How has the COVID-19 vaccination been rolled-out in small countries within the European Region?

Cross-Country Analysis

How has the COVID-19 vaccination been rolled-out in small countries within the European Region?

This snapshot examines the situation faced by small countries in the WHO European Region regarding their COVID-19 vaccination strategies in terms of supply, procurement, distribution, administration and vaccination uptake and coverage as well as related challenges.

The countries selected for analysis are part of the WHO Small Countries Initiative (SCI) and have 2 million or fewer inhabitants, including 6 EU countries, namely Cyprus, Estonia, Latvia, Luxembourg, Malta, Slovenia and 5 non-EU countries, namely Andorra, Iceland, Monaco, Montenegro and San Marino. These countries differ considerably in land mass and population density as well as in terms of single country negotiation and purchasing power, which raises diverse challenges for COVID-19 vaccine deployment and vaccination.

This snapshot presents the experience of small countries during the COVID-19 vaccine roll-out until the end of May 2021, highlighting general and country-specific major challenges and examples of good practice. Specifically, this analysis will:

  • identify the challenges that countries have faced in procuring vaccines, setting up vaccination sites and administrating vaccines to different priority groups;
  • describe the current systems for vaccine registration and vaccination efforts for the general population as well as for vulnerable groups; and
  • share the methods that countries have used to address issues such as vaccine wastage and low vaccination uptake.

The vaccine coverage data presented were collected from the WHO/Europe COVID-19 Vaccine Programme Monitor. If not otherwise referenced, the information presented comes from the COVID-19 Health System and Response Monitor (HSRM), national ministry of health COVID-19 websites and interviews with country focal points in the SCI network up to 31 May 2021 (email correspondence). There were different response rates from each country to the vaccination-related interviews and as a general disclaimer, data and information should be interpreted with caution, due to differences in data completeness.

Countries are moving at different speeds with their COVID-19 vaccination roll-out

Table 1 shows the percentage of the whole population in each country who had received at least one dose or have completed the dose series of any vaccine by the end of May 2021 (week 21). By 1 June 2021, more than half of the population of Malta and San Marino had already received their first vaccine dose, while in most of the other selected countries over one third of the population had received their first dose.

1 Data officially reported to WHO are current for epidemiological week 21, 2021 as reported by 1 June 2021.

2 Data reported directly from the Principality of Monaco

3 Percent of total national population receiving the first dose series of any product administered by end of reporting week (week 21, 2021)

4 Percent of total national population receiving a complete dose series of any product by end of reporting week (week 21, 2021)

Small countries have overcome many challenges in their roll-out

All SCI countries have drafted and launched National Vaccine Deployment Plans (NVDP) for COVID-19, and regularly updated them. The challenges faced by small countries in terms of their vaccination programme included vaccine procurement, administration, public communication, booking appointments, prioritizing population groups and increasing uptake, which are presented below and summarized in Box 1. Further, Box 2 presents some examples of good practice in COVID-19 vaccination programmes within the small countries.

Procurement has relied on vaccine availability and/or country power to negotiate

One of the major challenges in the small countries has been vaccine procurement. The 6 EU countries were part of the EU joint procurement of European Medicines Agency (EMA)-approved vaccines. The non-EU countries secured vaccines using different mechanisms. Iceland signed direct agreements with AstraZeneca, Janssen, Moderna and Pfizer. Andorra used a hybrid method by procuring bilaterally (with France and Spain from their EU negotiations) and from COVAX, purchasing ChAdOx1-S [recombinant] vaccine against COVID-19 (AstraZeneca COVID-19 vaccine AZD1222) as a self-financing country. In Montenegro, procurement was mainly realized through direct orders from companies, through COVAX and via bilateral and trilateral agreements with countries and vaccine manufacturers. San Marino’s hybrid approach included a bilateral procurement with Italy then a direct purchase of Sputnik V. Although the bilateral procurement related to all vaccines that are sent to Italy, the countries agreed that only the Pfizer/BioNTech COVID-19 vaccine would be sent to San Marino. As the Sputnik V vaccine has not yet been approved by the EMA or the WHO Emergency Use Listing Procedure (EUL), there has consequently been uncertainty over vaccinating frontline workers who commute daily from Italy to San Marino in terms of which country’s NVDP should be followed. Regardless of the way small countries procured their vaccines, initial shortages were experienced by all countries at different points in time.

