Rolling out the COVID-19 vaccines (Part 2): Allocating vaccines and necessary equipment equitably

The Bottom Line

  • In a context of a limited supply of vaccine doses, who should be prioritized and on what grounds?

  • Several national and international organizations developed frameworks consisting of key principles to guide COVID-19 vaccine allocation and prioritization.

  • These principles should be accompanied by additional considerations based on the best available research evidence and the feasibility of the implementation of the vaccination campaigns.

After months of waiting, vaccination campaigns have finally started in order to fight the COVID-19 pandemic. While health systems are used to running vaccination campaigns, the global COVID-19 pandemic raises many challenges. For example, in a context of a limited supply of vaccine doses, who should be prioritized and on what grounds?

To help Canadian decision-makers as they respond to unprecedented challenges related to the pandemic, the COVID-19 Evidence Network to support Decision-making (COVID-END) has reviewed what is known about the COVID-19 vaccine roll-out.(1) This blog post is the second in a series which examine evidence and experiences from Canada and other countries about the COVID-19 vaccine roll-out. It focuses on the set of challenges facing decision-makers, most notably:
- how to develop and adjust rules to allocate vaccines allocation rules;
- what are those allocation rules; and
- how to ensure equity in the allocation of vaccines and other necessary equipment.(1)

What the research tells us

The World Health Organization developed a framework consisting of six key principles to guide COVID-19 vaccine allocation and prioritization:
1) human well-being (“protect and promote human well-being including health, social and economic security, human rights and civil liberties, and child development”);

2) equal respect (“recognize and treat all human beings as having equal moral status and their interests as deserving of equal moral consideration”);

3) global equity (“ensure equity in vaccine access and benefit globally among people living in all countries, particularly those living in low-and middle-income countries”);

4) national equity (“ensure equity in vaccine access and benefit within countries for groups experiencing greater burdens from the COVID-19 pandemic”);

5) reciprocity (“honor obligations of reciprocity to those individuals and groups within countries who bear significant additional risks and burdens of COVID-19 response for the benefit of society”); and

6) legitimacy (“make global decisions about vaccine allocation and national decisions about vaccine prioritization through transparent processes that are based on shared values, best available scientific evidence, and appropriate representation and input by affected parties”).(2)

This is consistent national agencies have developed similar frameworks. For example, the U.S. Advisory Committee on Immunization Practices recommended an approach which is guided by four principles: 1) maximize benefits and minimize harms; 2) promote justice; 3) mitigate health inequities; and 4) promote transparency. These four principles should be accompanied by additional considerations based on the best available research evidence (for example, what is known about the safety and efficacy of vaccines) and the feasibility of the implementation of the vaccination campaign (for example, the storage and handling of vaccines).(3)

This resonates with the allocation approach used in Canada. Indeed, the Chief Public Health Officer of Canada indicated that equitable allocation of vaccines when there is limited supply needs to take into account who is most at risk of exposure and severe outcomes, feasibility and acceptability of the vaccine, as well as ethical considerations.(4)

In light of these principles, most countries that have begun their vaccination campaigns have prioritized healthcare workers, long-term care residents, and some other at-risk populations (for example, older adults, individuals with chronic conditions, and at-risk adults in Indigenous communities).(1)

As the mass-vaccination campaigns unfold, allocation rules and priorities may be adapted to respond to the supply of vaccines and other considerations (for example, the spread of new variants). In the third part of our series, we will examine the challenges of communicating how the vaccines will be allocated and the safety and effectiveness of vaccines.

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Author Details


  1. Wilson MG, DeMaio, Wang Q, Gauvin FP, Alam S, Ahmad A, Bain T, Bhuiya A, Drakos A, Sharma K, Whitelaw S, Bain T, Lavis JN. COVID-19 living evidence profile #1 (version 1.2): What is known about anticipated COVID-19 vaccine roll-out elements? Hamilton: McMaster Health Forum, 31 January 2021.
  2. World Health Organization. (‎2020)‎. WHO SAGE values framework for the allocation and prioritization of COVID-19 vaccination, 14 September 2020.
  3. McClung N, Chamberland M, Kinlaw K, Bowen Matthew D, Wallace M, Bell BP, Lee GM, Talbot HK, Romero JR, Oliver SE, Dooling K. The Advisory Committee on Immunization Practices' ethical principles for allocating initial supplies of COVID-19 vaccine - United States, 2020. MMWR Morb Mortal Wkly Rep. 2020 Nov 27;69(47):1782-1786. doi: 10.15585/mmwr.mm6947e3.
  4. Chief Public Health Officer's report on the state of public health in Canada 2020: From risk to resilience – An equity approach to COVID-19. October 2020.

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Many of our Blog Posts were written before the COVID-19 pandemic and thus do not necessarily reflect the latest public health recommendations. While the content of new and old blogs identify activities that support optimal aging, it is important to defer to the most current public health recommendations. Some of the activities suggested within these blogs may need to be modified or avoided altogether to comply with changing public health recommendations. To view the latest updates from the Public Health Agency of Canada, please visit their website.