Cost-based COVID-19 vaccination and willingness to pay: A post-pandemic review

ABSTRACT

The primary objective of this paper is to serve as a valuable resource for policymakers who are confronted with the evolving landscape of the coronavirus disease 2019 (COVID-19), considering both free and cost-based vaccination approaches. The potential consequences of shifting from free to cost-based vaccination are explored, encompassing its impact on global vaccine equity and prioritization, economic well-being, healthcare systems and delivery, public health policies, and vaccine distribution strategies. Examining past studies on willingness to pay for the initial COVID-19 vaccine dose and booster shots provides insights into how individuals value COVID-19 vaccinations and underscores the significance of addressing issues related to affordability. If COVID-19 vaccinations incur expenses, using effective communication strategies that emphasize the importance of vaccination and personal health benefits can increase willingness to pay. Making COVID-19 vaccines accessible through public health programs or health insurance can help alleviate financial barriers and increase vaccination rates.

KEYWORDS:

• Cost-based vaccination
• COVID-19
• willingness to pay

Background

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged as a global health crisis of unprecedented scale in late 2019.¹ It rapidly spread across borders, leading to widespread loss of lives as well as disruptions in social economic, and healthcare systems worldwide. As the COVID-19 pandemic progressed, it became increasingly clear that vaccination would be a crucial factor in reducing incidence, hospitalizations, and deaths.^2–4 The scientific community and pharmaceutical industry joined forces to rapidly develop reliable and effective COVID-19 vaccines,⁵ leading to the accelerated approval and distribution of multiple COVID-19 vaccines in an unprecedented manner.⁶ On December 11, 2020, the US Food and Drug Administration (FDA) granted its initial emergency use authorization for the Pfizer – BioNTech vaccine,⁷ and subsequently, several other COVID-19 vaccines received approval. Consequently, a coordinated effort to administer COVID-19 vaccines was undertaken worldwide, with governments, multilateral entities, and healthcare authorities collaborating to ensure global access to COVID-19 vaccines.

As the COVID-19 vaccines were urgently needed to combat escalating cases and deaths worldwide, numerous countries adopted the pivotal strategy of offering COVID-19 vaccines free of cost during the initial stages of the pandemic.^8–10 This approach aimed to guarantee extensive vaccine coverage. However, while vaccines became freely available to combat the pandemic, the financial impact remained a critical issue. Continuously providing COVID-19 vaccines for free, while essential for public health, may also present certain unintended consequences. As the cost of implementing and maintaining vaccination programs is high, the prolonged provision of free COVID-19 vaccines can come with significant financial burdens, putting pressure on government funds and healthcare resources. Although the COVID-19 pandemic has subsided, and many people have returned to their normal, pre-pandemic life, the emergence and spread of new COVID-19 variants warrants the ongoing administration of booster shots,¹¹ which further strain budgets and healthcare systems. The allocation of resources to free vaccination programs may divert funds from other vital healthcare priorities, potentially affecting the delivery of other essential medical services.¹² Therefore, ensuring the sustainability of free vaccine initiatives in the long term becomes a pressing challenge for many countries.

Many countries globally face intricate choices regarding whether to provide COVID-19 vaccines for free or to introduce costs.¹³ The purpose of this review is to highlight the potential ramifications of transitioning from free COVID-19 vaccination to a cost-based approach. The past empirical evidence concerning individuals’ willingness to pay for the COVID-19 vaccine, along with recent studies examining their willingness to pay for booster shots, was examined to gain insights into the future direction of COVID-19 vaccine pricing. By delving into the existing research on willingness to pay, policymakers can gain a deeper understanding of how individuals value COVID-19 vaccination and booster shots. This knowledge can be instrumental in shaping appropriate strategies for pricing, accessibility, and distribution to ensure that the general public has access to the necessary COVID-19 vaccination and additional booster doses while maintaining financial sustainability.