There were temporary concerns over vaccine safety aspects

The administration of doses of the AstraZeneca vaccine was temporarily suspended as a precautionary measure in many countries in March 2021 after concerns over the potential risk of blood clots. However, it quickly resumed after the assessment of available evidence and statements from the EMA and Global Advisory Committee on Vaccine Safety (GACVS). In April 2021, the government of Estonia decided that the AstraZeneca vaccines would only be administered to people aged 70 and lower. Montenegro reported that there is a slightly lower interest in the AstraZeneca vaccine in their population.   

The administration of vaccines has called for the repurposing of existing facilities and staff and help in acquiring vaccination materials

Most countries lacked sufficient, existing vaccination centres to cope with the unprecedented demands and scale of vaccination, particularly in remote areas. The smallest countries (<100 km2), i.e., Monaco and San Marino, opened 1- 2 vaccination centres. Other countries temporarily boosted capacity by repurposing other facilities as COVID-19 vaccination sites. All countries have used vaccination centres, health centres and other medical facilities. Malta has also created non-medical vaccination sites (such as university campuses, council offices and military facilities) and Estonia has offered vaccination in some workplaces and has engaged 4 mobile units. Due to a shortage of vaccination sites in some parts of Latvia, mobile vaccination units have also been deployed there.  Andorra required help from France and Spain to get sufficient amounts of vaccination materials.

Most countries, including Andorra, Cyprus, Iceland, Malta and Latvia currently employ nurses and/or physicians to administer vaccines, while Malta also involves medical, dental, pharmacy  and nursing students amongst others. San Marino engaged the support of retired medical staff to meet patients on arrival at the vaccination centres and process consent forms. Estonia created a free online training course for immunizers.

Vaccination campaigns have kept the general public informed about who is eligible

Vaccination plans have largely been supported with poster and digital campaigns targeted to the general population informing them of which groups are currently eligible for vaccination and encouraging uptake. For example in Luxembourg, clear campaign posters have been created in multiple languages (Luxembourgish, French, German, English and Portuguese), with specific information on the characteristics (age range, specific medical conditions, etc.) of people eligible for vaccination at each new phase. Malta also has a broad communications strategy targeting the specific age groups through various media, and pro-actively managing misinformation.    

Booking systems are largely digital, while some vulnerable groups may be contacted directly or vaccinated where they live

Combinations of online and telephone booking systems have been used. All countries have now implemented some form of digital system for their vaccination services, including for registration, booking appointments and/or joining a waiting list via official websites, mobile apps and telephone hotlines. Latvia and Estonia have interactive maps on their COVID-19 websites to enable individuals to search for the closest vaccination centres.

Initiatives were created to target high-risk and vulnerable groups who may have low digital health literacy or are unable to independently book their vaccinations, even by telephone, such as people with advanced age, serious illness or cognitive impairment. Alternative, non-digital booking procedures have been initiated to ensure that such people do not miss out on vaccinations. For example, in Estonia, people in the first priority group are contacted directly via their family physician. Andorra uses records from local authorities to identify and contact people who are unable to independently book appointments. In Malta, persons in the high priority groups were sent appointment letters by post, whereas persons in the lower priority groups who are under 60 years of age can register online or through a text messaging service. Latvia initiated a campaign of proactively calling individuals aged 60 years and over in less vaccinated areas of the country to inform them of the ongoing vaccination campaign and offer appointments.

In all countries, a major challenge relates to the vaccination of individuals who have physical or health problems that limit their ability to reach vaccination sites, who are often in the high-risk priority groups for vaccination. For example, individuals living in long-term care facilities or geriatric medical wards are usually vaccinated on-site by the institutions’ staff or external health care providers, while people receiving medical care at home are vaccinated by mobile teams in Estonia, Luxembourg, Montenegro and Malta.

