Vaccine Cooperation of LMICs across South and South-East Asia

ANKUR Shrestha

Abstract

SARS-CoV-2, commonly known as Covid-19, and its subsequent mutated variants have disrupted the entire world since the first virus case was confirmed in the Chinese city, Wuhan, in late December 2019. Though strict restrictions by governments worldwide have helped control the spread of the virus to some extent, vaccines are the only way to manage the crisis in the long run. As the virus does not discriminate against people based on their gender, age, race, or nationality, equitable distribution of vaccines needs to be at the forefront if we wish to minimize the damage from the ongoing pandemic. This paper compares the pandemic’s impacts on five LMICs and the efforts made by the respective governments to manage it. The document aims to learn from those LMICs and provide applicable and feasible policy interventions that Nepal can take better to manage the Covid-19 and other future public health crises.

Keywords

LMICs, COVID-19, vaccine, measurements, variants, response

Background

SARS-CoV-2, novel coronavirus or more commonly known as COVID-19, has devastated the world and held it in its firm grasp since the past year. On 30 January 2020, the World Health Organization Director-General declared the novel coronavirus outbreak a public health emergency of international concern (PHEIC), the World Health Organization’s highest level of alarm. At that time, there were 98 cases and no deaths in 18 countries outside China, among which four countries had evidence (8 cases) of human-to-human transmissions outside China (Germany, Japan, the United States of America, and Viet Nam) (Adhanom, 2020). The World Health Organization (WHO) reported that over 1 million cases of COVID-19 had been confirmed worldwide by 4 April 2020, a ten-fold increase in less than a month (WHO, 2020).

With the cases of COVID-19 rising, governments started to implement restrictions; in the beginning, barring international flights and later on also barring domestic travel. “Lockdowns”, restricting people from coming out of their homes for certain periods, became commonplace, as did mask mandates and social distancing. As the initial shock of the pandemic died down, and people got into living with these restrictions, the total number of cases started decreasing. The restrictions effectively controlled the pandemic to a certain extent, and as cases decreased, normalcy began to return with governments lifting restrictions.

The global economy, though, had been devastated due to the pandemic. Predictions made show that most countries posited a negative growth rate. The Global Economic Prospects on June 2021 estimated that the world economy shrunk by 3.5% in 2020, while a much worse decrease of -4.3% was estimated in January 2021. With everything shut down, the world moved into the virtual world. IT companies saw a large growth while the rest of the other industries posted losses.

In addition to restrictions, the fight against COVID-19 was helped by the excellent response of the medical community and the quick availability of vaccines. In July, China approved vaccines for limited and emergency use (Press Trust of India, 2020), while Russia approved them in August 2020 (Kramer, 2020). The United States FDA granted emergency use approval to Pfizer-BioNTech COVID-19 Vaccine on 11 December 2020 (FDA, 2021). The UK had already granted the vaccine temporary regulatory approval on 2 December 2020, becoming the first country in the Western world to approve the use of any COVID-19 vaccine (Reynolds et al., 2020). Similarly, other vaccines such as Oxford/AstraZeneca, Moderna, Janssen & Janssen all started rolling out, providing much-needed relief to the whole world and becoming a turning point for the fight against COVID-19. Vaccine rollout programs in the world also began massively, and although scepticism against vaccines remained around the world, vaccine mandates helped control the spread of the virus.

The arrival of variants was obvious. WHO has monitored new variants and marked any new dangerous variants as variants of concerns providing countries opportunities to be aware of the variant and try and restrict it before it spreads. However, these new variants have raised serious questions for the governments in how to deal with the pandemic. People have been hesitant to go back into lockdown as they face serious economic crises. At the same time, the rollout of vaccination programs has also begun to slow due to misinformation campaigns and the western model of “Freedom of Choice”. As of 31 October 2021, there were 247 million cases with 5 million deaths. Seven billion doses of the vaccine have been administered, while three billion people are fully vaccinated. Additionally, four variants of the SARS-CoV-2 virus have been deemed Variants of Concern (VOC), meaning those pose an increased risk to global public health. The new VOCs are named using the Greek alphabets with Alpha, Beta, Gamma, and Delta variants currently used for the four variants (WHO, n.d.).

