Scoping review of literatureInternational factors that may foster corruption in COVID-19 vaccine access

The studies included in our review spanned between 2020 and 2022, reflecting the years of the COVID-19 pandemic. The research team retrieved and reviewed a total of 40 documents. The review found that the urgent need to procure COVID-19 vaccines provided opportunities for corruption throughout the development and supply chain. Conflicts of interest arising from governments working closely with vaccine manufacturers may have impaired objective review in downstream vaccine selection and funding processes [2]. The resulting alignment between governments and the pharmaceutical industry meant that agreements on terms of engagement and contract details were inaccessible and confidential, creating information asymmetries between officials involved in vaccine procurement decision-making and the public [17, 18]. This limited information meant that the public was less aware of government commitments of public funds, and civil society groups were less aware of who to hold accountable and less able to identify when decision-makers failed to meet their commitments [18]. Governments and the pharmaceutical industry justified this information secrecy by claiming it is needed to protect proprietary rights.

Human Rights Watch observed that the high demand for and low supply of COVID-19 vaccines, facilitated by constricted supply chains for required raw materials, enabled high-income countries to maintain a stranglehold on vaccine supplies by pre-ordering doses that severely limited low-income countries’ access to COVID-19 vaccines [19]. High-income countries and countries with vaccine manufacturing capacity also adjusted their export policies to ensure that their citizens had access to vaccines before allowing vaccines to be exported [20]. The scarcity created by the inequitable distribution of COVID-19 vaccines was identified as a driver of vaccine theft and the emergence of fake or substandard vaccine products [10], as well as financial leaks, nepotism, and favouritism in the procurement system [2].

COVID-19-related misappropriations and procurement scandals were reported to have resulted in the loss of millions of dollars in both high-income countries, such as the United Kingdom, and low- and middle-income countries, such as Kenya and South Africa [20, 21]. These misappropriations were often traced to high-level officials and were associated with poor population-wide access to vaccine-related resources. One commentary identified that discriminatory resource distribution practices across sectors (including education, agriculture, and health) typical of African settings were also observed in the distribution of COVID-19 vaccines and resources [22]. Cronyism and tribalism may similarly influence vaccine allocation and distribution. A perception of acute vaccine shortages led to vaccine corruption scandals, the development of black and opaque markets for vaccines, and bribes to allow certain individuals to jump vaccination queues [23].

Poor testing capacity and surveillance can lead officials to underestimate the cases of COVID-19 and underprepare for its impact, thus preventing actors from procuring vaccines when they are most needed [24]. More demand pressure may then build up, increasing incentives to engage in corrupt practices to access limited supplies. Decision-making related to allocating vaccines to priority groups is particularly vulnerable to corruption risks, including conflicts of interest, nepotism, and favouritism [2]. Health care professionals exercising their discretion to dispense legitimate products based on nepotism and favouritism may further contribute to product scarcity and increase opportunities for substandard or falsified vaccines to proliferate [2].

Factors that may foster corruption in COVID-19 vaccine access in Nigeria

A need for rapid access to COVID-19 vaccines meant that procurement and bidding best practices were often overlooked [25]. The Nigeria Vaccine Policy, released in September 2021, demonstrates how procurement speed was prioritized over process accountability [26].

Within Nigeria, vaccine procurement concerns were complicated by events related to the COVID-19 pandemic that made people suspicious of the government. Food and other relief materials meant to alleviate the burden of the pandemic were spotted in warehouses across the country, undistributed [27]. The public perceived that these resources were stockpiled for politicians and political parties, causing massive protests and revolts about the government pandemic response and plummeting trust in the government’s COVID-19 policies. In the midst of these events, many Nigerians avoided COVID-19 vaccines and instead attempted to unlawfully acquire vaccination cards [28]. This was particularly prevalent among people seeking to travel abroad, as vaccine certificates were often required for international travel [28]. Health officials were implicated in vaccine certificate falsification, with rogue officials charging high informal fees to issue vaccination certificates to individuals who had not yet been vaccinated, yet health managers reported that they were unable to gather sufficient evidence to arrest corrupt officials [28].

