The global plan for COVID-19 vaccine fairness fell short. Will next time be different? – Science

COVAX, the unprecedented global effort to distribute COVID-19 vaccines more fairly, is set to wind down over the next 2 years. On 8 December, the board of Gavi, the Vaccine Alliance—a key partner in the project—voted “in principle” to phase out much of its support for COVID-19 vaccines in middle-income countries starting in 2024, and to incorporate COVID-19 vaccinations into its regular vaccine programs for the poorest countries—if they still want them.
The decision isn’t final, but critics of COVAX—many from poorer countries—would not mourn its demise. The effort has delivered some 1.84 billion vaccine doses to 146 countries, but many, if not most, arrived too late to have a big impact. “COVAX was completely useless for developing countries,” says Claudia Patricia Vaca González, an expert on access to medicines at the National University of Colombia, Bogotá. “It was a failure and we should admit it,” says Christian Happi, a molecular biologist at Redeemer’s University in Ede, Nigeria.
Others have a more positive take. “Gavi and COVAX were in my mind transformational and inspirational in their aims,” says Lawrence Gostin, an expert on global health law at Georgetown University. “It got a lot of shots in a lot of arms.” Still, “I totally understand Gavi’s reasoning,” Gostin adds. Demand for COVID-19 vaccines dropped sharply after the pandemic ebbed, and Gavi wants to refocus on campaigns that have lagged during the crisis, including vaccination against the cancer-causing human papillomavirus, and ensuring no child fails to receive routine childhood vaccinations.
The COVID-19 Vaccines Global Access Facility, as COVAX is officially called, was formed in April 2020 as an alliance between Gavi, the World Health Organization (WHO), UNICEF, and the Coalition for Epidemic Preparedness Innovations. Its initial goal was to secure roughly 2 billion doses, enough to vaccinate 20% of the populations of low- and middle-income countries. That, leaders calculated, would be enough to cover health care workers and high-risk groups. (WHO later set a goal of fully vaccinating 70% of the population in developing countries by the middle of this year, but many experts say that was never really feasible—or necessary, given that young people are less likely to develop serious disease from COVID-19 and many developing countries have a median age below 20.) The plan was to pool resources and buy vaccines in bulk for both rich and poor countries. Participating countries would receive doses based on their population instead of their purchasing power.
But early in the pandemic, wealthy countries—including some COVAX members—bought up huge quantities of vaccines for themselves, at higher prices, leaving COVAX at the back of the line. “COVAX was built on the status quo of market dynamics: Whoever pays the most is first in line,” says Victorine de Milliano, a policy adviser for the Doctors Without Borders Access Campaign. “COVAX missed out.”
The initiative suffered another major setback in the spring of 2021 when India banned the export of vaccines in the middle of its deadly Delta wave. One of COVAX’s main suppliers, the Serum Institute of India, suspended its delivery of 1.1 billion doses to COVAX. When COVAX did ship vaccines, they arrived unpredictably, making it difficult for recipient governments to plan effective vaccination campaigns.
By mid-November 2021, when most Western countries had fully vaccinated 70% of their populations or more and started to administer booster shots, COVAX had still only distributed about 500 million doses. Less than 2% of COVAX country populations were fully vaccinated with doses supplied by the program and 18 countries had not received any vaccines at all. (A Gavi spokesperson notes some successes, however: Some 81% of health care workers in COVAX-recipient countries are now fully vaccinated, and only eight countries still have vaccination rates below 10%.)
Meanwhile, demand for the vaccine has plummeted. Several big COVID-19 waves have come and gone, and the Omicron variants that started circulating early this year seemed to cause less severe disease.
With that in mind, a Gavi spokesperson says, the board moved to adopt a “planning framework” that focuses on seasonal boosting of high-risk groups rather than trying to cover entire populations. Starting in 2024, 37 middle-income countries would no longer receive free vaccines or extra support for their distribution. They would still be able to purchase vaccines through COVAX, however, and would receive a one-time sum to boost their ability to purchase and distribute them. Another 54 of the poorest countries would remain eligible for free vaccines and distribution support.
Last week’s decision drew fire from some observers, who say Gavi did not consult the affected countries. From the start of COVAX, “the countries that were going to benefit were not included in the decision-making. And now, in the wrap-up, they are again not included,” de Milliano says. “It is very condescending for Gavi to think that they know better than the countries themselves,” Happi says. (A WHO report about COVAX released in October acknowledged that low- and medium-income country governments “were insufficiently included” in planning, which hobbled the response.)
Gavi leaders emphasize that the board will discuss the topic further when it meets again in June 2023. In the meantime, Gavi will ask for input from affected countries, collect more data on the state of the pandemic, and assess how much difference vaccines can make in populations now that the virus has already swept through, says John-Arne Røttingen, a global health expert at the Norwegian Ministry of Foreign Affairs and a Gavi board member.
There’s widespread agreement the world needs to do better the next time a pandemic requires a global vaccination drive. That will require a “major rethink,” Vaca González says. “We can’t just say, ‘OK, we did our best. We didn’t really achieve our goal, but let’s wind it down,’” Gostin says. “We should have a COVAX 2.0 that goes beyond COVID and provides a far more robust way to ensure equitable access.”
Making developing countries less dependent on donors is crucial, he and others say. Happi says a robust system “should support countries to produce the vaccine themselves rather than create a situation where there are donors on one end and recipients on the other.”
WHO is taking some steps in that direction. In 2021, it established a hub in South Africa for transferring messenger RNA vaccine technology to companies in low- and middle-income countries. And at last week’s meeting, the Gavi board voted to support “the development of a regionally diversified vaccine manufacturing ecosystem,” including helping countries and companies decide which vaccines to make. It also is considering setting up a specific fund to purchase vaccines manufactured in Africa.
Making vaccines where they are needed is the way forward, says Gostin, who thinks it’s unrealistic to expect wealthy countries not to put their own populations first. “Vaccine nationalism is a fact of life.” Vaca González agrees. She says COVAX’s basic premise—buying vaccines developed in wealthy countries from large pharmaceutical firms—was flawed from the start: “That was the original sin of COVAX.”
Gretchen Vogel is a contributing correspondent for Science magazine based in Berlin, Germany.
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