Vaccine access and uptake
This briefing note explores factors influencing the access and uptake of vaccines; the different approaches taken by public health authorities to promote vaccines; and the ethical considerations that arise in this context.
Decisions about whether and how to implement vaccination programmes, and about whether or not to be vaccinated, can involve a complex negotiation of the various interests and concerns of individuals and families, the communities they are embedded in, and the public good. This section sets out some of the key ethical considerations for vaccination programmes.
Promoting good health and reducing the burden of disease
Vaccination is considered to be one of the most effective public health interventions to reduce the burden of infectious disease.58 Vaccinations can protect against diseases for which there is no effective treatment or cure and which can cause death and disability. They can also prevent or reduce transmission, stopping outbreaks from becoming endemic, and are sometimes pursued as the most effective, or least intrusive, way to bring an end to major epidemic outbreaks.
By reducing illness, vaccination can reduce healthcare costs and loss of education or productivity in the population. Vaccines are also thought to have significant broader economic impact, for example, by improving financial security, leading to increased investment and improved political and economic stability.
Addressing health inequalities
Vaccines can help reduce health inequalities, for example, by protecting those who might be more likely to suffer from severe illness and its effects. In countries where healthcare is not freely provided by the state, vaccines can help prevent or reduce healthcare costs that would otherwise be borne by individuals and families.
However, inequality of access to, and uptake of, vaccines persist at global and national levels, and lower vaccination uptake in some groups can further exacerbate health inequalities. This has prompted calls for governments to address access issues and factor social determinants of health and existing health inequalities into epidemic preparedness plans. A 2021 WHO declaration on vaccine equity called on all countries to work together in solidarity to ensure health workers and older people in all countries are offered COVID-19 vaccines as a matter of priority.
Balancing individual, community, and wider public interests
Factors that might be considered in programmes that aim to increase the uptake of vaccines include weighing up choice and individual and relational autonomy alongside individuals’ responsibilities to others (including to children or others that lack capacity to consent to vaccination) and the wider public good. These are not necessarily competing interests; for example, individual interests can be motivated by altruism or solidarity with others, and vaccination motivated by self-interest can benefit the wider community.
Some argue that the threat of infectious disease and the potential collective good of population immunity could justify mandatory vaccination. A 2007 Nuffield Council on Bioethics report on public health concluded that policies to mandate vaccination might be justified given the state’s role in promoting public health and minimising risks of harm to others, but that this would depend on the risks associated with the vaccine; the seriousness of the threat of disease (and whether disease eradication might be within reach); and whether there is evidence that a mandate would be more effective than other measures to encourage voluntary vaccination.
Fair and effective use of public resources
Cost and cost-effectiveness are considerations for governments deciding whether to approve and provide vaccines. In the UK, the Joint Committee on Vaccination and Immunisation (JCVI) advises the Government on whether and how to implement vaccination programmes, with cost-effectiveness as a key criterion, in the same way that the National Institute for Health and Care Excellence (NICE) evaluates the cost-efficiency of medical interventions. In practice, this means that vaccines that are effective against diseases might be rejected or restricted on the basis that the economic cost outweighs the predicted economic benefit. What should be included in this evaluation (e.g., whether and how the weighting of quality-adjusted life-years (QALYs) should be used) is a matter of debate.
International obligations and global health security
Infectious diseases spread between nations through international travel and trade, and their incidence can also be affected by other factors that transcend national borders such as antimicrobial resistance, climate change, and conflict. In response to this, vaccination is a component of global agreements such as the International Health Regulations (IHR) 2005, a legally binding agreement between 196 countries (including all WHO member states) to work together for global health security. This is also a rationale for the UK’s role as a major funder of Gavi, a public-private partnership of national governments, international agencies, NGOs, and the private sector to improve access to new and underused vaccines for children in the world’s poorest countries.
The Nuffield Council on Bioethics’ policy briefing on fair and equitable access to COVID-19 treatments and vaccines highlighted the importance of global solidarity and the moral responsibilities of governments to ensure fair and equitable access to vaccines beyond their own borders.