It feels like COVID-19 is here to stay, and vaccines may be the only weapon that we have to fight the virus. Newer variants have called into question the efficacy of vaccines, but as we learn more about the virus, we can hope that more effective vaccines might be developed. The global economy is also forecasted to expand 5.6% in 2021, the fastest post-recession pace in 80 years, largely on strong rebounds from a few major economies. However, many emerging markets and developing economies continue to struggle with the COVID-19 pandemic and its aftermath (World Bank, 2021). If newer variants spread, this growth forecast will also surely shrink. Therefore, equitable access to vaccines through vaccine cooperation is the only solution in fighting this pandemic.

Vaccine Cooperation

Vaccine cooperation has been at the forefront of the response to the Covid-19 pandemic. LMICs have been fighting to win the vaccine battle in a battle to administer vaccines to everyone. Hotez (2014) argues that the historical and modern-day accounts of vaccine and vaccine diplomacy are remarkably great. However, these have not taken an overarching framework for its expanded role in foreign policy.

Vaccine diplomacy incorporates the crucial work of the GAVI Alliance and aspects of the WHO and other critical international organizations. It refers to nearly any facet of global health diplomacy that relies on the use or delivery of vaccinations (Hotez, 2014). What is happening today is a combination of exactly this, the COVAX initiative, bilateral donor agencies, donor countries, and vaccine manufacturing countries working directly to provide vaccines to LMICs. COVAX is an initiative coordinated by Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations (CEPI) and the WHO. COVAX, Gavi believes, will become a global solution to the pandemic, ensuring that people in all corners of the world will get access to the COVID-19 vaccines once they are available, regardless of their wealth (Berkley, 2020). Moreover, while donors and vaccine manufacturers usually have been found to use vaccines as a tool to enhance their diplomatic image, COVAX believes in ensuring equitable distribution to every nation.

Another important aspect of the global rollout of vaccines has been measuring the success of said rollouts. With vaccine shortages prevalent, high-income countries have invested and got priority to vaccines from manufacturing companies. In contrast, Low-Income countries and LMICs have continued to struggle in getting access. The consequences of unequal distribution of vaccines would be hundreds of thousands of deaths and huge economic losses globally due to a prolonged pandemic. Delays in vaccinating people in all the world regions bring the possibility of a resurgence of the virus, perhaps in an even stronger form, endangering the world once again (Dahal, 2020). Thus, measuring the success of vaccine cooperation in these countries becomes an important tool to understand what needs to be improved to get equitable access to the vaccines.

Study Framework

A study framework is necessary to understand the current situation of the COVID-19 pandemic and the subsequent status of access to vaccines and vaccine rollout plans of these countries. Understanding all these would help guide this study regarding the success of vaccine diplomacy in these countries.

For this study, LMICs have been chosen from South and South East Asia with comparatively similar economies. Five countries, three from South Asia and two from South East Asia, were chosen: Bangladesh, Cambodia, Lao PDR, Nepal, and Sri Lanka. These five countries have similar development status and are all in the LMICs categorical classification done by World Bank that met the criteria for this study. According to the IMF’s World Economic Outlook Database (2021), the average GDP and current prices for these countries for 2021 amount to 104.2406 billion USD.

The country with the highest Gross Domestic Product (GDP) among the five is Bangladesh at 352.908 billion USD, and the lowest is Laos at 20.44 billion USD. With the rise of new variants on a regularly occurring basis and the changes in data that occur every day, the study’s last date has been taken as 31 October 2021.

Identifying indicators to measure and assess the status is another important task in the study. With differences in the size of the population, access to health facilities, and quality of health services available among the five chosen LMICs, indicators have been divided into three different sections of measurement; Situational, Endeavour, and Prevention. According to their nature, some indicators have been reversed, meaning the higher the value of data, the worse the actual condition.

1. Situational Measurements

Situational measurements provide an overview of the current situation of the COVID-19 pandemic in the country. The number of infections, number of tests, and deaths all provide an outlook of the country’s healthcare system while also implying the readiness and preparedness of the country to deal with a pandemic. Taken along with government policy decisions during the pandemic, such as lockdowns, or travel bans, it can show the effectiveness of the government to keep the pandemic at bay. The total number of tests that a country does is representative of its responses to the pandemic. The number of tests together with the number of infections reflect the true status of the country as, at times, the number of infections could be less as the number of tests is low.

