The World Health Organization defines vaccine hesitancy as a ‘delay in acceptance or refusal of vaccines despite the availability of vaccination services,’ with the problem being one of the greatest threats to global health since over 90% of countries worldwide have to deal with it [46]. In the African context, low Covid-19 vaccine coverage and the resultant inequality in vaccination are aggravated by vaccine hesitancy as well as vaccine nationalism and vaccine diplomacy [47]. LMICs are struggling with inadequate vaccines and concerning proportions of the population who are unwilling to get the jab, thereby undermining the efforts to fight to end the SARS-CoV-2 pandemic. During the initial vaccine rollouts, a majority of the LMICs were unable to attain at least 10% population coverage. An ecological study evaluating the country’s economic standing against increased toll on cumulative cases and death revealed countries with the smallest economies reported first vaccination much later than larger economies [48]. Based on the study, LICs experiencing a one-day increase until the first vaccination had a 1.92% increase in cumulative cases at a 95% confidence interval (CI) compared to HICs. Similarly, there was a positive percentage increase in cumulative mortality among LMICs experiencing a 1-day increase in first vaccination, with the magnitude and direction of interaction with economic models mirroring those of cumulative cases. This is confirmation enough of the persistent Covid-19 vaccine inequalities that continue to plague LMICs such as those in Sub-Saharan Africa.
The efforts to achieve global vaccine equity through initiatives such as the COVAX program faced challenges related to vaccine nationalism that superseded these efforts and reveal the existence of structural inequities in accessing Covid-19 vaccines. Through a data-driven, age-stratified epidemic model to evaluate the effects of Covid-19 vaccine inequities focused on 20 LMICs from all WHO regions, it has been revealed that as of October 1, 2022, 77% of individuals in high and upper middle income countries completed the initial vaccination course, with its equivalent in LMICs being 50% [49]. In this same study, the vaccine coverage by October 1, 2021 in HICs was more than 1 dose per person while that of lower middle income countries was 40 doses per 100 and low income countries stood at 3.6 doses per 100, with these inequalities further discussed in several other studies [50, 51, 52, 54, 55]. In HICs, challenges related to vaccine hesitancy and dose scarcity have been anticipated, with governments implementing potential solutions like mass media interventions and population groups prioritization to increase uptake. However, in LMICs, there are greater and additional challenges affecting the rates of vaccinations, with vaccine hesitancy, low resource availability, inadequate cold-chain and storage, limited finances for surveillance, and lack of coordination with a significant private healthcare sector [53]. Therefore, with these challenges and the subsequent government response, the disparities in vaccine coverage between the wealthy versus poor nations are presented clearly.
The vaccine inequality facing the African continent is difficult to solve as countries still face challenges to procure life saving vaccines in a context where the wealthier countries are buying vaccines directly from the manufacturers or through multilateral initiatives. The vaccination supply problems across LMICs are compounded by the behavior of HICs offering Covid-19 booster doses to the immunocompromised and vulnerable populations, as well as the entire general populations that are often regarded low-risk to SARS-CoV-2 [56]. This level of vaccine nationalism is characterized by rapid mobilization of resources to amplify booster campaigns, paying high costs to procure additional doses, and closing borders. The efforts of HICs delay the end to the pandemic as variants and infections do not respect borders. Furthermore, the behaviors of the wealthier nations undermine solidarity for global health and weaken the pandemic response. These HICs have pre-ordered large numbers of doses directly from the vaccine manufacturers like BioNTech/Pfizer, in contrast to the LMICs that relied on the COVAX facility that procured doses for distribution from AstraZeneca, Novavax, and Janssen, which were slower to overcoming scale-up challenges in manufacturing that were unknown to BioNTech/Pfizer [57]. There were also allocation, affordability, and deployment challenges facing Sub-Saharan Africa that were uncommon to HICs, with the wealthier nations prioritizing national access over global equity and bypassing COVAX to access the vaccines directly from the manufacturers [58, 59]. Further evidence indicates the inadequate financial resources in SSA to procure the quantity of required vaccines, the lack of financing for sustainable funding for logistics and cold chain requirements, as well as problems of delivering vaccines to remote and hard-to-reach areas where the most vulnerable reside [60].
