Four people turned up at a health clinic tucked in a sprawl of commercial maize farms on a recent morning, looking for COVID-19 vaccines. The staff had vials of the Johnson &amp; Johnson vaccine stashed in the fridge, but the staff members apologetically declined to vaccinate the four and suggested they try another day.

A vial of the Johnson &amp; Johnson vaccine holds five doses, and the staff was under orders not to waste a single one.

Ida Musonda, the nurse who supervises the vaccination effort, suspected that her team might have found more takers if they packed the vials in Styrofoam coolers and headed out to markets and churches. “But we have no fuel for the vehicle to take the vaccines there,” she said.

They vaccinated 100 people on their last trip to a farm; the records from that trip sat in a paper heap in the clinic because the data manager had no internet connection to access an electronic records system.

For months, the biggest challenge to vaccinating Africans against COVID, and protecting both the continent and the world from the emergence of dangerous variants, has been supply: A continent of about 1.4 billion people has received just 404 million doses of vaccine, and only 7.8% of the population is fully vaccinated.

But as supply has begun to sputter into something like a more reliable flow, other daunting obstacles are coming into focus. All of them are on view at and around Ngwerere.

Weak health care systems with limited infrastructure and technology, and no experience vaccinating adults, are trying to get shots into the arms of people who have far more pressing priorities. At the same time, the global flow of information, and deliberate misinformation, on social media is generating the same scepticism that has stymied vaccination efforts in the United States and other countries.

Some Zambians are hesitant, but others have an attitude that could better be described as vaccine indifference. This is a poor country where the economy has contracted sharply during the pandemic, and many unvaccinated people are more focused on putting food on the table.

“I’d like to get it, but I work Monday to Saturday, and I don’t know if they vaccinate on Sunday,” said Bernadette Kawango, who supports a large extended family with her wages from an auto parts store in a low-income neighbourhood on the edge of Lusaka, the capital. She has heard many rumours: that people who receive the vaccine will die in two years, that the vaccine is part of a plot by Europeans to kill Africans and take their land, that Bill Gates is on a campaign to reduce the world population.

Such stories make her roll her eyes. But COVID is not at the top of her list of health care worries. “It’s cholera season, and people have malaria, and there is HIV and TB,” she said. She does not know anyone who has been diagnosed with COVID.

All these challenges create two major problems. First, the pace of vaccination is far too slow to prevent unnecessary deaths in a fourth wave, which is already beginning in southern Africa, or to prevent the emergence of new variants such as omicron, which was first identified in South Africa late last month. The vaccines in stock — many of them donations close to their expiration dates when they arrive — may not be used before they must be destroyed.

Second, the push to vaccinate against COVID is drawing resources from health systems that can hardly spare them, which could lead to disastrous consequences for the fight against other devastating health problems.

At the Ngwerere health clinic, the usual bustle and screeching at the mother-and-child health area, where babies are monitored for signs of malnutrition and given childhood immunizations, was absent because everyone on that staff had been repurposed as COVID vaccinators.

“Every time we have a wave here it really threatens the investments that have been made in HIV, maternal and child health, and TB and malaria, and it’s important that we protect those,” said Dr Simon Agolory, who runs the large Zambia program of the U.S. Centers for Disease Control and Prevention.

Dr Andrew Silumesii, director of public health for Zambia’s health ministry, said there was clear evidence that infant growth monitoring and childhood immunization had declined over the course of the pandemic. He worries that malaria, TB and HIV infections will also increase.

So far, 7% of Zambians have been vaccinated against COVID, according to Silumesii. President Hakainde Hichilema has set a target of vaccinating another 2 million by Christmas, and 70% of the population by the third quarter of 2022, a goal that looks exceedingly ambitious.

Zambia’s vaccines come mostly from Covax, the global vaccine-sharing initiative, with additional donations from China and the African Union. The fact that Zambia is dependent largely on donations means that it must adapt its program to whatever shipments arrive — a bit like making a meal with whatever arrives in a farm subscription box. The country is managing distribution of five different vaccines, each with different dosing regimens, storage requirements and vial volumes.

