Alena Ilanova, Global Justice UK –

On 15 January 2022 COVAX marked a key milestone – its first 1 billion vaccines delivered[i]. However, the occasion left access to medicines campaigners and experts feeling cold. What happened to COVAX’s lofty goals and was its failure all but guaranteed from the outset?

The world ushered in the year 2020 with the first officially reported case cluster of the novel SARS-CoV-2 virus in Wuhan, China. It’s unlikely that ‘travel less’, ‘see family and friends less often’ and ‘wash your hands constantly’ were on any of our New Year’s resolutions lists, and yet those would soon be the new realities of our lives. The situation escalated quickly in ways experts may have predicted, but the general public was only familiar with disaster Hollywood productions. On 11 March 2020 it became official – the World Health Organisation declared a pandemic.

While that first year saw over 85 million cases[ii] and up to 3 million deaths[iii] attributed t the new virus globally, by December an extraordinary scientific effort had produced several promising vaccines. Pfizer-BioNTech (COMIRNATY) received emergency authorisation for use in the UK[iv], paving the way for the fastest global rollout of a vaccination program – and marking the company’s rise to dominate the vaccine market for the next 12 months[v]. But the story of the Covid-19 vaccine development and deployment shows both the best and the worst of our times in terms of international cooperation, institutional response, and of course equity.

At the time of writing (19 January 2022) less than 6% of the population in lower-income countries (by World Bank income group) are fully vaccinated[vi]. Only 5 African countries achieved the WHO set the goal of vaccinating at least 40% of the population by the end of 2021[vii]. Vaccines are not the solution, vaccination is, and unequal access will have lasting consequences. Over 160 million more people now live in poverty compared to 2 years ago.[viii]

It is, therefore, crucial to look at the strategies and decisions adopted by the global community in attempting to tackle Covid-19. Experience from previous public health crises pointed towards lessons, but did COVAX show we’ve learned them?

What is COVAX?

Back in April 2020, the World Health Organisation launched the Access to Covid-19 Tools Accelerator (ACT-A), a multi-stakeholder partnership working across four pillars: diagnostics, treatment, vaccines and health system strengthening. COVAX, the vaccines pillar, is convened by the Coalition for Epidemic Preparedness (CEPI), Gavi and WHO[ix]. The Gates Foundation is a major funder of WHO and is heavily involved in founding CEPI and Gavi.

The Gavi-managed COVAX procurement facility in particular is in charge of delivering equitable access to Covid-19 vaccines across countries irrespective of income levels. The mechanism aimed to pool funding, resources, procurement and delivery, with 92 lower and middle-income countries receiving doses for free, and 76 self-financing, or ‘investor’ countries paying at a cost[x]. Initially, COVAX was supposed to deliver 2 billion vaccines worldwide by the end of 2021, but that goal was reduced in December 2021 to 1.2 billion. It wasn’t until 15 January 2022, 2 years since the start of the pandemic, that COVAX delivered its 1 billionth dose.

Did things go wrong, or was COVAX a flawed concept from the start?

It is important to start our analysis with a shared understanding of the key principle underpinning the creation of COVAX: to ensure equitable access for the most vulnerable populations across nations irrespective of income levels. That the world’s nations will have different access to vital Covid-19 vaccines and treatments, once in production, was clearly going to be an issue that needed addressing. The story goes that Gavi’s CEO Dr Berkeley and CEPI’s CEO Dr Hatchett came up with the rough concept for COVAX in conversations back in January 2020, before the need for vaccines was even evident.[xi] However, the self-selecting circle of influence which created COVAX had an impact in its disappointing performance. Despite its vision for a global mechanism, WHO did not develop a government-led process for decision-making. Neither were AMC countries (the 92 funded participants in COVAX) or their regional representative bodies invited to participate in the design process. This led to a two-tier system for nations, invalidating the unifying ambitions of the programme.

While lower-income countries and civil society were not given a seat at the table, high-income countries had a lot to say about the initial proposals. Under the UK’s influence for example ‘investor’ countries received the right to choose which vaccines they wanted to request via the mechanism in exchange for higher upfront cost – an option not offered to AMCs. Moreover, rich countries could use COVAX for anything between 10 to 50% of their populations, while the funded countries only ever had the 20% option.[xii]

The unrepresentative practises embedded during the design stage would then naturally translate into an opaque and complex governance structure without any formal avenue for accountability[xiii]. Most decision-making powers are centred within existing Gavi structures, which don’t represent all COVAX-included countries. At the same time, Gavi simply lacked the experience of working with higher-income countries and pharmaceutical companies, which further limited its ability to resist or at least account for and plan for their separate agendas.[xiv] The stage was set.

The unprecedented crisis requires unprecedented solutions – as long as they’re within the status quo

Gavi does have expertise when it comes to the Advance Market Commitment (AMC) model but its past experience should have raised flags about relying on it in the first place[xv]. In particular, the reliance on the Public Private Partnership is deeply problematic as it assumes the cooperation of pharmaceutical companies without proposing any commitments on pricing or transparency. It is no wonder the model is preferred by higher-income countries and companies alike, as it does not fundamentally challenge their way of operating but entrenches the market incentive.