Prioritization for vaccination has been extended to specific population groups according to their risk of being infected with SARS-CoV-2 or potential COVID-19 complications

Due to vaccine shortages and difficulties in administering vaccines on a large scale, a major challenge has been to plan how to use the vaccines most effectively. All selected countries have devised a clear list of priority population groups in their plans, with different administration phases according to risk. Generally, these have similar features, with priority given to individuals with advanced age and those living in medical or long-term care facilities, followed by people with comorbid conditions that could put them at high risk of adverse COVID-19 outcomes. Commonly, health care workers, especially those working with COVID-19 patients or within emergency medicine, have also been prioritized due an increased risk of being infected with SARS-CoV-2.

Iceland, Andorra and San Marino included criteria specifying when certain employment groups, such as emergency services, prison and education staff should be vaccinated. San Marino and Iceland explicitly deprioritized people who have had a documented COVID-19 infection in the past 6 months to achieve quicker immunity coverage at the population level, i.e., by first vaccinating people who have no known natural antibodies.

Some countries changed dosing schedules to facilitate faster access to the first dose among the population. For example, in Luxembourg, the previous dosage interval of 4 weeks was changed to 8-12 weeks for the AstraZeneca vaccine, and in March 2021 the Estonian Immunoprophylaxis Expert Committee recommended extending the interval between the first and the second dose of the AstraZeneca vaccine from 8 weeks to 12 weeks, and the interval between the doses of the Pfizer/BioNTech vaccine to 6 weeks.

Some countries allow excess vaccines to be administered to lower priority groups to avoid wastage

Initially, vaccines were targeted to the high-risk priority groups but many countries have since introduced systems to allow individuals from non-priority groups to register an interest (usually digitally) in receiving vaccine doses to reduce any waste (e.g., in Andorra, Estonia, Luxembourg and San Marino). Usually, individuals must demonstrate that they are able to reach a vaccine site with short notice (e.g., volunteers in Luxembourg can register if they are able to arrive at a vaccination site within 20 minutes). A similar approach is adopted by Malta. Vaccination sites in Latvia have been instructed to administer excess doses to people from low priority groups in cases where individuals from a higher priority group are unavailable or cancel. San Marino now offers vaccinations to tourists. Since April 2021, nurses in Estonia have been authorized to vaccinate any carers or other household members of people who are being vaccinated at home because they are unable to leave their house for health reasons. 

Efforts to address low vaccine uptake are underway

Although there are little data currently available on the characteristics of people with low vaccine uptake, issues such as vaccine hesitancy and differential access to information and vaccine sites is likely to have led to challenges in equal distribution and uptake. Estonia recognized that there was especially low uptake in older individuals in one county (Ida Viru). In response, the authorities launched a “1+1 campaign” where younger persons can receive a vaccine if they accompany an older relative, friend or neighbour to the vaccine site. Latvia has observed lower vaccine coverage in older individuals over 88 years of age, possibly due to greater vaccine hesitancy and lower access to information issued by national bodies. Montenegro reported that some regions have lower coverage, but that more research is needed to establish the reasons behind low turnout.

Issuing vaccine certificates

Countries are now addressing how to accurately document and certify vaccination status. The European Union already plans to issue (from 1 July 2021) the EU Digital COVID Certificate to immunized individuals or those with a negative test result or who have recovered from a COVID-19 infection. Challenges remain for SCI countries which are not part of the EU.

