For COVAX to work as its originators intended, it needed all governments to buy into it, rather than making their own deals with potential producers.
COVAX is a new mechanism which can be seen as an expression of global solidarity – to ensure there is a fair global distribution of vaccines. As such, it represents an important institutional innovation relative to previous pandemics. One interviewee compared the current experience with the 2009 H1N1 (swine flu) pandemic, where each country purchased the vaccine on its own account and no mechanisms existed for systematically rolling out vaccines to LMICs:
For COVAX to work as its originators intended, it essentially needed all governments to buy into it, rather than making their own deals with potential producers. There are a number of reasons why this ideal vision of a universal COVAX has not been achieved. The idea was conceived at the same time as several countries were already building their bilateral vaccine portfolios. While some of these vaccine strategies did encompass an international dimension (e.g. the EU and the UK), the primary objective was to secure vaccines for their own populations. There was, therefore, always an inevitable tension, even contradiction, between the expressions of support for equitable global access by governments and their simultaneous pursuit of bilateral deals for domestic populations.
The inequity introduced by the bilateral purchases, mainly by HICs, inevitably meant that COVAX was behind in the queue, along with direct purchasers from LMICs. As one interviewee explained:
Just as individual countries have invested in a portfolio of vaccine candidates, so COVAX with full support from HICs could have invested in a wider portfolio of candidates, thereby sharing the risk of failure more efficiently than was the case with the array of bilateral portfolios countries had developed. In principle, such an arrangement could have been fairer, more cost-effective and more efficient than multiple bilateral portfolios, and could have facilitated earlier access by the majority of countries not in a position to make their own deals. An interviewee noted:
The issue of vaccine allocation within and between countries has brought into sharp focus the meaning and importance of solidarity, and it can be argued that globally equitable access to vaccines will be the ultimate test of global solidarity in 2021 and beyond. Dr Tedros expressed very strong concerns in opening the virtual meeting of WHO’s Executive Board in January 2021:
His concern was motivated by the large number of bilateral deals, mainly by HICs, securing up to 500 per cent more vaccines than their populations needed. As the failure rate of vaccine development has been much lower than expected, most of these countries will be left with sizeable surpluses once they have vaccinated their populations. On 22 February 2021, while welcoming the additional financial contributions from the G7, Dr Tedros noted that ‘if there are no vaccines to buy, money is irrelevant’. Additional financial contributions could not, in the short term, expand the available vaccine supply, so equitable global distribution according to public health need required countries to share their surplus doses ‘immediately’. His key point was that equity and solidarity demanded that HICs release some of their surplus vaccines as soon as they had secured enough vaccines for their elderly and most vulnerable people, rather than waiting until their entire populations had been vaccinated.
Several countries have responded to this appeal. These include France, Spain, New Zealand, Sweden and Norway. In May 2021 the EU committed to share 100 million doses by the end of 2021. At the COVAX AMC summit hosted by Japan in June 2021, Belgium, Denmark and Japan offered doses, and there were further commitments by Spain and Sweden, bringing the total to 54 million doses. In June 2021, at the G7 Leaders’ Summit held at Carbis Bay, UK, the group’s member countries together committed to supply at least 870 million vaccine doses via dose-sharing over the next year. According to the summit communiqué, this would mean that the G7 members’ financial contributions to COVAX and commitments to direct dose-sharing have facilitated 2 billion doses since the start of the pandemic. However, Dr Tedros had told the summit that to end the pandemic the aim should be to vaccinate at least 70 per cent of the world’s population – requiring some 11 billion doses – by the time of the next G7 summit. Notably, too, the G7 dose-sharing commitments more or less match the amounts COVAX is itself committed to supply to its mainly high-income self-financing participants in 2021.
The slowness of the vaccine roll-out in LMICs has opened the way for the manufacturers of Russian and Chinese vaccines to exercise so-called ‘vaccine diplomacy’. Although China reportedly pledged 10 million doses to COVAX, as of mid-July 2021 it had donated 26 million doses bilaterally. In May 2021, at the World Health Assembly, China reaffirmed its intention to support access bilaterally but did not announce plans to supply vaccines through COVAX. In addition, it has sold over 850 million doses around the world. Russia has donated or sold more than 380 million doses to 20 countries. India has supplied 66 million doses in grants and commercial supplies to 95 countries, including via COVAX. In March 2021 the ‘Quad’ countries (the US, Japan, India and Australia) announced a vaccine partnership to expand safe and effective COVID-19 vaccine manufacturing in 2021, and to assist countries in the Indo-Pacific region with vaccination. Whatever their political or economic motivations, these countries are contributing to filling the vital gap left in LMICs by the slow roll-out of COVAX and the hoarding of surplus doses in HICs. On the other hand, the abrupt cessation of India’s vaccine exports in March 2021 has severely disrupted not just COVAX but also countries’ ability to complete their vaccination programmes. For example, Bhutan remarkably vaccinated 90 per cent of its adult population in two weeks in March–April 2021 using donations from India; and it only now, in July, appears to have secured enough second doses from other countries, including 250,000 doses donated by Denmark.
At the heart of the controversy over vaccine distribution are two important aspects of the notion of solidarity. On the one hand there is the moral aspect – solidarity is about treating people equitably according to relative need irrespective of their social and economic status. In the context of vaccines, equitable treatment means distributing them, within and between countries, according to the assessed public health priorities rather than ability to pay or other criteria such as political influence.
It is in the interest of every country, richer and poorer, that vaccines be distributed according to public health need, both within and between countries.
On the other hand, solidarity can be about efficiency linked to enlightened self-interest. Allocating vaccines according to public health need also means allocating them in ways that will mitigate the pandemic most effectively by protecting the most vulnerable across the world to reduce mortality and transmission and hastening the time when societies and economies everywhere can be revived. It is therefore in the interest of every country, richer and poorer, that vaccines be distributed according to public health need, both within and between countries.
So-called ‘vaccine nationalism’ is an example of what economists term the prisoner’s dilemma. When vaccine supplies are limited, countries acting in their perceived self-interest by vaccinating their whole population may be better off in terms of averted deaths (at least in the short term) than in a situation where the same amount of vaccines are distributed across all countries in relation to their population. But far more global deaths would be averted by the latter strategy – one modelling study estimated nearly twice as many. However, as the recent experience of the EU with vaccine procurement has shown, in conditions of vaccine shortage some larger countries (e.g. Germany) that could have acted individually but chose the collective route may feel this has not been to their advantage, while other, smaller member states feel they have benefited from collective procurement. Yet others, such as Hungary and the Czech Republic have, as noted below, looked to Russia and China for supplies as the EU vaccination roll-out initially faltered.
Moreover, because of the interconnectedness of the global economy, not only does equitable allocation of vaccines save lives; it also reduces the economic fallout from the pandemic. The International Monetary Fund has estimated that vaccinating 60 per cent of the world’s population by mid-2022 would cost $50 billion, but would avoid costs to the world economy of $9 trillion.
Ultimately, the much-used phrase ‘no one is safe until everyone is safe’ represents a profound truth. The recent resurgence of travel bans and travel restrictions in the face of new variants of the virus, with their associated enormous economic costs, demonstrates that we cannot be truly out of trouble until we have reduced the disease globally to something akin to seasonal flu.
