Pakistan's messy vaccination drive risks isolating the country

It is undersupplied, underfunded and underprepared. And its neighbours can only do so much to help

epa09085246 An ice cream vendor walks at a closed market in the provincial capital of Khyber Pakhtunkhwa as the government reduces market business hours after new cases of COVID-19 were reported across the country in Peshawar, Pakistan, 20 March 2021. Pakistani Health Minister Faisal Sultan said in a tweet on 20 March 2021 that Prime Minister Imran Khan, 68, tested positive for COVID-19, two days after he received the first shot of the vaccine. Pakistani authorities had imposed smart lockdowns in an effort to curb the outbreak of a third wave of infections with SARS-CoV-2 coronavirus which causes the COVID-19 disease.  EPA/BILAWAL ARBAB
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Pakistani Prime Minister Imran Khan's Covid-19 diagnosis earlier this month, coming as it did after his first jab of the Sinopharm vaccine, received significant coverage worldwide. Given that he had only just had his first dose of a two-dose vaccine, Mr Khan's infection had little to do with the inoculation itself. Quite the opposite. It could be argued that he was given his first shot too late, highlighting the challenges that Pakistan's vaccination campaign faces.

The country’s vaccine acquisition problem is especially difficult, and it has been compounded by an unsettled government response, oscillating between laissez-faire free marketeering on the one hand and frantic improvisation on the other.

The first problem is scale. Pakistan has the sixth-largest population of any vaccine market in the world, including the EU, with some 225 million residents. The stated goal of herd immunity requires at least 60 per cent of the adult population to be vaccinated, equating to roughly 66 million adults (which means up to 132 million doses).

That puts Pakistan in the same boat as Indonesia and Nigeria – countries with very large populations, but without the production infrastructure of the vaccine superpowers. That brings us to the second problem: vaccine nationalism.

With their large ageing populations, the US and EU have limited capacity to meet the rest of the world’s needs. Other large entities such as India and China have embarked on vaccine diplomacy campaigns, but even they are still working out how to balance the diplomatic benefits of meeting global demand and the need to administer hundreds of millions of doses at home.

At first, it looked as though Pakistan had managed the impossible – getting help from both countries – but securing access at scale has proved to be elusive.

The Covax programme led by the Gavi Vaccine Alliance was supposed to slice through these issues and deliver whatever was needed, regardless of a country's finances or alliances. The Anglo-Swedish firm AstraZeneca lent the intellectual property to Gavi, but manufacture relies on the Serum Institute of India (SII), a private for-profit company not far from Mumbai.

When Gavi's interim distribution forecast was first published in early February, Pakistan was earmarked for 17.1m doses, the second-largest allocation after India, and financed entirely by donor nations.

The irony, if not risk, of Pakistani reliance on India – given the strained diplomatic relations between the two neighbours – wasn't something anyone had an interest in playing up at the time, especially since the two countries recently have reportedly been exploring avenues for a mutual peace.

Pakistan had already primed the pump of its rollout with half a million doses of the Sinopharm vaccine gifted by the Chinese government, earmarked for frontline medical staff. Much was made of its privileged position as the first to receive Chinese vaccine aid shipments, although Cambodia received more doses, even as Islamabad was overwhelmingly relying on Gavi's funding and SII's manufacturing in India.

This image grab taken from a handout video released on March 18, 2021 by the Pakistan Prime Minister Office shows Pakistan's Prime Minister Imran Khan (L) receiving a dose of the Chinese-made Sinopharm vaccine  against the Covid-19 coronavirus, at the Prime Minister House in Islamabad. Khan has tested positive for Covid-19, his office said on March 20, just two days after he was vaccinated against the disease. - RESTRICTED TO EDITORIAL USE - MANDATORY CREDIT "AFP PHOTO/Pakistan Prime Minister Office" - NO MARKETING - NO ADVERTISING CAMPAIGNS - DISTRIBUTED AS A SERVICE TO CLIENTS

What is astonishing is the level of confusion over how Pakistan can plug the enormous gap between what Gavi had promised in vaccine aid and the country’s vaccination goals. Tens of millions of additional doses will need to be purchased on contract, but Pakistani officials have publicly disagreed with one another over the funding available for this. Figures have varied from zero to $150m to $250m.

This lack of consensus or urgency in some quarters reflects the relatively low death rates (almost half of India's on a per capita basis), and its limited effect on public opinion. Pakistan is reportedly in negotiations with China, but no agreement seems to have been reached yet. This may not be surprising, given that China is now stepping up its own domestic inoculation campaign.

But Pakistan’s dependence on global governance came into question on February 21, when SII announced it had been "directed" to meet India's quota before it met foreign needs. Gavi was forced to release an updated plan in early March, with Pakistan’s quota being revised downwards to 14.6m doses.

Gavi deliveries were supposed to start in earnest in mid-March, with the bulk to arrive in June. However, there has been no indication if any of those timelines will be met, given that the size of India’s quota hadn’t even been agreed on.

Workers unpack a delivery of the Sputnik V Covid-19 vaccine at a cold storage facility in Karachi, Pakistan, on Friday, March 19, 2021. Islamabad has granted permission to Russia’s Sputnik V, which has been validated by global experts as being more than 90% effective. Photographer: Asim Hafeez/Bloomberg

Facing this unexpected shortfall, Pakistan immediately turned to China, which gifted another 500,000 doses to keep the vaccination programme rolling forward until Gavi could sort its issues out. These arrived mid-March, allowing Prime Minister Khan to get his shot as an over-60. Islamabad, it was reported on Tuesday, will import an equivalent of 3m doses made by China’s CanSino Biologics next month.

Pakistan and Indonesia, meanwhile, have authorised commercial importation of vaccines, to be distributed for sale through entirely private channels. The first to arrive was the Russian Sputnik V, and the second was another Chinese vaccine by CanSino Biologics.

Initially, the Pakistan government intended to allow these to be sold without any price caps, which would have put them entirely out of the reach of the middle class. The government reversed its position as soon as that decision came to light. But the small numbers mean that these will probably serve only a very limited segment of the population.

Pakistan is currently experiencing a third wave, but given the low baseline, and small import volumes, it is likely that this private stream will end up serving the demands of the evolving international travel regime rather than domestic public health needs.

As high-income countries open up, their governments and airlines are looking at adding vaccination status to the already lengthy list of requirements, and Pakistan’s migrant workers, students and business communities simply cannot afford to be excluded.

The country’s experience of isolation and discrimination at the peak of the terrorist threat in the post 9/11 era is something that many Pakistanis have painful memories of, and something the government has worked diligently to reverse.

Certainly, if visa and boarding rules are based on national inoculation rates instead of individual vaccination status – as is being considered – Pakistan will do everything in its power to persuade China, India, or both, to move its requirements further up the queue. Given the unexpected shoots of peace, including Indian Prime Minister Narendra Modi's get-well tweet to Prime Minister Khan, this isn't impossible, although far from certain. As is so often the case, ordinary Pakistanis are likelier to find their way forward through dramatic events and murky prospects with little more than their own emotional fortitude to rely on.

Johann Chacko is a writer and South Asia analyst