Weak leadership and decision-making within the Nigerian health sector, as well as existing accountability issues, meant that infrastructure to store and distribute vaccines was frequently unavailable [5]. Decision-makers were also unable to recommend COVID-19 vaccines that were suitable for the level of infrastructure available in the Nigerian system [27]. Even after doses were procured, slow vaccine distribution increased public distrust and fostered suspicions that doses were being reserved for the elite class [29]. For example, a state governor’s wife was reported to travel abroad to get a COVID-19 vaccine shot from the United States while Nigeria was struggling to access COVID-19 vaccines [30]. Distrust also arose when international staff of multinational aid agencies, including those connected to COVAX, appeared to have earlier access to vaccines than local staff [31].

Factors that improve accountability and transparency in COVID-19 vaccine procurement and distribution

Several researchers and policy analysts have suggested mechanisms to bolster vaccine procurement and distribution. Although many of these mechanisms have not been evaluated for effect or impact, they nonetheless reflect standard ACTA practices and are expected to have positive effects. Implementing corruption risk assessments into routine government monitoring processes was proposed to identify potential entry points for corruption [2, 32]. Since pharmaceutical procurement and distribution, especially during emergencies, present opportunities to make money, privilege seekers deploy deviant mechanisms to secure supply/service deals and make undue profits, risk assessments can increase public awareness of corruption risks and help countries prevent it.

Digital platforms that regulate and track vaccine importation and distribution, as well as share quality surveillance information across regulatory agencies, were also identified as tools to increase monitoring of vaccine supply chains, thus enhancing procurement-related ACTA measures [32].

Factors that may hinder accountability and transparency in COVID-19 vaccine procurement and distribution

Opacity around COVID-19 vaccine procurement decision-making resulted in limited public access to relevant information and data sharing, which hindered transparency in vaccine procurement and distribution [18, 19, 32]. This was the case both locally and internationally, with scholars lamenting the lack of public information to track who should be held accountable for COVID-19 vaccine inefficiencies [31]. Similarly, using special commissions to negotiate the purchase of COVID-19 vaccines, as opposed to usual procurement mechanisms, also hindered transparency and increased the risk of corruption in the distribution of pandemic-related funds [2].

The complexity of the COVAX governance structure, as well as its shortfalls in delivering vaccines as projected, was also considered a serious accountability problem. COVAX held lofty ideals of efficient and equitable vaccine distribution, but it has been criticized for enabling vaccine nationalism and failing to distribute vaccines to disadvantaged populations within poorer countries [17]. Researchers point to COVAX’s relatively weak governance mechanisms, which allowed wealthier countries and powerful private pharmaceutical companies to wield influence and secure resources to their advantage [17, 33, 34].

Mechanisms that can help reduce the risk of corruption in the COVID-19 vaccine procurement and distribution

Several recommendations to improve ACTA in COVID-19 vaccine distribution were identified in the literature. Many of the suggestions were not exclusive to COVAX, but were designed to improve efficiency of COVID-19 vaccine procurement and distribution more broadly.

One paper suggested waiving patent rights on vaccine technology and making it more freely available, thereby boosting vaccine production and availability, and lessening the scarcity that creates a climate that encourages corruption [20]. While this proposal would infringe on the intellectual property rights of manufacturers, Amnesty International suggests that expanding and diversifying manufacturing through sharing intellectual property and open, non-exclusive licensing are important for a more accountable and transparent vaccine procurement and distribution system [35].

