This leads to unaffordability and inaccessibility of COVID-19 vaccine in the LICs (14, 15). With low funding, LICs find themselves in ethical dilemmas of either: (a) completely transferring funds that were meant to finance the rest of the national health system; (b) increasing her loan burden by borrowing from the World Bank COVID-19 vaccine loan facility, AU AVATT COVID-19 vaccine mechanism or Afrexim Bank COVID-19 vaccine facility; (c) inequitably leave the rest of population behind; or (d) wait for the goodwill of COVAX COVID-19 vaccine facility to increase its allocation.

Although vaccines are a global public good, obtaining intellectual property (IP) for COVID-19 vaccines by LICs from vaccine developers remained difficult (16). Initially, India and South Africa proposed manufacturers in HICs to relinquish intellectual property rights associated with COVID-19 vaccines and therapeutics to increase manufacturing and access in LICs; but faced strong opposition from several members of the European Union (EU) and UK (17). Nevertheless, unrestricted access to IP of COVID-19 vaccine was later granted to a few countries like India, the Republic of Korea, Brazil, Indonesia, South Africa, Egypt, Morocco, Senegal, and Tunisia, which have already started producing vaccines (5, 18). Despite this development, LICs cannot easily take advantage of this due to weak systems like lack of domestic vaccine manufacturers; and lack of vaccine-producing resources such as well-equipped laboratories, research and developments, policy, programs, and government funding.

This refers to a situation where the countries prioritize their own vaccine needs and push to get first access to the vaccines' supply during a transnational public health crisis (19). The world's richest countries procured and reserved more doses of the best COVID-19 vaccines to immunize their own populations multiple times and provide two or more booster shots (20). Figure 2 shows confirmed number of doses purchased by countries disaggregated by economic status. Among the HICs, by mid-August 2020, the USA had secured 800 million doses of at least 6 vaccines, the UK had purchased 340 million doses, followed by EU countries, Canada and Japan that had each ordered hundreds of millions of doses through advance market commitments to cover more than their entire populations (21, 22). By early 2022, HICs had stockpiled more doses of COVID-19 vaccine to provide their citizens with booster shots when some LICs had not fully administered a single dose to some of their populations (23). For LICs, purchases commenced in January 2021 through the African Union's pooled procurement approach leaving out many LICs in Latin America, Africa and Asia with few vaccines to cover their entire populations (22). This lowered the chances for LICs to access the vaccine on time as they were relatively out of stock.

The weak health infrastructures like limited laboratory facilities coupled with COVID-19 vaccine supply chain and logistics challenges contributed to vaccine inequity across LICs. Many health facilities in LICs lack proper cold storage facility with refrigerating and freezing temperatures to store vaccines at the recommended temperature like for Oxford-AstraZeneca at 2–8°C and the Pfizer at −70°C (5) which increases vaccines stock outs in very remote areas. To a greater extent, the geographical landscape of many LICs poses a significant challenge to distribute vaccines (5). Therefore, vaccines are delayed and sometimes arrive few months before their expiry date leaving little time for usage. Some countries in LICs are characterized by political instability and this results in untimely and inequitable distribution of the COVID-19 vaccine.

COVID-19 vaccine misconceptions remain a significant issue with regards equity. Recent studies investigated COVID-19 vaccine hesitancy, misconceptions and uptake in both LICs and HICs (24, 26). The existing literature cites the rapid pace of vaccine development as a primary reason for hesitancy in higher-income settings (24). Whilst reasons for hesitancy in LICs varied with most common ones being fear of adverse effects after vaccination, vaccination disinformation and myths or beliefs, religion, and lack of trust in the government and pharmaceutical companies (24, 25). For example, in Malawi, it was observed that many people have misconceptions about the COVID-19 vaccine, and believe it contains a microchip or deoxyribonucleic acid (DNA) marker. This conforms to the findings by World Health Organization (WHO) that despite increased supply of the vaccine through COVAX facility in Africa, only 28% of the adult population was vaccinated as of December 2022 (1). Low vaccine uptake is more prevalent in rural areas where myths and misconceptions about COVID-19 are most prevalent but are also areas that have less been hit by the pandemic. Thus, provision of COVID-19 vaccine alone, is only the first step to achieving the vaccine coverage required to tackle the pandemic.

