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Small countries and Covid-19 vaccination: the example of Serbia

In Belgrade, Serbia, residents and visitors queue to be vaccinated against the Covid-19 virus
In Belgrade, Serbia, residents and visitors queue to be vaccinated against the Covid-19 virus (March 28, 2021). Oliver Bunic/AFP

With the development of a wide range of Covid-19 vaccines, countries large and small have been accelerating their vaccination efforts. Serbia launched its campaign on January 19, and has since positioned itself as the eighth globally and third in Europe for the share of population that has received at least one dose, reaching nearly one third of its citizens. The country also has the highest fully vaccinated population share in Europe, 20%.

Serbia positions itself among the leading countries for the fully vaccinated share of the total population. Our WorldinData

As with other countries, fluctuating infection numbers continue to shadow Serbia’s efforts. At the start of the immunisation process, the average daily number of new Covid-19 cases was 1,500. It rose to more than 5,000 in March and has since dropped to average of 2,500 in April. Some of the responsibility goes to the country’s desire to open up its economy. While most of its European neighbours were in lock-down this winter, Serbian ski resorts received record numbers of visitors. Even as late as March 22, restaurants and coffee shops continued to welcome the public without restrictions.

Cable car crowds at the Kopaonik ski resort, which received unprecedented number of guests this year. Goran Vesic/official Facebook page

While Serbia’s Covid-19 infection rate continues to be worrisome, the country has shown the ability to vaccinate a higher proportion of its population than many other European nations. This article examines some of the factors in their success.

Securing a diversified vaccine portfolio

Key challenge for any country in this challenging moment is to secure sufficient quantity of vaccines. Rich nations such as UK or Canada have an upper hand in vaccine procurement, as November 2020 study showed: “Just over half of the 7.48 billion ordered doses will go to the 14% of the world’s population who live in high-income countries”.

Serbia approach from the start was to pursue a highly diversified vaccine portfolio, relying on its global trade relations and diplomatic ties. The country has so far received vaccines from four different suppliers: Pfizer-BioNTech (United States), Sinopharm (China), Sputnik V (Russia) and Oxford-AstraZeneca (United Kingdom).

Serbian foreign policy has traditionally been characterized by its balancing position between the West and the East. On one hand, Serbia is the EU member candidate and remains strategically committed to the EU accession. In addition, the bloc is its leading investor and largest trading partner, and the majority of the donations in the Serbian health care over the past years originated from the EU.

However, with the rising number of coronavirus cases and no clear timeline on when vaccines from the COVAX system and EU procurement scheme would be available for the non-EU members, Serbia used its traditionally warm relations with Moscow and Beijing to secure vaccines.

This is how it became the first European nation to allow the use China’s Sinopharm vaccine – 1 million doses arrived at Belgrade airport on January 16. Since then, the country was supplied with 2.5 million doses in total and a new order for additional 2 million has been confirmed.

Similar approach on a lower scale was evident with Russia’s vaccine. Serbia has so far received nearly 400,000 doses of Sputnik V, with the latest contingent of 100,000 doses delivered on March 23rd.

Vaccine diplomacy – what risks?

Needless to say, China and Russia aren’t neutral sources for vaccines. The two countries seized the opportunity to practice “vaccine diplomacy” in Central and Eastern Europe and the Balkans, and even stirred things up among the EU members. Slovakian prime minister Igor Matovic and several members of his cabinet resigned in March due to the revelation of a secret deal to buy 2 million doses of Sputnik V vaccine, which is not yet authorized in the EU.

The growing Chinese and Russian influence in the Western Balkans during the pandemic has also initiated some calls to action from the EU. Nine EU foreign ministers urged the union to “take a strategic look at the Western Balkans”. In a letter addressed to Joseph Borrell, high representative of the union for foreign affairs and security policy, they indicated that “the pandemic had exacerbated existing trends, with their geopolitical implications”. The ministers also suggested that “other actors are ready to step into regional affairs, often at our expense”.

Produce your own vaccines

One of the ways how low- and middle-income countries can secure sufficient doses is to produce their own Covid-19 vaccines.

Serbia’s ambitious plans to produce both Chinese and Russian vaccines have recently been announced. By taking part in a joint Greenfield partnership with the UAE and China, Serbia will build a production site for China’s Sinopharm vaccine. The factory is expected to be operational from mid-October and roll out 24 million shots annually to cater to the needs of the Serbian population, as well as regional countries.

Furthermore, the launch of the local production of the Sputnik V vaccine in Serbia by the Torlak Insitute is anticipated in June, with estimated production capacity of 4 million doses in the first phase. So far, there has been no official reaction from the EU on these announcements.

If these plans come to life, this will not only allow vaccine self-sufficiency for the country, but will also enable Serbia to exercise its own “vaccine diplomacy”. The country has already donated vaccines to North Macedonia, Bosnia and Herzegovina, Republika Srpska and Montenegro. However, as with Russian and China’s “vaccine diplomacy”, Serbian generosity in Covid-19 vaccines may not be as benign as it seems – that its real ambition is to extend its influence in the region.

Ease of access

To ensure mass roll-out of the vaccination campaign in Serbia, it was essential to create simple and easy access to vaccines and facilitate vaccine distribution.

Thanks to a digital platform, all stakeholders in the immunization circle – citizens, call-center and medical staff, warehouse and supply-chain workers – have access to the necessary information. Using the platform, Serbian as well as foreign nationals can express their interest in vaccination by filling out a questionnaire.

Foreign nationals with or without residency in Serbia can get vaccinated, providing they book an appointment via Serbia’s portal. BBC

So far, Serbia is the only European country where people can choose the vaccine they wish to receive.

Furthermore, the form collects information on current medical condition (if any), and whether there are medical conditions that do not permit the person to leave their home. The input is then integrated in the system and made available to relevant stakeholders in the vaccination process, who consequently organize and manage different stages – from registration of the immunization, issuing vaccination certificates, vaccine procurement and distribution, management of the vaccination sites and staff, to reporting and monitoring. The vaccination appointments are scheduled automatically by an algorithm several days in advance.

Another element is availability of sufficient number of vaccination sites. Since February, the vaccination is organized in more than 400 sites throughout the country. While the health care institutions are central to the process, event venues are also being used, allowing vaccination to progress relatively quickly. The government has also put in place financial incentives for citizens to be vaccinated: those 16 or older who has received at least one dose or who will have their first shot by May 31 will receive an equivalent of 25 euros.

Given that Serbia is actively working to build significant vaccine production capacity and allows foreigners to be vaccinated, this has opened door for a new form of “medical tourism”. By the end of March, more than 22,000 foreign nationals, mostly from the region, visited Serbia in order to be vaccinated.

In short…

While Serbia has shown resourcefulness in procurement and management of the vaccination process, its efforts in keeping the pandemic under control are more debatable. Finding the right balance between health and economy has proven to be difficult even for developed and far richer nations, let alone a small middle-income country.

As with other nations, Serbia’s ambition is to vaccinate enough of its population to reach the elusive “herd immunity”. Until then, the main challenges are keeping up the momentum of the immunization while simultaneously managing the virus’ spread. Failure to do so risks undercutting the excellent head start it has in the vaccination race.

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