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Why Hesitancy is Not the Cause of Low Vaccination Rates in Africa

Dr. Ernest Darkoh-Ampem, co-founder of BroadReach Group

At this year’s World Economic Forum in Davos, the topic of the COVID-19 pandemic and its destructive impact was central to many of the discussions that took place. Among them, was the issue of vaccine hesitancy around the world, especially in underdeveloped nations such as those in Africa. According to Africa CDC, as of September 2022, Africa, the second most-populated continent, has only vaccinated 21% of its people; an inadequate number In comparison to other populated countries such as India (65%) and China (89%). Even in the United States, where vaccination misinformation ran rampant throughout the pandemic, 67% of the population has been fully vaccinated against COVID-19. 

Even though several effective vaccines are available to combat the COVID-19 pandemic, wide disparities in vaccine distribution and acceptance rates between high- and low-income countries are major threats to achieving population immunity. It’s easy to blame low vaccination rates on community unwillingness and distrust, but this may be rushing to a conclusion that is not supported by enough data. We can only properly assess the true extent of hesitancy if we are providing equitable large-scale access to vaccines and delivering them in a culturally and linguistically appropriate manner. Partnerships and innovation is how Africa can achieve superior vaccination results with its limited resources.

The vaccination challenge in Africa is nuanced 

The COVID-19 pandemic hit Africa hard and overwhelmed the capacity to test for and treat the disease, highlighting existing gaps within its national health systems. Health resources are unevenly distributed and often of poor quality. According to a 2021 report from AHAIC, only half (52%) of African citizens, about 615 million people, have access to the healthcare they need. The World Health Organization estimates that in the majority of African countries, there is one hospital per one million people, one doctor per 10,000 people and one hospital bed per 10,000 people. A lack of resources (money, infrastructure, equipment, skilled personnel), weak systems and overly centralized reactive models of delivery (patient must go to the healthcare, not healthcare going to the patient) pose a massive challenge to effective access and service delivery in Africa. These challenges are complicated by the large demand from a massive population, socioeconomic hardships, and cultural and linguistic barriers to care. While the lack of adequate resources is a problem, it’s also a massive opportunity to avoid the mistakes of others and build a better, more equitable and effective healthcare system across the continent. 

Equitable and effective healthcare through partnerships

Partnerships and innovation are the only ways Africa can achieve superior health outcome results with markedly fewer resources. Partnerships with NGOs, FBOs, the private sector and its local communities can provide an immediate capacity boost that the country’s government lacks.

First, we need to reinvent the healthcare delivery model from one that expects people to come to the vaccine to one that takes the vaccine to them. In many poorer, rural areas, the financial and personal cost of accessing healthcare far away from home is simply too high. A round trip to the health facility may involve multiple transfers and take a whole day or sometimes more. Individuals have to choose between the cost implications of either reporting to a job or taking the time off to travel to a clinic to get the vaccination. Those with children have to find affordable and safe childcare options. Without the proper education on the threat of a disease, it’s much easier to assume the threat is not worth the inconvenience or the potential lost income. Due to the multiple boosters required, it is simply unrealistic to expect people to do this multiple times for any disease, let alone a disease they know little about.

There are many safe spaces in communities such as schools, houses of worship, workplaces and pop-up space options that can be used as extra screening, testing and vaccination sites. Private companies can support some of the required cold-chain transportation and storage requirements. And finally, there is a large potential workforce that can be rapidly on-boarded and deployed across the spectrum of need- this includes private, NGO and FBO medical and other supply chain-related personnel such as doctors, nurses, pharmacists, drivers and security personnel.

Thirdly, we must combine 21st-century technology with grassroots efforts. Artificial intelligence, big data and cloud computing can help solve the challenges associated with ensuring health facilities have adequate resources, targeting resources for the highest impact, reducing wastage and predicting ahead where the next threats are going to occur. Innovative low and high-tech solutions exist to solve challenges associated with transport (e.g., motorcycle and bicycle delivery) and cold chain management. There are also numerous green affordable technological innovations to provide electrification to rural health clinics. Many of these options offer the dual benefit of creating jobs that can stimulate skills development and job creation in the areas where it is most needed.

The BroadReach team in South Africa has had the fortune of working in collaboration with USAID and the South Africa Department of Health to aid in the rollout of COVID-19 vaccination to clinics within rural communities, where vaccination levels were 25% below the national average. Extensive education and mobilization was done through trusted local leaders and intermediaries in each community prior to the arrival of the actual vaccines. Communities were informed well ahead of time as to when and where the vaccines would be made available. Clear plans were made with employers like farm owners ahead of time to mobilize their workers and either allow vaccinators to come and perform the vaccinations at the worksite or to allow their workers to leave the site to be vaccinated.

Over the initial two months of the program, BroadReach helped to vaccinate more than 50,000 people. With this targeted approach, a success rate of over 90% was across the workforce of farms that were targeted. This radical movement of the needle indicates that a well-prepared community given convenient access shows a high willingness to be vaccinated and that true hesitancy, although present and possibly growing, is not yet the overriding determinant. 

Finally, although strong sustainable local long-term healthcare financing vehicles like National Health Insurance (NHI) will provide the means to ensure more Africans have access to healthcare, this is decades in the making. In the short term, partnerships and collaboration can go a long way in offsetting costs, better rationing the supply and leveraging scarce resources and expertise. For example, if Africa negotiated and procured tests, vaccines and supplies as a continent instead of 54 disparate individual countries, all countries could be assured of the best possible price. Partnerships structures that bring together public health expertise, donor financing and manufacturers can also go a long way in addressing some of the large immediate gaps while the continent develops the much-needed local capacity in manufacturing. A good example of this is the African Vaccines Acquisition Trust (AVAT) in coordination with the African CDC was able to obtain 40% of Africa’s COVID vaccine needs in 2021. 

Hesitancy: a convenient scapegoat

Saying that simple hesitancy is the cause of low vaccination rates in Africa ignores the access issues across the continent. There are many structural factors on the demand and supply side that constrain health systems in Africa. Equal access to quality care, education and financial support are all key components needed in order to improve the systems that currently exist. Governments cannot do this alone. That said, we can do a lot better with what we have if we align behind effective delivery models that improve access and embrace the right innovations and partnerships that allow for intentional, controlled and rapid large-scale mobilization and deployment of all actors who can contribute meaningfully to the mission. These partnerships are the key to expanding the last-mile delivery of health services and will solidify efforts to achieve long-term health access for all. 

About Dr. Ernest Darkoh

Dr. Ernest Darkoh is a founding partner of the BroadReach Group. He is an internationally respected expert in strategic planning, systems and large-scale health system program implementation. His recent work focuses on using new cutting-edge technologies to radically improve healthcare delivery and catalyze broader development sector outcomes.

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