The race to vaccinate against COVID-19 has exposed wide disparities in vaccine access and distribution on every level—global, regional, and local. While international debates over intellectual property, vaccine nationalism, and global access have taken center stage, a close look into domestic vaccine access and distribution in the Middle East and North Africa and relevant international legal standards is critical.
Distribution progress within the MENA region has been far from uniform, as each country faces its own political, social, and economic hurdles to procurement and distribution. To date, the wealthier Gulf countries have managed to vaccinate a reported 35 to 65 percent of their populations with at least one dose, with Qatar and UAE fully vaccinating upwards of 70 percent. Meanwhile, Jordan, Morocco, and Tunisia have only been able to vaccinate 30 to 50 percent of their populations with at least one dose, and Lebanon falls slightly behind at 20 percent. The remaining MENA countries all fall below a shockingly low 13 percent, with Sudan, Syria, Iraq, and Yemen each below 2 percent.
Vaccines are slowly arriving to the region, primarily through the COVAX Facility—Jordan and Libya have so far been the only recipients to receive even half of their allocated doses. International finance institutions have supported the development of procurement plans and provided vaccine financing for a select few nations, as is the case of Lebanon. Others have received donations from the European Union, the United States, and the Gulf countries. The UN and World Health Organization have provided implementation assistance, most notably to Syria and Yemen, and UNHCR has assisted with the rollout in refugee camps across the region.
What has distribution looked like so far?
While some governments such as Lebanon, Sudan, and Tunisia have publicly released theoretically transparent and detailed methodologies indicating how individuals are prioritized, others like Egypt, Jordan, and Iraq have only provided vague information. Jordan’s registration website, for instance, informs users that prioritization is “automatically assigned based on risk, benefit, and justice, depending on factors such as age, work sectors, chronic diseases, and others,” without providing further detail. The vast majority of governments, however, have committed to prioritizing health workers, the elderly, and those with preconditions. Some countries, such as Morocco and Algeria, have gone as far as to explicitly prioritize security forces as well.
In most countries, certain requirements built into national action plans impede universal access. Registration systems are via state website in most countries, requiring internet access. Some such as Egypt, Lebanon, and Algeria have now allowed registration via telephone hotline or in-person at local hospitals and municipality centers, but participation in the overwhelming majority of national rollouts necessitates a phone capable of receiving text messages and documents. Identification requirements are present in all countries to varying degrees, whether it be presenting an ID at the time of registration or vaccination or at minimum a disclosure to the state that one does not possess legal residency.
Significant gaps remain in many countries between national action plans in policy and in practice that also contribute to inequitable access. In Lebanon and Egypt, for example, private actors who have been permitted to deal directly with pharmaceutical companies have procured and distributed vaccines with their own prioritization schemes that are not necessarily in line with the nationally mandated plan and instead facilitate access based on wealth, political affiliation, or formal employment. Moreover, while some rollouts have been able to target and reach rural areas at least to some extent, such as in Jordan, geography remains a significant barrier to access in Upper Egypt and conflict areas such as Syria, Yemen, and Gaza. National action plans have also been undermined by corruption scandals in Egypt, Lebanon, Palestine, and Iraq, where, contrary to the nationally mandated plans, the political elite received vaccines ahead of officially prioritized groups.
Migrants and refugees, poor households, and people with disabilities have faced barriers to access across the board. While countries such as Jordan and Sudan have made strong efforts to integrate migrant, refugee, and internally displaced communities into their plans and others such as Lebanon have even held targeted vaccine drives, a wide variety of barriers impede access for these populations. Identification requirements work to discourage—and in some cases prohibit—the integration of these populations into the vaccine rollout. Moreover, language barriers and physical inaccessibility to these communities add additional impediments both to vaccine distribution and access to information. For migrant domestic workers in countries such as Lebanon, where some employers restrict their movement and retain control over their identification documents, mobility may prove an even greater barrier to access. While government-distributed vaccines are free of charge, the rise of private sector distribution in countries such as Lebanon and Egypt means those who can afford to purchase a vaccine will receive their doses before those waiting on government-provided vaccines. Vaccines secured privately by politicians and distributed based on political affiliation widen these gaps even more. Moreover, people with disabilities have been largely left out of the conversation—Jordan is the only country to have explicitly and publicly addressed vaccination access for those with disabilities from the early days of the rollout.
Countries facing ongoing armed conflict such as Syria, Yemen, and Palestine do not have the capacity or infrastructure for effective vaccine rollouts. Conflicts in Syria and Yemen have left the health systems physically crumbling and without the means to facilitate mass distribution, especially as hospitals continue to be demolished in targeted attacks. Weaponization and strategic debilitation of aid in Syria and the West Bank has intentionally left thousands of individuals deemed by the state as opposition or threats precariously without access. In each of these countries, geography is a primary variable influencing vaccine access, which is dependent on who retains control of a given area.