1. Number of Cases (R)^[1]
   1. Number of Tests
   1. Number of Deaths (R)

2. Prevention Measurements

Vaccinated population data is another important data source to measure the success of the country’s battle against the raging pandemic. Vaccination is the only solution to the current pandemic, and populations that have been partially vaccinated, fully vaccinated, and received booster doses provide different pictures. Partially Vaccination Population and Fully Vaccinated Population show vaccine willingness, and Booster Doses Administered can show countries’ ability to procure vaccinations and roll out vaccination programs.

• Vaccine Doses Administered
  • Partially Vaccinated Population
  • Fully Vaccinated Population
  • Booster Doses Administered

3. Endeavour Measurements

Measurements of the governments’ ability to procure vaccines show their proactiveness and international diplomatic strength. With shortages in vaccines due to time limitations, on top of the pressures faced by countries by the recurring waves and mutations in the COVID-19 virus, being able to procure vaccines is an important win. LMICs are also heavily reliant on donors to directly receive the vaccines through bilateral diplomatic efforts, facilities such as COVAX, or to get aid to buy the vaccines themselves. Thus, the number of vaccines received in donations compared to the number of vaccines secured through bilateral/multilateral agreements both become important measuring tools to evaluate the success of the LMIC’s vaccine efforts in battling the pandemic.

• Number of Vaccines Procured
  • Number of Vaccines Received in Donations
  • Number of Vaccines secured through bilateral/multilateral agreements
  • Vaccines procured from unknown sources

Per capita measurements of all these indicators provide a basis for comparison between the five LMICs chosen for study (except for indicators 3.2, 3.3, and 3.4, which is measured in terms of the total number of vaccines procured). Similarly, the number of vaccines procured from unknown sources is a relatively unsafe indicator. With gaps in trusted data sources, adjustments had to be made to keep some vaccines procured in the unknown sources indicator.

Scale and Score Development

While constructing a scale for the indicators, the global average of each indicator is taken as the mid-point. Deviations of 33.33% on both sides would be considered the average, while each 33.33% deviation from that point would move the scale from 0 to +1, +2, or -1, -2. These scores generate a comparative scale that is extremely helpful for us to compare the progress of LMICs in these indicators with each other.

Global Average (Mid-point)

-2                                         -1                                         0                     +1                                              +2

Additionally, taking the same scale but considering the average of LMICs instead of the global average can provide another level of understanding in our comparison. The scale and indicator scores would remain the same. However, the scale would change slightly to:

LMIC Average (Mid-point)

-2                                         -1                                         0                     +1                                             +2

The scale would be helpful to measure the overall performance of the country. It can then compare the chosen LMICs on the various indicators and understand how well they are doing against one another compared to the global average.

The indicators each are weighted according to:

The total weightage combined with the total possible score would provide a range of -14 to +14 for the countries, with 0 considered the World Average or the LMIC Average in the two scales.

Overall Scores

1. In comparison to the World,

The World comparison scores show a definite winner in responses to the pandemic. While Cambodia seems to be doing excellent in most of the indicators compared to the world, Bangladesh and Nepal seem to be struggling in all aspects. Specifically, among the worse two performers in Bangladesh and Nepal, Bangladesh has performed well in managing the number of Covid cases among its population. At the same time, Nepal does slightly better in testing and providing better health care to its infected population, as shown by the low number of deaths. Sri Lanka is towards the higher end of the scale, while Laos has a very similar score to the World Average. 

Looking at specific indicators, Laos has performed significantly better in controlling the number of cases and subsequently reducing the number of deaths. While, in the measurements of endeavours and preventions, Cambodia considerably outperforms the rest of the countries. It presents a great picture of the Cambodian government’s efforts in procuring vaccines and rolling them out to the general population, which has also been appreciated by UNICEF (UNICEF Cambodia, 2021).

2. In Comparison to LMICs,

Compared to other LMICs, the results are pretty similar except for Laos. Laos performs excellently and ranks among the best in the group compared to other LMICs. While the situational measurements are similar, Laos fares comparatively well in endeavour and prevention measurements compared to other LMICs. Cambodia ranks second among the five while Bangladesh ranks among the bottom two, albeit with improved overall scores.