Box 1. Summary of key challenges faced by small countries in the European Region during the COVID-19 vaccine roll-out
– Need for National Vaccine Deployment Plans to be constantly updated to account for the continually changing situation concerning the pandemic and vaccine security/approval/availability
– Various strategies needed for vaccine procurement in non-EU countries (e.g., through bilateral agreements, direct procurement, COVAX etc.)
– Initial lack of sufficient, already-existing vaccination centres to cope with the unprecedented storage and administration demands
– Initial lack of an already-established COVID-19 workforce to administer vaccines
– Difficulties for high-risk groups (e.g., individuals who have physical or health problems) to reach vaccination sites
– Initial lack of already-established booking systems for COVID-19 vaccination
– Difficulties for some individuals to use digital booking systems due to low digital health literacy, cognitive impairment or other issues that impede their ability to independently book vaccinations online or by telephone (especially high-priority groups)
– Vaccine wastage due to cancelled appointments or excess doses
– Inequalities in vaccine uptake due to access/distribution issues and vaccine hesitancy
Box 2. Examples of good practice
– Creation of non-medical vaccination sites and mobile vaccination units
– On-site vaccination of people in long-term residential facilities and long-term medical wards
– Joint procurement and use of Advanced Purchase Agreements for improved timely access and price transparency of vaccines 
– Redeployment of health care professionals from other areas to cope with demand, and use of medical students and retired medical professionals
– Prioritization of vaccination in people at high risk of being infected with SARS-CoV-2 or potential COVID-19 complications
– Use of digital booking systems, apps and telephone hotlines to manage vaccination invitations and bookings
– Alternative (non-digital) booking strategies for individuals who have difficulties using digital technologies or telephones
– Administration of excess vaccine doses in non-priority groups
– Offering vaccines to accompanying younger persons to increase low vaccine uptake in older people (1+1 campaign)
– Vaccination campaigns with clear information to the general public (in multiple languages where necessary) both offline and online

Countries need to plan for a potential range of unknown challenges

In April 2021, the European Technical Advisory Group of Experts on Immunization (ETAGE) recommended an interim vaccination uptake target of 80% of the adult population, as soon as possible. As the SCI countries strive to meet such goals, medium- and long-term planning may be challenged due to uncertainty in how the pandemic will progress. At the time of writing, there has been insufficient time, and studies to observe the duration of immunity following vaccination, and the impact of variants of concern (VOC) is a challenge. Monaco has initiated a project to assess antibody levels in the general population post-vaccination (after 1, 6, 12 and 24 months). Challenges may increase as health care professionals who have been temporarily deployed into COVID-19 vaccine administration roles eventually return to their pre-pandemic positions. Most SCI countries have already set up COVID-19 vaccination planning groups to discuss long-term strategies beyond 2021. Booster or additional doses are being discussed and trials are underway.

Countries can work to assess ongoing challenges and develop multi-faceted campaigns using different means or incentives to increase vaccine uptake and address access inequalities

In conjunction with planning the practical aspects of ongoing and future vaccination strategies, it is essential to develop interventions to increase vaccination uptake in groups with vaccine hesitancy and to assess the effectiveness of such initiatives. Within the small countries, it may be relevant to establish whether there have been geographical limitations due to land mass, population density or situation (e.g., landlocked versus island), or any challenges within urban versus rural locations. In remote areas, increasing mobile units such as those currently used by Estonia may be an essential solution for vaccinating hard-to-reach individuals and reducing health inequalities. It is also relevant to understand how effective digital tools have been in vaccination monitoring, allocation and booking in the small countries and which population groups need alternative non-digital booking and monitoring systems. Countries need to analyze the potential spread of vaccine misinformation that may affect uptake in the population and address these via effective communication strategies that target groups who have vaccine hesitancy. Research and information campaigns on vaccine safety and effectiveness could be important components to inform such strategies.


Small countries in the European Region made tremendous efforts to address numerous challenges faced during their COVID-19 vaccination roll-outs. This report has revealed numerous innovative solutions that have been implemented. However, many barriers still create challenges to ongoing and potential future vaccination roll-outs, which will also need to account for a potential range of unknown challenges.

Authors and Acknowledgements

This snapshot was prepared by Katie Palmer (WHO consultant), Leda Nemer (WHO consultant) and Bettina Menne (WHO European, Office for Health for Development, WHO Regional Office for Europe). Special thanks go to Siddhartha Datta, Jose Hagan and Roberta Pastore (WHO, Regional Office for Europe) for their technical input and revisions. We are grateful to Sherry Merkur and Anna Maresso (European Observatory on Health Systems and Policies) for their technical review and input throughout the preparation of this policy snapshot. Finally, thanks go to the Member States of the Small Countries Initiative for providing us with data and information which made the development of this snapshot possible.