As the pace of the race to the vaccine becomes less salient, equal access to vaccines will become a more prominent issue

As of 28 January 2021, Israel continues to be the country with the highest rate of vaccine doses administered per capita. Among Israelis aged 70+, approximately 70% have been fully vaccinated with two doses. Approximately 30% of the total population have been vaccinated with at least one dose and 16% have been fully vaccinated. Many of the factors that enabled this achievement have been discussed elsewhere; here we highlight three factors that have implications for the long run. We focus on availability, provision, and compliance.

It is difficult to compare the current pace of vaccination in Israel to that in other countries because by January 2021 Israel had received more doses per capita than most other countries. This was, in part, due to a collaboration agreement between Pfizer and Israel with the objective “to determine whether herd immunity is achieved after reaching a certain percentage of vaccination coverage.” Israel committed to provide anonymised, aggregated epidemiological data about its residents, and Pfizer has provided Israel with enough doses.

While Israel was not the only candidate for this agreement, it certainly has advantages. Besides the structure of the country (small size and population, defined and closed borders), Israeli health plans have universal and coherent electronic medical records that can be unified and used to support research. Israel has also the foundation for this type of agreement, as health plans and hospitals have been providing anonymised data from their electronic medical records to domestic research entities through standardized collaboration agreements for years. Compared to the European Union, Israeli privacy and data protection laws allow for more latitude (and were last updated back in the 1990’s). The agreement has had the positive effect of helping Israel secure a large number of vaccine doses promptly, and most of the text of the agreement has been made publicly available as an effort to increase transparency. Yet questions remain about the levels of aggregated data that will be shared and how the data will be protected. 

Having the vaccine is not enough to achieve high rates of vaccination, and a second factor that facilitated the fast rollout was the decision of the Ministry of Health to rely on Israel’s strong primary care structure to deliver the vaccine, instead of other options, such as the underfunded public health system. In Israel, nurses are authorized to administer vaccinations without physicians being present. Yet Israel has  below average rates of nurses compared to the OECD. Since most of the outpatient nurses are employed by health plans, they were able to rapidly deploy nurses to the vaccination campaign. The question is to what extent the massive vaccination campaign is sustainable without undermining nurses’ other primary care tasks.

A third factor necessary for the high vaccination rates was a successful reduction in vaccine hesitancy, which was achieved through a combination of efforts. The Ministry of Health, together with the Israel Medical Association and several non-profit organizations that promote public health, launched exhaustive public health and awareness campaigns in the social and mass media to fight fake news, and publicise images of  well known people getting the jab. These ranged from political and religious leaders to cultural and popular celebrities, and the hope was that by showcasing their vaccinations, this would increase compliance. 

Unplanned initiatives also emerged. For example, health plans together with civic society groups informally mobilised and advertised daily (via WhatsApp groups) the vaccination sites where vaccine doses had been distributed to, but were unused toward the end of the day, and therefore could be given to non-priority groups. They would often proudly publish images of their receipt of vaccinations in social media. The sense of a “race for the vaccine” spread through these messages and highlighted the vaccine’s popularity, increasing demand and reducing hesitancy.

However, it is still too early to see whether compliance will be sufficiently high, particularly among cultural minorities such as ultra-orthodox Jews and Arab communities, who might need more tailored out-reach and enhanced access. In addition, mechanisms for the provision of vaccines for uninsured residents such as undocumented immigrants are only just now being established. Whether and how Israel should be playing a role in helping the Palestinian Authorities access vaccines is being discussed, with the support of the Israeli public health community. 

We are now in a state of emergency, and the speed of the vaccination rollout is important. However, it is clear that steps need to be taken to ensure that the rapid rollout does not undermine the provision of other essential services in an equitable and high-quality manner. Just as healthcare systems had to learn how to treat covid-19 patients along with other patients, they will have to integrate covid-19 vaccinations into their broader set of activities. With time, the pace of the race to the vaccine will become less salient, while equal access to vaccines will become a more prominent issue, particularly regarding vulnerable and harder to reach populations, such as homebound older people.

 

Ruth Waitzberg is a research scholar at the Smokler Center for Health Policy Research of the Myers-JDC-Brookdale Institute, Jerusalem, Israel; a research fellow at the Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Germany; and a PhD student at the Ben Gurion University of the Negev, Israel.

 

Nadav Davidovitch, MD, MPH, PhD, is an epidemiologist and public health physician. He is a Full Professor and Director, School of Public Health at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel.

 

 

Competing interests: none to declare

Acknowledgements: the authors thank Bruce Rosen, Michal Laron, Gabriel Zimmerman and Avi Israeli for their constructive comments on earlier drafts of this piece.

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