ACADEMIA | Letters Carrot or stick approach to COVID-19 vaccines demand generation? The need for more of the former in Low and Middle Income Countries (LMIC) – The case of Democratic Republic of Congo (DRC). Carrot or stick approach to COVID-19 vaccines demand generation? The need for more of the former in Low and Middle Income Countries (LMIC) – The case of Democratic Republic of Congo (DRC). Eta Ngole Mbong, Arsene Baleke Ombeni, Alfred Kongnyu Njamnshi Eta Ngole Mbong,1 § Arsene Baleke Ombeni1 and Alfred Kongnyu Njamnshi2,3 Eta Ngole Mbong: mbongeta@yahoo.fr Arsene Baleke Ombeni: abaleke@internationalmedicalcorps.org Alfred Kongnyu Njamnshi: alfredknjamnshi@gmail.com 1 2 International Medical Corps, Goma, Democratic Republic of Congo Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Cameroon 3 Brain Research Africa Initiative, Cameroon § Corresponding author – email: mbongeta@yahoo.fr Academia Letters, May 2022 ©2022 by the authors – Open Access – Distributed under CC BY 4.0 Corresponding Author: Eta Ngole Mbong, mbongeta@yahoo.fr Citation: Ngole Mbong, E., Baleke Ombeni, A., Kongnyu Njamnshi, A. (2022). Carrot or stick approach to COVID-19 vaccines demand generation? The need for more of the former in Low and Middle Income Countries (LMIC) – The case of Democratic Republic of Congo (DRC).. Academia Letters, Article 5479. https://doi.org/10.20935/AL5479 1 ABSTRACT: Background: Three years into the COVID-19 pandemic and despite ongoing initiatives to increase access to vaccines, just a third of the world’s population have received at least a dose of COVID-19 vaccines. A deep dive into COVID-19 vaccination coverage reveals lots of disparities. COVID-19 vaccination coverage for example in low and middle income countries (LMIC) is way lower than that of high income countries. Main Text: With the race against time to put an end to COVID-19, governments often go for options that oblige people to take COVID-19 vaccination. However, in addition to this “stick” approach to spur demand for COVID-19 vaccines, some countries have opted for “carrot” options including nonmonetary incentives for vaccination. Most of these incentive initiatives are implemented in high income countries with LMICs (like those in Africa) often using just the “stick” approach. This article documents a carrot approach recently put in place in the DRC to spur demand for COVID-19 vaccination. Conclusion: Rather than primarily going for the “stick” approach used in other countries to get people to get COVID-19 vaccination, LMIC need to consider “carrot” approaches which encourage people to opt to get vaccinated including the example from the DRC presented in this article and other ingenious ideas being implemented other regions and countries. Initiatives should include social marketing and nudge initiatives as well as non-monetary incentive schemes implemented jointly with for-profits as part of their corporate social responsibility. KEY WORDS: COVID-19, Vaccination, Low and Middle Income Countries (LMIC), Democratic Republic of Congo (DRC) ARTICLE: BACKGROUND: Three years into the COVID-19 pandemic and despite multiple initiatives to increase access to vaccines, just a third of the world’s population have received at least a dose of COVID19 vaccines [1]. A deep dive into COVID-19 vaccination coverage reveals lots of disparities. For example, less than a tenth of Africa’s 1.4 billion population have received at least a dose of COVID-19 vaccine [1]. Should vaccination be able to contribute to prevent or reduce the Academia Letters, May 2022 ©2022 by the authors – Open Access – Distributed under CC BY 4.0 Corresponding Author: Eta Ngole Mbong, mbongeta@yahoo.fr Citation: Ngole Mbong, E., Baleke Ombeni, A., Kongnyu Njamnshi, A. (2022). Carrot or stick approach to COVID-19 vaccines demand generation? The need for more of the former in Low and Middle Income Countries (LMIC) – The case of Democratic Republic of Congo (DRC).. Academia Letters, Article 5479. https://doi.org/10.20935/AL5479 2 impact of new waves of COVID-19, these disparities have to be levelled through not only initiatives to increase access to COVID-10 vaccines but also demand for these. By the end of the first quarter of 2022 and 2 years after the first COVID-19 case was confirmed in the country on March 10, 2020, the DRC had experienced four waves of the COVID-19 pandemic. The 86,735 total confirmed cases and 1337 deaths from the disease registered by the end of March 2022, are underestimates of the pandemic in the country due to low care seeking behaviour when people have symptoms of the disease as well as frequent stock outs of test kits and supplies to confirm cases [2], [3]. Just as was the case with care seeking by suspect COVID-19 cases, rumours, fear and not enough information provided in response to questions people have about COVID-19 vaccines have been major obstacles for people to opt to be vaccinated against the disease [4]. With the race against time to put an end to COVID-19, the pandemic which has caused huge economic losses worldwide, many governments (including those of LMICs) have begun instituting ways to oblige people to go for COVID-19 vaccination. These include requiring vaccination certificates prior to granting access to public transport and some public places [5] [6]. Mandating the presentation of vaccination certificates in order to get people to opt-in for COVID-19 vaccination, however increases the risk of people acquiring falsified COVID-19 vaccination certificates, something which for example in the Democratic Republic of Congo (DRC), communities during community consultations conducted on COVID-19 vaccination, had indicated they will do should COVID-19 vaccination be made mandatory [7]. However, in addition to these “stick” approach