March 2021
By Dr Swee Kheng Khor, Independent Health Policies Specialist
COVID-19’s first year in Southeast Asia (SEA) has carried a human cost of more than 2.5 million cases and 54,000 deaths. This partly explains the optimism and cheer surrounding the arrival of COVID-19 vaccines, alongside hopes of economic recovery and a return to social interactions. How can SEA best deploy COVID-19 vaccines in the coming months and years to maximise the speed of recovery?
Firstly, SEA nations must surmount three technical hurdles to reach the population coverage (or herd immunity) needed for the fullest impact of vaccines. These technical hurdles include issues around vaccine supplies, confidence and delivery, which can all cause significant delays if not addressed appropriately.
Sufficient vaccine supplies remain a challenge worldwide, with the European Union even extending its export controls to allies like Australia. Therefore, SEA countries should consider medium-term pooled vaccine purchasing strategies for their 650 million citizens and domestic or regional manufacturing strategies in the long-run. This should occur alongside short-term strategies of continuous procurement, with built-in contractual protections for new vaccine variants in response to emerging virus variants and with strengthening of regulatory agencies in SEA.
Vaccine confidence requires multi-stakeholder coalitions of the willing, able and relevant, particularly in the Philippines (post-Dengvaxia), the rural communities of Indonesia and Vietnam and in the migrant populations in Malaysia, Singapore and Thailand. Trust is an important currency for successful public vaccination programs. Therefore, all SEA countries must rapidly build it through multi-lingual and multi-platform communications delivered by familiar and trustworthy messengers, like neighbourhood religious leaders, sports personalities or respected public figures.
A multi-stakeholder and public-private approach is needed for effective vaccine delivery. A whole-of-society approach can ensure an effective cold chain infrastructure, adequate and well-trained vaccinators working in safe and convenient physical facilities and efficient databases to manage recipients and track adverse events.
Secondly, there are three socio-political objectives in parallel to the technical ones. SEA countries must deliver vaccine equitably, manage public expectations that the vaccine is not a magic bullet and protect themselves from unintended consequences of rapid vaccination programs.
Right now, vaccine procurement, prioritisation and distribution are almost exclusively led by governments in SEA. This is necessary for equitable distribution of a scarce resource, as market mechanisms during vaccine scarcity are unfair and perhaps even dangerous. It is acceptable for prioritisation to differ due to different characteristics, demographics, disease burdens and social contracts of countries. For example, Indonesia prioritises its working-age population while Malaysia prioritises senior citizens, with their leaders providing different reasons for these decisions. However, countries cannot compromise on vaccine equity, which means no queue-jumping, double standards, corruption or abuse. Public health outcomes and their performance legitimacy rely on vaccine equity that prioritises the vulnerable.
SEA countries must also manage their citizens’ expectations about the vaccine. Expectations can be individual, such as feelings of personal invulnerability after one dose, causing an immediate disregard for facemasks or physical distancing. Expectations can also be population-wide, such as increasingly vocal demands for a complete reopening as the country approaches the commonly accepted figure of 70-80% herd immunity. Therefore, SEA countries must manage the delicate balance of expectations: promise too little and citizens will not be incentivised to be vaccinated but promise too much and citizens will get upset at governments breaking promises.
However, even successful or rapid vaccination programs can cause unintended consequences, which SEA governments must consider. Devoting large resources to adult vaccination programs may shift attention away from childhood immunisation programs, which are already negatively impacted by COVID-19. Speed to attain coverage is important, but it can cause vaccine hesitancy if citizens perceive that governments are coercing them or if adverse events following immunisation are not handled with adequate compassion or liability protection. Successful vaccination programs may lead to pressure for vaccine passports (Thailand being the most recent country to support the idea), which could lead to inequality or premature reopening. Governments must consider and plan to mitigate these unintended consequences.
Thirdly, SEA governments must vaccinate their populations while keeping an eye on the bigger picture. Vaccination programs will help fight the pandemic, but they are only one piece of the jigsaw puzzle. Indeed, the objectives of the vaccination program must be subservient to the overall goals of pandemic management. Therefore, continuous improvement is needed in public health capacity regarding testing, contact tracing, isolation and epidemiological surveillance. Doctors, nurses and paramedics must also be protected from physical and emotional fatigue, even as they add vaccinations to their routine workload. Vaccinations will help but cannot come at the expense of non-pharmaceutical interventions.
At a higher level, vaccination programs are a subset of health, which is, in turn, a subset of a society. COVID-19 has shown that health is a determinant, not a consequence of progress. It has also shown that health is a key consideration in a wide range of government policies, rather than solely with the health ministry or agency. That is why any COVID-19 vaccination program’s infrastructure must be designed to be leverage-able by other areas of society and not built as single-use one-off infrastructure. For example, vaccine education efforts can complement scientific literacy in a fake news world and temporary vaccination sites in rural areas (like in the Philippines) can be upgraded to full-scale health or community facilities.
Finally, domestic vaccination programs do not occur in isolation and must be appropriately integrated with regional and global programs. For example, SEA governments must immediately start the long-term work to achieve regulatory standards and database harmonisation that enables regional vaccine passports. This work could be led by the ASEAN Secretariat as part of the Comprehensive Recovery Framework approved in November 2020. Governments must also consider geopolitics and vaccine diplomacy in SEA, particularly if procurement decisions influence foreign policy (or vice versa).
The heterogeneous and archipelagic region of SEA will reach adequate population coverage only in 2022 or onwards. Success depends on the nine factors described in this essay, in addition to other factors like the right role of the private sector, sustainable funding, especially if annual vaccinations or booster shots are needed, clamping down on black markets and profiteering and the overall governance abilities and state capacity of a country.
Success is very much possible, but it is not guaranteed. Therefore, countries in SEA should consider the technical hurdles, socio-political objectives and the bigger picture of COVID-19 vaccination programs on their way to durable and effective long-term pandemic strategies.
Author’s Note: this essay introduces several themes that will be covered in greater detail throughout the Vaccines in Southeast Asia essay series launched by the SingHealth Duke-NUS Global Health Institute.
About the author
Dr Swee Kheng Khor
Dr Khor is a Malaysian physician specialising in health policies and systems, with fellowships in Chatham House, United Nations University and Institute for Strategic and International Studies, Malaysia, and with international experience in the public, private, non-profit and think tank sectors. Previously, he held progressively senior roles in four other practice areas (clinical medicine; refugee & disaster relief; clinical research; and healthcare anti-corruption). In these roles, he was based in Malaysia, Singapore, UAE, China and France, covering over 90 countries across Asia, Africa, Europe and the Middle East. He holds postgraduate degrees in internal medicine (Royal College of Physicians), public health (Berkeley) and public policy (Oxford).
About the SDGHI Perspectives essay series
The SDGHI Perspectives essay series is a collection of contributed essays from authors around the world, showcasing their distinctive viewpoints on pertinent global health topics of our time.
Following a year of global uncertainties, shifting national policies and unprecedented scientific breakthroughs, the inaugural theme for SDGHI Perspectives is COVID-19 A Year Later. The first essay series under this theme delves into different dimensions of COVID-19 Vaccines in Southeast Asia, including issues related to vaccine supply, confidence, delivery, distribution and beyond. Visit the SDGHI website to read the other essays in the series.
For any enquiries, please contact: sdghi@duke-nus.edu.sg
The views expressed by authors contributing to the essay series are their own and do not necessarily reflect the views of SDGHI.