Implication of shifting from free COVID-19 vaccination to a cost-based approach

Before considering the implementation of cost-based COVID-19 vaccination, it is essential to elucidate its potential consequences. The shift toward a post-pandemic era has far-reaching consequences that impact multiple areas, including challenging global vaccine equity and prioritization, the economic well-being of the population, healthcare delivery and systems, public health policies, and vaccine distribution strategies.¹²

Global vaccine equity and prioritization

The rapid development of COVID-19 vaccines represents a remarkable achievement, but it also shines a spotlight on the significant inequality in vaccine distribution. Looking back, over the course of the pandemic’s first 18 months, approximately 1.5 billion vaccine doses have been administered worldwide. However, a striking 75% of this vaccine supply has been distributed to only 10 countries.¹⁴ In stark contrast, the entire African continent, with a population of 1.36 billion, has received fewer than 25 million vaccine doses.¹⁵ The global vaccine distribution has been severely unequal. With the threat of recurring waves of emerging SARS-CoV-2 variants of concern, this continued inequitable access to vaccines creates a long-term threat to global population health.¹⁶ Introducing cost-based COVID-19 vaccination within individual countries can further exacerbate the existing global vaccine equity and prioritization issues. Cost-based vaccination frequently prioritizes wealthier individuals who can afford to purchase vaccines, potentially worsening the situation. In countries with limited access to COVID-19 vaccines, this policy can result in even greater barriers for the underprivileged segments of the population, making it increasingly difficult for them to access COVID-19 vaccines.

Economic wellbeing

Primarily, the economic ramifications are substantial. The motivation for vaccination is inversely influenced when immunization costs are borne as out-of-pocket expenditures.¹⁷ As evidenced by findings from a study involving 10 low- to middle-income countries (LMICs) in Asia, Africa, and South America, economic factors play a crucial role in shaping individuals’ willingness to pay for COVID-19 vaccination.¹⁸ Therefore, if the transition from free to cost-based COVID-19 vaccination occurs, it may place a notable financial strain on individuals, as the added cost of vaccination can strain household budgets, particularly for those with multiple members. The economic burden on low-income and vulnerable populations may lead to lower vaccination rates, making them more susceptible to COVID-19 infection, and resulting in increased healthcare expenses. Economic disparities may further widen, exacerbating existing health disparities and increasing the gap in health outcomes between different socioeconomic groups. Organizations worldwide strive to improve cultural competence to minimize health inequities, as it is acknowledged as a vital tool in mitigating racial and ethnic differences in healthcare outcomes.¹⁹ With the introduction of costs for COVID-19 vaccines, health inequalities present an even greater challenge. This suggests that ensuring the availability of free COVID-19 vaccination services should be a top priority, especially in LMICs, for effective pandemic control in these regions. Similarly, maintaining ongoing free COVID-19 vaccination for LMICs, especially for those in the most vulnerable segments of these economies, may be essential to protect these populations and for overall public health.¹⁸

In LMICs, COVID-19 vaccines are often distributed through global initiatives such as COVID-19 Vaccines Global Access (COVAX), Coalition for Epidemic Preparedness Innovations (CEPI), and the World Health Organization (WHO), either for free or at a minimal cost. Additionally, in some LMICs, the public can access COVID-19 vaccination for free. Although studies found that individuals from LMICs generally show a higher willingness to accept vaccinations than higher-income countries,^20,21 nevertheless in terms of vaccine coverage, high-income countries (HICs) showed higher vaccination coverage than LMICs.²² HICs were able to rapidly procure COVID-19 vaccines, establish efficient distribution networks, and launch vaccination campaigns due to their advanced healthcare systems. These efforts helped mitigate logistical challenges and address vaccine hesitancy among their populations. In contrast, LMICs, especially during the early phases of the pandemic and possibly continuing to date, faced multiple access challenges, including geographic access, wealth disparities limiting access, and health promotion constraints.²³ According to a study conducted on 170 countries, the overall COVID-19 vaccination rate reached 49.257% by the end of 2021. HICs such as the United Arab Emirates, Cuba, Brunei, Portugal, and Chile achieved high vaccination rates, with over 90% of their populations vaccinated. In contrast, Yemen, Chad, Haiti, the Democratic Republic of Congo, and Burundi had lower vaccination rates, with less than 2% of their populations vaccinated.²² Implementing a fee for COVID-19 vaccination might deter people in LMICs from getting vaccinated. This is evident from public opinion surveys conducted in Ghana and Bangladesh, where a considerable portion of respondents expressed hesitation to receive the vaccine if they had to pay for it.²⁴ Similarly, the implementation of cost-based vaccination undeniably may lead to a decrease in vaccine uptake in China, as clearly demonstrated by the distinction between the coverage of National Immunization Program (NIP) vaccines and non-NIP vaccines in the country. In China, vaccination initiatives are categorized into NIP and non-NIP. NIP vaccines are both freely provided and mandatory, with their budget being supported by the Chinese central government,²⁵ consequently leading to a high coverage rate for NIP vaccines.²⁶ In contrast, non-NIP vaccines are optional and necessitate self-payment, which results in lower coverage rates. A recent report indicated that the coverage rate of all NIP vaccines exceeds 90% in China.²⁷ For the majority of non-NIP vaccines, coverage rates remained notably below 50%, with figures spanning from 1.8% for the third dose of the rotavirus vaccine to 67.1% for the initial dose of the varicella vaccine.²⁸ Moreover, the greatest portion of inequity in non-NIP vaccine coverage was associated with monthly family income per capita,²⁸ which suggests a pronounced economic influence on vaccination outcomes.

