Early on Wednesday 24 Febrary 2021, Ghana became the first country in Africa to take delivery of Covid-19 vaccines from the COVAX facility. President Akufo-Addo officially launched his country’s mass vaccination programme the following Monday morning, visiting 37 Military Hospital in Accra to receive the first dose.
With this step the largest vaccine procurement and supply operation in human history has entered a new phase. COVAX consignments have now arrived in Côte d’Ivoire, Nigeria, DRC, Kenya, Gambia, Rwanda, Lesotho, Uganda, Malawi, São Tomé & Príncipe, Mali, Ethiopia, Togo and Mozambique. This first wave for Africa totals around 11 million doses — less than 1 per cent of the continent’s population, but a start nonetheless.
Looking ahead, plans to scale up global vaccination programmes give us all hope for a return to life without the restrictions currently in place around the world. Vaccines save lives and prevent health-care systems from being overwhelmed by critical care needs. But they are also vital for future prosperity, with mass vaccination the key to reopening economies battered by restrictions on social contact and travel.
The interconnected nature of the modern world means that countries have an interest not just in their own vaccination programmes but also those of their neighbours and trading partners. International travel is a two-way street; knowing that your own citizens are vaccinated against what they might encounter abroad is one thing, but countries will also want to be confident that visitors are not bringing infections in with them.
Some form of internationally recognised health pass is therefore a matter of practical necessity. For travel, trade and tourism to return to anything like pre-pandemic levels, people will need to be able to prove their vaccination status as easily as they currently prove their age or nationality. The sorts of paper certificates first introduced in the 1930s and 1940s will not be enough; their 21st-century equivalent needs to be more convenient, more flexible and more secure – all of which ultimately means it will need to be digital.
Chapter 1
There are now numerous initiatives underway to build Covid-19 health and travel passes. Some are focused on domestic use, others are looking at travel corridors, and others still are looking at regional systems. There are also important efforts to consolidate global standards and promote interoperability. The Africa CDC Trusted Travel initiative is a first step to streamline travel requirements between countries in Africa; worldwide, the CommonPass framework is being designed to help people prove their health status wherever they are.
Sooner or later the international community will settle on some common standards for describing people’s health status, and citizens will choose from a selection of consumer apps capable of generating compatible digital proofs – most likely some form of privacy-preserving QR code that can be easily scanned and validated.
A country’s ability to participate in this global system will depend entirely on it having comprehensive, machine-readable, secure and portable data on vaccinations.
Old-fashioned paper records of every vaccination administered – as are often used for routine child immunisation programmes – cannot meet this requirement.
In some countries, computerised systems are also used to record some health data. These systems collate records from different places onto a single database, which can then be used to produce reports and analyse progress.
Until the pandemic this approach was often sufficient. A range of tools, including the widely used and locally deployed DHIS2 and other open source frameworks like the Community Health Toolkit, have been a lifeline for lower- and middle-income countries looking for better health information management without a huge price tag.
The challenge now, however, is that traditional health information systems are focused on recording data and recalling it for administrators. This helps policymakers interested in seeing the aggregate position, and front-line health-care workers dealing with individual patients, but it is less well suited to powering a citzen-centric health pass.
For a health pass to be reliable and widely trusted, population-scale data on vaccinations needs to be secure and portable in a very specific way: allowing individuals to authenticate their identity and acquire unique digital proofs that in turn can be validated whenever and wherever required, all without leaking personal data to third parties (e.g., credibly proving vaccination status without revealing a person’s medical history or home address).
This sort of secure recall requirement at scale is novel and flows directly from an external environment upended by the pandemic. Before Covid-19 there was no widespread need for people to regularly prove their vaccination status in order to go about their daily business. Pointing out that needs have changed is not to criticise what was put in place before; it is simply stating a fact arising from the situation the world now faces.
Chapter 2
As countries await further supplies of vaccines, there is a window of opportunity that can be seized to prepare for the next phase of the pandemic. Travel, trade and tourism will reopen fastest for countries that manage both to vaccinate a significant number of people and to capture reliable, trusted data on who has been vaccinated.
Whatever specific tools or technologies are chosen to manage vaccination data, there are three critical dimensions that countries need to look out for:
Scale. Covid-19 vaccines need to go out in greater numbers and at greater speed than anything existing health-care systems are used to – in some cases health systems will be expected to administer tens of millions of doses in weeks, whereas the child immunisation programmes countries are accustomed to typically run to hundreds of thousands per year. Data systems need to be able to handle huge numbers of records being created by tens of thousands of health-care workers, without slowing down or collapsing if too many people try to connect at the same time.
Security. Covid-19 vaccine data needs to be reliable and trusted by the rest of the world if a country wants to regain full international connectivity. The health passes that its citizens use will only be accepted if the data that underpins them is credible – which in turn requires robust authentication for users, effective processes to mitigate fraud and error, and strong cyber-security provisions to protect against malicious actors. Data systems for Covid-19 will need to be as reliable and secure as those powering international payments and other global infrastructure.
Future-proofing. Covid-19 vaccines are unlikely to resolve the pandemic in a single leap; instead there is a reasonable likelihood that countries will need to pivot quickly to deal with new variants, multiple booster doses and possibly even new restrictions to counter a resurgence in infections. Data systems will need to put individuals at the centre and be flexible enough to accommodate new use cases for individual health data – with features like two-way communication with citizens, permissioned APIs and privacy-preserving credentials all part of the architecture from the outset.
This leaves policymakers with an important choice: whether to carry on with existing systems and record Covid-19 vaccinations in the traditional way, or instead to adopt new systems built specifically to cope with the new and significant pressure of the pandemic.
The former is familiar and will therefore minimise institutional resistance, making it the easiest course of action in the short term. But it also means accepting the limitations of existing systems in terms of scale and functionality, and deferring some critical decisions for a later date — which in turn will only increase the scale of the challenge when countries do finally come to make the leap to more sophisticated systems.
The latter course of action is the better strategic option, putting today’s vaccination data directly onto scaleable platforms designed from the outset to meet countries’ future needs for multi-purpose, citizen-centric digital health records. Making this sort of shift when the status quo involves legacy on-premises infrastructure inevitably comes with practical challenges; the reality is countries need to be prepared to work through them to get to a better position to face what comes next.
In the end leadership and vision will be the most important factors when it comes to determining which countries get ahead in the race to reopen. The huge pressure that the pandemic is piling on governments will leave many overwhelmed with intense and detailed preparations to vaccinate their populations. Nevertheless, the big picture remains important for leaders to focus on – as vaccination programmes progress, having best-in-class data systems will make or break efforts to reopen travel, trade and tourism.
To paraphrase a well-known proverb for the Covid-19 era: The best time to fix your country’s health data is yesterday; the second-best time is now.