Even in areas without active conflict, previously weakened infrastructure resulting from compounding economic, social, and political crises has only been exacerbated by the pandemic and vaccine rollout. Tunisia’s healthcare system was already at capacity, facing major supply shortages, and doing little to alleviate poor working conditions for frontline workers before the pandemic; now, Tunisia lacks the capacity or manpower to effectively implement any form of national plan. In Iraq, healthcare workers have faced attacks by officials and private citizens alike, frustrated with the state of the healthcare system. In Lebanon, mass infrastructure failures and electricity shortages have forced officials to cancel mass vaccination drives for days at a time. Meanwhile, the economic crisis has driven one third of healthcare professionals to leave the country.
Even when vaccines are available, vaccine hesitancy remains high across the board, largely a product of distrust in state institutions and lack of information. One survey indicates that vaccine hesitancy in Egypt has more than doubled over the past year, from 11 percent responding they would not seek the vaccine in July 2020 to 26 percent at the end of March 2021. High hesitancy has also been documented in Sudan, Lebanon, Iraq, and Jordan, among others.
MENA governments on the whole have not been forthcoming with vaccine statistics and the details of public-private business dealings to procure vaccines—Egypt is one country that has actively restricted access to this data. Lebanon is the only nation to “open source” vaccine data, although people have little trust in its source. Linguistic and technological barriers also exist in accessing what little state-provided information there is. Registration platforms and online information are available in Arabic and occasionally also either English or French. However, for someone who lacks literacy, this information is inaccessible. Moreover, information is primarily dispersed online, culminating in differential access based on age, education level, wealth, and ethnicity.
Even when information is made accessible, some citizens do not trust the source enough to believe it and search out information through less-than-reputable channels, particularly when it comes to vaccine efficacy and risks. Governments such as Egypt and Yemen have attempted to combat misinformation and disinformation by publicizing the vaccination of high-ranking officials. However surrendering personal data to the state remains a major reason for vaccine hesitancy, notably for migrants, refugees, and those associated with political opposition or those deemed threats to the state who fear retribution, deportation, or imprisonment.
What should MENA governments be doing?
The International Covenant on Economic, Social, and Cultural Rights (ICESCR) provides the most comprehensive international legal standards for vaccine access and distribution under the frameworks of the right to health and the right to enjoy the benefits of scientific progress. Under the ICESCR, MENA governments must ensure, for all within their borders, that COVID-19 vaccines are available, accessible, acceptable, and of good quality. States that have the resource capacity to do so should also provide economic, scientific, and technical assistance to countries struggling to accomplish this on their own.
“Availability” requires that governments ensure that functioning health care facilities, distribution services, and the vaccine itself are available in sufficient quantities to all. This is especially relevant to marginalized and vulnerable groups, such as refugees, migrants, prisoners and political opposition groups, people with disabilities, and those who live in rural areas.
“Accessibility” applies not just to vaccines, health facilities, and distribution centers but also to information regarding the benefits, risks, and procedures for obtaining vaccines. Under the ICESCR, accessibility has four distinct dimensions: non-discrimination, physical accessibility, affordability, and information accessibility.
Firstly, vaccines must be accessible, both on paper and in practice, to all segments of the population and especially those who are vulnerable or marginalized. Even for the few MENA countries who are not signatories and therefore not bound by the ICESCR, this non-discrimination obligation as it pertains to the right to health is echoed in a slew of other international legal standards from the Convention on the Rights of Persons with Disabilities (CRPD) to the Refugee Convention.
Secondly, vaccines must be physically accessible, meaning within safe physical proximity, for the entire population, including for those with disabilities and in rural or hard-to-reach geographic areas.
Thirdly, vaccines should be affordable to all, especially poor households. This obligation applies to vaccines distributed both publicly and privately, and governments have the responsibility of ensuring private sector actors abide by these standards.
Finally, the information surrounding vaccines should be presented in formats and through channels that are accessible to all, regardless of literacy, disability, or access to technology. This encompasses the right to seek, receive, and also impart information concerning health issues and the vaccine, and MENA governments should not limit feedback or criticism from experts, medical professionals, journalists, or any other members of the public.
“Acceptability” requires distribution to be implemented in a way that is consistent with medical and ethical standards, respects the privacy and confidentiality of citizens, and guarantees their autonomy and informed consent. Moreover, vaccine-related information should be explained and vaccines should be disseminated in a way that facilitates their acceptance across different social and cultural contexts.
“Good quality” requires states to provide access to the most advanced, up-to-date, and generally accepted vaccines. Moreover, this prong also requires governments to ensure there are skilled medical personnel, hospital equipment, and scientifically approved and unexpired vaccines.
In addition to guaranteeing these components of vaccine access and distribution, the ICESCR also obligates MENA governments to ensure that private sector actors comply with these same standards and do not impede anyone’s equitable access to the right to health.
While the ICESCR takes into account a state’s available resources as they impact the ability to effectuate these rights, even those with limited resources are still required under international law to meet certain basic requirements in ensuring equitable vaccine access and distribution. This means that despite the global inequalities in resource distribution, MENA governments are still obligated to ensure nondiscriminatory access; equitable distribution of facilities, vaccines, and information about vaccines; and the implementation of a national action plan that is developed in a participatory and transparent manner and prioritizes vulnerable and marginalized groups.