Only Nepal performs substantially worse off than the average LMIC country among the five chosen countries. Looking at specific indicators, Nepal is slightly better off only in endeavour measurements while it is performing poorly in situational and prevention measurements. It shows that although the government has been active in procuring vaccines through various sources, it fails miserably in testing, controlling the pace of infection, and rolling out an effective vaccine program to administer it among its populous, in comparison to other LMICs.

Policies during COVID

The scores, representative of the efficiency of government responses in controlling the pandemic, show a huge variation among the five chosen countries. The policies implemented by the respective governments during the COVID-19 pandemic might explain why this is the case. The Oxford Covid-19 Government Response Tracker is a reliable source to understand the policy responses of different governments. Coded into 23 indicators, with four indices that aggregate the data into 0-100, the tracker provides an insight into how the overall government response was during the various pandemic stages. Among the indices, while other indices look at particular indicators, the Overall Government Response Index is important in understanding how the response of governments has varied overall indicators in the database, becoming stronger or weaker throughout the outbreak (Blavatnik School of Government, n.d.). The indices record the number and strictness of government policies. Although they cannot be interpreted directly as the appropriateness or effectiveness of a country’s response, they can provide some semblance of understanding.

The data from Oxford shows that the measures taken by the various governments during the pandemic were successful in helping them control the effects of the pandemic. However, learnings can be taken on where the interventions occurred. Through the policies taken, the governments can be categorized as either responsive, actively taking policies to limit the effects of the virus, or reactive, taking out policies only after the number of cases is drastically high. Additionally, more policies do not particularly represent better governance as the implementation of the policies matter. Therefore, the comparison of both of these provides an understanding of if and when policies were taken and if policy implementations were successful in decreasing the impacts of the pandemic.

Bangladesh and Nepal showed a high rise in COVID-19 cases throughout the measured period. Nepal has a distinct first-wave and second-wave period, while Bangladesh’s COVID-19 cases do not seem to have dropped significantly before rising again to new highs during the second wave.

The Overall Government Response Index in Nepal showed a general trend of greater response when the COVID-19 pandemic started, with a gradual decline in policy responses as the number of cases decreased during the first wave. The second wave seems to have caught Nepal unawares, with the number of cases rising dramatically in a very short period. The government subsequently took out policies to counter its effects. The response trend seems similar to the first wave, where the response index decreased as the number of cases in the second wave decreased.

Bangladesh seems to have dealt with the pandemic similarly to Nepal, wherein the first wave was controlled better with a high response from the government. In contrast to Nepal, the government response index does not decrease during the decreasing phase of the number of cases in the first wave. The second wave similarly seems to begin with an increased response leading to a slight decrease in cases. However, after a slight decrease in response, the pandemic raged massively, and the number of cases dramatically increased, reaching around 16,000 cases per day. The government response seems to have worked in the later parts bringing the number of cases down towards the end of October.

Source: (Hale et al. 2021)

Notes: The scale for the total number of cases is different for each country. The time and scale for Government Response Index for all the countries is the same.

Cambodia, Laos, and Sri Lanka were excellent in controlling the first wave of the pandemic in their respective countries. The graphs show that the government response was timely, high, and properly implemented. Cambodia seems to have taken stricter measures beginning from February 2021 as the number of cases began to increase, reaching an all-time high of around 1100 cases per day. The government response has remained similar after then while the number of cases seems to be fluctuating but decreasing towards the end of our measuring period.

Laos is similar to Cambodia, with very strict measures taken at the beginning of the pandemic, which helped limit its number of cases during the first wave. Even during the second wave, when the number of cases started to rise, immediate actions were taken to try and prevent the spread, which did control the spike. However, as government response dwindled, the number of cases increased again. With the number of cases reaching a record-high of 952 cases per day on 25 August 2021, the Laos government has again responded with stricter measures, but the pandemic does not seem to be currently stopping.

Sri Lanka was excellent in responding to the first wave, but the second wave has taken it by storm. Cases started rising to highs of 3,000 around May and June 2021 while the government responded to the increase. Even with a higher government response, Sri Lanka could not control the pandemic. The pandemic reached an average of around 3000 cases per day from April to September, with daily cases sometimes reaching upwards of 11,000. The second wave seems to be slightly subsiding as daily cases have fluctuated around 500 to 1,000 in October.