That has created a huge additional administrative burden for skeleton staffs such as Musonda’s team. Her staff has no budget for cellphone calls to remind people about second shots, and the effect can be seen in the charts stapled on the vaccination room wall: Of the 840 people who received a first dose of the AstraZeneca vaccine in April, only 179 came back for a follow-up shot in July.

When Zambia experienced a severe third COVID wave earlier this year, media coverage of people dying in the parking lots of hospitals that ran out of oxygen rattled a population that had been thinking of the virus as something that affected only white or rich people. There were predawn lineups outside vaccination sites that couldn’t keep shots in stock.

But when the wave abated, so did the demand.

Many people here recall the time when Zambians were dying of AIDS in huge numbers, and Western pharmaceutical companies refused to produce affordable lifesaving medications. There is scepticism now that those same companies have come offering free solutions.

Vaccine misinformation spreads on TikTok and WhatsApp, and in evangelical churches where pastors warn that the shot “contains the mark of the beast.”

“No matter how educated people are, if their pastor says don’t trust the vaccine, they don’t trust,” said Dr Morton Zuze, the clinical care coordinator at Chongwe District Hospital, where seven staff members sat idle in an empty vaccination tent.

As in the United States, there are false rumours in Zambia that the vaccine causes female infertility or erectile dysfunction. Zambians have heard AstraZeneca is not being used in many countries because of reports of blood clots in a very small number of people who received that shot. “It’s a global village, and everyone can switch on CNN,” Zuze said.

Zambia normally vaccinates only small children, and it has no primary care practices. An adult goes to a clinic only when pregnant or receiving HIV treatment, or in an emergency.

Dr Lawrence Mwananyanda, an assistant professor with the Boston University School of Public Health and a special adviser to Hichilema, said the government must balance between trying to create vaccine demand and not creating too much, when it can’t be sure if it will have the supply to deliver.

“To just walk up — and these health facilities are sometimes very far away, 2, 5, 7 kilometres away, and people don’t have cars, you have to be very motivated — sometimes people have gone to a health facility, and then there is no vaccine,” he said. “All they are told is, ‘You can only vaccinate if there’s five or six people, so you can’t be vaccinated today’. How likely are you to come back?”

Charity Machika was vaccinated recently at a rural health centre in Chongwe district. She went to the clinic for a prenatal checkup and then was encouraged to head to the next building, where the HIV treatment centre was repurposed for vaccinations. “I was scared because people say a lot of stories, that I will faint, that I will not be able to walk, that I will die,” she said. “I took the risk to come and protect myself and my baby.”

She is the only vaccinated person in her family. Her husband tried twice but the sites he went to never had vaccines in stock, and it was difficult for him to find the time to make the 4-kilometre walk to try again, she said.

Felix Mwanza, a veteran HIV activist in Lusaka, said the government had yet to tap into the vast network of HIV and TB treatment activists in the country. “We seem not to learn from our past,” he said, recalling how testing and treatment for HIV only reached critical mass when care was delivered in bars, at schools and on doorsteps.

“If they don’t use the structures we already have, donors will keep sending the vaccines and they’ll pile up here and expire and then they won’t send us anymore,” he said.

Mwananyanda said the key strategy for the planned rapid scale-up in vaccination was to do exactly that, taking vaccines to people in malls and at bus stops.

Amid the scramble, no one is thinking about what happens next. “We’re really just addressing the vaccination problems for now — but we don’t have a system for the long run,” said Agolory. “And what are we going to do when boosters are needed or if there’s some new variants that escape the vaccine altogether, and we need to start from zero and give people more vaccines?”

Zambia will need help procuring more, and it will need funding to help bring on temporary health care workers to administer vaccines so that existing programs, like the Ngwerere mother-and-child clinic, are not abandoned, Agolory said.

Even with a huge boost in vaccination rates, the country won’t have enough coverage to blunt the coming wave, or, most likely, the one after it.

