Intended for healthcare professionals


Why are vaccination rates lower in low and middle income countries, and what can we do about it?

BMJ 2022; 378 doi: (Published 13 July 2022) Cite this as: BMJ 2022;378:e069506
  1. Hasan Mahmud Reza, professor of pharmacy1,
  2. Vaishnavi Agarwal, postgraduate associate2,
  3. Farhana Sultana, lecturer of sociology3,
  4. Razmin Bari, research assistant4,
  5. Ahmed Mushfiq Mobarak, professor of economics5
  1. 1Department of Pharmaceutical Sciences, North South University, Bashundhara R/A, Dhaka 1229, Bangladesh.
  2. 2Yale Research Initiative on Innovation and Scale (Y-RISE), New Haven, USA
  3. 3Department of Political Science and Sociology, North South University, Bashundhara R/A, Dhaka 1229, Bangladesh.
  4. 4College of Arts and Sciences, University of North Carolina at Chapel Hill, North Carolina, USA
  5. 5School of Management and Department of Economics, Yale University, New Haven, USA
  1. Correspondence to: A M Mobarak ahmed.mobarak{at}

Hasan Mahmud Reza and colleagues argue that access to vaccines enabled by predictable supply of vaccine doses and delivery to remote areas are critical for vaccine uptake in low and middle income countries

Covid-19 vaccine distribution has brought global inequities in healthcare access into sharp relief. In the first six months of vaccine distribution, over 90% of all doses were given to residents of high and upper middle income nations. Many other countries are now catching up, but less than 21.5% of Africans were vaccinated 18 months after vaccine development.1

There are competing narratives as to why vaccination rates in low and middle income countries are lagging behind. The governments of these countries and public health experts have argued that high income nations effectively hoarded covid-19 vaccines by pursuing direct purchasing agreements with vaccine manufacturers instead of buying through the Covid-19 Vaccines Global Access (Covax) initiative.234 The ensuing bidding wars, lack of effective global price regulations and barriers to local vaccine production, in their opinion, have hindered access to vaccines for low and middle income countries.5 By contrast, some drug company executives have claimed that high rates of vaccine hesitancy in low and middle income countries make allocation of greater vaccine stock to those countries inefficient, as doses would go unused, citing cases of unused vaccines reaching their expiration dates in Africa.6 Less frequently discussed are supply chain problems in low and middle income countries, which might be key limiting factors to widespread vaccination, especially in remote, rural areas.

These explanations are not mutually exclusive: both deficiencies in international supply and “last mile” infrastructure challenges to reach remote communities have hampered covid-19 vaccine distribution at different points during the pandemic.7 Further, a new vaccine must be socialised in any given population to overcome …

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