How will Pakistanis get vaccinated for Covid-19?

Around October, more than six months after the still ongoing coronavirus pandemic became truly global, news started to surface that initial testing of different coronavirus vaccines was beginning to show promise. By December, less than a year after the virus became global, the first jabs have started with vaccination drives all over the world catching steam, and even Pakistan beginning its own drive in January 2021. 

Looking back, having gotten to this point has been a miracle. Hopes of a vaccine being ready in a year were slim, and everyone said so. They were not wrong either. Vaccine development is slow, it takes a lot of trial and error (which means a lot of money), and there is little motivation for the free market to develop vaccines since they do not translate to big profits. 

Despite this, because of the urgency of the pandemic and the push of different governments to usher along the vaccine development process, viable vials were made ready within a year of the pandemic having struck. On February 2, 2020, US pharmaceutical company Pfizer forecasted $15 billion in Covid vaccine sales in 2021. The Pfizer vaccine is among the leading vaccines that have been approved for use in multiple countries. 

But here is the catch, where Pfizer has forecasted $15 billion in sales from Covid vaccines, Pakistani pharmaceutical companies have no idea if they will be able to get their hands on the vaccine in time, let alone earn profits from its sales. 

There is currently only one pharmaceutical company in Pakistan, Karachi-based AGP Ltd, that has been able to get permission from the government to import Russian Sputnik vaccine for Covid-19. The rest of the vaccines in the country have been either bought by the federal government, or have been gifted from other countries and will be used to vaccinate front line medical workers and those segments of the population most vulnerable to the virus. 

So this is the situation – even though Pakistan’s vaccination drive has begun, there is little knowledge about what exactly the business potential of these vaccines will be. According to one BBC report, while investment analysts are forecasting that at least two companies, American biotech company Moderna and Germany’s BioNTech with its partner, US giant Pfizer, would be likely to make billions of dollars next year, not clear how much vaccine makers really are set to cash in beyond that. And with the government largely controlling the vaccines that come into the country, the private sector will not have a big role to play, but they will still have a role.

Vaccine roll outs 

Pakistan was never going to be one of the leading countries producing their own vaccines. Our best bet was getting on board an experimental vaccine and hoping it works, as we did with a few Chinese vaccines. You see the problem is that vaccines need to be almost universally administered to have a lasting effect. Take for example Pakistan’s coronavirus testing capacity. 

Initially, the government was conducting a few thousand tests a day through tracking and tracing and eventually started doing free testing on request. The government, of course, was conducting these tests for free. Meanwhile the private sector was quick to get testing kits themselves and charge big sums of money for coronavirus tests. This is the same model that was being followed in the rest of the world as well. 

If the government finds out you have been exposed to the virus, they will test you for free to mitigate the spread of the virus. However, if you need a test to travel, go somewhere, for work, or just for your own peace of mind, in that case you pay for the test yourself. And while testing capacity is important, vaccines have to be mandatory. Now, the problem is that the government has limited doses so give it to those that need it the most. Meanwhile, if private pharmaceutical companies can import vaccines, those that are lower down on the priority list can get vaccinated by paying these companies. 

“Just like with the Covid-19 testing, the vaccination challenge is huge. And just like the Covid testing, the government was at the forefront and the private sector had a supporting role,” says Omar Chughtai, CEO of Chughtai Labs.  “In order of magnitude, the vaccination challenge is estimated to be bigger than the testing challenge. Testing was voluntary. Vaccination is mandatory.” 

Since Pakistan is not developing any vaccine of its own, the country will have to rely on imports from other nations that have production facilities and the research companies and labs to produce such vaccines.

But these vaccine producing companies have to vaccinate people of their own nations first. Vaccinating frontline health workers, the elderly, the young, in that order.  What that means is that Pakistan will always remain dependent on vaccine producing nations, and it will remain dependent for some time to come. This is one of the key issues of global vaccination – developing countries are left for last. 

But as the process continues, the largest procurement of Covid vaccines is state to state or from company to state. “Governments are the largest purchasers and users of vaccines and I think that would be the case with Pakistan as well. What that means is that the government will try to vaccinate as many people as possible, and the rest will be catered to by the private sector, that is pharmaceutical companies will be providing vaccines into the market,” says Omar Chughtai. “The private market would be there to supplement the role of the government. Every person that we vaccinate is one less person for the government to vaccinate from taxpayer money.”

But even this minimal role for the private sector is tricky. “When it comes to vaccines, they are considered a public health good and governments are either the only customers of the vaccine or they are the majority customers, 90% or more. EPI (Expanded Programme on Immunisation) programmes in Pakistan are all government programmes,” explains Osman Waheed, CEO Of Ferozsons Ltd. This means that even in case private companies are able to import Covid-19 vaccines, it is probably going to be the government that is going to purchase the bulk of these vaccines from these companies.

Market potential

But the government has to vaccinate a population of 220 million people, and the number of vaccines procured so far are much less. So it goes that the government would be happy if the private sector took over some of this burden. Presently, the leading Covid-19 vaccines are Pfizer-BioNTech, Moderna, Gamaleya, Oxford-AstraZeneca, Cansino, Johnson and Johnson, Vector Institute, Novavax, Sinopharm, Sinovac, SinoPharm-Wuhan, Bharat Biotech, Sputnik. 

The government of Pakistan has so far secured 500,000 doses of the coronavirus vaccine made by the Chinese firm SinoPharm to Pakistan in donation. That is besides a contract with SinoPharm for another 1.2 million. Covax, the global multinational initiative to provide equitable access to Covid-19 vaccines regardless of wealth of a country, 17m doses of Astra­Zeneca would be provided to Pakistan in the first half of 2021.