“I am hoping that we keep receiving vaccines so that we don’t get into a situation where people need vaccines and they can’t get them,” said Silumesii. “The flip side, which is something that I would really hate to see happen, is where we have brought in vaccines, and we don’t have enough demand and vaccines go to waste. These are vaccines that cost a lot. Definitely that pinch would sting so badly.”

Four people turned up at a health clinic tucked in a sprawl of commercial maize farms on a recent morning, looking for COVID-19 vaccines. The staff had vials of the Johnson & Johnson vaccine stashed in the fridge, but the staff members apologetically declined to vaccinate the four and suggested they try another day.

Four people turned up at a health clinic tucked in a sprawl of commercial maize farms on a recent morning, looking for COVID-19 vaccines. The staff had vials of the Johnson & Johnson vaccine stashed in the fridge, but the staff members apologetically declined to vaccinate the four and suggested they try another day. A vial of the Johnson & Johnson vaccine holds five doses, and the staff was under orders not to waste a single one. Ida Musonda, the nurse who supervises the vaccination effort, suspected that her team might have found more takers if they packed the vials in Styrofoam coolers and headed out to markets and churches. “But we have no fuel for the vehicle to take the vaccines there,” she said. They vaccinated 100 people on their last trip to a farm; the records from that trip sat in a paper heap in the clinic because the data manager had no internet connection to access an electronic records system. For months, the biggest challenge to vaccinating Africans against COVID, and protecting both the continent and the world from the emergence of dangerous variants, has been supply: A continent of about 1.4 billion people has received just 404 million doses of vaccine, and only 7.8% of the population is fully vaccinated. But as supply has begun to sputter into something like a more reliable flow, other daunting obstacles are coming into focus. All of them are on view at and around Ngwerere. Weak health care systems with limited infrastructure and technology, and no experience vaccinating adults, are trying to get shots into the arms of people who have far more pressing priorities. At the same time, the global flow of information, and deliberate misinformation, on social media is generating the same scepticism that has stymied vaccination efforts in the United States and other countries. Some Zambians are hesitant, but others have an attitude that could better be described as vaccine indifference. This is a poor country where the economy has contracted sharply during the pandemic, and many unvaccinated people are more focused on putting food on the table. “I’d like to get it, but I work Monday to Saturday, and I don’t know if they vaccinate on Sunday,” said Bernadette Kawango, who supports a large extended family with her wages from an auto parts store in a low-income neighbourhood on the edge of Lusaka, the capital. She has heard many rumours: that people who receive the vaccine will die in two years, that the vaccine is part of a plot by Europeans to kill Africans and take their land, that Bill Gates is on a campaign to reduce the world population. Such stories make her roll her eyes. But COVID is not at the top of her list of health care worries. “It’s cholera season, and people have malaria, and there is HIV and TB,” she said. She does not know anyone who has been diagnosed with COVID. All these challenges create two major problems. First, the pace of vaccination is far too slow to prevent unnecessary deaths in a fourth wave, which is already beginning in southern Africa, or to prevent the emergence of new variants such as omicron, which was first identified in South Africa late last month. The vaccines in stock — many of them donations close to their expiration dates when they arrive — may not be used before they must be destroyed. Second, the push to vaccinate against COVID is drawing resources from health systems that can hardly spare them, which could lead to disastrous consequences for the fight against other devastating health problems. At the Ngwerere health clinic, the usual bustle and screeching at the mother-and-child health area, where babies are monitored for signs of malnutrition and given childhood immunizations, was absent because everyone on that staff had been repurposed as COVID vaccinators. “Every time we have a wave here it really threatens the investments that have been made in HIV, maternal and child health, and TB and malaria, and it’s important that we protect those,” said Dr Simon Agolory, who runs the large Zambia program of the U.S. Centers for Disease Control and Prevention. Dr Andrew Silumesii, director of public health for Zambia’s health ministry, said there was clear evidence that infant growth monitoring and childhood immunization had declined over the course of the pandemic. He worries that malaria, TB and HIV infections will also increase. So far, 7% of Zambians have been vaccinated against COVID, according to Silumesii. President Hakainde Hichilema has set a target of vaccinating another 2 million by Christmas, and 70% of the population by the third quarter of 2022, a goal that looks exceedingly ambitious. Zambia’s vaccines come mostly from Covax, the global vaccine-sharing initiative, with additional donations from China and the African Union. The