Policy Recommendations and Way Forward

The presented data provide a bleak outlook into Nepal’s situation and its response to the COVID-19 pandemic compared to the world, other LMICs, and the five chosen countries. The policies taken during the pandemic by the other chosen countries can be a reflection and learning into what Nepal can do to respond to the pandemic, in the beginning, during, and after the pandemic waves. With the new variant, Omicron, starting to spread worldwide, lessons learnt can be used to deal with the potential new wave.

1. Address issues of liquidity crisis going on in the current economy. Nepal Rastra Bank has issued Repurchase Agreements (Repos) to increase liquidity (Fiscal Nepal, 2021). However, other additional measures are also required as Nepal still faces a liquidity crunch even after the pandemic has receded.
2. Engage the community to increase citizen participation in COVID prevention as well as increase vaccine acceptance
3. Address pre-existing inequities and the disproportionate impact of COVID-19 on marginalized and vulnerable populations (WHO, 2021).
4. Increase preparedness in taking localized measures such as movement restrictions, mask mandates or, in extreme cases, short-period lockdowns.
5. Allocate budget for prevention, control, and containment measures and health emergency funds.
6. Limit outward remittances while providing exemptions for inward remittances to maintain the balance of payments.
7. Provide stimulus packages and tax exemptions to affected industries, salary support to the public and private workers, deferral of tax payments, and temporary reduction in prices of government services (IMF, 2021).

References:

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Annexe:

The following things need to be considered before taking a look at the data used in the report:

1. Sri Lanka and Laos Data are from 28 October 2021, while other data is from 31 October 2021. The latest data for October has been used in all cases.
2. For Vaccinations,
   1. Total Vaccinations means the total number of doses administered.
   2. People vaccinated means the total number of people that received a dose of a vaccine (1 or 2)
   3. People Fully Vaccinated means the total number of people that received a full dosage of a vaccine (1 or 2 depending on the vaccine)
   4. People Only Partially Vaccinated = People Vaccinated – People Fully Vaccinated.
3. Wherever doses administered (plus wastage) is greater than the total number of reported deliveries for a country, the difference between the doses administered (plus wastage) and the doses delivered (through COVAX, AVAT, donations, and/or bilateral/multilateral agreements) is categorized as “Unknown”.
4. Vaccination Data Source:
   1. Mathieu et al. (2021) and UNICEF (2021).
   2. For Nepal, missing vaccination data was added from Nepal Press (2021) and WHO Nepal (2021).
5. Testing Data Source: Hasell et al. (2020)
6. For Cambodia, the Number of Test Data was taken from Cambodia Coronavirus Situation Report #70 (WHO Western Pacific Region, 2021).
7. Data for the Total Number of Tests for the World and LMICs is missing as every country does not report the number of tests done. Therefore, available data were aggregated to get an approximation. The indicator, therefore, may not truly represent the actual status of tests.

Data and scores for the various indicators:

1 Situational Measurements

1.2. Number of Cases

Type: Reserved

Unit: Percentage of population

Weightage: 1

1.2. Number of Tests

Type: Normal

Unit: Percentage of population

Weightage: 1

1.3. Number of Deaths

Type: Reserved

Unit: Percentage of total cases

Weightage: 1

2. Endeavour Measurements

2.1. Number of Vaccines Procured

Type: Normal

Unit: Percentage of population

Weightage: 1

2.2. Number of Vaccines Received in Donations

Type: Normal

Unit: Percentage of total Vaccines procured

Weightage: 0.33

2.3. Number of Vaccines secured through bilateral/multilateral agreements

Type: Normal

Unit: Percentage of total Vaccines procured

Weightage: 0.33

2.4. Vaccines procured from unknown sources

Type: Normal

Unit: Percentage of total Vaccines procured

Weightage: 0.33

3. Prevention Measurements

3.1. Vaccines Doses Administered

Type: Normal

Unit: Percentage of population

Weightage: 1

3.2. Only Partially Vaccinated Population

Type: Normal

Unit: Percentage of population

Weightage: 0.33

3.3. Fully Vaccinated Population

Type: Normal

Unit: Percentage of population

Weightage: 0.33

3.4. Booster Doses Administered

Type: Normal

Unit: Percentage of population

Weightage: 0.33