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COVID-19 vaccine success is cause for optimism but the rollout may take years in poorer countries. Here are the major challenges they face.

COVID-19 vaccine success is cause for optimism but the rollout may take years in poorer countries. Here are the major challenges they face.
A young girl waits to be tested for COVID-19 in the Kibera slum in Nairobi, Kenya. Tony Karumba/AFP via Getty Images Throughout November, the developed world has celebrated milestones in the race for a COVID-19 vaccine. But lower-income countries may have to wait for years before they can vaccinate the majority of their population. Cost…

Kenya Covid

A young girl waits to be tested for COVID-19 in the Kibera slum in Nairobi, Kenya.

Tony Karumba/AFP via Getty Images

  • Throughout November, the developed world has celebrated milestones in the race for a COVID-19 vaccine.
  • But lower-income countries may have to wait for years before they can vaccinate the majority of their population.
  • Cost and availability, combined with transport, storage, and distribution issues pose serious problems. 
  • Visit Business Insider’s homepage for more stories.

Every American could have access to a COVID-19 vaccine by the end of April. This is not the case, however, for the majority of people in low-income countries, who may have to wait years longer.

As drugmakers ramp up their efforts, governments across the world are negotiating deals to buy prospective COVID-19 vaccines – but this “frenzy of deals” could prevent poorer countries from accessing enough vaccines for most of their population until 2024.

This is according to researchers at Duke University’s Global Health Innovation Center. Scientists at the center’s Launch and Scale initiative have looked into the barriers that could affect access to a vaccine – and found a myriad of factors.

It isn’t just the cost and availability of vaccines that is pricing lower-income countries out. Many of the most vulnerable segments of society also lack the infrastructure to transport, store, and distribute the vaccine.


Pfizer, Moderna, and AstraZeneca all marked major milestones in the global race for a vaccine earlier this month.

However, when vaccines are approved, it takes time to manufacture doses.

The leading vaccines use several different technologies, such as mRNA, recombinant protein, and adenoviruses. Each of these has its own complex manufacturing process, meaning the vaccines take a long time to make.

It could take three to four years to produce enough vaccines to immunize the global population, the researchers found. Wealthier countries may be able to issue multiple doses of the vaccine to their populations before the immunization becomes widespread in poorer countries.

India covid

A health worker wearing protective gear collects a swab sample from a resident during a COBID-19 coronavirus screening at a civic clinic in Dharavi slums, in Mumbai.

Indranil Mukher/AFP via Getty Images

Even if drugmakers heavily invest in their manufacturing facilities, “there is a limit to how much global vaccine manufacturing capacity can expand in the next few years,” said Andrea Taylor, the lead analyst for Launch and Scale.

“High-income countries are making deals with major vaccine developers who are in turn reserving the lion’s share of the world’s manufacturing capacity to meet those commitments,” she said. 

Experts are also worried about a shortage of glass vials to store the vaccines in.


The vaccine will also be expensive to buy. Pfizer charged the US $19.50 per dose for the first 100 million doses, its partner company BioNTech said. Each person requires two doses of the vaccine, putting its cost at $39 per person.

Moderna, meanwhile, plans to charge from $25 to $37 per dose.

Brazil covid

A worker cleans the Botafogo Favela in Rio de Janeiro, Brazil.

Fabio Teixeira/NurPhoto via Getty Images

Some drugmakers, however, have promised to guarantee lower-income countries can also have access to the doses.

AstraZeneca is reserving 400 million doses of its vaccine for low- and middle-income countries, and said it would sell its vaccine at cost during the pandemic for between $3 and $5 per dose. But this no-profit guarantee could expire before July 2021.

Johnson & Johnson also said it would not profit from sales of its vaccine to poorer nations, and China said its vaccine would be “made a global public good.”


Since May, wealthy countries have been placing pre-orders for potential vaccines.

To prevent wealthier countries from snatching up vital doses of the vaccine, the World Health Organization (WHO), Gavi, and the Coalition for Epidemic Preparedness Innovations (CEPI) launched a scheme called Covax in April.

Countries sign up to access an equal share of successful vaccine candidates, meaning that the doses are shared among richer and poorer countries. The scheme aims to provide lower-income countries with enough doses to cover 20% of their population, and so far, 184 countries have signed up.

“For lower-income funded nations, who would otherwise be unable to afford these vaccines, as well as a number of higher-income self-financing countries that have no bilateral deals with manufacturers, Covax is quite literally a lifeline and the only viable way in which their citizens will get access to COVID-19 vaccines,” the companies behind the initiative said.

As of November 11, the Duke University researchers had found no evidence of any direct deals made by low-income countries, suggesting that they would be “entirely reliant on the 20% population coverage from Covax.”

Despite being a “phenomenal effort at international collaboration,” Covax is “seriously underfunded,” Ted Schrecker, professor of global health policy at Newcastle University Medical School, told Business Insider.

Some countries, notably China and the US, haven’t joined. The US could eventually control 1.8 billion doses, the Duke University researchers found, or about a quarter of the world’s near-term supply – and none of this would be shared with lower-income countries via Covax.