to spur demand for COVID-19 vaccines, some countries have opted for “carrot” options including non-monetary incentives like getting vaccinated persons enrolled in raffles with catchy prices to win and providing discounts during travels and at restaurants for vaccinated persons [8]. Most nudge and incentive initiatives are done in high income countries with LMICs (especially those in Africa) often going for a “stick” approach. A nudge scheme has however been observed in the sub-Saharan country of Chad whereby, vaccinated persons pay half the cost for COVID-19 PCR tests compared to those who have not been vaccinated. Academia Letters, May 2022 ©2022 by the authors – Open Access – Distributed under CC BY 4.0 Corresponding Author: Eta Ngole Mbong, mbongeta@yahoo.fr Citation: Ngole Mbong, E., Baleke Ombeni, A., Kongnyu Njamnshi, A. (2022). Carrot or stick approach to COVID-19 vaccines demand generation? The need for more of the former in Low and Middle Income Countries (LMIC) – The case of Democratic Republic of Congo (DRC).. Academia Letters, Article 5479. https://doi.org/10.20935/AL5479 3 MAIN TEXT: As of January 1, 2022 and almost a year after the DRC launched COVID-19 vaccination, less than 1% of the country’s 53 million population more at risk persons have received COVID-19 vaccination (one of the lowest rates in Africa) [1]. Despite this, government’s approach has been to repeatedly reassure people that COVID-19 vaccination is voluntary. DRC government’s approach however changed suddenly some months into 2022 when on February 12, 2022, government suddenly mandated through a widely communicated announcement the presentation of proof of COVID-19 vaccination prior to entry or exit from the country [9]. This probably was an attempt to oblige people to opt for COVID-19 vaccination and ramp up the country’s low vaccination rates. However, less than 48 hours after, government rescinded the decision and replaced it with another which rather cancelled mandatory COVID-19 re-testing (PCR) on arrival in the country for vaccinated persons, which had been in force for almost three years [10]. Mandatory COVID-19 testing (PCR) which had been in place for travels between provinces of the country for over two years was also scrapped. Given that rapid testing were not accepted for such travels, having to pay each time at least $30 for PCR testing, were substantial expenses people in the DRC have had to regularly foot themselves for over 2 years now given the absence of a functional universal health insurance scheme in the DRC, a country which has the third largest population of poor globally and 60 of its 80 million people (73%) living on less than $1.90 a day (the international poverty rate) [11]. The above mentioned recent nudge by the DRC government, hopefully will serve as a carrot approach to spur people to opt in for COVID-19 vaccination as they try to reduce costs related to having to do PCR tests on return or arrival in the DRC as well as when traveling between its provinces. This is one of the first documented “carrot” measure in the DRC, officially put in place to spur demand for COVID-19 vaccination. CONCLUSION: Rather than primarily copying initiatives from other countries, that restrict access to public places and liberties for unvaccinated persons [12], more of such carrot-like approach are needed in the DRC and other LIMC to increase demand for COVID-19 vaccination and permit us together reach global herd immunity. These should include social marketing and Academia Letters, May 2022 ©2022 by the authors – Open Access – Distributed under CC BY 4.0 Corresponding Author: Eta Ngole Mbong, mbongeta@yahoo.fr Citation: Ngole Mbong, E., Baleke Ombeni, A., Kongnyu Njamnshi, A. (2022). Carrot or stick approach to COVID-19 vaccines demand generation? The need for more of the former in Low and Middle Income Countries (LMIC) – The case of Democratic Republic of Congo (DRC).. Academia Letters, Article 5479. https://doi.org/10.20935/AL5479 4 nudge initiatives as well as non-monetary incentive schemes implemented jointly with forprofits as part of their corporate social responsibility. LIST OF ABBREVIATIONS: DRC: Democratic Republic of Congo LMIC: Low and Middle Income Countries PCR: Polymerase Chain Reaction DECLARATIONS: • Ethics approval and consent to participate: Not Applicable (N/A) • Consent for publication: N/A • Availability of data and materials: N/A • Competing interests: The authors declare that they do not have any conflict of interest which influenced the submission of this article for publication • Funding: N/A • Authors’ contributions: ENM, ABO and AKN drafted and proofread the article. All authors approved of the content and for its submission for publication. • Acknowledgements: N/A • Authors’ information (optional): N/A Academia Letters, May 2022 ©2022 by the authors – Open Access – Distributed under CC BY 4.0 Corresponding Author: Eta Ngole Mbong, mbongeta@yahoo.fr Citation: Ngole Mbong, E., Baleke Ombeni, A., Kongnyu Njamnshi, A. (2022). Carrot or stick approach to COVID-19 vaccines demand generation? 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Kenya bans unvaccinated from public places as COVID-19 cases soar. eNCA. https://www.enca.com/news/kenya-bansunvaccinated-public-places-covid-cases-soar Academia Letters, May 2022 ©2022 by the authors – Open Access – Distributed under CC BY 4.0 Corresponding Author: Eta Ngole Mbong, mbongeta@yahoo.fr Citation: Ngole Mbong, E., Baleke Ombeni, A., Kongnyu Njamnshi, A. (2022). Carrot or stick approach to COVID-19 vaccines demand generation? The need for more of the former in Low and Middle Income Countries (LMIC) – The case of Democratic Republic of Congo (DRC).. Academia Letters, Article 5479. https://doi.org/10.20935/AL5479 7