What COVID-19 vaccines will Africa get, when and at what cost?

Supply agreements for COVID-19 vaccines to help protect people in African countries are far from adequate, without enough doses to vaccinate enough of the continent’s population to provide herd immunity. The question remains how cash-strapped African governments will fund this.

African countries have three main ways of securing supplies for COVID-19 vaccines – directly with pharmaceutical companies, through the COVAX facility, a global initiative, and the African Vaccine Acquisition Task Team (AVATT) set up by the African Union regional bloc.

Few cash-strapped African countries have the financial means to compete with rich countries also battling to obtain vital coronavirus vaccines. Plus, there are few big pharma companies based on the continent, putting Africa at a disadvantage in negotiating contracts, while other countries leverage a home advantage.

“On their own at the current market price, there will be very few African countries that will be able to procure the vaccine,” Mosoka Fallah, a public health specialist who worked on Liberia’s Ebola outbreak, told this week’s Africa Calling podcast.

Collective bargaining

The COVAX facility, which is designed to provide equitable access to vaccines for all participating nations, recently announced their estimated distribution forecasts for what is essentially a kind of procurement consortium.

“This planned rollout is a critical first step in ensuring that the continent gets equitable access to vaccines,” said Dr Matshidiso Moeti, Africa director for the World Health Organisation (WHO). WHO leads the COVAX facility alongside Gavi and the Coalition for Epidemic Preparedness Innovations (CEPI).

“Africa has indeed watched other regions start Covid-19 vaccination campaigns a little bit from the sidelines,” added Moeti, in a recent press briefing.

COVAX will provide 88.7 million doses of the AstraZeneca/Oxford and Pfizer-BioNTech vaccines to 47 African countries.

Delivery of the AstraZeneca/Oxford vaccine, manufactured by the Serum Institute of India and South Korea’s SK Bioscience, will start in February, with all the doses expected to be distributed by the first half of 2021.

The Serum Institute of India will deliver 75 million doses of the AstraZeneca/Oxford vaccine to 38 African countries – at least 26 million doses by the end of April, and 49 million by the end of June, according to a calculation by RFI based on the COVAX interim distribution forecast.

A further nine African countries will receive some 13 million doses of the SK Bioscience manufactured AstraZeneca/Oxford vaccine, with 2 million doses delivered before May, and more than 7.5 million by 30 June. The remainder will be supplied in the second half of 2021.

Rigorous requirements for Pfizer-BioNTech

Cabo Verde, Rwanda, South Africa and Tunisia have been selected by COVAX to receive almost 320,000 doses of Pfizer-BioNTech vaccines, which has stricter cold storage requirements.

“We are extremely glad that we are part of a few countries getting this Pfizer vaccine,” Dr. Daniel Ngamije, Rwanda’s health minister, told journalists. “This is an indicator of the performance of the health sector because we were able to meet all the tough requirements.”

Some African countries are self-financing their participation in COVAX, while the vast majority are eligible for donor-funded support to pay for vaccines.

Equatorial Guinea and Gabon signalled their intention to participate in COVAX, with a non-binding confirmation of intent before 15 December, however, they are not included in the interim forecast, presumably because they no longer want to take part.

Burundi, Eritrea, Madagascar and Tanzania, all classified as low income countries, could have had vaccines doses supported by COVAX, but decided not to enter into the facility.

Authorities in Burundi say they do not need vaccines, the government in Antananarivo says it prefers local treatments and in Tanzania, the health ministry says it has no plans to accept vaccines since it does not have the virus.

The interim distribution forecast by COVAX covers just 3.3% of the total population for the 145 participants globally, but the facility says it is on track to deliver at least 2 billion doses by the end of the year, with at 1.3 billion for 92 lower income countries, covering 20% of each countries population.

“Covax has a challenge of funding, to see if they can raise the bar above the 20%,” said Mosoka Fallah, who works at the National Public Health Institute of Liberia.

Home-grown African initiative

AVATT is solely focused on African countries and was set up in August 2020 under the stewardship of former African Union Chairperson and South African President Cyril Ramaphosa.

Some 270 million doses have been secured with at least 50 million available for delivery from April to June, and the rest by the end of 2021.

