Equitable Access to COVID-19 Vaccines in Botswana: A Scoping Review

John Thato Tlhakanelo^1,2*John Ele-Ojo Ataguba^3,4,5,6Vincent Pagiwa⁷Nankie Ramabu²Khutsafalo Kadimo⁸Dintle Molosiwa²Grace Njeri Muriithi³Daniel Malik Achala³Elizabeth Naa Adukwei Adote³Chinyere Ojiugo Mbachu⁹Senait Beshah¹⁰Nyasha Masuka¹¹Chijioke Osinachi Nwosu¹²James Akazili^13,14Ifeanyichukwu Chikezie¹⁵

• ¹University of Botswana, Gaborone, Botswana
• ²Department of Family Medicine and Public Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
• ³African Health Economics and Policy Association, Accra, Ghana
• ⁴Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada, Winnipeg, Manitoba, Canada
• ⁵Partnership for Economic Policy (PEP), Nairobi, Kenya, Nairobi, Kenya
• ⁶School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
• ⁷Okavango Research Institute, University of Botswana, Gaborone, Botswana
• ⁸Department of Library and Information Science, University of Botswana, Gaborone, Botswana, Gaborone, Botswana
• ⁹Department of Community Medicine, University of Nigeria, Enugu Campus, Nigeria, Enugu, Nigeria
• ¹⁰Ethiopian Public Health Institute, Addis Ababa, Addis Ababa, Ethiopia
• ¹¹Zimbabwe College of Public Health Physicians, Harare, Zimbabwe
• ¹²University of the Free State, Bloemfontein, South Africa, Bloemfontein, South Africa
• ¹³C.K Tedam University of Technology and Applied Sciences, Navrongo, Upper East Region, Ghana
• ¹⁴Bergen Centre for Ethics and Priority Setting, Faculty of Medicine, University of Bergen, Bergen, Hordaland, Norway
• ¹⁵Health Systems and Development Research Group. Veritas University Abuja, Abuja, Nigeria

Introduction Despite global market complexities, Botswana acquired about 2.6 million COVID-19 vaccine doses between March 2021 and March 2022, 76% of which were purchased while 24% were donations. Thus, the study was envisaged to aggregate evidence on the case of Botswana's COVID-19 vaccine access patterns, hesitancy, and uptake. Materials and methods We conducted a scoping reviewof Botswana-based articles using a predetermined search strategy to search databases including Medline, CINAHL, Web of Science, PubMed, Scopus, and Google Scholar. The review included all the English-language written peer-reviewed and grey literature reporting on vaccination in Botswana, to broaden coverage in recognition of limited publications on COVID-19 vaccinartion in Botswana. Non-English articles were excluded due to limited translation resources. Due to the heterogeneity of studies, a narrative synthesis approach was used to collect, synthesize, and map the literature. Results As of 31 December 2021, 80.6% of the Botswana national target of 1,390,856 people over 18 years had received at least one dose of a COVID-19 vaccine, while 71.9% were fully vaccinated. Various vaccine distribution channels were utilized, including public facilities and outreaches, to improve access and uptake of vaccines. COVID-19 vaccine acceptance was considered generally high (73.4% amongst adults), and found positively associated with the male gender, those with comorbidities, those with non-restrictive religious beliefs, and those aged 55-64 years who thought the vaccine was safe for use. COVID-19 vaccine delivery relied on existing Expanded Program on Immunization (EPI) structures and therefore experienced to existing EPI challenges including, lack of transport, shortage of human resources, and vaccine stock-outs. Conclusions Under-performance of immunization programs at the district level, characterized by declining immunization coverage and inadequate outreach services, exacerbates disparities in vaccine access. Efforts to strengthen healthcare infrastructure and expand outreach services are essential for reaching populations with limited access to healthcare facilities, particularly in rural and hard-to-reach areas. Collaboration with other government entities and the private sector improved vaccine access.