Vaccine inequality during the Covid-19 pandemic in Africa is reflected in the form of vaccine hesitancy/acceptance factors as determined in this review. A cross-sectional study reported in rural and urban West Africa that despite the respondents being worried about getting infected with SARS-CoV-2, half of those interviewed were unsure about the safety of the vaccine, leading to their unwillingness to get vaccinated [61, 65]. Indeed, in an explanatory, sequential, mixed-methods design study carried out in Senegal between December 24, 2020 and January 16, 2021 for quantitative data collection and February 19 to March 30, 2021 for the qualitative data, it was reported that the proportion of those who refused to be vaccinated due to the belief the vaccine could endanger their health was 67.9% [62, 64]. Accordingly, poor attitudes toward the Covid-19 vaccine were significant barriers to vaccination and this was part of the challenge facing the efforts toward achieving global vaccine equity, with most individuals in LMICs worried about the safety and effectiveness of the jab [63, 71, 72]. In a scoping review focused on SSA, participants in Cameroon, Kenya, Ethiopia, and Nigeria perceived that the vaccine effectiveness is not well studied, with 61.8% uncertain about vaccine efficacy. In Kenya alone among pregnant women, 17.4% believed in the effectiveness of the vaccines compared to 29.6% in Congo and 48.1% in Zambia [66, 67, 68].
In this review, the lack of vaccine-related information was another barrier to vaccine acceptance and contributed to vaccine inequity in SSA. Following a qualitative study involving interviews with pregnant and lactating women (PLW), health workers, and policymakers in Kenya, a total of 59 participants were interviewed and the emerging themes from the results indicated uncertainty regarding PLW eligibility for Covid-19 vaccination as a matter of concern [69]. The lack of clear guidelines regarding Covid-19 vaccine use is further emphasized by the global disparities in policies, with a systematic screening of public health authorities’ websites from 224 countries indicating 176 countries had issued explicit guidance, with 38% recommending use, 28% permitting administration, 15% permitting use with qualifications, 2% not recommending but with exceptions, and 17% not recommending administration whatsoever [70]. Notably, policymakers felt that the vaccination policy was prohibitive for administering the jab, further noting the need for individual risk assessment before administration. Another study that confirms the findings of this review was done in Tanzania’s Moshi in the Northern part of the country, which involved 232 participants in a cross-sectional interview that revealed only moderate knowledge about Covid-19 as 48.3% believed SARS-CoV-2 was man made [73]. This contributed to vaccine hesitancy because of the misinformation surrounding Covid-19 and the vaccine safety and efficacy.
A lack of trust in political actors, both local and foreign, is another factor associated with vaccine hesitancy in SSA. A study analyzing data from the Kenya Rapid Response Phone Survey (RRPS) measured vaccine refusal and the associated factors, noting that distrust in the government’s response to Covid-19 was a determiner [74]. Due to the political nature of the SARS-CoV-2 vaccine, the mandatory administration in some countries as well as the lack of trust in the pharmaceutical industry also influence vaccine acceptance, with some individuals even holding religious beliefs regarding the jab as a representation of the “mark of the beast” [75]. The delayed response to the pandemic by African governments further hampered the people’s belief in their capability to manage the crisis. In Chad, 21% of participants in a survey reported lacking trust in the government as a factor related to their refusal to vaccinate [76]. Another study among healthcare workers in Cameroon and Nigeria based on a web-based cross-sectional study also determined mistrust in the pharmaceutical industries, the government, and public health regulatory authorities influenced their decision to refuse vaccination [77].
The review also evaluated the Covid-19 vaccine policies implemented in Africa, with a mixed methods study among health workers in rural Uganda corroborating the findings by reporting to feel coerced to take the Covid-19 vaccine [78]. Mandatory policies invoked fears in the health workers, making them hesitant about their trust in policymakers. Moreover, research in Uganda and Sierra Leone confirm ensuing anxieties and fears associated with mandating vaccination for conditions of employment. Villagers in rural Gulu, Uganda perceived support for mandatory vaccination as betrayal and alignment with the interests of the state rather than the residents [79]. Community engagement is another vaccination policy to boost uptake in Africa, which was revealed in a cross-sectional study focused on Malawi Covid-19 vaccination program where over just six months of implementing the “vaccinate my village” (VMV) program, 2.3 million vaccines were administered [80]. There were other policies like mass vaccination, mobile vaccination provision, and enhancing vaccine communication to boost acceptance.