In collaboration with China, Pakistan is also conducting a Phase 3 trial of another Chinese anti-coronavirus vaccine from Cansino Biologics, Inc. Pakistan is also entitled to receive 20 million doses from Cansino Biologics  provided that the results are positive and the vaccine proves to be effective. All in all, that is 38.7 million vaccines if Cansino Biologics proves to be effective. In a country of 220 million people, that is a shortfall of 181.3 million. That is the potential market of Covid vaccines for private pharmaceutical companies, but right now, there is no clue what is going to happen. 

“The situation is in a flux. Reportedly, private deployment will also be done by the government. What this means is that even if a third party imports the vaccine, the deployment is in the government’s hands,” says Nadir Mumtaz, CEO of Sehat.pk. Deployment comes second. What is still rather unclear is whether or not enough vaccines are going to be allocated to Pakistani companies. 

The CEOs that Profit talked to were all in talks with companies producing these vaccines and none of them could give us a concrete timeline of the availability of vaccines from the company, price of an individual vaccine dose, and number of people that would get the dose. That does not mean the companies are being secretive, but that the negotiations are in such a nascent stage that 

“We are in contact with various representatives of various vaccine options and our mission is to make it available in Pakistan as soon as it can be made available in Pakistan. And then to make sure it is utilised in a deliberate and careful manner so that there is no chaos,” says Omar Chughtai. “We have always maintained that with the limited information that we have, that it is probably going to be the second quarter of this year, April onwards, that we will have access to the vaccine. It seems to be playing out that way right now.”

Normally, the government is not involved. Local parties register products with DRAP that they want to bring in a certain product and then they get permission from the government to bring this in. According to the demand that they have gauged, they bring in the quantity. They bring it in after fulfilling certain regulatory and quality requirements and then sell it to hospitals and pharmacists. It is sold via the existing pharmaceutical supply chain.

Who will get vaccinated?

As we have discussed earlier, the government’s priority in Pakistan is that they have started off with healthcare workers, which makes absolute sense, followed by vaccinating people that are most vulnerable; people over the age of 60 because they are most likely to develop severe cases of Covid-19. But even if private  companies are able to get their hands on the vaccine, private companies will also try to make the vaccine available to elderly population first.

The problem at the end of the day is demand and supply. The magnitude of the disease is global whereas the production is not global. All the producers of vaccine candidates – Pfizer, AstraZeneca, Moderna and others – are facing challenges fulfilling the demand because of the scale at which the vaccine is required. 

It is just one of those unique situations where vaccine availability is going to be a challenge for sometime because of the demand. So people who are producing the vaccine are intelligent about who gets the vaccine first. Add to this the fact that vaccines are already a low profit margin production since they are only administered once to each person and developing countries have high demand but a lower ability to pay big prices. 

“Chughtai Lab is going to make vaccines, as soon as we have access to it, available to senior citizens on priority in the first phase. We want everyone to be vaccinated but it is going to be started from the elderly,” says a hopeful Omar Chughtai. “Vaccine rollout has to be managed carefully and deliberately. We are going to go about it in a streamlined manner where people can see that we are giving priority to those people that are most vulnerable to the illness,” he adds. 

As far as the number of people that Chughtai Labs plans to vaccinate, Omar says they are not shooting for a high or a low number. Because of the uncertainty around allocation, whatever becomes available, the Lab will try to get it utilised as quickly and fairly as possible. 

“There might be situations where we would not have access to enough vaccine doses and we would have to turn people away. Then there might be situations where we would have enough vaccines but we do not have enough infrastructure to get the vaccine delivered or get people vaccinated, in which case we might try to work with other vaccine providers so that they can use vaccines.” 

When it comes to pricing, things are still very murky. Different numbers have been floated globally concerning the price of different vaccines. But negotiations might turn in different numbers. The rates that companies quote or government’s quote from state to state or from companies to state are very different when the volumes are in the millions or tens of millions. “A private enterprise will probably not have that kind of scale,” says Omer. “There is a lot of ambiguity right now, so it is hard to say what the price of Covid vaccine is going to be.”

Then there is the supply chain. Normally, all the vaccines require storage at temperatures between 2 to eight degrees celsius. But there is a particular concern around Pfizer vaccine and the difficulties in making that available in Pakistan particularly because Pfizer maintains a very strict cold-chain protocol that requires the vaccine to be stored at -70 degree celsius.

Nadir Mumtaz, the CEO of online pharmacy Sehat.pk, explained that because they are an online pharmacy that ships to many regions in Pakistan and have an efficient supply chain in place, they analysed how Covid-19 vaccines can be managed and kept. “We have almost two years of data on vaccines generally. The temperature requirement is different in winter and it is different in summer. In our supply chain, we developed protocols, tested by multinational companies, that makes our cold-chain efficient. Most of the vaccines in Pakistan are required to be kept between 2 to 8 degree range but the Pfizer one is at a different level.”

“We have a cold chain in place for 99% of the medicines that require a cold-chain. It is at 2-8 degrees celsius. That is the normal fridge temperature,” Nadir says. “Pfizer vaccine on the other hand is radically different that requires it to be stored at -70 degrees celsius and that is beyond what is commercially available in Pakistan,” he adds.

“Not that the supply chain that supports keeping vaccines at -70 degrees celsius is not possible, it is simply difficult in Pakistan. On the other hand, the infrastructure for vaccines that require the temperature range to be between 2 and 8 degrees is in place and can be done properly.”