Factors Affecting Vaccine Distribution to Sub-Saharan Africa

Vaccines are perhaps the most important medical innovation. They prevent 4 million deaths every year of over 25 different diseases [3]. However, one out of five children still cannot get the necessary vaccines that they need [26]. Why is this? Like everything, it is not a simple answer. Inefficient supply chains, lack of funding, and little outreach to entire populations all play a part [5, 11, 17, 19, 28]. This project intends to look at different factors that influence how well vaccine campaigns have worked in low-income countries in sub-Saharan Africa. This will hopefully provide some insight into how to increase success rates in the future as well as open more questions for future research.

While some may argue that it is not the responsibility of high-income countries to donate vaccines to low- and middle-income countries, there are a plethora of moral and mutually beneficial reasons in favor of helping those countries. First, access to lifesaving medical resources should not only be available to those with the money to buy them, particularly when vaccines are not a scarce product. Second, vaccinating other parts of the world not only helps that area, but also helps the rest of the world. Vaccination prevents future outbreaks and the rise of new variants that can spread and harm other parts of the world [29]. Vaccination protects everyone, not only those who have the vaccine. Furthermore, there is economic incentive to vaccinate the globe. Increased health of countries increases their workforce and economy helping other economies around the world [30]. Vaccines in particular also save countries a lot of money in the long run. The total cost of vaccines is significantly less than the cost of treatment for the diseases they prevent [31]. This money can then be implemented in other ways to boost the economy.

Even though there have been large initiatives to vaccinate the world, vaccine inequality is still apparent. For example, at the end of 2021, 22% of Europe had received the COVID-19 booster while only 0.1% of Africa’s population had [2]. This is partially because high-income countries hoarded the COVID vaccines. These rich countries bought more than their fair share of vaccines and many ended up going to waste when they could have been administered in another country [11]. The US alone has wasted over 82 million COVID vaccines [14]. Another astonishing fact is that “Africa accounts for 23 percent of the world’s overall disease burden yet only 1 percent of global consumption of healthcare goods and services” [2]. Africa has been left behind and the rest of the world pays the price when new variants arise and preventable diseases spread.

Low-income countries lack the funds and systems to distribute vaccines like high-income countries do. Instead, they get most of their vaccines from donations [9]. These donations are usually facilitated by campaigns formed by varying organizations like WHO, UNICEF, and GAVI. For example, COVID-19 Vaccines Global Access, or COVAX, was formed by GAVI, the Coalition for Epidemic Preparedness Innovations, and the World Health Organization, alongside key delivery partner UNICEF to ensure equitable distribution of the COVID-19 vaccine to low-income countries. These countries then administer the vaccines to their population. This however comes with its own unique challenges.

While funding and obtaining vaccines is part of the challenge that needs to be overcome for vaccine distribution, it is not the largest or only problem. Most of the problems stem not from a lack of supplies, but from a lack of information. Low-income countries do not have accurate systems to relay how much of a certain medical supply or vaccine is needed [5, 9, 11, 19, 28]. Supply chains work in levels. The nation receives supplies that get distributed down to lower levels such as state, regional, local, etc. These lower levels then pass information upwards to indicate what and how many supplies are needed [5, 19, 24, 28]. However, the correct information usually gets lost as it works its way up the levels. Think of it as a game of whisper down the alley. Another problem is the transportation of resources. Many countries’ governments use their own system of transportation. However, it often breaks down or takes too long to reach its destination [5, 28]. These supply chain problems, coupled with the short shelf life of vaccines and the cold temperatures needed to store them, make it hard for countries with low infrastructure and a lack of advanced technological systems to vaccinate their citizens [5, 17]. In fact, only ⅓ of vaccines that reach middle- and low-income countries are used [17].

First and foremost, high-income countries and the organizations that facilitate vaccine distribution to low-income countries should help set up reliable systems to be able to obtain accurate information about the medical supplies needed [9, 21, 11]. That means using systems that do not rely on a consistent power grid, teaching citizens how to use and fix the system, and incentivizing citizens to maintain and utilize the system. One way to accomplish this is to educate people of influence like church leaders, politicians, or school principals [12, 21, 22]. Their large influence over the population can help persuade citizens of the importance of vaccines and the distribution of them. 

Improvements to the system itself include limiting the number of levels in the supply chain, outsourcing transportation, and incentivizing people to relay accurate information in a timely manner. Limiting the number of levels in the supply chain would decrease the number of times information and vaccines have to be transferred, minimizing the risk of information changing or vaccines being lost or becoming expired. More correct information leads to more of the correct amount of supplies being delivered down the supply chain [17, 19, 28]. Increasing incentives for workers to pass on information from level to level with accuracy and efficiency is also imperative. This can be done by receiving certain benefits based on the accuracy of the information, for example [5, 28]. Outsourcing transportation has also been shown to increase the amount of supplies and decrease the rate at which they are delivered. Using companies that are designed to deliver resources rather than government-owned transportation increases efficiency [5, 17, 28].

Some other solutions that would help reduce the number of vaccines lost is to use vaccines with a longer shelf life or ones that are produced to be stored at higher temperatures [5]. Another idea is to set up vaccination clinics in high-traffic areas such as bus stops or train stations [8, 13, 17, 22]. The key point to note is that these organizations should not try to impose Western values or systems in these countries. Instead, they should find what works best for their culture and how they operate. 

