Intended for healthcare professionals

Opinion Covid-19

Vaccine inequity and hesitancy persist—we must tackle both

BMJ 2023; 380 doi: (Published 03 January 2023) Cite this as: BMJ 2023;380:p8
  1. Jeffrey V Lazarus, head of the health systems team at the Barcelona Institute for Global Health, associate professor at the Faculty of Medicine, University of Barcelona, Barcelona, Spain, and senior scholar1,
  2. Salim S Abdool Karim, director of Centre for the AIDS Programme of Research in South Africa and professor of global health2,
  3. Carolina Batista, head of global health affairs, member of the Drugs for Neglected Diseases initiative access committee, and former elected member of the international board of Médecins Sans Frontières3,
  4. Kenneth Rabin, senior scholar1,
  5. Ayman El-Mohandes, dean1
  1. 1CUNY Graduate School of Public Health and Health Policy, New York, USA
  2. 2Columbia University, New York
  3. 3Baraka Impact Finance
  1. Follow the authors on Twitter: @JVLazarus, @ProfAbdoolKarim, @carolin51299534, @CUNYSPH

Since the start of the covid-19 vaccination rollout, repeated concerns have been raised about global vaccine inequity.12345 In an April 2022 commentary in BMJ Global Health, we called specific attention to the importance of minimising vaccine wastage as a strategy for reducing vaccine inequities.6 While much of the world now has access to vaccines, both the United Nations’ Data Futures Platform and the World Health Organization maintain that regional access to vaccines and their global uptake remain issues.78

Covid-19 persists as a threat to public health despite the desire of many governments to move on from it. In fact, WHO still considers the world to be in the emergency phase of the pandemic. Unfortunately, inequitable access to vaccines remains a challenge, especially in low and middle income countries.9 Just 24.6% of people in low income countries have received at least one vaccine dose.10

The issue is even more vexing in regions where vaccines are readily available, suggesting that low uptake is partly due to vaccine hesitancy that may be fuelled by the unusual combination of reduced levels of mortality and intense anti-vaccination propaganda. These campaigns sow distrust in the science underpinning the vaccines, the authorities recommending their use, and even the seriousness of getting covid-19. Mistrust of governing bodies and drug companies contributes to vaccine hesitancy, and marginalised communities may avoid vaccination because of historically negative experiences with healthcare or a lack of effective health messaging.1112

Hesitancy and uptake

In November 2022 a collaboration of 386 multidisciplinary experts across 112 countries proposed 57 actionable recommendations to help end the covid-19 pandemic.13 One of the top three recommendations, which built on an urgent call in TheBMJ earlier in the year, states that all countries should adopt a “vaccines-plus” approach.14 This includes a combination of covid-19 vaccination and other prevention measures, such as wearing a face mask, improved ventilation of buildings, effective new treatments for infected people, and financial incentives such as support measures for affected individuals and their families.

Adopting this approach requires vaccines to be available in sufficient quantity and quality in all regions of the world, for a coordinated global effort. This approach will require substantial changes in intellectual property law, development of more widespread and appropriately regulated manufacturing capability, and improved logistical coordination. Developing new, more effective, longer lasting vaccines must also be a priority.

However, greater access, availability, and improvements to vaccines alone are insufficient. Decision makers must also take steps to increase vaccine uptake. While some of the world is at risk of low access to vaccines, all the world is at risk of low uptake.

Vaccine hesitancy is a key underlying factor in low uptake. Therefore, rebuilding trust in the vaccines and the health authorities promoting them must be a priority, and vaccination messaging should be retooled to explain more clearly the efficacy and limitations of current vaccines in reducing SARS-CoV-2 transmission and the severity of covid-19. This includes tailoring messaging to ensure that as many people as possible around the world have received the vaccine and to fully engage trusted local leaders and organisations in the process.

To tackle vaccine access where it remains low we need governments, industry, and health systems to minimise closed and open vial vaccine wastage and anticipate procurement and supply management needs. Affordability is a barrier to vaccine access. Global organisations should negotiate the donation of excess doses and sharing of technologies that enable manufacturers in lower income countries to develop vaccines and adequately store them.15

It is profoundly disappointing that today, three years into the pandemic, these issues have still not been dealt with systematically.16 Global trade and health organisations should collaborate immediately to tackle the legal and technical issues that continue to constrain the affordability and availability of safe, highly effective vaccines.

Vaccines remain the central component of a vaccines-plus approach to ending the global health threat presented by covid-19. If we want a safer world we must address these issues and challenge vaccine hesitancy—including the burgeoning spread of vaccine misinformation—with a level of urgency that has been sadly lacking in most countries.


  • Competing interests: JVL reports research grants from AbbVie, Gilead, and MSD, and speaker fees from Novavax and Novo Nordisk, outside of the work discussed here. SSAK reports research grants from Janssen and the National Institutes of Health for covid-19 vaccine trials, as well as meeting honorariums from Sanofi. CB, KR, and AEM have read and understood BMJ policy on competing interests and declare no competing interests relevant to this article.

  • Provenance and peer review: Commissioned, not externally peer reviewed.

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