The United States this week announced it will offer booster shots of Covid-19 vaccine from September. The decision “makes a mockery of vaccine equity” when African countries are still struggling to get vaccine supplies, said Dr Matshidiso Moeti, the World Health Organisation’s Africa director, in a media briefing.

The WHO had previously called for a moratorium on booster shots until the end of September to prioritise vaccines for lower-income countries.

For many African countries Covax is the main source of Covid vaccines. The initiative aimed to supply 600-million doses to the continent by the end of 2021, enough to vaccinate 20% of the population. By mid-August about 51-million doses had been delivered to 47 countries.

Only about 4%, or 55-million people in Africa, have received a dose of a vaccine so far. And, until relatively recently, African countries were using two-dose vaccines, such as AstraZeneca, so that means only 2%, or around 25-million people, have been fully vaccinated, according to the Africa Centres for Disease Control.

What is Covax? 

Covax is an international coalition set up with the aim of guaranteeing “fair and equitable access to vaccines to every country in the world” regardless of their ability to pay. 

It is managed by Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations (Cepi) and the World Health Organisation. Unicef is the coalition’s delivery partner.

Its initial target was to deliver 2-billion vaccines around the world by the end of 2021. By mid-August Covax had shipped about 200-million vaccines – or 10% of the target. 

Who has joined Covax?

The countries that have signed up to Covax fall into two categories: those that can afford to buy vaccines – these are “self-financing” members that pay for their Covax-supplied vaccines – and those lower-income countries that would otherwise have been unable to afford Covid-19 vaccines – these receive vaccines through a financing mechanism set up by Covax called the Advance Market Commitment model (AMC).

Ninety-two countries were considered eligible to receive funded vaccines through Covax, most of them because their gross national income per capita was less than $4,000. Half of those countries (46 in total) are in Africa.

All told, 85% of Africa’s countries are eligible to receive funded vaccines through Covax. 

South Africa is one of only eight African countries that does not qualify to receive funded vaccines from Covax, the others are Botswana, Namibia, Mauritius and Seychelles, Gabon, Libya and Equatorial Guinea. 

Only three countries have not joined the initiative, Burundi, Equatorial Guinea and Eritrea.

Four countries – Zimbabwe, Seychelles, Gabon and the Republic of Congo – are on the Covax schedule but by mid-August they had yet to receive any doses. 

African countries have received nearly a third (30%) of the vaccines Covax has delivered to funded countries and 60% have been delivered to Asian countries. Asia has three times the population of Africa, with 4.6-billion people compared with Africa’s 1.3-billion, according to Our World in Data. 

How is Covax funded?

A mechanism called the Gavi Covax Advance Market Commitment (AMC) was set up to fund vaccines for lower-income countries.

​​Money for the AMC is raised from official development assistance, the private sector and philanthropy.

What do self-funded countries get out of Covax?

By being a self-funded member of Covax, countries like South Africa theoretically have better access to vaccines at lower prices than if they enter into negotiations with pharmaceutical companies on their own.

By mid-August 2021, 138 countries have received vaccines from Covax,  54 were paying participants, the rest were funded by the AMC.

Which vaccines is Covax delivering? 

To be a part of Covax a vaccine has to be approved for emergency use by the WHO. At present, six vaccines have received this approval: AstraZeneca, Pfizer BioNTech, Johnson & Johnson, Moderna, Sinopharm and Sinovac.

Up until June 2021 Covax was distributing two vaccines in Africa, AstraZeneca and Pfizer. Both require two doses.

Most of the AstraZeneca vaccines were produced by the Serum Institute of India (SII). 

Only 10 African countries had received Pfizer vaccines by early August: Angola, Botswana, Cape Verde, Chad, Côte d’Ivoire, Libya, Rwanda, South Africa, Togo and Tunisia.

The Pfizer vaccine needs to be stored at ultra-low temperatures and many lower-income countries do not have the necessary infrastructure. 

In June rich countries, such as the United States, Japan, New Zealand and France, pledged to cover the vaccine shortfall by donating vaccines to Covax. 

These donations added Moderna and Johnson & Johnson vaccines to Covax’s mix.

Vaccine shortage

The supply of AstraZeneca was interrupted by a vicious second-wave of Covid-19 infections in India in March driven by the more contagious Delta variant of the coronavirus. The Serum Institute stopped exporting its vaccines.  

India had planned to distribute 100-million vaccines through Covax by April 2021 but had supplied only 19.8-million vaccines (20% of the promised allocation) by mid-April.

Countries in Africa that were relying on Covax as their only source of vaccines, such as Nigeria and Uganda, started to run out of supplies before they could fully immunise people with the required two doses. About 30 countries were relying on either Covax or donations of vaccines from countries such as India and China.

Meanwhile, richer countries that preordered vaccines from the pharmaceutical companies were sitting on more doses than they needed for their populations and created a global outcry when some began administering booster shots. 

On 27 May, a joint statement from the head of the WHO, Unicef, Gavi and Cepi was issued asking countries to fund the AMC and donate vaccines to Covax to make up a two billion vaccine shortfall for the end of 2021.

“We are starting to see countries stepping forward with doses, with the United States and Europe collectively pledging to share 180 million doses. But we still need more, we need them to go through Covax, and we need them to start moving in early June. At least one billion doses could be shared by wealthy countries in 2021,” the statement said.

African Union steps in

On March 28, the African Union signed an agreement with Johnson & Johnson to supply the continent with 400 million vaccines. These are one-dose vaccines, so they’re easier and cheaper to administer, and they are partly manufactured in South Africa.

During an Africa CDC briefing African Union Special Envoy Strive Masiyiwa said that if the AU had known of Covax’s difficulties in sourcing vaccines and funds, it would have made plans to source its vaccines earlier. 

Rollout of these vaccines started on 6 August and in less than two weeks about 1.5-million had been delivered to 10 African countries.

Donations from wealthy countries also boosted Covax supply. In just under a month, between 16 July and 13 August, the United States had donated 19,7-million vaccines to Africa; France donated 2.4-million between May and June; and the United Kingdom, Norway and Denmark donated a combined 815 820 doses. 

Although the rollout of Covax vaccines has been slower than expected, “for the sake of humanity, we need Covax to work,” wrote chief executive of Gavi, the Vaccine Alliance Seth Berkley in a letter to the New York Times in August. 

“Because if it doesn’t, then the appalling global inequities in Covid-19 vaccine distribution would not only be much worse but would also inevitably persist for some time — meaning continued spread of new infections and new variants.”

The next round of Covax deliveries will be of Sinopharm and Sinovac vaccines. 

Note: The data on Covax vaccine deliveries used in this story was collected by Media Hack Collective, the publisher of The Outlier, for the Africa Data Hub. It is compiled from a number of diverse sources that are believed to be reliable, and every effort is made to keep it as up to date as possible. The information used in this story covers up to 13 August 2021.