In recent months, condemnation of rich countries’ hoarding of doses and vaccine manufacturers not prioritising COVAX contracts has escalated[xvi]. Yet the challenge with a pandemic was always going to be global demand outstripping supply, not pharmaceutical companies lacking a market incentive. It shows a fundamentally flawed logic to let high-income countries and a handful of advisory and philanthropic bodies set the rules, then attach no conditions to pharmaceutical companies – and expect a different result.

Within a PPP model pharma companies are a key decision-maker. It is up to them to enter into contracts and expand production or sign licensing agreements. The participation of the Gates Foundation for example ensured that COVAX and C-TAP[xvii] (the WHO knowledge-sharing platform that not a single vaccine manufacturer has entered) remain separate with no attempt to use COVAX’s purchasing power as leverage for C-TAP participation. ACT-A funding for research and development does not stipulate leverage and access commitments[xviii].

Gavi seems wilfully oblivious to other calls that could expand supply as well – they have nothing to say about the WTO proposal for a waiver on IP rules over Covid-19 vaccines and therapeutics (so-called TRIPS waiver), despite the overwhelming support for the initiative among the countries it set up its mechanism to support. A diversified pool of supply should have been a priority for the initiative, especially after the major disruption caused by the spring 2021 outbreak of Covid-19 in India. This led to the Serum Institute (SI) to freeze exports of its AZ vaccine in March[xix], in what would become the biggest blow to COVAX for the year. Yet the decision to overwhelmingly rely on SI for supply was not an accident[xx] but once again came after advice from the Gates Foundation.

Results on the ground

It is worth pointing out that COVAX’s failure is not only the missing 1 billion vaccines that were part of that initial 2021 goal, although each one represents a person whose health is compromised as a result. In setting out to comply with the rules of the market, COVAX failed even its funder participants. Deliveries to both AMCs and self-funding countries were late, poorly communicated and chaotic[xxi]. This left most participating governments unable to implement carefully planned vaccination programmes and put additional pressure on scarce resources mobilised on the ground for the delivery of jabs. Delays and unpredictability adds fuel to vaccine hesitancy and misinformation online, warn some officials[xxii]

Pan American Health Organisation (PAHO) members have paid for close to 202 million doses via COVAX as self-funding countries, but only around 93 million of those have been delivered as of 23 January.[xxiii] This leaves member countries out of pocket for the time being with no guarantees as to delivery dates. While COVAX never expected high-income countries not to make bilateral deals directly with pharmaceutical companies, its inability to fulfil obligations to both AMC countries and self-funding ones created an environment in which countries had little choice but to scramble for alternatives. In other words – they end up competing with each other, with COVAX *and* with high-income countries, albeit with a bigger delay built into entering the market and in some instances at higher costs[xxiv].

Justice, not charity

The G7 Summit in Cornwall marked a turning point for world leaders when it came to equitable vaccine access. Pledges for vaccine dose donations sought to distract from the vast quantities rich countries had procured through bilateral agreements. The UK Government pledged to donate 100 million doses by mid-2022, yet by that point it had already purchased 500 million doses for its 67.2 million population[xxv]. Short expiration dates and lack of vaccination supplies are often cited as challenges of dose donation, yet COVAX seems unable to ensure minimum standards are followed[xxvi]

Crucially, despite dose donations being a temporary and unsustainable solution to vaccine scarcity, over 35% of all COVAX vaccines have been donated.[xxvii] This further embeds an outdated model of rich countries sharing ‘the crumbs off the table’ with poorer nations – exactly the opposite of what COVAX intended to achieve. Given the outlined shortcomings of the procurement process and its reliance on the cooperation of pharmaceutical companies and higher-income countries, COVAX ultimately put too much faith in finding market solutions to what are essentially institutional power imbalances.

Should COVAX be scrapped?

There are a number of urgent and key improvements that COVAX must implement going forward to ensure 2022 delivers life-saving vaccines to the world’s most vulnerable. There are also signs that some of these may be underway – in particular focusing on the 25 most at-risk nations and prioritizing need as opposed to the initial goal of blanket coverage[xxviii][xxix]. These are welcome developments in so far as they will have a material impact on citizens receiving much-needed vaccines.

But we are still in danger of fighting fires in the present while further embedding a model that simply does not deliver justice for the future. Without a reckoning with the failures of PPPs in delivering public health outcomes that build capacity, decentralise resource access, and create self-sustaining infrastructure in public control, it matters little whether COVAX is written into the future pandemic preparedness treaty[xxx].

We need governments and international bodies that are transparent, accountable, and representative, and we need them to use their political leverage to wrestle control over life-saving drugs, treatments, and vaccines away from a handful of pharmaceutical corporations through robust knowledge transfer schemes. Initiatives, such as the WHO mRNA hub in South Africa point in an interesting, and ultimately a more empowering direction. All legal and political avenues should be explored and followed to ensure that these – and future vaccines – cease to be private commodities denied to those who can’t pay but are instead global public goods available freely at the point of need.