Furthermore, many wealthy countries which have signed up to the scheme, including the UK, EU, and Canada, have also struck “side-deals” with pharmaceutical companies to guarantee their supply, the Duke University researchers found.

This “undermines” Covax, “drives inequality and threatens to prolong a global pandemic,” Duke University’s Elina Urli Hodges said. 


Distributing the vaccines globally will be a mammoth task. 

Cargo airline execs have already warned that getting a COVID-19 vaccine to everyone on Earth could take up to two years, saying that it could be “one of the biggest challenges for the transportation industry.”

Some require ultra-cold chain storage which requires significant investment. Pfizer’s vaccine, for example, has to be transported at -94 degrees Fahrenheit through a system of deep-freeze airport warehouses and refrigerated vehicles using dry ice and reusable GPS temperature-monitoring devices.

Even when the vaccines do make it to low-income countries, they might lack the transport links and road networks to distribute the doses to everyone in need.

Ethiopia rural

Rural farming communities, like this one in the valleys of Debre Berhan, Ethiopia, may not have access to a local health center.

Edwin Remsberg/VWPics/Universal Images Group via Getty Images

Specially-adapted vehicles may also be needed, Alison Copeland, professor of human geography at Newcastle University, told Business Insider. Lower-income countries may not be able to afford them, however. 


When doses do reach local communities, vaccines such as Pfizer’s still have to be kept in cold-chain storage. Even some of the most reputable US hospitals, such Minnesota’s Mayo Clinic, lack adequate facilities to store the vaccine, leading to a scramble for hyper-cold freezers – and in lower-income countries, this access to ultra-cold freezers is even less likely.

After the shots reach health centers, they can be thawed in a regular fridge – but they have to be injected within five days.

In many low-income countries, only metropolitan areas are well-resourced, Schrecker explained, and some villages and informal settlements may not have a working fridge.

Even if communities are able to afford storage for the vaccine, they may not have working electricity, Copeland explained.

Bogota slum

Slums such as Ciudad Bolivar in southern Bogota are unlikely to have access to the hyper-cold storage systems needed for the vaccine.

Juan Barreto/AFP via Getty Images

And the various vaccine candidates being developed by drugmakers have different storage needs, making it difficult for countries to know how to prepare and whether to invest in cold-chain facilities.

AstraZeneca’s vaccine, for example, can be stored, transported, and handled at normal fridge temperatures of between 36 and 46 degrees Fahrenheit for at least six months.

Once it reaches its destination, it can be “administered within existing healthcare settings,” AstraZeneca said, rather than requiring investment in expensive ultra-cold storage equipment.

Moderna’s vaccine can also be transported and stored at fridge temperatures, but only for a month.

Philippines covid

Drivers queue to be swab tested for COVID-19 in Manila in the Philippines.

Ezra Acayan/Getty Images

Pfizer is also looking into alternatives to solve the storage problem. The US drugmaker is looking into developing a second-generation coronavirus vaccine in powder form, which would only need to be refrigerated, not deep-frozen. This could be developed in 2021, Pfizer’s CEO told Business Insider, but it’s currently uncertain.

Health centers and infrastructure

Given that urban areas have the most transport infrastructure, they also have the majority of healthcare infrastructure, too.

Although many African countries improved their health services during the Ebola pandemic, most rural communities remain isolated, Schrecker told Business Insider.

Alongside the vaccine doses themselves, other supplies are needed to carry out the vaccinations. For example, countries need to ensure they have syringes available in time for the arrival of vaccines, Taylor said.

DR Congo vaccine

A girl gets inoculated with an Ebola vaccine in Goma, the Democratic Republic of the Congo.

Pamela Tulizo/AFP via Getty Images

Low-income countries may also have to launch vaccination drives where health literacy is poor. While childhood vaccinations are becoming increasingly common in low-income income countries, people of all age groups, especially the elderly, will need the COVID-19 vaccine. This will require the counties to carry out major vaccination education campaigns, Taylor and Copeland both said.

Another challenge is that most vaccines require two shots, including Pfizer’s, which needs two shots injected three weeks apart. In rural parts of India, where people are harder to contact or may live a long way from vaccination centers, some people don’t come back for a second shot, public health experts told Bloomberg.

The country will also have to roll out mass paramedical training to teach healthcare staff how to administer the two-shot doses, Pankaj Patel, chairman of drugmaker Cadila Healthcare, told the publication.

Cause for optimism

Despite the hurdles that lower-income countries face, mass global vaccination is still a possibility.

After their mid-November summit, the G20 states said they will “spare no effort to ensure their affordable and equitable access [to COVID-19 diagnostics, therapeutics, and vaccines] for all people.”

Wealthier countries could also be motivated to provide aid to ensure all countries have access to a vaccine, because of herd immunity beliefs. 

“In order to control the virus, we need worldwide herd immunity, so between 60% and 72% of the population need immunizing,” Copeland told Business Insider. “This will hopefully be enough incentive for richer countries to help out.”

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