fact that Zambia is dependent largely on donations means that it must adapt its program to whatever shipments arrive — a bit like making a meal with whatever arrives in a farm subscription box. The country is managing distribution of five different vaccines, each with different dosing regimens, storage requirements and vial volumes. That has created a huge additional administrative burden for skeleton staffs such as Musonda’s team. Her staff has no budget for cellphone calls to remind people about second shots, and the effect can be seen in the charts stapled on the vaccination room wall: Of the 840 people who received a first dose of the AstraZeneca vaccine in April, only 179 came back for a follow-up shot in July. When Zambia experienced a severe third COVID wave earlier this year, media coverage of people dying in the parking lots of hospitals that ran out of oxygen rattled a population that had been thinking of the virus as something that affected only white or rich people. There were predawn lineups outside vaccination sites that couldn’t keep shots in stock. But when the wave abated, so did the demand. Many people here recall the time when Zambians were dying of AIDS in huge numbers, and Western pharmaceutical companies refused to produce affordable lifesaving medications. There is scepticism now that those same companies have come offering free solutions. Vaccine misinformation spreads on TikTok and WhatsApp, and in evangelical churches where pastors warn that the shot “contains the mark of the beast.” “No matter how educated people are, if their pastor says don’t trust the vaccine, they don’t trust,” said Dr Morton Zuze, the clinical care coordinator at Chongwe District Hospital, where seven staff members sat idle in an empty vaccination tent. As in the United States, there are false rumours in Zambia that the vaccine causes female infertility or erectile dysfunction. Zambians have heard AstraZeneca is not being used in many countries because of reports of blood clots in a very small number of people who received that shot. “It’s a global village, and everyone can switch on CNN,” Zuze said. Zambia normally vaccinates only small children, and it has no primary care practices. An adult goes to a clinic only when pregnant or receiving HIV treatment, or in an emergency. Dr Lawrence Mwananyanda, an assistant professor with the Boston University School of Public Health and a special adviser to Hichilema, said the government must balance between trying to create vaccine demand and not creating too much, when it can’t be sure if it will have the supply to deliver. “To just walk up — and these health facilities are sometimes very far away, 2, 5, 7 kilometres away, and people don’t have cars, you have to be very motivated — sometimes people have gone to a health facility, and then there is no vaccine,” he said. “All they are told is, ‘You can only vaccinate if there’s five or six people, so you can’t be vaccinated today’. How likely are you to come back?” Charity Machika was vaccinated recently at a rural health centre in Chongwe district. She went to the clinic for a prenatal checkup and then was encouraged to head to the next building, where the HIV treatment centre was repurposed for vaccinations. “I was scared because people say a lot of stories, that I will faint, that I will not be able to walk, that I will die,” she said. “I took the risk to come and protect myself and my baby.” She is the only vaccinated person in her family. Her husband tried twice but the sites he went to never had vaccines in stock, and it was difficult for him to find the time to make the 4-kilometre walk to try again, she said. Felix Mwanza, a veteran HIV activist in Lusaka, said the government had yet to tap into the vast network of HIV and TB treatment activists in the country. “We seem not to learn from our past,” he said, recalling how testing and treatment for HIV only reached critical mass when care was delivered in bars, at schools and on doorsteps. “If they don’t use the structures we already have, donors will keep sending the vaccines and they’ll pile up here and expire and then they won’t send us anymore,” he said. Mwananyanda said the key strategy for the planned rapid scale-up in vaccination was to do exactly that, taking vaccines to people in malls and at bus stops. Amid the scramble, no one is thinking about what happens next. “We’re really just addressing the vaccination problems for now — but we don’t have a system for the long run,” said Agolory. “And what are we going to do when boosters are needed or if there’s some new variants that escape the vaccine altogether, and we need to start from zero and give people more vaccines?” Zambia will need help procuring more, and it will need funding to help bring on temporary health care workers to administer vaccines so that existing programs, like the Ngwerere mother-and-child clinic, are not abandoned, Agolory said. Even with a huge boost in vaccination rates, the country won’t have enough coverage to blunt the coming wave, or, most likely, the one after it. “I am hoping that we keep receiving vaccines so that we don’t get into a situation where people need vaccines and they can’t get them,” said Silumesii. “The flip side, which is something that I would really hate to see happen, is where we have brought in vaccines, and we don’t have enough demand and vaccines go to waste. These are vaccines that cost a lot. Definitely that pinch would sting so badly.”

