When it comes to the COVID-19 vaccination deployment, we did things wrong and missed the mark at a global level. This resulted in a highly inequitable vaccine deployment. Although more than 5.7 million doses have been administered globally, 73 percent have been administered in just 10 countries, and only three percent of people in Africa have had inoculations as of September 2021 .
The global health community is working to redress these stark inequities. The ‘mark’ or goal set by World Health Organisation (WHO) is to reach 40 per cent of people worldwide by the end of 2021, and 70 per cent in the first half of 2022. Goals have also been set by countries. For example, Kenya intends to quadruple the number of people vaccinated on a daily basis over the next three months (October to December). Other lower-and-middle-income countries (LMICs) have similar acceleration goals.
In Kenya and other LMIC contexts, vaccine deployment has followed a similar approach to high income countries. Firstly, vaccinate people at the frontline delivering basic services - health workers, teachers and other essential workers. Next, vaccinate older age groups and people with pre-existing conditions. An urban focus has also prevailed, in an effort to restart economies, and facilitate safer movement within congested urban centres. Age has been progressively lowered to accommodate a greater proportion of the population as vaccines become increasingly available.
In Kenya and other LMIC contexts, vaccine deployment has relied upon public and some private health infrastructure. Deployment has also been accelerated through vaccination drives and “pop up” sites. Erratic supply of vaccines has in part dictated such strategies, given the need to rapidly vaccinate populations and use vaccines before they expire. However, these strategies, while expedient, draw health personnel away from other duties, including essential services. They are expensive, and may not be equitable. For example, already Kenya is seeing a gender divide in those fully vaccinated (55% male, 45% female) as reported in mid-September 2021 .
As LMICs look to progressively vaccinate their populations, they will need to consider more sustainable “keep up” strategies. These should enlist all public and private health infrastructure, inclusive of primary care settings and paramedical personnel. Strategies should learn from traditional immunization programs, which have traditionally struggled to reach the hard-to-reach. Populations may be left behind not by choice, but by circumstance, due to socioeconomic, geographic, or other demographic characteristics.
Inequities in vaccine deployment are a governance failure, at global level [3-5]. Failure can be averted at country level. This is a matter for government, working to ensure that ingrained inequities do not become the bedrock of COVID-19 vaccine deployment plans. This is a matter of health governance and should enlist a “whole-of-government, whole of society” approach to vaccine deployment, as advocated for by WHO.
Health governance is intended to promote joint action of the health and non-health sectors, of public and private actors and of healthcare consumers for a common interest. It necessitates making critical decisions to manage and distribute scarce health resources such as COVID-19 vaccines based on the principles of health equity without distinction of race, religion, political belief, economic or social condition.
To aid a “whole-of-government, whole of society” approach, the WHO Country Connector has developed an emergency actions checklist and diagnostic for vaccine deployment. This seeks to guide a resource-based approach and build core governance competencies for the COVID-19 response. The WHO Country Connector encourages countries embarking on ambitious acceleration goals to diagnose their approach to vaccine deployment and ensure this is calibrated to circumstance, of those most likely to be left behind.
We also encourage learning from experience, of market and governance failures that have marked the COVID-19 emergency response. This has exposed the need for more robust governance of health systems. This is good for both the private and public sectors, but most importantly, consumers, including those most likely to be left behind. In times of crisis, real solutions do not benefit from divisive tactics, but arise through collective action and responsibility, that places the ‘public’ at the centre of health systems. These efforts should facilitate market reliability and build trust between consumers and the whole health system.
 United Nations. ‘We can end the pandemic’, UN chief says in new call for global vaccine plan. UN News. https://news.un.org/en/story/2021/09/1100742
 As of September 13th, 2021, the uptake of the second dose among those who received their first dose was 36 per cent with the majority vaccinated being males at 55 per cent while females were 45 per cent.
 Lal A, Erondu NA, Heymann DL, Gitahi G, Yates R. Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage. Lancet. 2021;397:61-7.
 Binagwaho A, Mathewos K, Davis S. Equitable and Effective Distribution of the COVID-19 Vaccines - A Scientific and Moral Obligation. Int j health policy manag. 2021.
 Urgent needs of low-income and middle-income countries for COVID-19 vaccines and therapeutics. Lancet. 2021;397:562-4. doi: 10.1016/s0140-6736(21)00242-7.