Who’s First for Vaccines, and What’s Missed Along the Way

There has been much debate recently about who should have priority for vaccines – nursing home residents, health care workers, essential workers, people over 75, people over 65, and so on. The debate has inevitably led to a discussion of which objective is most important – saving lives, ensuring equity, encouraging economic recovery, or others. The extremely disappointing performance in the rate of actual vaccine delivery has made clear that a fundamental element has been left out of this discussion: the throughput of the system.

The rate at which vaccines are delivered to the arms of Americans is perhaps as important as anything else. Any approach that vaccinates 80 percent of the population in six months would likely save more lives, treat all population subgroups better and lead to superior economic performance than an approach that takes 12 months to achieve.

In the case of COVID vaccine delivery, while seeking to insure that the vaccine goes only to those on top of the prioritization list – nursing home residents and staff and certain health care workers – the rate of vaccine delivery has been painfully slow. Prioritizing certain groups should not mean others cannot also receive some vaccine, especially if doing so improves the rate at which the vaccine is delivered and reduces the time it takes to achieve high levels of population vaccination.

There have been many instances in which the principles of equitable allocation have been applied to address challenges of national importance, from the return of soldiers from Europe after World War II, to the allocation of kidneys for transplantation, to the prioritization of flights by the Federal Aviation Administration during major weather events. In nearly all such cases, perfect adherence to prioritization order or policies is not possible or more likely not desirable.

The Organ Procurement and Transplantation Network prioritizes kidney recipient candidates based on a variety of factors. New rules were recently implemented that set a time limit for acceptance by the higher priority candidates. Once the limit passes, lower priority candidates are contacted. While this approach sometimes allows lower priority candidates to move ahead of higher priority ones, it reduces the risk that kidneys will go unused and increases system throughput, i.e. the rate at which transplants are performed. When non-monetary allocation schemes are implemented in practice, there inevitably is a tradeoff between the most desired prioritization and overall system throughput or efficiency.

Operation Warp Speed had the right goals but overlooked a critical component, the one that is almost always the most difficult and expensive in any supply chain – the local distribution leg. During December, the rate at which vaccines were produced and delivered to the various states fell below the original promise of 20 million by about 35 percent. This was perhaps understandable given the complexity of the system that was starting up. However, the real tragedy was that the rate at which shots got into arms was about 80 percent below the 20 million projection.

Many reasons have been given for this shortfall, but what is absolutely clear is that the local distribution step did not get the attention or investment required several months ago when Operation Warp Speed was established. It is true that states and local entities ultimately should take a large degree of the responsibility, but the federal government should have taken leadership and made investments in this area from the beginning. An all-out effort is now required. There are critical actions that must be taken.

Entities that will distribute vaccines – hospitals, pharmacies, clinics, nursing homes, general practitioners and perhaps special-purpose facilities – must be mobilized. Additional personnel to deliver vaccines should be identified and trained. Mechanisms must be put in place to bring together vaccine deliverers with vaccine recipients in an orderly, safe fashion.

Overlayed on all of these actions should be a philosophy that simultaneously seeks to achieve the Centers for Disease Control and Prevention’s prioritization goals and maximize the rate at which vaccines are delivered. Safeguards can still be put in place to insure that the wealthy or politically connected do not go to the head of the line. However, there is no reason why CVS locations cannot start vaccinating those over 65 while nursing homes and hospitals complete their vaccinations of the elderly and essential health care workers. The vaccine flows to those CVS locations could be set while ensuring the rate at which higher priority groups get shots is not reduced – rather the goal should be to insure that the number of shots administered each month is nearly equal to the number transported by Operation Warp Speed from the vaccine makers. It is only by emphasizing speed of vaccine delivery with other goals that high levels of nationwide vaccination levels will be achieved by mid-summer.

Michael O. Ball, professor emeritus of the University of Maryland’s Robert H. Smith School of Business, has over 200 scholarly publications, covering a range of subjects including air transportation, revenue management and pricing, supply chain management and system reliability.

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