As vaccines trickle into Africa, Zambia’s challenges highlight other obstacles

When Ghana received 50,000&nbsp;COVID-19&nbsp;vaccine&nbsp;doses from India last month, it hit a frustrating roadblock: it had not trained enough staff to distribute them.

The country was still rolling out shots received in late February from the global&nbsp;vaccine-sharing scheme COVAX, and didn't have the capacity to expand that operation, according to the head of Ghana's immunisation programme.

Rather than going straight into the arms of health workers, the additional doses were put in cold storage in the capital Accra, Kwame Amponsa-Achiano told Reuters, adding that his team had received two days' notice about the shipment.

"We were in the middle of the first campaign," Amponsa-Achiano said. "How do you plan for 50,000 when you already are doing another campaign?"

The problems faced by Ghana, one of sub-Saharan&nbsp;Africa's more economically developed nations, illustrate how a continent with experience in battling deadly infectious diseases has found itself ill-prepared to inoculate people against this pandemic.

Many&nbsp;African countries, already facing a shortage of affordable&nbsp;vaccines, are being stunned by the unprecedented scale of the distribution&nbsp;challenge&nbsp;when doses do arrive.

Authorities do not have enough equipment like masks and cotton wool because of funding shortfalls that could total billions of dollars, according to more than a dozen health experts and some internal government documents seen by Reuters.

They also lack sufficient personnel and training to distribute&nbsp;vaccines at short notice.

While&nbsp;Africa&nbsp;has thus far been relatively unscathed by&nbsp;COVID-19, some experts fear stuttering rollouts could draw out the outbreak in the region, potentially leading to more deaths and economically damaging restrictions in a continent that is already the poorest in the world.

Benjamin Schreiber, COVAX coordinator at the UN&nbsp;children's agency UNICEF, said logistical problems could mount in the coming weeks and months as countries tried to get&nbsp;vaccines to their general populations.

"As we start rolling out bigger quantities, we are going to start seeing more issues," Schreiber said.

"The gaps in the healthcare systems will be the gaps that hinder the rollouts," he added. "My worry is that we miss complete communities."

NEEDED: MILLIONS OF DOLLARS

Ghana, where the novel coronavirus has infected more than 91,000 and killed over 750, is considered one of the better-prepared countries in&nbsp;Africa&nbsp;to carry out a mass vaccination drive because of its political stability and economic development.

The government aims to initially inoculate 17.6 million people - about half of its population - at a cost of $51.7 million, according to a national plan seen by Reuters.

It hopes to cover $7.9 million of that money with a World Bank loan but is short of $43.8 million, described as a "funding gap" in the internal government document.

Immunisation chief Amponsa-Achiano said he was not aware that the situation had changed since the plan was formulated in February.

The Ghanaian finance and health ministries did not respond to requests for comment.

Ghana was the first country in the world to receive a shipment from COVAX, taking delivery of 600,000 doses of the AstraZeneca/Oxford University&nbsp;vaccine, manufactured in India, on Feb. 24.

It started its&nbsp;vaccine&nbsp;drive on March 1, and had vaccinated 599,000 people by April 7.

While that vaccination rate is better than many of its&nbsp;African peers - Ivory Coast vaccinated just over 53,000 people between March 1 and April 6 - it is far behind the fastest countries globally. Britain, for example, administered doses to about 2 million people in roughly the first month of its drive.

