Box 4.

Vaccine Rollout: early signs of Punt Politics

Limited national stewardship in Brazil and Mexico, and the lack of evidence-based coordination with sub-national entities continues to impact vaccine access, as it did with NPIs. Yet, the punting pathways differ for vaccines because access depends on purchasing and distribution.

As of August 2021, procuring COVID-19 vaccines continues to be almost entirely restricted to centralized, country-level purchasing on the global market, or via the COVID-19 Vaccines Global Access Initiative (COVAX) [63]. So long as this continues, sub-national governments – even without regulatory or budgetary constraints - have little capacity to bypass their national governments and directly procure vaccines, even if that government is failing to purchase or distribute vaccines effectively.

In Mexico and Brazil, access to vaccines has been insufficient, deficient, and inequitable. Up to May 31, 2021, overall coverage was low, rollout slow, and distribution patchy in both countries. In June and July, distribution and overall vaccination rates improved and the average daily rate over the entire period reached approximately 7 vaccine doses per 1000 people in Brazil and nearly 6 in Mexico. As of August 22, 26% of Brazilians were fully vaccinated and 24% of Mexicans. Still, they continue to lag behind Chile and Uruguay, where approximately 70% are fully vaccinated [13].

Given the limited success of national governments in Mexico and Brazil to procure vaccines, some state governments have struggled to break into purchasing despite an array of barriers. Both countries seem to be ramping up their todate underutilized manufacturing capacity and state governments may use this to break into vaccine purchasing. Yet, in the meantime, lobbying without achieving access to vaccines places state governments in a difficult position, as they remain responsible for controlling transmission and minimizing the impact of the pandemic in their jurisdictions, yet lack the resources and ability to purchase from global markets or influence vaccine allocation decisions. Further, “punting” vaccine responsibility can generate inequities that allows variants to emerge and spread.

Transparency and lack of data on vaccines are problems in Mexico and Brazil. Although both governments periodically make announcements, information has been contradictory and timelines repeatedly changed, the size of stocks remains unknown, and there is a sizable gap between vaccines purportedly received and evidence on vaccination.

Brazil: Throughout 2020, national stewardship was sparce and convoluted. President Bolsanaro stated publicly that vaccinated Brazilians might become “crocodiles” [64]. As with NPI, President Bolsonaro repeatedly questioned the need for vaccines, and set a poor example by pledging not to accept one himself and continuing to refuse to be vaccinated.

Purchasing was slow and disorganized in 2020 and the first half of 2021. Initially government failed to respond to the Pfizer offer of 100 million doses in mid 2020, and commissioned only a fraction of the COVAX offer [65]. Limited amounts were purchased from Oxford-AstraZeneca in late 2020 and, more recently in March of 2021 from Pfizer to supplement inadequate supply stemming from disruptions in vaccine production in China [66]. The government reversed course and in June began promoting vaccines extensively and accelerated purchasing to attempt to make up for slow entry into the market.

Given limited supplies, several states attempted to bypass the national government. Vaccine trials in São Paulo provided an edge on purchasing SINOVAC and manufacturing CoronaVac. In a politicized move by the state governor who is planning to run in the 2022 presidential elections against Bolsonaro, São Paulo bypassed the Ministry of Health and purchased vaccines directly from China, and began to vaccinate ahead of the federal campaign [67,68].

Brazil's federal government centralized vaccine distribution but generated roll-out bottlenecks, supplies to the municipalities have been sporadic and national distribution began later than in several other Latin American countries.

Mexico: Mexico's president shed disdain and publicly embraced science as vaccines became available [69]. As per the official vaccination plan, 46.9 million citizens, almost half of the population, would have been fully vaccinated by the end of July. Yet, plans have not worked out and only 20% are fully, and 17% partly, vaccinated. Earlier, López Obrador had promised to vaccinate all 14 million Mexicans over 60 by end of March 2021 – a goal left unmet.

The federal government began negotiating vaccines early (late 2020). Yet, while vaccine deliveries were to reach 106 million doses by end of May, only 80 million were received by late July [69]. In the face of limited supply, the federal government announced that by the end of 2021 Mexico will manufacture its own vaccine “Patria” (Fatherland) [70].

Vaccine distribution and roll-out is centralized, inequitable, inefficient and not evidence-based [71]. Limited collaboration with subnational governments and civil society in the vaccination campaign, coupled with failure to rely on existing health infrastructure for implementation, have kept vaccine administration at low levels. Instead, the President formed special, itinerant vaccination brigades that administer vaccines in pre-selected localities [72]. Supply in any given area is temporary and restricted to residents, making vaccines inaccessible for those who miss the date or live in localities that have yet to be selected for the campaign. Thus, whereas almost 80% of the adult population had received at least one dose in the wealthier Baja California by mid-July, only 21% had done so in Chiapas. In addition, although the official vaccination plan prioritizes frontline health workers [63], those in the private sector were for a period excluded from the official plan. Finally, in the lead up to the June midterm elections, concerns emerged about vaccine politicization [73]. The number of administered vaccines peaked in the weeks before the elections and decreased afterwards, and the peak included groups not deemed high priority [71].

Simillarly to Brazil, Mexican state governors have sought to bypass the federal government and lobbied for the right to purchase vaccines [74,75], however, in the face of scarcity and regulatory restrictions, they have been unable to move forward.