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Commentary

Adil Ashraf,¹ Ameer Muhammad,¹ Zoha Fazal,² Noor Zeeshan² and Yasir Shafiq^3,4

¹VITAL Pakistan Trust, Karachi, Pakistan. ²Medical College, Aga Khan University, Karachi, Pakistan. ³Aga Khan University, Karachi, Pakistan. ⁴Università degli Studi del Piemonte Orientale “Amedeo Avogadro”, Novara, Italy (Correspondence to Yasir Shafiq: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Keywords: civil society organizations, COVAX, COVID-19, vaccine equity, inclusive

Citation: Ashraf A; Muhammad A; Fazal Z; Zeeshan N; Shafiq Y. The role of civil society organizations in fostering equitable vaccine delivery through COVAX. East Mediterr Health J. 2023;29(4):232–235. https://doi.org/10.26719/emhj.23.053 Received: 24/12/21; accepted: 05/11/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons

Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

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Background

The COVID-19 pandemic and the subsequent vaccination campaigns have effectively exposed the frailties of global healthcare delivery and public governance systems (1). The COVID-19 Vaccines Global Access (COVAX) was created as a pillar of Access to COVID-19 Tools Accelerator (ACT-A) to streamline COVID-19 vaccine rollout globally (2).

It has been suggested that the engagement of civil society organizations (CSOs) in development programmes can reinforce transparency, monitoring, public trust, and programme delivery through uncorrupted resource mobilization mechanisms (3). Three international organizations – the Coalition for Epidemic Preparedness Innovations (CEPI), Gavi, the Vaccine Alliance and the World Health Organization (WHO) – are the leading COVAX actors and they have been working in close coordination with CSOs to ensure vaccine equity (2–5). They are closely connected to a global network of CSOs that provide key research, implementation and advocacy support. For example, Gavi has a network of more than 4000 CSOs, which are well-represented on its board, board committees and task teams (6).

These CSOs are an integral part of public health emergency management and have supported research, awareness, monitoring, and policy advocacy for outbreaks and epidemics such as HIV and Ebola virus disease (7,8). Through the activities of CSOs, community and religious leaders helped improve contact tracing for Ebola in West Africa (9) and polio vaccination in India (10).

Civil society organizations have also been at the forefront of the response to COVID-19 pandemic in different ways, including through service delivery, telehealth services, online education, fundraising, psychosocial counselling, and mass immunization (4–6). COVAX incorporated CSOs into 10 different workstreams based on their specific strengths and noting their crucial role for the successful integration and implementation of country programmes (10–13).

CSOs like Go Laadli in India, Local Youth Corner and Crusaders for Environmental Protection and Ozone Watch in Cameroon have been active in dispelling rumours and myths about COVID-19 and in advocating for prompt sharing of accurate and verified information (11,12). Their roles in extending welfare to Iraqi refugees and families, providing food to healthcare workers and vulnerable slum populations in India, and distributing aid materials to Venezuelan refugees in Columbia are commendable (11). CSOs like Sain Tus in Mongolia and the African Initiative for Mankind Progress Organization in Rwanda continue to provide necessities to indigenous families (12,13).

CSOs have also contributed to governance assessments and monitoring. For instance, the allegations of corruption regarding COVID-19 medical supplies in Zimbabwe and vaccine distribution in Palestine prompted CSOs like Human Rights Watch to request relevant authorities to take stringent actions against corruption related to COVID-19 supplies (14,15).

How can CSOs strengthen response by COVAX and national governments to the COVID-19 pandemic?

Despite the role of CSOs in supporting public health programming at the community level over the years, their inadequate representation in COVAX raises serious concerns. CSOs can play a vital role in COVAX (1–8) by supporting equitable cross-border vaccine distribution, outreach to marginalised groups, behaviour change activities, monitoring and evaluation, market shaping, and promoting vaccine manufacturing by developing countries. They can support the promotion of “active citizenship” by engaging local and national stakeholders and communities in demanding and contributing to vaccine rollouts. Through their involvement in the global governance processes, CSOs can influence policymaking in their countries and as members of the boards of international development organizations.

