African countries are expected to be last in the queue for Covid-19 vaccinations, complicating the global fight against the coronavirus pandemic . With encouraging results from late-stage trials for several candidates, attention is turning to the distribution of billions of doses around the world, and there are concerns most African countries will be left to the mercy of rich nations in the race for access to affordable vaccines. China has promised once its vaccines are approved, they will be shared with Africa to help fight the spread of coronavirus, which could be crucial for the countries fearing they will be left out as the US and some European countries make billions from vaccine orders amid rising cases of Covid-19 worldwide. Nearly all of these African countries are banking on Covax , the global initiative co-led by the Coalition for Epidemic Preparedness Innovations (CEPI), the Vaccine Alliance (Gavi) and the World Health Organization (WHO). However, analysts say most African countries will not gain full access to affordable vaccines until after the rich world has vaccinated its people. Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University in the US, said it could take two to three years before all of Africa was vaccinated to achieve so-called herd immunity. “This is not only ethically unconscionable but foolhardy. Unless all parts of the world are protected, there will be ongoing outbreaks in high-income countries,” he said. Gostin said experience suggested the vaccine would come late to Africa, as shown during the H1N1 influenza pandemic, when promised vaccines to lower-income countries were never delivered in a timely way. “Africa’s population is about 1.2 billion, representing 17 per cent of the world’s population. Assuming Africa needs 70 per cent coverage for herd immunity, and given most vaccines need two doses, it will need over 2 billion doses,” he said. It will be the biggest vaccine distribution plan ever – but can it work? David Shinn, a professor at George Washington University’s Elliott School of International Affairs and a former US diplomat, said that for all vaccine-producing countries, “the priority will be the nationals of the countries where the vaccine is produced”. In the US, Pfizer has applied to the Food and Drug Administration for emergency approval for its vaccine, which it says is 95 per cent effective. Earlier this month, American biotech company Moderna said the efficacy of its candidate in preventing the disease caused by the coronavirus was 94.5 per cent. And, on Monday, pharmaceutical company AstraZeneca and Oxford University in Britain said their Covid-19 vaccine was 70 per cent effective . Meanwhile, Chinese pharmaceutical firm Sinopharm has applied for regulatory approval for its vaccine, while Russia approved vaccines in August and October. London-based consultancy Capital Economics, using data from the Duke University Global Health Innovation Centre, puts confirmed purchases of 18 leading vaccines at 6.4 billion doses, with another 3.2 billion under negotiation. The US and European Union had placed the biggest orders, followed by India and Covax, Capital Economics said in a note last week. Of the successful vaccines so far, the US holds most orders for Moderna, while the EU dominates the Pfizer order book. “Sub-Saharan Africa is entirely dependent on Covax. Russia relies on its vaccine and, while the situation is opaque, the same seems to be true of China,” Capital Economics said. Beijing officials have repeatedly said that once a Chinese vaccine is ready, African nations will receive doses, with China planning to make the vaccine a “global public good”. Speaking at the 15th G20 leaders’ summit via video link on November 21, Chinese President Xi Jinping said Beijing would honour “its commitment of giving assistance and support to other developing countries, and work to make vaccines a global public good accessible and affordable to people around the world”. China says it will deliver on vow to make Covid-19 vaccines a global public good In June, Xi chaired the Extraordinary China-Africa Summit on Solidarity Against Covid-19 and pledged that “once the development and deployment of a Covid-19 vaccine is completed in China, African countries will be among the first to benefit”. And in mid-October, 51 African envoys and senior diplomats visited a vaccines factory owned by Sinopharm, which has also been conducting phase 3 trials for its vaccine in Morocco. The north African nation is planning to produce the Chinese vaccine once it is approved. On Tuesday, John Nkengasong, head of the Africa Centres for Disease Control and Prevention, told the Bloomberg Invest Africa online conference that the continent was in discussions with China and Russia for possible Covid-19 vaccine partnerships. The Africa CDC had met with China’s ambassador to the African Union on possible partnerships between Chinese vaccine manufacturing companies and clinical trial sites in Africa, he said. Coronavirus vaccine race: where are we and how far? Gostin, however, said he was sceptical of China’s offer. China’s Belt and Road Initiative in Africa showed China had a highly mercantile, transactional approach to health and infrastructure help, he said. “I believe China will help supply some of Africa’s needs, but it will come at a political or economic cost.” WHO regional director for Africa Matshidiso Moeti said the reports of three effective Covid-19 vaccines was a comfort to African countries and “has us determined to ensure that African countries obtain sufficient supplies to make an impact on the pandemic at the same time as all others”. “The potential impact of several high-income countries having arranged advance purchase agreements of hundreds of millions of doses needs to be closely followed,” Moeti said, during the 70th session of the WHO Regional Committee for Africa on Tuesday. For African countries, there remained much more to do to mobilise sufficient financing for vaccine supplies and most importantly for delivery operations, she said. The African Union estimates the continent will need about US$12 billion for vaccine purchases. It expects the funding to come from the World Bank and African Import-Export Bank, which has committed to raising up to US$5 billion. Virag Forizs, an emerging markets economist at London-based consultancy Capital Economics, said potential access and distribution issues could test policymakers in Africa. “In the absence of bilateral deals with vaccine manufacturers, most African countries will have to rely on the multilateral Covax facility with a slower expected roll-out of vaccinations,” she said. Forizs said even after securing doses – for up to 15 per cent of populations in Covax-participating countries by end-2021 – difficulties with distribution may push back the point at which widespread vaccination could enable the return to “normality”.