Keeping an eye on vaccine snatchers. Turning dial tones into public health messages. Selling vaccines to the wealthy to make sure they don't elbow their way to the front of the line.
These are among the strategies being employed by Pakistan as it gears up for an extraordinary task – acquiring enough vaccines for its enormous population of 220 million.
"A lot of things can go wrong" with Pakistan's vaccine rollout, says Fatima Akram Hayat, a health adviser to the government's COVID-19 response team. "Even if it goes very well, considering the costs, considering the far-flung areas, considering how big the population is, I don't think [nationwide immunization will] happen in 2021," she says.
But she remains hopeful. "Pakistan has so far been able to deal with COVID-19 better than [in] my imagination," she says. Currently, the country has over half a million confirmed cases and over 11,000 deaths. While its testing numbers are low, hovering between 30,000 to 40,000 a day, there's no sign that hospitals have been overwhelmed or that there are widespread shortages of ventilators or oxygen.
Hayat has had a hand in Pakistan's COVID-19 response from the get-go. She worked on procuring protective equipment and ventilators after the pandemic was declared and helped expand the social welfare safety net for the country's poorest. She's now working on vaccination programs, and her next job is overcoming vaccine hesitancy. She spoke to NPR about the expected contours of the government's COVID-19 vaccine rollout.
Here are three key takeaways from the conversation.
Worries about vaccine 'snatching'
The government hopes to begin its COVID-19 vaccine rollout by April at the latest. It will begin with frontline health-care workers. They number about 10 million people. Next will be Pakistan's elderly citizens, a cohort that numbers some 22 million people.
But even at this phase, there's concern that Pakistan's powerful elites could muscle in to obtain the free, government-provided vaccine.
They could do this by pressuring local health officials in charge of vaccinating particular districts to allow them priority access, threatening people administering the vaccine, or pressuring health officials to ensure they are offered the vaccine ahead of others. Elite Pakistanis could offer to pay for the vaccine, which could create a black market that would siphon off doses meant for high-priority people.
And if Pakistans with health vulnerabilities are eligible, that rule could likely favor elites. They are more likely to have access to health services and medical documents to demonstrate they have a condition that puts them at the head of the vaccination line. They also have access to the ears of decision-makers, from managers of health clinics to ministers.
Poor, less literate Pakistanis, particularly women and rural residents, will have far less sway, and so they'll be less likely to be part of the second cohort, unless there's a concerted effort to include them.
The concern that elites could elbow their way to the front of the line was most recently articulated by the former adviser to the prime minister on health.
"In developing countries such as ours, the influential people get vaccines first," said Zafar Mirza at a conference on Jan. 1, as reported by local media."The government, too, should take care that [the vaccine] should be given to those in line of priority, and there should not be any snatching."
Help from the private sector
There's one idea that could help address this conundrum: letting elites buy their own vaccines. Starting in the summer, the government will allow companies that import vaccines to conduct their own rollout.
"The government will be following its own plan, where they'll be focusing on the elderly and people with co-morbidities. But since the private sector will come in, other people can also get vaccinated," says Hayat.
So far, the government has given one Pakistani company, Sindh Medical Stores permission to import the AstraZeneca vaccine for private sale. Local media describes the company as "one of the biggest importers of vaccines and other pharmaceutical products in Pakistan." The company says it is likely to charge $13 for a dose, which they expect to be made available at large non-governmental hospitals. However, the company says it still has no timeframe on when it will be able to offer the AstraZeneca vaccine for sale because of stiff global competition on orders.
The government's decision to allow private vaccine sales reflects the stages of the rollout of COVID-19 testing. Initially the government was in charge. But weeks into the pandemic, diagnostic labs were given permission by the government to conduct tests for a fee. That appears to have helped boost testing numbers and reduce pressure on the government's free testing services.
Allowing Pakistanis to purchase the vaccine could lead to a similar result – reducing pressure on the government, with its scarce supplies, to vaccinate wealthier citizens.
Gearing up for vaccination
By the end of 2021, Hayat says the government expects to receive another 45 million doses of COVID-19 vaccine – she isn't sure which one – through COVAX. The initiative, co-led by the World Health Organization and a vaccines alliance, aims to distribute COVID-19 vaccines more equitably around the world.
By then, she hopes the government's immunization campaign will be in full swing. But she worries about attacks on vaccine workers and about people refusing to be vaccinated. Vaccine hesitancy is not unique to Pakistan. But here, where polio is still endemic, militants have in the past attacked and killed health workers who go door-to-door across the country to administer oral polio vaccine drops to hundreds of millions of children.
Most recently, in January, militants gunned down a police officer escorting polio vaccinators in the northwestern district of Karak. He is one of over 80 security officials and health workers to be killed over the past decade by militants trying to prevent polio vaccinators from working in their area, according to the head of the government's polio vaccination efforts, Dr. Rana Safdar.
Adding to Hayat's concerns, there are widespread misconceptions and outright lies that have built up about COVID-19 throughout Pakistan. "A lot of people are also s0-called deniers here, like they say there's no COVID," Hayat says. Others claim "this is Bill Gates trying to put a chip in our heads."
Already, there's a worrying sign: a poll released this week says 49% of Pakistanis in a survey of 1,081 people don't want to get vaccinated. Gallup Pakistan, the Pakistani affiliate of Gallup International, reported the findings as part of regular polling it has done on attitudes surrounding the pandemic in Pakistan.
The polling did not quiz respondents on why they would refuse the vaccine – but it appeared mistrust in Western vaccines could be a reason. Even among the 46% of Pakistanis who said they were willing to be vaccinated, only 4% said they'd prefer a Western-made vaccine, compared with 31% who said they wanted a Pakistani vaccine. (Pakistan does not produce its own vaccines).
Hayat says her next task is to lead the government's effort to counter anti-vaccination sentiments, and create campaigns to encourage people to get the COVID-19 vaccination.
The initial strategy will be to recruit celebrities, influencers and respected religious leaders who have had COVID-19 to underscore the disease's seriousness — and urge people to be vaccinated.
"We're talking about making public awareness ads that run on TV, the phone calls and the radio," she says. When you dial a number in Pakistan, the government can tweak the dial tone so instead of hearing ringing you get a government message instead.
Hayat is heartened that so far, Pakistan has deflected the worst of the pandemic. She says it reflects something that many Pakistanis feel about their country, which often feels like it's teetering on the edge of a calamity but never quite falls apart. "In all of our history, the 70-something years that we've been in existence, I just feel like there are so many moments where things could have gone terribly wrong," she says – but they don't, and Pakistan survives.