Unfortunately, the COVID-19 vaccination programme has failed to uphold ethical considerations, as reflected in the skewed vaccination rates reported globally (16). While the resource-rich countries report vaccination rates as high as 70.6% in Canada, for example, the developing countries experience abysmally low rates such as the 1.0% documented in Cameroon (17). Such low rates are deeply troubling because vaccination is currently the most effective health policy response to COVID-19.

Through representation in COVAX, CSOs can potentially challenge vaccine hoarding and demand vaccine equity through policy reforms in the bilateral dealings between the developed countries and the pharmaceutical giants (1,5,10). Experience has proven that broad coalitions and legal actions by CSOs have generated significant momentum in influencing similar actions that highlight unfair practices, raise awareness and facilitate discussion and debate on civil issues (1,5). There is evidence of successful CSO-led efforts in the environmental justice sector, where big corporations like ExxonMobil and Shell have been held accountable for their environmentally damaging business practices (18).

Outreach to vulnerable and marginalized populations needs to be prioritized in government-led vaccination programmes. For example, non-Lebanese in Lebanon, who are largely either migrants or refugees, constitute 30% of the population, however, as of April 2021 only 2.86% of those vaccinated and 5.36% of those registered to receive vaccinations were non-Lebanese (19). Similarly, vaccination seems a distant possibility for the 3 million undocumented citizens in Pakistan (20). And for indigenous communities, governments generally fail to provide disaggregated vaccination data and CSOs such as the National Indigenous Organization of Columbiathis are responding to this need by tracking the impact of COVID-19 specifically on indigenous peoples (21). Similarly, CSOs can ensure that COVAX beneficiary governments are held fully accountable for vaccine equity.

The COVID-19 pandemic has generated significant misinformation throughout the world and has led to vaccine hesitancy, as observed in 25% of the population of the United States of America (22). CSOs have become proficient in promoting behaviour change as evidenced by previous contraception and vaccination campaigns, and more recently for COVID-19 protocol implementation (23). They have great potential for gathering and accessing community level data on the cultural and social barriers to various health interventions, including vaccine hesitancy. Such data can inform the COVAX leadership in their efforts to devise better rollout plans in those communities. Using data-driven strategies which emphasize the value of vaccination and are cognizant of the cultural and religious customs and norms, CSOs can achieve behaviour and attitude change.

In the COVAX global vaccination campaign, serious monitoring of national governance programmes is crucial to ensuring equitable distribution (24). Gross mismanagement of COVAX-provided vaccines can cause delays that would lead to vaccines expiring and subsequent wastage, as reported in Guatemala (24). Evidence has shown how the Lebanese vaccine queue-jumping scandal led to public outcry and caused the World Bank and the International Committee of the Red Cross to start monitoring the process (25).

CSOs can ensure transparency in all official agreements between vaccine developers and COVAX by ensuring that licensing, procurement and manufacturing details, otherwise confidential, are open to independent evaluation by Gavi or CEPI and their competitors. The resulting transparency around contracts can foster accountability and make vaccination rollouts more effective nationally and internationally (14).

A CSO-COVAX alliance can promote vaccine manufacture through technology sharing, market shaping and raw materials trading (26). The Indian- and South African-led waiver for intellectual property patents on COVID-19 vaccines by the World Trade Organization is an example of how CSOs can focus their efforts to significantly increase manufacturing, reduce costs, remove barriers, and improve access to advanced technologies through COVAX (27).

Conclusion

CSOs have been at the centre of communal, regional, national, and global efforts to combat the COVID-19 pandemic and its associated pressures. While Gavi and CEPI, along with WHO, have taken up the challenge of vaccinating the world, meaningful integration of CSOs within COVAX can help in the realization of the agenda. Globally, CSOs have contributed to development efforts in multiple sectors and there is great potential for them to support COVAX and national vaccination programmes in achieving equitable vaccination. By concentrating on improved service delivery, monitoring, transparency, accountability, and behaviour change, and by focusing on marginalized people, CSOs can play an invaluable role in strengthening COVID-19 responses.

Acknowledgement

The authors would like to thank the secretariat of the Gavi CSO Steering Committee for their guidance.

Funding: None.

Competing interests: None declared.

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