Access to adult vaccines in Kenya: a case study of COVID-19 vaccines

Abstract

In contrast to childhood immunization, less emphasis has previously been placed on adult vaccinations. However, its importance has gained appreciation since the COVID-19 pandemic. The government of Kenya rolled out the COVID-19 vaccine in March 2021. This study aimed to examine facilitators and barriers to access of the COVID-19 vaccine among the Kenyan adult population. A mixed methods single case-study was conducted in four counties of Kenya. Data was collected using document reviews, epidemiological models, in depth-interviews, focus group discussions, and surveys. An activity-based approach was used to estimate the incremental costs of COVID-19 vaccine delivery. The cost-effectiveness analysis was conducted from a societal perspective over a 1.5-year time frame. The survey was phone-based and cross-sectional in nature. Qualitative data was analyzed using a framework approach. While the quantitative survey data was analyzed using a multilevel logistic regression. The cost analysis reports financial vaccine delivery costs per person vaccinated with 2-doses, ranged from $4.28-$3.29 in the 30% and 100% coverage strategies: The cost-effectiveness analysis reports that slow roll-out at 30% coverage largely targets over 50-year-olds and was cost-saving (ICER=US$-1,343(-1,345 to -1,341) per DALY averted). Increasing coverage to 50% and 70%, was not cost-effective. Rapid roll-out with 30% coverage was more cost-saving (ICER=$-1,607(-1,609 to -1,604) per DALY averted) compared to slow roll-out at the same coverage level. The process evaluation reports that COVID-19 vaccine delivery activities resulted in increased access to COVID-19 vaccines. In practice, most deployment activities leveraged on existing systems and were integrated with other routine processes, resulting in increased efficiency. A mixed approach to service-delivery increased vaccine reachability. The electronic data management system resulted in timely availability of vaccines and limited expired vaccines. Despite these strengths, some challenges persist. First, vaccine stock outs presented a barrier to uptake due to vaccine preferences or eligibility criteria. Second, financing for some deployment activities was insufficient and donor reliant, with limited financial autonomy at county and facility level. A month prior to vaccine rollout in the country, COVID-19 vaccine hesitancy was high: 36.5%. The qualitative inquiry reports that barriers to COVID-19 vaccine uptake were related to individual characteristics (males, younger age, perceived health status, belief in herbal medicine, and the lack of autonomy in decision making among women - especially in rural settings), contextual influences (lifting of bans, myths, medical mistrust, cultural and religious beliefs), and COVID-19 vaccine related factors (fear of unknown consequences, side-effects, lack of understanding on how vaccines work and rationale for boosters). These drivers of hesitancy mainly related to psychological constructs including confidence, complacency, and constraints. In conclusion, with prior exposure partially protecting much of the Kenyan population, vaccination of young adults may no longer be cost-effective. Further, I highlight the importance of pandemic preparedness including addressing public finance management bottlenecks, resource mobilization, and multisectoral approaches to alleviate inequities during vaccine deployment. Lastly, addressing vaccine hesitancy could include gender responsive immunization programs, appropriate messaging and consistent communication that target fear, safety concerns, misconceptions and information gaps in line with community concerns.