NEEDED: FRIDGES, COTTON WOOL

The Ghanaian national plan shows how even relatively prosperous&nbsp;African nations lack vital equipment.

Money is needed across the board, including $1.5 million for 11 walk-in cold rooms and over 650 fridges to keep&nbsp;vaccines at between 2 and 8 degrees Celsius.

About $25 million is needed for supplies and waste management, including 33,600 boxes of face masks, 240,000 bottles of hand sanitizer, and nearly 55,000 rolls of cotton wool, the plan says. About $21 million is needed to train over 171,000 health workers and volunteers.

To add to Ghana's&nbsp;challenge, its next COVAX shipments, expected in April and May, have been delayed until June, because India suspended major exports of&nbsp;vaccines manufactured there.

In its 2021 budget, outlined in mid-March, the Ghanaian government allotted 929,296,610 cedis ($160 million) for&nbsp;vaccine&nbsp;acquisition and deployment.

Amponsa-Achiano said, though, it was not clear how much would go towards distribution, or when the funds would materialise.

It is a common problem in&nbsp;Africa, UNICEF's Schreiber said.

"The question is at what point will this funding hit the ground? Will it be in time?"

CONGO EBOLA OUTBREAKS

Some&nbsp;African authorities are familiar with deadly contagions. Since 2018, Congo has contained four Ebola outbreaks with a&nbsp;vaccine&nbsp;which must be stored at between -60 and -80 degrees Celsius.

But the scale of the&nbsp;COVID-19 vaccination drive is new.

COVAX - the donor scheme co-led by the World Health Organisation (WHO) - has delivered over 18 million doses to 41&nbsp;African countries, according to Reuters data.

That's the first wave in a drive expected to deliver 600 million doses to&nbsp;Africa&nbsp;this year, enough to vaccinate 20 per cent of their populations. Russia, China and India have also donated some of their&nbsp;vaccines.

Funding is only one issue delaying&nbsp;vaccine&nbsp;rollouts.

Another is patchy record-keeping in many public health systems, which experts say make it difficult to identify people who should be prioritised because of age or co-morbidities.

Demand for shots is also weak in some countries due to mistrust of health authorities, lack of education about the&nbsp;vaccines and worries about potential side effects.

Spotty electricity and poor transport links in some places add to the&nbsp;challenge, while medical teams will have to negotiate safe passage across parts of Democratic Republic of Congo, Mali, Somalia and other places where insurgencies rage.

VACCINATING UNTIL END-2022?

John Nkengasong, who heads the&nbsp;Africa&nbsp;Centres for Disease Control and Prevention, says it could take until the end of 2022 to vaccinate 60 per cent of the continent's 1.3 billion people.

Take the task facing Mali, an impoverished country fighting an Islamist insurgency. It needs $14.7 million to deploy&nbsp;vaccines, including for gasoline,&nbsp;vaccine&nbsp;storage and training, according to an internal government vaccination plan seen by Reuters.

The government will need funding support from the WHO, UNICEF, the GAVI&nbsp;vaccine&nbsp;alliance and the World Bank, the plan says. Those organisations are all looking to provide funding to&nbsp;African nations facing shortfalls.

South Sudan, still racked by violence after a civil war ended in 2018, has seen&nbsp;COVID-19 infect at least 10,300 people and kill more than 100.

It began distributing 132,000&nbsp;vaccine&nbsp;doses from COVAX on April 7. However, authorities won't start administering shots outside the capital Juba and its surrounding county until May at the earliest, said Kawa Tong, a member of a&nbsp;COVID-19 steering committee that advises the government.

"The key reason is the lack of funds for a rollout outside Juba. The transport of&nbsp;vaccines, training of health workers, community outreach - all these are tied to funding," Tong told Reuters.

Adding to the difficulties, by May the rainy season will be well underway, cutting off transport links to large parts of the country, she said. The vast majority of the 11 million-strong population live outside Juba county.