Healthcare delivery and systems

It is widely documented that the COVID-19 pandemic has significantly impacted the delivery of and access to healthcare in both HICs and LMICs, placing an unprecedented strain on health systems worldwide²⁹ resulting in a cascade of negative effects. Shared challenges include disruptions in routine medical care, delays in essential surgeries, challenges in managing non-COVID-19 health conditions, and considerable strain on healthcare workers and healthcare resources.³⁰ However, crucial differences emerge in terms of resource disparities, with LMICs facing limitations in healthcare infrastructure and vaccine access, while HICs generally exhibit more robust systems and quicker vaccine procurement.

First and foremost, the introduction of costs for vaccinations may certainly result in decreased vaccination rates, as some individuals may opt to forgo or delay getting vaccinated due to financial constraints. Two immediate challenges foreseen for healthcare systems are: 1) a decrease in the utilization of preventive care services, and 2) a strain on healthcare facilities and resources due to the increasing number of COVID-19 cases among the unvaccinated. These consequences result in an imbalance in the healthcare system, with potentially detrimental effects on patient outcomes and overall public health, with LMICs facing particular severity in this regard.^31–33

China for instance witnessed a significant impact of the COVID-19 pandemic on healthcare service utilization. In 2020, there was a 14.37% reduction in outpatient visits and a 17.34% decrease in admissions. Furthermore, outpatient visits in the pediatrics department and admissions in the occupational medicine department both experienced declines of over a third.³⁴ Similarly, in Italy, the COVID-19 pandemic led to diminished access to both inpatient and outpatient services, resulting in a decreased volume of elective surgical procedures. Notably, the decline in cardiology services was particularly pronounced, even for urgent cases such as patients experiencing acute myocardial infarction, where hospital admissions saw a significant reduction of 48.4%. The repercussions are noteworthy, marked by a more than threefold increase in fatality rates for acute ST-elevation myocardial infarction.³⁵ While numerous services experienced a significant decline in their activities amid the pandemic, telemedicine was quickly established and played an essential tool for healthcare providers to maintain connections with patients, address non-COVID-19 health concerns, and contribute to the overall resilience of healthcare systems.³⁵

In LMIC with limited access to resources and poor healthcare infrastructure, the delivery of healthcare has suffered drastic consequences during the COVID-19 pandemic.³¹ For instance, there has been a 69% decline in breast cancer screening in Mexico and a staggering 96% reduction in Chile. Similarly, cervical cancer screening has witnessed a decline of 67% in Mexico and 66% in South Africa. Tuberculosis services have also experienced significant reductions, ranging from 25% to 65% in Ghana, Nepal, and South Africa.³¹

While numerous services experienced a significant decline in their activities amid the pandemic, however, in HICs, telemedicine was quickly established and played an essential tool for healthcare providers to maintain connections with patients, address non-COVID-19 health concerns, and contribute to the overall resilience of healthcare systems.³⁵ In contrast, the use of telemedicine is limited in LMICs,³⁶ exacerbating the challenges faced by these nations in maintaining adequate healthcare delivery and widening the healthcare disparities between regions.

Hence, the primary worry revolves around the potential consequences of implementing cost-based vaccination, which could lead to a decrease in vaccination rates, the reemergence of COVID-19 outbreaks, and a parallel catastrophic impact on healthcare delivery and systems. This scenario mirrors the challenges witnessed during the initial phase of the COVID-19 pandemic, with a notably greater impact on LMICs.