Other papers also strongly recommended strengthening vaccine procurement and distribution oversight and monitoring, including using domestic activists, civil society groups, or anti-corruption agencies to demand accountability from government [2, 20, 36, 37]. Since countries typically have local activists that push for health rights, some proposals suggested leveraging these activists to demand accountability from the actors involved in vaccine procurement and distribution. Others underscored the role of establishing accountability and reporting mechanisms to monitor financial disbursement processes and verify receipt of appropriate funds, as well as diversifying monitoring teams to include balanced gender proportions [2]. Specialized committees with a robust anti-corruption mandate to oversee and disburse emergency funds, distribute and prioritize vaccines, and monitor vaccine-related programmes were also recommended [2, 10]. Donor support of ACTA mechanisms to ensure the proper distribution of vaccines in recipient countries was highlighted as particularly important [38]. When distributing vaccines to vulnerable groups, monitoring distribution channels to ensure that supplies would not be diverted or tampered with was recommended [10].

Normal health procurement procedures that are employed during non-health emergencies should not be jettisoned and replaced with entirely new emergency committees. Centralized procurement procedures were considered effective in securing affordable pricing and reducing the public purchasing of substandard vaccines [32]. Routine procurement best practices, such as harmonizing packaging using a global standard (including a centralized track-and-trace system), can reduce administrative and financial burdens associated with repackaging products at the national level. Digital platforms that enhance within and between country communication about resource needs (e.g., by publishing information about procurement coordination, surveillance, operational support and logistics, timelines, and prioritization of different groups), such as the District Health Information Software 2 (DHIS2), can further strengthen ACTA in procurement [32]. Regional networks and systems that promote timely data sharing can also contribute to improving procurement efficiency [32, 39]. ACTA mechanisms ensure that vaccine supplies can be identified and redirected if individual officials abuse their positions and fail to distribute vaccines according to published standards or distribution plans [40].

Findings from in-depth interviewsSocio-demographic characteristics of participants

Participants were drawn from four different categories of vaccine distribution stakeholders from both surveyed states: state officials, LGA officials, health facility stakeholders, and patient communities. A total of 40 IDIs were conducted across these categories: state (10; M = 5, F = 5), LGA (11; M = 5, F = 6), health facility (8; M = 3, F = 5), and community (11; M = 7, F = 4). All participants played vital roles in either the distribution or administration of COVID-19 vaccines, or were patients who shared their experiences of accessing vaccines distributed by public officials. Table 2 shows details of respondents.

Table 2 Demographic characteristics of respondentsCoordination and distribution of COVID-19 vaccines

The results show that the National Primary Health Care Development Agency (NPHCDA), which receives vaccine supplies from the federal government or donor agencies and then distributes those vaccines to states through the State Primary Health Care Development Agency (SPHCDA), coordinates COVID-19 vaccination. The State Cold Chain Officer then develops a state strategy to distribute the vaccines across all LGAs in the state through either an LGA Cold Chain Officer or a third party. At the LGA level, the LGA Immunization Officer and Cold Chain Officer distribute vaccines to vaccination teams at the ward level through a ward focal person (usually a primary health care manager).

Primary health care managers employ both fixed (e.g., health centre) and mobile (e.g., malls, markets, town halls) posts as strategic public vaccination locations, with the aim of vaccinating large numbers of people at a single location. Vaccination teams are equally dispatched to remote communities to mobilize and vaccinate consenting individuals.

To ensure accountability, vaccinators are expected to account for the number of vaccines distributed each day, which should correspond with the number of vaccination cards distributed and the number of vaccinations uploaded in the electronic data records. At the LGA level, each ward focal person is expected to return empty COVID-19 vaccine vials alongside updated vaccination records to account for the number of vaccines supplied and people vaccinated. These records must match before new vaccines are released to the focal person. Records are then sent to the state-level electronic platform before being forwarded to the national level.

Corrupt practices in COVID-19 vaccine deploymentNepotism in hiring of COVID-19 vaccine staff

Three important components of planning for vaccine delivery were (a) recruitment of personnel, (b) contracting of personnel, and (c) budgeting. We found corruption issues across all three components.