Atem Riek Anyom, director general for primary healthcare at South Sudan's health ministry, said the government had requested World Bank funding, adding that&nbsp;vaccines would soon be deployed across the country.

"There's no&nbsp;challenge&nbsp;in regards to the&nbsp;vaccine&nbsp;rollout," he added. &nbsp;

The World Bank, which has a $12 billion fund to help developing countries around the world buy and distribute&nbsp;vaccines, said it was reviewing requests from Mali and South Sudan.

The bank said it has approved $2 billion to 17 countries, including seven in&nbsp;Africa: Ethiopia, Cape Verde, Ivory Coast, Eswatini, Tunisia, Rwanda and Gambia.

When Ghana received 50,000 COVID-19 vaccine doses from India last month, it hit a frustrating roadblock: it had not trained enough staff to distribute them. The country was still rolling out shots received in late February from the global vaccine-sharing scheme COVAX, and didn't have the capacity to expand that operation, according to the head of Ghana's immunisation programme.

When Ghana received 50,000 COVID-19 vaccine doses from India last month, it hit a frustrating roadblock: it had not trained enough staff to distribute them. The country was still rolling out shots received in late February from the global vaccine-sharing scheme COVAX, and didn't have the capacity to expand that operation, according to the head of Ghana's immunisation programme. Rather than going straight into the arms of health workers, the additional doses were put in cold storage in the capital Accra, Kwame Amponsa-Achiano told Reuters, adding that his team had received two days' notice about the shipment. "We were in the middle of the first campaign," Amponsa-Achiano said. "How do you plan for 50,000 when you already are doing another campaign?" The problems faced by Ghana, one of sub-Saharan Africa's more economically developed nations, illustrate how a continent with experience in battling deadly infectious diseases has found itself ill-prepared to inoculate people against this pandemic. Many African countries, already facing a shortage of affordable vaccines, are being stunned by the unprecedented scale of the distribution challenge when doses do arrive. Authorities do not have enough equipment like masks and cotton wool because of funding shortfalls that could total billions of dollars, according to more than a dozen health experts and some internal government documents seen by Reuters. They also lack sufficient personnel and training to distribute vaccines at short notice. While Africa has thus far been relatively unscathed by COVID-19, some experts fear stuttering rollouts could draw out the outbreak in the region, potentially leading to more deaths and economically damaging restrictions in a continent that is already the poorest in the world. Benjamin Schreiber, COVAX coordinator at the UN children's agency UNICEF, said logistical problems could mount in the coming weeks and months as countries tried to get vaccines to their general populations. "As we start rolling out bigger quantities, we are going to start seeing more issues," Schreiber said. "The gaps in the healthcare systems will be the gaps that hinder the rollouts," he added. "My worry is that we miss complete communities." NEEDED: MILLIONS OF DOLLARS Ghana, where the novel coronavirus has infected more than 91,000 and killed over 750, is considered one of the better-prepared countries in Africa to carry out a mass vaccination drive because of its political stability and economic development. The government aims to initially inoculate 17.6 million people - about half of its population - at a cost of $51.7 million, according to a national plan seen by Reuters. It hopes to cover $7.9 million of that money with a World Bank loan but is short of $43.8 million, described as a "funding gap" in the internal government document. Immunisation chief Amponsa-Achiano said he was not aware that the situation had changed since the plan was formulated in February. The Ghanaian finance and health ministries did not respond to requests for comment. Ghana was the first country in the world to receive a shipment from COVAX, taking delivery of 600,000 doses of the AstraZeneca/Oxford University vaccine, manufactured in India, on Feb. 24. It started its vaccine drive on March 1, and had vaccinated 599,000 people by April 7. While that vaccination rate is better than many of its African peers - Ivory Coast vaccinated just over 53,000 people between March 1 and April 6 - it is far behind the fastest countries globally. Britain, for example, administered doses to about 2 million people in roughly the first month of its drive. NEEDED: FRIDGES, COTTON WOOL The Ghanaian national plan shows how even relatively prosperous African nations lack vital equipment. Money is