea that certain people don’t know how to do certain things,” Rahman told an online press conference last week (25 August). “It has to be more nuanced, otherwise it’s lazy and problematic.”

While Rahman acknowledged that concerns relating to technologies derived from western companies were a legacy of colonialism, she said many of the vaccine access obstacles were structural.

“Because experiments have happened in the past on black bodies, so people are concerned, but this is not to say people distrust vaccines,” Rahman said.

Global health researchers examined access issues in Bangladesh, Democratic Republic of Congo (DRC), Haiti, Jamaica, Liberia, Madagascar, Nepal, Nigeria, Peru, Senegal, Somalia, Somaliland, Uganda and Ukraine.

While most countries in the global North have surpassed the 70 per cent vaccination rate recommended by the WHO, in places such as Haiti and DRC vaccination rates are below ten per cent, according to the report.

Overall, the report found a litany of multi-layered challenges to the expansion of COVID-19 vaccine coverage in some of the world’s poorest countries.

Among these are a lack of cold chain storage, unpredictable supply chains compounded by poor road networks, conflict and, in many places, language barriers. Proximity to vaccination centers and distrust of government were also cited as major factors.

The report made a raft of recommendations including targeted investment in health systems, prioritizing of local expertise in decision-making, and adequate pay for health workers.

Elia Badjo, founder and executive director of the Citizen Organization System for Advanced Medical Research (COSAMED) and lead consultant for the report, said many health workers in DRC involved in COVID-19 vaccination campaigns were not trained, while less than one per cent of them were vaccinated.

“Most [health workers] have not been paid since the beginning of the pandemic due to lack of funds and hence are disillusioned,” he said at the launch of the report.

Language barriers were a major obstacle to COVID-19 information access in Uganda, especially among people with disabilities, according to the study.

Community sensitization was done in English and Luganda, never mind that there are 56 different languages spoken in our country.”

Richard Musisi, Executive Director, Masaka Association of Persons with Disabilities Living with HIV and AIDS (MADIPHA)

In violence-stricken countries such as Nigeria, people were more concerned about getting home safely than about COVID-19, the researchers said.

“Overall, the report made me sad,” said Madhukar Pai, Canada research chair in epidemiology and global health at McGill University, Montreal, who did not participate in the research.

“With such stark inequalities in access to tests, vaccines and drugs, how will lower-income countries with already fragile health systems cope with new waves of [COVID-19 variants] BA.5, BA.2.75, or other future variants.

“How will the pandemic end, when we have left behind millions of people?”

An earlier report by the People’s Vaccine Alliance and development non-profit Oxfam found the death toll from COVID-19 was four times higher in lower-income countries than rich ones.

Pai believes that while the challenges facing vaccine rollout campaigns are multi-dimensional, rich countries cannot be excused for vaccine hoarding.

He says that self-sufficiency of low- and middle-income countries is now crucial, adding: “I truly hope the African region will soon be able to manufacture their own vaccines, tests and drugs, so they will never have to rely on generosity of rich nations.”