Public health policies

Administering COVID-19 vaccination at a cost also carries significant implications for various public health policies. Cost-based COVID-19 vaccination poses a challenge to the overarching goal of achieving widespread vaccination and controlling the pandemic. Consequently, public health policies need to adapt to ensure that vaccine access remains equitable, especially for underserved and vulnerable populations. Financial assistance programs and subsidies may be necessary to mitigate the impact of vaccination costs on low-income individuals and families. Governments and policymakers must also consider the potential reduction in vaccination rates due to cost barriers, which can affect the attainment of herd immunity. This, in turn, requires adjustments in public health strategies, including the need for vaccine mandates or targeted outreach efforts.

Reshaping or reshuffling public health policies can bring about various negative consequences alongside the intended positive changes. First, the process of policy modification can lead to budgetary constraints. In the event where new policies or policy changes require financial support, they may divert resources from other existing vital programs. In cases where new policies or policy changes require financial support, resources from existing healthcare programs may be redirected or reallocated. Sometimes, resources are redistributed from essential programs to support the new policies, which can result in budgetary constraints in existing programs. Additionally, the implementation of policy modifications can incur increased costs, such as staffing, infrastructure improvements, or technology investments, further straining the available budget. Such adjustments may disrupt the continuity of existing healthcare programs, causing service interruptions or discontinuity.

In addition to budgetary aspects, public resistance, confusion, and concern may arise due to significant shifts in healthcare access, affordability, and policies leading to diminished trust in the healthcare system. Over the last decades, health systems worldwide have faced a decline in public trust.³⁷ Mistrust might limit engagement with healthcare services and impact the health of the population.³⁸ In addition, policy reshuffling may increase administrative burden, introducing complexities and bureaucracy that hinder the effective delivery of healthcare services.

Vaccine distribution and communication strategies

As noted earlier, cost-based COVID-19 vaccination may pose challenges to achieving vaccine equity. Equity-based distribution strategies place a strong emphasis on ensuring fair and inclusive access to vaccines, with a primary focus on marginalized or disadvantaged communities.³⁹ This approach may eliminate disparities in vaccination rates by making vaccines available to all populations, regardless of their socioeconomic status, thereby promoting equal protection against the virus. The implementation of cost-based vaccination must include strategic distribution of COVID-19 vaccines. The implementation of cost-based vaccination should be accompanied by strategic distribution of COVID-19 vaccines. In this instance, mobile distribution strategies may help to substantially increase vaccine equity. Mobile vaccination units play a pivotal role in overcoming geographical challenges by deploying teams to remote or underserved areas where economic barriers hinder COVID-19 vaccination uptake. One such example is the Mobile Vaccine Equity Enhancement Program (MVeeP), a program created by UMass Memorial Health, Inc., to enhance the equitable availability of the COVID-19 vaccine in its community.⁴⁰ Therefore, these distribution strategies need to be adapted to ensure that cost does not become a barrier to access. Careful consideration is warranted to ensure that the imposition of cost-based vaccination does not impede the equitable distribution of vaccines.

Implementing costs for COVID-19 vaccinations that were previously free could have substantial ramifications for public health communication strategies. These strategies would need to focus on persuading individuals and educating them about the rationale behind transitioning to a cost-based vaccination system while setting reasonable goals. Previous research on HPV vaccination conducted in the United States found that cost can become an overriding barrier to vaccination, significantly diminishing the role of factors that can be modified via communication campaigns, like health beliefs and knowledge.⁴¹ Therefore, robust outreach and educational campaigns will play a crucial role in informing the public about the switch to cost-based vaccination, as well as the benefits of continuously receiving COVID-19 vaccination boosters. A recent study aimed at identifying effective communication strategies to boost vaccination rates examined the impact of different messages on COVID-19 vaccine acceptance.⁴² These messages included those highlighting vaccine safety, personal benefits, benefits to others, and the return to normalcy. The study revealed that the most effective message focused on personal health benefits. Therefore, in the context of implementing a cost-based COVID-19 vaccination program, messages should stress that the personal health benefits of COVID-19 vaccination outweigh the associated vaccination costs.