needed across the board, including $1.5 million for 11 walk-in cold rooms and over 650 fridges to keep vaccines at between 2 and 8 degrees Celsius. About $25 million is needed for supplies and waste management, including 33,600 boxes of face masks, 240,000 bottles of hand sanitizer, and nearly 55,000 rolls of cotton wool, the plan says. About $21 million is needed to train over 171,000 health workers and volunteers. To add to Ghana's challenge, its next COVAX shipments, expected in April and May, have been delayed until June, because India suspended major exports of vaccines manufactured there. In its 2021 budget, outlined in mid-March, the Ghanaian government allotted 929,296,610 cedis ($160 million) for vaccine acquisition and deployment. Amponsa-Achiano said, though, it was not clear how much would go towards distribution, or when the funds would materialise. It is a common problem in Africa, UNICEF's Schreiber said. "The question is at what point will this funding hit the ground? Will it be in time?" CONGO EBOLA OUTBREAKS Some African authorities are familiar with deadly contagions. Since 2018, Congo has contained four Ebola outbreaks with a vaccine which must be stored at between -60 and -80 degrees Celsius. But the scale of the COVID-19 vaccination drive is new. COVAX - the donor scheme co-led by the World Health Organisation (WHO) - has delivered over 18 million doses to 41 African countries, according to Reuters data. That's the first wave in a drive expected to deliver 600 million doses to Africa this year, enough to vaccinate 20 per cent of their populations. Russia, China and India have also donated some of their vaccines. Funding is only one issue delaying vaccine rollouts. Another is patchy record-keeping in many public health systems, which experts say make it difficult to identify people who should be prioritised because of age or co-morbidities. Demand for shots is also weak in some countries due to mistrust of health authorities, lack of education about the vaccines and worries about potential side effects. Spotty electricity and poor transport links in some places add to the challenge, while medical teams will have to negotiate safe passage across parts of Democratic Republic of Congo, Mali, Somalia and other places where insurgencies rage. VACCINATING UNTIL END-2022? John Nkengasong, who heads the Africa Centres for Disease Control and Prevention, says it could take until the end of 2022 to vaccinate 60 per cent of the continent's 1.3 billion people. Take the task facing Mali, an impoverished country fighting an Islamist insurgency. It needs $14.7 million to deploy vaccines, including for gasoline, vaccine storage and training, according to an internal government vaccination plan seen by Reuters. The government will need funding support from the WHO, UNICEF, the GAVI vaccine alliance and the World Bank, the plan says. Those organisations are all looking to provide funding to African nations facing shortfalls. South Sudan, still racked by violence after a civil war ended in 2018, has seen COVID-19 infect at least 10,300 people and kill more than 100. It began distributing 132,000 vaccine doses from COVAX on April 7. However, authorities won't start administering shots outside the capital Juba and its surrounding county until May at the earliest, said Kawa Tong, a member of a COVID-19 steering committee that advises the government. "The key reason is the lack of funds for a rollout outside Juba. The transport of vaccines, training of health workers, community outreach - all these are tied to funding," Tong told Reuters. Adding to the difficulties, by May the rainy season will be well underway, cutting off transport links to large parts of the country, she said. The vast majority of the 11 million-strong population live outside Juba county. Atem Riek Anyom, director general for primary healthcare at South Sudan's health ministry, said the government had requested World Bank funding, adding that vaccines would soon be deployed across the country. "There's no challenge in regards to the vaccine rollout," he added. The World Bank, which has a $12 billion fund to help developing countries around the world buy and distribute vaccines, said it was reviewing requests from Mali and South Sudan. The bank said it has approved $2 billion to 17 countries, including seven in Africa: Ethiopia, Cape Verde, Ivory Coast, Eswatini, Tunisia, Rwanda and Gambia.

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As vaccines trickle into Africa, Zambia’s challenges highlight other obstacles

Cash-strapped Africa overwhelmed by COVID vaccine challenge

Africa crosses 2.5 million COVID-19 cases as it witnesses second wave of infections

Virus could infect more than 200 million in Africa

COVID-19 spreads across Africa, First death reported