Evidence related to the recruitment of personnel, including vaccinators, recorders, and administrative staff, shows that advertisements were not used and assessments of recruited staff were not conducted. Staff involved in the emergency deployment of COVID-19 vaccine were largely recruited informally. Those recruited were expected to show unquestionable loyalty to their recruiters and not challenge any perceived anomalies observed on the job. One informant stated:

“The recruitment process is dishonest. People just brought in those they knew because they know that money is involved. No adverts, no screening, just people bringing relatives and friends. I am not surprised [that] accountability is poor, because you cannot challenge [those above you] when you know that you were recruited just anyhow.” (IDI, Monitoring and Evaluation (M&E) Officer, State A)

Clear personnel contracting was also absent in the planning stage. Those recruited did not formally sign contracts, suggesting that they had no idea how long they were expected to work or how much they should expect as remuneration. Some of the personnel interviewed corroborated this lack of job transparency and highlighted that payments were arbitrary and shrouded by many opaque processes:

“The process should be more transparent, especially when it comes to payment... They [wouldn’t] tell us [that] the job [would last] ‘from this time to that time.’ We just keep working. When we started the work, we worked March, April, ʼtil sometime around August, which was when they paid us. So, we were confused. Because we did not get a reasonable amount, and we started asking if [our pay] was monthly or daily or weekly. The mathematics was not adding up. So, we don’t know how they [paid us].” (IDI, Vaccinator 1, State A)

When key officers were asked if they were aware of the budget plan needed for administering COVID-19 vaccines or if they were involved in formulating the budget, they said they did not know if there was a budget and that no meeting was called to inform them of how much money was received or how the received money should be used:

“I don’t how the money is being shared, and I don’t know if issues like supervision and steady payments were incorporated into the budget. We have never contributed to the budget, and no one will show us, because if they do, they know we will raise concerns and become more watchful.” (IDI, Assistant State Cold Chain Officer, State A)

Falsification and manipulation of vaccination data

Vaccinators were reportedly paid based on the number of people they vaccinated, with higher pay for higher numbers of vaccinations given. Both the government and international partners involved in vaccination efforts employed this strategy. Government and non-governmental agencies frequently sought vaccination progress data, with one participant stating “there was this pressure everywhere for data you know, from agencies” [IDI, Assistant Mobilization Officer, State B]. However, due to vaccine hesitancy among the patient population, vaccinators sometimes resorted to falsifying identities to increase the recorded number of vaccinated individuals.

“[I]n giving us… a specified number [of vaccinations] to meet [per] day, I think it is bringing in forgery. I have to be frank. People don’t willingly want to be vaccinated, unless they are pressured or they have something to do with the [vaccination] card. So, in this kind of situation, how do you expect us to come up with … 20 or more [vaccinations] per day? We will definitely forge the data, especially when we know our money is dependent on the number of persons we report to have been vaccinated.”(IDI, Vaccinator 2, State B)

Interview respondents narrated the forgery process: Vaccinators input fake identities with fake phone numbers, or they would solicit the identities and phone numbers of people they would convince to receive vaccination cards without being vaccinated. Different strategies would apply in different locations and with different people, often determined by education level.

“In the rural areas, they go house to house to collect people’s data. They will just tell them, ‘Just give us your name and phone number that is all we just need. And they will register you.’ It is a village, so you will hardly have people to question you. But in town, you can’t just walk up to someone and tell him to give you his or her data. So, when they even accept to come for the [vaccination] cards, we are happy, and we just give [the cards] to them.” (IDI, Vaccinator 1, State B)

The national dashboard on COVID-19 vaccination rates showed the vaccination performance of each state, and high-ranking health officials wanted to see their states perform better. During daily review meetings at the SPHCDA, which frontline vaccinators and their managers attended, there appeared to be implicit pressure on vaccination teams to ensure that sufficient numbers of the population were vaccinated. One officer involved in mobilizing communities in State B described the following:

“Our ES [executive secretary] mandated us that we have to work, to the extent that our state will be the first or leading state in terms of the number of people vaccinated, so we devised strategies… at [one] point we were working like mad, the ES gave prizes for the best performing LGAs. We were competing, though it was a peaceful competition.” (IDI, State Mobilization Officer, State B)

Our results indicate that “data-hungry” state officials became aware of the vaccination rate falsifications, but were reluctant to follow up with verifications and sanctions. Instead, they collated the figures and presented them as official state data.

