Coronavirus vaccines have begun to trickle into some of the world’s poorest nations, in large part thanks to Covax, the World Health Organization-backed initiative to distribute vaccine doses equitably.

But once doses arrive on airport tarmacs, it is up to each country to finance distribution, including the salaries of health-care workers to administer the shots. In many cases, that funding isn’t readily available.

The flow of vaccine doses Covax has supplied so far, in the face of funding and supply shortfalls, remains relatively manageable. Countries in need can, in theory, apply for funding to support distribution from donors including the World Bank and United States.

But public health experts told The Washington Post that many low-income countries are on track to face acute shortages of trained and salaried health-care workers in a few months, when Covax shipments increase.

“There is this misunderstanding that Covax vaccines are going to be sent to countries and then delivered to people’s communities,” said Ayoade Alakija, a co-chair of the African Union Africa vaccine delivery alliance. “Countries are receiving them at airports, and that’s where Covax’s responsibility ends.”

She also worried about how limited resources would be allocated. Many African countries have a “shockingly low number of health personnel per capita,” she said. “If we pull them all out to go and do vaccinations, then the rest of our health will suffer.”

Health-care workers at risk

By some estimates, coronavirus vaccine rollouts would take 10 years in some poor countries, if they were to rely only on existing health-care worker capacity, said David Bryden, director of the Frontline Health Workers Coalition, which focuses on low- and middle-income countries. Policymakers must consider not just the number of workers available to administer shots, but also the need to train and fund additional staff and conduct community outreach to dispel vaccine hesitancy.

The world was already facing a massive shortage in health-care workers when the pandemic hit, increasing the strain. At least 84 countries saw strikes in the sector last year over poor working conditions, according to Bryden. Worldwide, women dominate health-care work and have disproportionally borne the effects of short staffing during the global crisis.

The gap in care is particularly pronounced in impoverished countries in Africa: Communities in sub-Saharan Africa have just 0.2 doctors for every 1,000 people, according to World Bank data — compared with 2.6 in North America, 3.7 in Europe, and 1.6 on average worldwide. Networks of unpaid or low-paid, mostly female community health workers do much of the work.

Since vaccination rollouts began three months ago, most jabs have been administered in wealthy and Western countries, who by pre-purchasing doses have dominated vaccine supplies. The WHO has urged governments to make health-care workers an inoculation priority.

But while Covax is intended to help even out vaccine distribution, the focus on getting doses to countries has overshadowed other factors limiting health-care access, said Emily Bancroft, the president of Village Reach, a Seattle-based organization focused on health care in low-resource communities in Africa.

“What we are seeing right now is that there is an expectation that the vaccine distribution can happen within the existing workforce and existing systems,” she said. That has not been the case for the United States — which has struggled to scale-up for vaccine distribution — and won’t be for countries without rainy-day funds, Bancroft said.

“Vaccines don’t vaccinate; health-care workers vaccinate,” she said. “Our concern right now is that we need surge capacity.”

Doctors at the Johns Hopkins University School of Medicine in Baltimore spent their Easter Sundays training nurses in Sierra Leone on how to use ventilators. (Danielle Paquette, Joyce Lee/The Washington Post)

Financial constraints

Before receiving vaccine allotments from Covax, low- and middle-income countries have had to submit National Deployment Vaccination Plans detailing their rollout intentions. In mid-January, Covax removed a requirement for a countries to demonstrate their plan for “costing and financing” of vaccine distribution, because some were struggling to do so within the required deadline, said Ann Lindstrand, who heads the WHO’s Essential Program on Immunization.

“We have to balance being able for all countries to access doses as fast as possible,” she said, calling it a “pragmatic choice.”

Many countries have opted to self-finance vaccine distribution by diverting funds from other domestic programs. This could exacerbate other health risks, for example if workers at a maternity clinic or those administering childhood immunizations are pulled away to administer coronavirus shots.

“We do not want one population group paying for protecting another,” Lindstrand said.

The humanitarian agency Care International estimated that for every one dollar a country or donor governments invests in procuring vaccine doses, another five dollars must also be put toward delivery.

“Of the $5.00 in delivery costs, $2.50 has to go to funding, training, equipping, and supporting health workers — especially women — who administer vaccines, run education campaigns, connect communities to health services, and build the trust required for patients to get vaccines,” Care said in a statement. “For these investments to work, they must pay, protect and respect women front line health workers and their rights — a cost that is largely absent from recent WHO estimates on vaccine rollout costs.”

There are funding streams available to cover the costs of scaling up a country’s health-care workers from the World Bank and other multilateral and regional development banks with which Covax has relationships. So far, 10 countries have received financing while “more than 40 additional projects are in the pipeline and will be approved in the coming weeks and months,” according to The World Bank.

But the bureaucratic red tape around accessing financial help has hindered timely access to these funds for many countries in Africa, Alakija said. She called on banks and other donors to streamline the application process and offer technical assistance to make “the space for us to do what we need to do.”

For some low-income countries, among which rates of debt are already high, there’s also a worry about taking the World Bank loans, “as they are not sure about what the long term payback will be,” said Lisa Hilmi, executive director of CORE Group, an association of international health and development organizations.

A World Bank representative said that zero- or low-interest loans were being made available for low-income countries and partial or full grants for countries with high debt. risks.

Among donors to multinational funds, “so far there has been very little interest and direct support guided toward the operational costs,” Lindstrand said.

One notable shift has occurred in the United States, where in February the Biden administration committed to join Covax, reversing former president Donald Trump’s approach. In early March, national security adviser Jake Sullivan said half of the administration’s $4 billion commitment to Covax would be used “not just for straightforward vaccine delivery, but vaccine delivery in the context of building up and strengthening the capacity of health systems.”

Still, Lindstrand said she was “quite worried.”

“I think we have a little bit of a window to now intensely work on the financing solutions in the next two three months,” she said. “When the Covax doses will be ramping up and coming in much larger numbers to countries, that’s where we will see the real bottleneck coming up.”