Beyond educational campaigns, alternative strategies to enhance vaccine coverage include community engagement and mobilization, building trust and addressing concerns, and establishing accessible vaccination centers, all aimed at reducing barriers to access and targeting outreach to underserved populations. These efforts have proven effective in increasing COVID-19 vaccination rates.⁴³ For instance, in India, a communication and community engagement initiative reached over half a million people over a period of six months, resulting in a remarkable 25% increase in the vaccination rate.⁴⁴

Past lessons and future direction in COVID-19 vaccine pricing

Examining prior research on individuals’ willingness to pay for COVID-19 vaccines can offer valuable insights into shaping future decisions regarding the pricing or provision of free COVID-19 vaccines. The significance of understanding public sentiment concerning COVID-19 vaccine cost has been widely acknowledged, as evidenced by the fact that numerous scholarly articles on willingness to pay for COVID-19 vaccines can be traced back to a time when the vaccine was still in the development process. An examination of existing literature on willingness to pay for the COVID-19 vaccine prior to the official roll-out of mass COVID-19 vaccination^45–59 indicates a spectrum of willingness to pay, with figures ranging from 49% in Nigeria²⁴ and 53% in Pakistan,⁵⁵ to as high as 78% in Indonesia⁵² and 80% in Kenya.⁵⁶ Although over half expressed willingness to pay in three of these countries, the level of support dropped precipitously with increased cost. For instance, in the Pakistani study, willingness to pay dropped from 53% at a cost of $6.25 USD to 6.8% at a cost of $6.26 to $12.50 USD. Similarly, in Nigeria,⁴⁸ while 49% indicated that they would be willing to pay 500 Nigerian naira (approximately $0.62 USD), only 26% said that they would be willing to pay over 500 naira. Similar trends were apparent in the Indonesia and Kenya studies. In addition, vaccine characteristics (e.g., efficacy, duration of protection) also may influence how much individuals are willing to pay.⁵² These sets of findings suggest a willingness to pay for COVID-19 vaccines but point to the highly sensitive nature of pricing and its influence on acceptability. In general, these studies suggest a substantial level of acceptance and readiness for free or low-cost COVID-19 vaccination during the early phase of the pandemic.

However, it’s crucial to note that during the early phase of the COVID-19 pandemic, as the death toll was rapidly increasing, people were left with little choice but to receive COVID-19 vaccines, despite the unclear knowledge about the vaccines’ efficacy and potential side effects. Fast forward to almost three years since the pandemic’s onset, and the COVID-19 vaccines have demonstrated their effectiveness. The vaccines have been instrumental in controlling the severity of the pandemic and improving clinical outcomes.⁶⁰ This demonstrated that the effectiveness of vaccination against disease, hospitalization, and death may indicate ongoing willingness to pay for vaccines. However, the relatively short duration of protection provided by vaccination, necessitating multiple boosters, may work against willingness to pay. A study examining COVID-19 vaccine acceptance in 10 LMICs across Asia, Africa, and South America has found that individuals’ perceptions of the vaccine’s safety and effectiveness play a significant role in their decision to accept the vaccine.⁶¹ Additionally, the study identified a correlation between a heightened perception of vaccination’s adverse side effects and a decrease in vaccination acceptance. The study’s findings emphasize the importance of sharing clear and accurate information about vaccine safety and effectiveness to enhance public confidence in COVID-19 vaccination. Hence, it may imply that individuals are more likely to accept a COVID-19 vaccination for a cost if they perceive it as safe and effective, and if it does not result in significant adverse side effects, which could have implications for pricing structures in LMICs.It is important to acknowledge, as well, that a significant portion of anti-vaccine propaganda and hesitancy originated well before the release of the COVID-19 vaccines and persists to this day. The rapid development and emergency authorization of vaccines, despite unknown long-term side effects, have fueled hesitation, especially toward mRNA vaccines, among the global community. Concerns, largely unfounded, have been raised regarding the safety of COVID-19 vaccines, particularly in relation to platelet function,⁶² cardiovascular complications,⁶³ and the potential for increased risk of DNA damage, chronic autoinflammation, autoimmunity, and cancer.⁶⁴ On 5 May 2023, the WHO declared that the COVID-19 pandemic no longer constituted a global health emergency.⁶⁵ With the reduced threat of the pandemic, the public might perceive vaccination as less vital, particularly considering the anti-vaccine messaging promoting uncertainty about potential adverse effects. Consequently, the implementation of cost-based vaccination may further exacerbate the likelihood of reduced vaccination rates in the future.