Doses will be supplied by Pfizer-BioNTech, AstraZeneca/Oxford and the one shot Johnson & Johnson vaccine, according to a statement from the South African presidency on 13 January.

This initiative is effectively underwritten by the African Export-Import Bank (Afreximbank) to the tune of US$2 billion.

AVATT was opened up on 19 January and has received expressions of interest by 20 countries, according to John Nkengasong, head of the Africa Centre for Disease Control and Prevention, speaking on Thursday.

“Of the 20 countries, they have expressed an interest to order above 200 million doses,” said Nkengasong. “I think that’s going on very well,” he added.

Afreximbank will guarantee the purchase agreements and then upon delivery countries can settle their bills by themselves or use an instalment plan over five years, the South African presidency said.

“AVATT is not clear to me, can African countries afford it, at what interest rate,” said public health specialist Fallah, a visiting lecturer at the Harvard School of Public Health. “What happens to those countries that are heavily indebted?”

Later on 27 January, the South African presidency said AVATT has also received offers for an additional vaccine doses, although the timetable and financing for these doses is not yet clear.

Borrowing for vaccines

The South African presidency said in mid-January the African Union was working with the World Bank so that African countries could access US$5 billion to buy vaccines. This was later said to be US$12 billion for vaccination purchases through “grants or on highly concessional terms”.

“We’re preparing emergency vaccine financing projects in 21 countries in Africa, including DRC, Ethiopia, Niger, Mozambique, Tunisia, Eswatini and Cabo Verde to name a few,” said World Bank President David Malpass.

Combining currently outlined supplies, from both COVAX and AVATT, including the offer of 400 million doses, provides for a possible 758 million vaccine doses for the African continent, but does not include distributions from COVAX in the second half of 2021 when supplies are said to be ramped up considerably.

Given the need for two doses of the Pfizer-BioNTech and AstraZeneca/Oxford vaccines this would cover 379 million people, although the Johnson & Johnson vaccine only requires one dose.

Africa would need to vaccine 780 million people out of its 1.3 billion population to achieve the 60% target thought to be needed for herd immunity.

Chinese and Russian efforts

Besides vaccines developed by Western pharmaceutical companies, other contenders developed by China and Russia are also being made available to help protect people in African countries.

Less safety and testing information is known about these vaccines, though some the details of some studies and trials are starting to be revealed, with the Lancet recently publishing data about Russia’s Sputnik V vaccine.

Chinese vaccines will be supplied to Egypt, Equatorial Guinea, Morocco, Sierra Leone and Zimbabwe. Morocco has reportedly ordered 10 million doses of the Sinopharm vaccine and the Seychelles, a small island nation, started a vaccination campaign with the Chinese vaccine through a donation by the United Arab Emirates.

The exact supplies destined for Africa do not seem clear, but the Chinese foreign affairs ministry said recently it had exported or was in the process of exporting vaccines to 22 countries.

The Sputnik V vaccine has received approvals for use in Guinea and Tunisia, while a vaccination campaign is underway in Algeria, according to the Sputnik website. Supply agreements and financing details for African countries remain elusive.

The Africa CDC has said it is engaging in discussions about Chinese and Russian vaccines, with Mr Nkengasong saying the organisation is “open to any vaccine manufacturing and manufacturers”, adding that they had signed a confidentiality agreement with the Russians to review data on Sputnik.

Improve multilateral endeavours

The overall picture for vaccine supplies is subject to constant change, as new deals with manufacturers are struck and details of financing are disclosed. The AVATT initiative is less established than COVAX, which was put in place earlier.

“The two platforms are good but they have their challenges,” said Fallah, who was lauded for his contribution in the fight against the West African Ebola epidemic in 2014-2016.

Publicised supplies remain far from adequate for protecting the African continent’s population, and aside from donor support through COVAX, as well as potential support from China and Russia, the AVATT initiative seems reliant on countries seeking financing.

“Each of these platforms is great because it does collective bargaining for the African continent, but we need to refine these platforms,” added Fallah, questioning whether some supplies through AVATT could be obtained through grants, rather than loans.

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