While all of these findings are useful, they are also generic. What other factors influence the rate of vaccination in low-income countries? Why do similar countries have such different success rates? Can any of these factors teach a lesson on what works and what does not? Can they be implemented for current or future vaccine campaigns?

The countries chosen to look at in this project are part of the GAVI alliance. To be eligible for the alliance the countries have to have "a Gross National Income (GNI) per capita below or equal to $1,730 on average over the last three years" [6]. GAVI then supports the procurement and distribution of vaccines in these countries which they could otherwise not obtain. While there are countries part of the GAVI alliance in other continents, Africa was chosen due to the abundance of countries that qualify for GAVI in proximity to each other and the historic lack of medical resources. Eritrea was excluded from the data because of the lack of information due to the instability of the country. South Sudan is excluded from the polio data because it was not recognized as an independent country until 2011. It is also important to note that data collected in sub-Saharan Africa and used in this research comes with inaccuracies due to the lack of infrastructure and data collection systems.

Polio eradication was spearheaded by Rotary International, World Health Assembly, and Global Polio Eradication Initiative (GPEI). National immunization days played a large part in vaccinating children against polio and were used in 23 African countries in 2004. The goal to eradicate started in 1988 and was successful in all but four countries by 2006 and now all but Pakistan and Afghanistan. [35]

The COVID vaccine became available in early 2021 in Africa and the initiative to vaccinate is ongoing with the goal of immunizing 70% for herd immunity according to WHO. However, this goal is nowhere near being met in Africa [36]. The Africa CDC alongside Mastercard Foundation are focused on integrating the COVID vaccine into routine vaccinations while also strengthening the vaccination programs through the Saving Lives and Livelihoods initiative to increase COVID immunization in Africa. This mainly includes training healthcare workers and setting up laboratories to identify COVID and other diseases [37].

The maps below show the factors used to determine success in both the COVID and polio campaigns as well as all of the factors that were suspected to have an influence on the effectiveness of the campaigns. The success of the overall polio campaign was determined based on a combination of the number of one-year-olds vaccinated in 1985 and 1988 and the reduction in the number of cases between 1985 and 1995 since polio is usually contracted in the first five years of life. The success of COVID was determined by looking at a combination of the percent of doses consumed and the percent of the population that is totally vaccinated.

Note: use the slider to compare two map layers and the legend is in the bottom left corner

The overall rankings for polio and COVID were compared to different factors such as access to electricity, motor vehicles per 1000 citizens, and number of health facilities. All of these factors were hypothesized to have some correlation with the success rates of the campaigns. Increased democracy and less corruption were hypothesized to have a positive correlation with campaign success due to higher stability in the country. Different colonizers were suspected to have a different impact on each society such as the implementation of systems or the amount of resources taken. The colonizers that set up more systems and took fewer resources were suspected to have a positive impact on success. Increased electricity, internet access, literacy rate, and motor vehicles also were thought to have a positive correlation since they could facilitate the spread of information about the vaccine, its availability, and the ability to get to health facilities. Finally, the higher number of health facilities might also indicate a higher vaccination rate. It was found that none of these factors had a noticeable influence on the success of individual or the campaigns combined.

Due to a lack of time and knowledge about numerically comparing these factors, another method of comparison may be useful to analyze the influence of these factors in a more quantitative way. In addition, these are a few of many factors that could have an influence on campaign success. Other factors such as the previous number of epidemics or the extent of advertising might also be significant. The possibility of confounding factors is also plausible and should be studied in the future. For example, the number of motor vehicles and the number of health facilities might not individually have an impact on campaign success but combined they might.

Nonetheless, the importance of vaccination cannot be overstated. Finding ways other than trying to fix systemic problems like lack of funding or the abundance of inaccurate information may be more effective to improve vaccination distribution in low-income countries. While systemic change is important and should not be overlooked, it is often slow and difficult. Finding other factors that influence distribution may be easier to implement and increase the efficiency of campaigns.

Emilia Blechschmidt is an undergraduate student in the class of 2026 at Bucknell University originally from Kempton, Pennsylvania. She is studying mathematical economics in the College of Arts and Sciences. She has done previous research on the consequences of overturning Roe v. Wade and the political climate surrounding that topic working with Professor Amy Wolaver and Professor Jan Knoedler alongside librarian Carrie Pirmann. This project partly stems from her travels to Africa. Her father is part of Engineers Without Borders and was able to go along on one of the trips to Mattru, Sierra Leone. There she took pictures and interviews for promotional purposes at the local hospital and school the engineers were helping. She quickly learned about the lack of resources in other parts of the world and the challenges they face to provide simple medical care. She plans on continuing this project about vaccine distribution and both hopes to learn more about and spread information about vaccine inequality and the need for medical resources in areas often overlooked.

This project was possible due to the Digital Scholarship Summer Research Fellowship at Bucknell. Founded and run by Carrie Pirmann and Claire Cahoon, this program gives its fellows the freedom to conduct their own research as well as the tools to present them digitally. Thank you to the many faculty members who took the time to talk to the group and teach a plethora of different tools. A huge thank you to Carrie and Claire alongside everyone else who made this project possible, including Janine Glathar and Professor Wolaver, who took the time to talk with the group this summer.

Link to the DSSRF website:  https://dssrf2023.blogs.bucknell.edu/