I'm writing this with a dull ache in my left arm, sore from my third COVID booster. My second was in April when I also got a flu vaccination, which was funded by my employer. The arrival of the fifth wave of COVID in Aotearoa New Zealand, as well as the new variant, prompted me to get my booster sorted.
Author
Paula Lorgelly
Professor of Health Economics, University of Auckland
I should also admit I saw news over the weekend that universal access to COVID vaccinations may come to an end next year. Always keen to get something for nothing, I booked my booster.
It seems I was ahead of the curve.
New Zealanders, especially those at high risk of becoming severely ill, are now being encouraged to get their booster before Christmas. Anyone over 30 years old who hasn't had a vaccination or an infection in the last six months can get this booster. And it may be the last free COVID vaccination they receive.
Nothing for free
I jest about getting something for nothing. As a health economist, I'm aware there is no such thing as a free lunch - there is an opportunity cost to everything.
Funding COVID vaccinations, tests and treatments means we are not able to fund other types of health care. During the peak of the pandemic it made economic sense to have publicly funded vaccinations and tests.
As we learn to live with the virus - treating it as an endemic disease like the flu - there is a need to re-evaluate the public provision of tests, vaccines and treatment.
Manatū Hauora - Ministry of Health had previously funded COVID vaccines. In July that was transferred to Pharmac and Pharmac's budget was adjusted to accommodate the extra cost.
Pharmac also funds antivirals and most recently widened access to these. Te Whatu Ora funds RAT and PCR tests.
This week new health minister Shane Reti said the funding of vaccines and antivirals beyond June 2024 is under consideration. This comes after news that lower-than-expected booster uptake has resulted in a large number of expired doses. It has also recently been announced that RATs may no longer be free after the February 2024.
All this points to New Zealanders learning to live with the virus, by paying out-of-pocket for preventative measures - assuming you can afford it.
Targeting
Moving away from a universal programme to a targeted approach for those at risk is very different to the targeted rollout of the initial vaccine programme. Prioritisation was required due to the scarcity of the vaccine and the logistics of managing the rollout of a mass vaccination programme. It seems scarcity is now due to financial constraints not delivery constraints.
My colleague, vaccinologist Helen Petousis-Harris, has argued such targeted approaches, where only those at risk are offered free vaccinations, places a substantial obstacle in the way of getting vaccinated. Add cost to the misinformation/disinformation around vaccines and uptake will be further impacted.
What's available elsewhere?
How are other countries managing COVID nearly four years on? Vaccination is still universally free in Australia, Singapore and Canada.
Since September 2023, vaccination in the United States is covered by private insurance plans and Medicare/Medicaid, but also available locally for free for the uninsured.
The United Kingdom and the Netherlands have a targeted seasonal vaccination programme - thus treat COVID much like the flu.
In terms of accessibility to COVID tests there is also variability. The Netherlands has not had subsidised testing since October 2021, although those on low income, at high risk and who provide care can get free tests until the end of this year.
Singapore stopped providing subsidised tests in February 2023. The US and Canada still have free tests available, and Australia has made tests free for concession card holders, and states may have additional allowances.
In the UK you can get a free COVID test only if you have a health condition or are a health-care worker.
Who should pay?
Universally free influenza vaccination programmes are rare. Most countries - including Aotearoa New Zealand - target those at greatest risk of hospitalisation and death.
This is because protecting these vulnerable populations is considered to be the most cost-effective from a health sector perspective. Employers, including my own, fund flu vaccines for employees as the virus is a costly productivity killer.
A challenge Pharmac and its advisors will face when deciding the scope of a future COVID vaccination programme is that there remains considerable uncertainty surrounding the long-term consequences of COVID infection.
Long COVID appears to be indiscriminate. The 5-10% of individuals who are infected are often healthy and don't fit the usual vulnerable population classification. While vaccination can lower the risk of long COVID, repeat infections appear to increase the chances of developing it. Antivirals - which Pharmac also needs to make funding decisions on - seem to lower the risk.
Future vaccination strategies should take account of the chronic health conditions and symptoms that encompass long COVID, as the health burden is considerable.
To fund or not to fund COVID vaccinations, tests and treatments - these are difficult questions as we learn to live with COVID.
Paula Lorgelly received funding from the Ministry of Health to establish Mātauranga Raranga, the Long COVID Registry Aotearoa.