A meta-analysis, which included studies published up to June 2022, revealed disparities in global COVID-19 booster vaccine acceptance rates across various regions. The pooled acceptance of booster doses in the WHO region of the Americas stood at 77%, with the Western Pacific region showing the highest acceptance at 89%. In the European region, the acceptance rate was 86%, followed by the Eastern Mediterranean region at 59%, and the lowest acceptance rate was observed in the Southeast Asian region, at 52%.⁶⁶ However, a recent study published in 2023 in the United States reported that less than 20% of eligible individuals had received an updated booster.⁶⁷

There have been several studies examining individuals’ willingness to pay for COVID-19 vaccine boosters. The findings of an Indonesian study showed that 66% indicate that willingness to pay for a booster dose of the COVID-19 vaccine, and willingness to pay is lower compared to the acceptance of free vaccines.⁶⁸ The study also found a higher willingness to pay observed among the more affluent and educated individuals.⁶⁷ Similarly, in the Philippines, willingness to pay was found to significantly decrease with the vaccine price and increase with income.⁶⁹ In a study conducted in Taizhou, China, it was found that 50% of healthcare workers were willing to cover the cost of a booster dose.⁷⁰ In a survey of 871 respondents in Vietnam, it was discovered that 25.8% were unwilling to pay for a COVID-19 booster, while 22.9% were willing to cover the full cost, and 25.4% were willing to pay only half of the full cost.⁷¹ These findings illustrate significant variance in willingness to pay among different regions and underscore the importance of tailoring vaccine accessibility and pricing strategies to meet specific needs and vaccine coverage goals. These collective findings also show that, as expected, economic disparities and education levels play a significant role in individuals’ willingness to pay for COVID-19 vaccine boosters, with higher willingness to pay observed among more affluent and educated individuals, emphasizing the importance of addressing affordability issue to ensure widespread coverage in these countries.

To date, there has been no study that directly compares individuals’ willingness to pay for the initial dose of the COVID-19 vaccine with their willingness to pay for the booster dose. Consequently, it remains uncertain whether people are more inclined to pay for the initial COVID-19 vaccination dose as compared to the booster. Study comparing individuals’ willingness to pay for the initial dose of the COVID-19 vaccine with their willingness to pay for the booster dose is a crucial area of future research as it holds several significant implications. Firstly, it can provide valuable insights into the pricing and affordability of booster vaccines, informing policymakers about the appropriate cost structure to ensure broad accessibility. Additionally, such study may help public health authorities plan resource allocation and budgeting, understanding the economic impact of booster vaccination. The comparison of willingness to pay for the initial COVID-19 vaccine and the booster dose can provide insights into people’s current priorities regarding COVID-19 vaccination. A higher level of prioritization may signify a greater willingness to pay for the COVID-19 vaccine. This information can play a pivotal role in guiding future strategies to increase COVID-19 booster vaccination rates. It is also important to note that the future pricing strategies for COVID-19 vaccinations rely on individual country differences, considering their capabilities in accessing, manufacturing, and distributing vaccines. Countries with the ability to manufacture or acquire vaccines might be more inclined to provide free COVID-19 vaccinations or offer them at a lower cost, thereby achieving a higher vaccination coverage rate compared to other nations.⁷² Negotiation dynamics and the delicate balance of supply and demand also significantly impact the cost of COVID-19 vaccines⁷³ Countries with greater economic strength wield stronger negotiating power, leaving resource-limited nations striving for access⁷⁴ Therefore, global stakeholders should encourage collaborative efforts, establish transparent frameworks for negotiation, and facilitate international partnerships to ensure fair and equitable access to COVID-19 vaccinations, addressing both public health needs and economic considerations.

The choice of a country to adopt either free or cost-based COVID-19 vaccination strategies is also closely tied to the effectiveness of its healthcare system and the resources available for widespread vaccine distribution. Nations with robust and well-equipped health systems, characterized by ample healthcare facilities, trained personnel, and efficient logistics, are better positioned to absorb the consequences of providing vaccinations for free. In such cases, the ability to handle increased demand and administer vaccines efficiently is more viable. On the other hand, countries facing limitations in health system capacity may find it challenging to manage a large-scale vaccination program, especially if offered for free.