The COVAX facility- led by Gavi, the Vaccine Alliance, WHO and Coalition for Epidemic Preparedness Innovations (CEPI) was established solely to bring nations together, regardless of their income level, to ensure the procurement and equitable distribution of COVID-19 vaccines (31). More than a year since the COVAX facility initiated the delivery of the COVID-19 vaccines to LICs, development partners like the United Nations Children Fund (UNICEF) and manufacturers partnered to procure and deliver COVID-19 vaccine doses for almost 92 LICs and supported procurement for more than 97 upper middle-income and HICs (32). Ethically, by accepting the COVAX COVID-19 facility, all countries have a moral obligation not to leave behind or out the rest of the population unvaccinated. After all, we live in a global village and COVID-19 has been highly transmissible among others due to people's travel. Nonetheless, the COVAX initiative proved to be insufficient on its own as it covers only 20% of COVID-19 vaccine needs for all countries, far below the target population required for a coverage of 60% (33). This left an estimated financing gap of LICs, many of which are in Africa, of over $10 billion and $108 million in Sub-Saharan Africa (SSA) and Malawi, respectively (33). Either expanding the COVAX facility or taking advantage of other sources of funding like the World Bank COVID-19 facility and the African Export-Import Bank (Afrexim Bank) COVID-19 vaccine facility, among others, will increase allocation of COVID-19 vaccine in LICs.

Initially, as indicated above, India and South Africa proposed manufacturers in HICs relinquish intellectual property rights associated with COVID-19 vaccines, diagnostics and therapeutics to increase manufacturing and access in LMICs (17). Notwithstanding its importance, the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS agreement) waiver faced strong opposition from some HICs which host large domestic pharmaceutic industries e.g., European Union and UK, mainly on economic basis (34). The estimates suggested that BioNTech, the biotechnology company behind Pfizer's mRNA vaccine, alone could boost Germany's gross domestic product (GDP) by 0.5% in 2021 (35). Nonetheless, in 2022, the USA offered support to the TRIPS waiver with the key limitation that the waiver be issued to the production of vaccines only, not therapeutics and diagnostics (36). To achieve global vaccine equity, a nationalistic approach based on the welfare of the global community must be prioritized over private profits. Moreover, the waiver should go beyond vaccines to cover diagnostics and therapeutics as they are equally important to combat the SARS-CoV-2.

As highlighted above, following the partial approval to the TRIPS waiver by the USA, manufacturing sites around the world were identified as candidates in scaling up vaccine production such that few countries like India, the Republic of Korea, Brazil, Indonesia, South Africa, Egypt, Morocco, Senegal, and Tunisia already started producing vaccines. Through the Africa Center for Disease Control (CDC), sites for vaccine clinical trials were established across the African continent (37). Currently, five COVID-19 vaccine clinical trials [e.g., Biological: Bacille Calmette-Guerin (BCG); SARS-CoV-2 rS/Matrix-M1 Adjuvant; Biological: ChAdOx1 nCoV-19 with placebo comparators] were established in South Africa. Other countries (e.g., Egypt, Tunisia, Senegal, Morocco, Ghana, Guinea Bissau, and Kenya) with varying capacities initiated trial activities in an attempt to facilitate successful vaccine implementation. India alone has the pre-existing infrastructure in place to manufacture more than three billion vaccines doses a year and a long-standing track record of cost-effective biosimilar vaccine manufacture on a large scale and a commitment to support equitable vaccine distribution and provide vaccine assistance to LICs (38). Nonetheless, patent holders rarely voluntarily agree to share manufacturing knowhow externally to facilitate this. Thus, IP flexibilities alone cannot address the shortage of infrastructure, capacity, technical knowledge, and regulatory recognition (39). Therefore, making vaccines available requires more collaboration among partners, increasing manufacturing capacity in LICs and providing new legal mechanisms to share technical production processes.

Most LICs have weak health systems characterized by weak infrastructure such as limited laboratory facilities, and lack of cold storage facilities coupled with challenges of long distances to static vaccination sites. This consequently affects both the availability and uptake of vaccines. Investments should be made into strengthening the health systems as this would not only benefit the COVID-19 response, but also promote future pandemic preparedness, potentially creating a sustained impact for COVID-19 and other related pandemic's responses.

Access to vaccines is one step toward vaccine equity but the negative public perceptions of the vaccine in LICs stall the progress. All the ongoing initiatives would be futile if populations across LICs remain hesitant to accept the vaccines. Studies on misconceptions and misperceptions of COVID-19 vaccine revealed that some misleading myths and numerous faith-related rumors led to the spread of wrong information on the cure of COVID-19 causing fears and mistrust of health care systems across affected countries (24, 25). To boost the COVID-19 vaccine uptake in LICs, the WHO, UNICEF, Gavi, the Vaccine Alliance, and partners are supporting mass vaccination drives in at least 10 priority countries to reach 100 million people by the end of April 2022 (9). This drive ignited a positive momentum against the pandemic, however, limiting the initiative to few populous countries will likely hinder the progress. Scaling up mass vaccination campaigns across all LICs where local communities have access to information, counseling, support related to COVID-19 vaccine will improve uptake. Moreover, designing an equitable and effective vaccine delivery plan for the populace will be equally important.