“It is sad that it could be that the vaccination was said to be done in State X, [but] when you call the person [recorded] the name does not match and the person will say ‘I live in State Y and I have never been to State X.’ But we do not make such calls all the time. We just take the data and submit. We know that some of them could be falsified.” (IDI, M&E Officer, State B)

Lastly, some of the vaccinators withheld data or provided incomplete datasets because state and national agencies did not provide logistics such as transportation and internet data, and payments were delayed. This, in turn, contributed to a distorted vaccination rate picture at both the local and national levels.

“There is a need to always provide [vaccinator] stipends and as well as subscribe… their data bundle. Another thing is to compensate them for their transportation, but all these are not regularly provided. Sometimes, it takes more than the necessary time for this money to get to them, and when it is like that, many of them will become reluctant to go to the field. When it is like that, they [are more likely to] manipulate the data or not even upload their data and synchronize them. When it is so, our data will not even speak for us at the national level. You will see us stalling behind other states. So that is the problem that we have.” (IDI, M&E Officer, State A)

Nepotism, favouritism, and bribery

Some respondents reported favouring their friends and acquaintances during the vaccination process, particularly when demand for vaccines was high and wait times were long. One Electronic Management of Immunization Data (EMID) Officer in a vaccination team explicitly mentioned that sometimes they were biased when conducting services related to their position and decided to give their friends and family faster access to COVID-19 vaccines.

“In the field, we might have about 200 people to vaccinate. We [then] queue them and start registering them. [If I] see my brother at the back, I will signal [to him], register him, and vaccinate him first. It’s corruption, but we do it anyway.” (IDI, E-recorder, State A)

Respondents also reported payoffs. For example, sometimes service users who wanted to jump queues to gain quicker access to a COVID-19 vaccine would pay a member of the vaccination team for priority access. A service user who had been vaccinated confirmed that vaccination teams would favour people who gave payments, and sometimes users gave tips to vaccination teams.

“The only thing that I also noticed is that people [who came after me] were vaccinated before me. That’s Nigeria for you: ‘who you know’ syndrome. Once you know someone, they will just mingle you in, they will attend to you, then you leave. That’s what they do. Some [patients] do give tips to the health workers, [and the health workers then] attend to them quickly.” (IDI, Service user, State A)

Fee for COVID-19 vaccination cards

By far, the most-reported irregularities were the issuing of COVID-19 vaccination cards to non-vaccinated individuals and the collection of unofficial fees by health care workers for the distribution of legitimate vaccination cards. When COVID-19 vaccines became a strict requirement for some activities such as international travel, demand for vaccination cards increased. In this context, some health care workers issued COVID-19 vaccination cards to people who were not vaccinated but needed the document. When this happened, some members of the vaccination team demanded bribes to register these unvaccinated individuals on the online vaccination registration platform and issue them vaccination cards without actually vaccinating them. The below quotes describe this situation in more detail:

“We cannot say somebody can sell the vaccine, but someone can sell the card. Like in those days when they say that you must have the card before travelling, someone may try to do something to give people the card without vaccinating.” (IDI, M&E Officer, State A)

“Some people would walk in and call you [to] the side to say that they want the card for travel, but don’t want the vaccine. No matter how hard you try to convince them, they will say no, you can see they are suspicious or afraid. They know that one can get the card without the vaccine, so they just want the card. So you help them get the card and collect small money.” (IDI, Vaccinator, State B)

Demand for informal payment

In addition to collecting informal payments for vaccination cards, frontline COVID-19 vaccine officials were reported to have demanded unofficial fees for vaccinations, claiming that these fees covered logistics expenditures, internet subscriptions, and transportation. Since vaccine officials entered vaccination records on the official e-recorder platform and these e-records were used to verify vaccination certificates at border crossings, those requiring vaccination cards to engage in international travel faced heightened pressure to comply when faced with demands to make informal payments.