The decision to implement cost-based or free COVID-19 vaccination strategies is intricately tied to a country’s available financing resources for preventive medical services. Nations with abundant public funding may lean toward offering free vaccinations, absorbing the associated costs to ensure widespread accessibility. In contrast, countries facing limited public funding may adopt cost-based approaches, utilizing vaccination fees to bridge financial gaps. The presence of widespread private health insurance coverage could support free vaccine offerings, with insurance companies contributing to costs,⁷⁵ while regions with limited coverage might rely on cost-based strategies. Access to international aid and partnerships can influence the availability of vaccines at reduced or no cost, particularly in LMICs. Additionally, the affordability of out-of-pocket payments for healthcare services plays a role, as countries with affordable payments might opt for cost-based vaccinations, while those with high payment burdens may prioritize free vaccines to ensure equitable access and mitigate disparities in vaccine coverage. In essence, the financing landscape significantly shapes a country’s approach to COVID-19 vaccination, reflecting its commitment to accessible and equitable preventive medical services. Therefore, country-specific nuances must guide the formulation of cost or free-based COVID-19 vaccination approaches, recognizing the unique circumstances and capacities of each nation. Other important factors influencing pricing strategies for the COVID-19 vaccines include the severity of the disease and prevalence of its variants. The impact of the disease’s severity, such as the risks of hospitalization or ICU admission, signifies substantial health risks and potential strain on healthcare systems, directly impacting the perceived value and urgency of vaccination efforts.⁷⁶ If the prevalence of SARS-CoV-2 variants remains high, there could be a more compelling argument for retaining a cost for COVID-19 vaccines, as the population may be more willing to pay for vaccination. Furthermore, the effectiveness of vaccines against these variants becomes pivotal in determining vaccine pricing. Should the variants exhibit resistance to existing vaccines, the demand for ongoing research and development of new effective vaccines may persist, making cost-based vaccination more likely.

An essential aspect to consider is the timeline of transition. The timeline for transitioning from free to cost-based vaccination will vary across countries due to differences in healthcare systems, economic conditions, and government policies. It is important to carefully consider the need for rapid vaccination coverage alongside ensuring equitable access for all populations, taking into account public health and economic considerations. Factors such as vaccine availability, vaccination coverage, economic recovery, and public health priorities will also influence the transition timeline.

Lastly, the shift from free to cost-based COVID-19 vaccination requires a thorough assessment across various criteria to gauge its pros and cons. Accessibility and equitable distribution of vaccines emerge as critical factors, demanding scrutiny of how charging for vaccination influences vaccine availability for diverse demographic segments and population groups. The economic repercussions of this shift require a comprehensive analysis, considering both immediate and long-term effects on healthcare costs and potential economic burdens. Finally, assessing a healthcare system’s resilience to adapt and manage the shift is imperative, encompassing an evaluation of infrastructure, capacity, and preparedness. Through a systematic examination of these criteria, policymakers and stakeholders can gain a holistic understanding of the implications of transitioning from free to cost-based COVID-19 vaccination.

Conclusion

The COVID-19 pandemic necessitated the rapid development and distribution of free vaccines as a crucial strategy to combat the crisis. However, sustaining free vaccination programs presents economic and practical challenges for many countries. The transition from free to cost-based vaccination is likely to have profound implications on global vaccine equity and prioritization, the economic well-being of the population, healthcare delivery and systems, public health policies, and vaccine distribution strategies. Whether to offer vaccinations at a cost or continue with free vaccination requires careful consideration to uphold equity, accessibility, and affordability in a post-pandemic context. In cases where vaccinations have associated costs, the implementation of effective communication strategies that emphasize the value of vaccination and its health benefits can enhance willingness to pay. Ideally, vaccinations can be covered by public health programs or health insurance to reduce financial obstacles and motivate more people to get vaccinated.

Disclosure statement

With the exception of GZ, no potential conflict of interest was reported by the author(s). GZ has served as an advisory board member to Pfizer (regarding meningococcal vaccination) and Moderna (regarding COVID-19 vaccination) and as a consultant to Merck (regarding HPV vaccination). In addition, he has received research funding from Merck, administered through Indiana University.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article..