The multi-country studies that exist show relatively high levels of hesitancy to take the COVID-19 vaccine, but many of them focus on high-income countries. A systematic review and meta-analysis of 28 large (>1,000) nationally representative samples in 13 high-income countries collected between March and October 2020 found, across all 13 countries, that 72.9% of the sample intended to vaccinate (95% CI: 66.6% to 78.4%) (Robinson et al. 2021). The study also found that as the pandemic progressed (between March and October 2020), the percentage of people intending to vaccinate decreased and the percentage of people intending to refuse vaccination increased, although intentions varied between samples and countries. Another study of nationally representative surveys from mid-2020 in 19 countries, including 12 high-income countries (HICs), found an average across countries of vaccine acceptance rate across the 12 HICs of 66.6%, with wide variation ranging from 80% in the Republic of Korea to 55% in Russia (Lazarus et al. 2021). Both studies observed that being female, younger, of lower income or education level, and belonging to an ethnic minority group was consistently associated with being less likely to intend to vaccinate.

Less is understood about the levels and reasons of COVID-19 vaccine hesitancy in low- and middleincome countries. A few studies reported multi-country survey results from developing countries (de Figueiredo and Larson, 2021, Facebook 2021, Gallup 2021, Kanyanda et al. 2021, Lazarus et al. 2021, Solis Arce et al. 2021, and Wouters et al. 2021) or systematic reviews of individual country surveys (Sallam 2021), but few of the studies were based on nationally representative samples of respondents or included comparable results for many countries. Taken together, the available literature from low- and middleincome countries suggests that vaccine acceptance is higher in East and South Asia and Latin America and lower in the Middle East and Eastern and Central Asia. Results from Africa were mixed, as were results for different subpopulations. Some studies indicated women were more hesitant than men, younger respondents were more hesitant than older respondents, and those with less education were more hesitant than persons with more education. The predominant reason for hesitancy was concern over side effects from the vaccine. Given the limited availability of randomly selected samples that are representative at the national level, an important contribution of this analysis will be to validate these findings.

This paper extends the existing literature in the following four ways. First and most importantly it provides estimates of vaccine hesitancy for 53 developing countries, which are comparable across countries and largely based on household surveys that are more representative of the national population. In total, these 53 countries represent approximately 30 percent of the population of all low- and middle-income countries and 53.3 percent excluding India and China. Second, it investigates heterogeneity in hesitancy across demographic characteristics of the respondent such as urban or rural residency, gender, age and level of education. Better understanding this heterogeneity can inform the design of vaccination rollouts by helping to target specific population groups. Third, the study expands the evidence base on the reasons behind individuals’ reluctance to take the COVID-19 vaccine, even when it is available and free to them. Finally, the analysis enables a comparison between representative and previously published results from less representative sources. Taken together, the paper provides a rich set of results which can aid policy makers in the design of vaccination campaigns in developing countries.

The rest of the paper is structured as follows. Section 2 describes the data and methods, and section 3 provides the results, first for levels and correlates of vaccine hesitancy, followed by changes over time and concluding with reasons reported for being hesitant. Section 4 discusses the results, compares them with the existing literature and suggests some lessons including policy implications.

4