While vaccine inequity among African countries has played a major role in the continent's low COVID-19 vaccination rate, experts say capacity and logistical challenges, along with vaccine hesitancy, are also creating significant challenges.
"I've seen a number of articles say it's just vaccine inequity — and that's wrong. It's not just vaccine inequity," said Dr. Ron Whelan, who heads health insurer Discovery's COVID-19 task team in South Africa.
"[It's] one part supply, one part health-system capacity and the third part is the hesitancy component," he said.
"It is a multi-factorial problem that's got to be solved."
Dr. Saad B. Omer, an epidemiologist and director of the Yale Institute for Global Health, agrees it's a more nuanced explanation than just blaming vaccine inequity for low vaccination rates across the continent.
"We expect people to land the plane with a few doses at the airport, do a photo op, [and] people to run to the airport to get their jabs. That's never happened," he said.
While about 76 per cent of Canada's total population is fully vaccinated, on the African continent — home to 1.3 billion people — it's only about 7.5 per cent, according to Our World in Data.
Delivery expected to ramp up
In October, a report by the People's Vaccine Alliance — a coalition which advocates for equitable and sustainable use of vaccines, and includes Oxfam, ActionAid and Amnesty International — found that only one in seven COVID-19 vaccine doses promised to low-income countries were actually delivered.
However, vaccine shipments have been on the rise over the past three months and are expected to ramp up in coming weeks and over the new year, according to the World Health Organization.
Yet despite the increases in vaccine supply, experts suggest inoculation efforts in Africa could still face hurdles.
About 40 per cent of vaccines that have arrived on the continent so far have not been used, according to data from the Tony Blair Institute for Global Change, a policy think-tank.
Some countries have been forced to destroy thousands of doses of donated vaccines from their stockpiles. Namibia, for example, announced on Monday that it had to destroy 150,000 expired doses.
"It is highly regrettable that we are forced to destroy in excess of 150,000 vaccines, which have reached expiry date, because those who are eligible are refusing to be vaccinated," Namibia President Hage Geingob is reported to have told a news conference on Monday.
According to the Washington Post, Malawi, Mozambique, Namibia, South Africa and Zimbabwe have all asked drugmaker Pfizer in the last several months to pause vaccine shipments because of challenges with uptake.
Vaccination rates vary widely across Africa and many experts are quick to note that vaccine hesitancy is not unique to the continent; it has been an issue in other parts of the globe, including the U.S and Europe. Child vaccination campaigns for various diseases, meanwhile, have been quite successful in Africa.
"Africa is, in many instances, a well-established vaccine culture overall, " Whelan said.
But Dr. Matshidiso Moeti, the WHO regional director for Africa, recently told the New York Times that "there's no doubt that vaccine hesitancy is a factor in the rollout of vaccines."
News or rumours of potential side effects, she said, "gets picked out and talked about, and some people become afraid."
1 in 4 health workers vaccinated
Additionally, only one in four of Africa's health-care workers has been fully vaccinated against COVID-19, according to WHO. That compares to 80 per cent of health workers vaccinated in 22 mostly high-income countries.
Many of Africa's health-care workers, including those working in rural communities, still have "concerns over vaccine safety and adverse side effects," Moeti recently told reporters.
Capacity has also been a major issue for many African countries, specifically their health systems' ability to absorb and distribute vaccines, particularly in rural areas, where health resources are scarce.
"We need significant capacity to deliver those vaccines," Whelan said.
'Weak supply chains'
That includes the need for strengthened supply chains and temperature-controlled cold chains required to store Pfizer doses, Whelan said, together with infrastructure to actually track and deliver vaccines to hospitals, clinics and other vaccination sites.
"Many of the countries have weak supply chains, particularly weak cold chain infrastructure. And the cold chain infrastructure is not well set up for the Pfizer vaccine in particular," he said.
Some countries, including South Sudan and Congo, have had to send some vaccines back because they could not distribute them in time.
Often, Whelan said, that's the result of issues with health-system capacity, storage capacity and administration capacity.
But reliable capacity also cannot be built without reliable access to doses, said Omer.
"When you are the head of a public health agency or a health minister in a country, you want not only doses, but also predictability in doses," he said.
Instead, he said, many government officials "don't know what kind of doses are coming and when they are coming."
"Often what would happen is that [some African countries] would receive a call saying that, 'We have doses that we are sending your way, with a month's expiration left. Please distribute.' That's an obviously challenging thing for any country," said Omer.
Last month, African Vaccine Acquisition Trust (AVAT), the Africa Centres for Disease Control and Prevention (Africa CDC) and COVAX put out a joint statement, calling the majority of vaccination donations to date "ad hoc" and "provided with little notice and short shelf lives."
"This has made it extremely challenging for countries to plan vaccination campaigns and increase absorptive capacity," the statement said.
"Countries need predictable and reliable supply. Having to plan at short notice and ensure uptake of doses with short shelf lives exponentially magnifies the logistical burden on health systems that are already stretched."
According to a recent WHO statement, since last February, Africa has received 330 million doses from the COVAX program, the African Vaccine Acquisition Task Team and bilateral agreements.
Of those, more than 80 per cent have been delivered since August alone.
And so, as vaccine supply picks up, it said, "addressing uptake bottlenecks and accelerating rollout become more critical."