Higher informal payments were demanded from individuals who wanted a COVID-19 vaccine certificate but did not want to receive the vaccine.

“Yes, I paid N5000. [The vaccinator] said… that I will pay N2000 [to cover internet subscription]. I felt bad because I wanted to take the vaccine. I decided to pay N5000 [rather] than stressing myself, because [the vaccinator] complained that [if I didn’t pay] the vaccine [wasn’t] available at the moment and I have to come back.” (IDI, Service user, State A)

Remuneration irregularities

The budgeting, recruitment, and contracting processes in COVID-19 vaccine administration in Nigeria lacked transparency, with a major consequence being irregularities in paying vaccine workers. As workers were recruited informally and on a temporary bases, they were paid arbitrarily. Some state-level officers reported that they received complaints about payment variations, delayed payments, and even no payments at all. Unfortunately, the complaints were resolved either too late or not at all. Implying the possibility of forfeiture of due payments, one vaccinator stated:

“I don’t know, but we had the issue reported at the platform, where they paid some [vaccinators] 36,000 naira, and they paid some 19,000 naira, and they paid some 22,000 naira, and they paid some 25,000 naira. These are people doing the same job. ʼTil this moment, we cannot tell why such variations.” (IDI, Vaccinator 2, State B)

Sometimes, non-remuneration was attributed to deliberate corrupt behaviour, with reports of account details of vaccinators being swapped or account details of people who were not workers being included in the payroll. A top manager added:

“…[S]ome will deliberately replace people’s account numbers with the account numbers of their family members. So, people that did the work won’t get the money, while the state has actually released the money.” (IDI, Assistant State Health Educator, State B)

Payment irregularities were reported to lead frontliners, who then demanded informal payments and bribes from patients, with the rationale that they had to self-fund their transportation costs and procure internet subscriptions:

“If we go to the field with our money and we are lucky to have people who really need to be vaccinated, we will go ahead to vaccinate them, but they must give us some money or send call credits that we can use to purchase data to upload their details as being vaccinated. That is how we cover up. There are some people that will tell you straight away to give them some money to help them in transporting themselves.” (IDI, Vaccinator 1, State B)

Efforts by local establishments to control corruption in COVID-19 vaccine deployment

Some ACTA mechanisms were reported to be implemented to ensure equitable access to COVID-19 vaccines. These included maintaining the proper documentation for COVID-19 vaccine supplies, using external consultants to distribute COVID-19 vaccines, maintaining joint supervision of COVID-19 vaccination teams, conducting daily debriefings and reports of field experiences by vaccine teams, and maintaining oversight of and investigating reported irregularities.

Rigorous tracking of vaccine demand and supply in manual and digital formats

Both the State Primary Health Development Agency and the State Ministry have processes in place to document state-level vaccine supply and demand. The documentation process begins at the national level, where vaccines are received, and continues throughout the supply chain to the health facilities. The State Cold Chain Officer (SCCO) sends vaccine requests to the national level. When vaccines are delivered to the state, the SCCO, with support of store keepers, checks to ensure that the quantity supplied is documented both in hard copy (registers and forms) and on the open Logistic Management Information Systems (LMIS), the designated software for vaccine data collection, processing, and reporting. One respondent noted:

“Yes, even this tablet that you are seeing was given to me for vaccine accountability. As you receive [a vaccine], you queue it in by the State Cold Chain Officer and send it to the national [level]. You send [the information] to the state at the same time [as you do] to the national. This gives account of every vaccine collected.” (IDI, Disease Control and Immunization Officer, State B)

On the supply side, the SCCO is responsible for deploying vaccines to the LGA level. The Local government Immunization Officers and LGA Cold Chain Officer (CCO) receive vaccines from the state and document these deliveries u