This is part one of a two-part series, The links between vaccine hesitancy, mistrust, and corruption. Read part two – Community mobilisation: a strategy to rebuild trust and promote vaccine uptake in sub-Saharan Africa.

Vaccination is a formidable and cost-effective bulwark against ill-health, saving millions from measles, polio, mumps, and rubella. In the ongoing battle against Covid-19, the world has placed its hopes on an equitable rollout through the Gavi COVAX Advanced Market Commitment. However, the vaccine rollout across middle- and low-income countries has met with both new and familiar challenges. While vaccine hesitancy – the delay or refusal to accept vaccination – is as old as vaccines, the flow of information has never been greater – nor more distorted.

The recent past

The roots of mistrust are many, overlapping, and constantly changing. As a colonial past of medical abuse taints trust in the health programmes of today, so does a history of corruption in many sub-Saharan African countries. The neglect of health services, and years of corruption, have eroded public trust in their governments, turning many people away from official channels of care and information to seek support elsewhere.

Take the example of Nigeria in 2003 and its mass vaccination programme against polio. During that time, polio was endemic in the country and accounted for 80% of the cases reported in all of Africa. To contain the spread of the virus, the international community launched a mass vaccination programme. However, a community-organised boycott put a halt to the mass effort, and its consequences were felt globally. Misinformation and institutional mistrust were at the centre of the boycott. Conspiracy theories circulated that the vaccine was a way for the government to control their growing population. This misinformation was amplified by public mistrust formed from years of neglect of basic healthcare services, high-profile allegations of malpractice on the part of pharmaceutical companies, and weak health governance systems plagued with corrupt practices.

The overall pattern from Nigeria – of the erosion of confidence in government programmes; consequent health problems; and a slow, partial rebuilding of trust – has been repeated in several other countries in sub-Saharan Africa, and with several other vaccine programmes.

Vaccine hesitancy and Covid-19

Despite recent successes like the polio programme, the Covid-19 pandemic poses new challenges. For example, 72% of Nigerians surveyed in 2020 pointed to political corruption as their main reason for political distrust and non-compliance with coronavirus recommendations. This does not bode well for vaccine uptake among an already sceptical public.

Vaccine hesitancy is a persistent challenge for Covid-19 vaccine rollouts in sub-Saharan Africa. Only a third of people surveyed in November 2020 across six African nations strongly agreed that the vaccine is safe and effective, yet about 60% are willing to take the vaccine if it were to be free and available. These numbers are promising but fall short of reaching the uncertain threshold for community immunity against SARS-CoV-2, which ranges from 50% to 90% depending on the virus variant.

With new and more contagious virus variants constantly being discovered, it is safe to say that the safest path forward is to have more people vaccinated. However, achieving this requires an equally high level of vaccine confidence.

(Mis)trust, corruption and vaccine uptake

Institutional trust is an important determinant of vaccine confidence and uptake. Vaccine confidence embodies trust in the vaccine itself, trust in the healthcare system and its professionals, and trust in the political institutions that manage the services. In a survey by Afrobarometer, informal institutions came out on top as the most trustworthy, beating formal institutions across all 36 African nations in the study. Within the informal institutions, religious and traditional leaders were considered the most trustworthy.

When trust in formal institutions is low, public health and development efforts falter. Take the examples of the Ebola outbreak in Liberia and in the Democratic Republic of the Congo (DRC). In both cases, mistrust in the government made citizens less likely to comply with recommended public health measures. The low trust in the state, combined with widespread misinformation, also made people less likely to seek care and less accepting of vaccines. These experiences from Liberia and DRC illustrate that vaccine confidence and uptake rests on a fragile continuum of trust/mistrust and information/misinformation.

Conspiracy theories around vaccines

Conspiracy theories are a common symptom – and cause – of mistrust. Two of the most prevalent across several African countries are that vaccines are a way for governments to control their growing populations, and that they are a way for corrupt government elites to make money. After all, 4 out of 10 Africans believe that most, or all government officials are corrupt.

The first example is perhaps not surprising, given the public reaction to the polio vaccine less than 20 years ago, as well as ill-judged comments by French scientists who suggested that a potential Covid-19 vaccine should first be trialled in Africa. Dispelling fears that the vaccine is intended to harm Africans will not be easy, but it can be done. The example of the polio vaccine in Nigeria is cause for optimism, and there have been substantial improvements in vaccine uptake for a number of other diseases as well.

We at U4 are much more concerned about the perception that elites are in it to make money for themselves. A corrupt government is perceived as ill-intentioned and self-serving. Thus, in the mind of the people, who is to say that the Covid-19 vaccination campaigns are not just another charade for their own benefit? The threat this poses to state-led Covid-19 vaccine rollouts is far too real.

Creating the conditions for trust to grow

Development actors, including bilateral donors, can contribute to tackling vaccine hesitancy in several ways. One of the most important things they can do is to promote integrity-building initiatives in the health sector – and indeed in the whole of government – as a way of strengthening public trust and vaccine confidence.

In part two of this series, we will consider what donors and governments can do in the short term to build trust in public health messaging and promote vaccine uptake.