Global promises of equitable distribution of coronavirus vaccines are falling flat as the tool that was created to prevent wealthy countries from buying up the world’s supply has yet to distribute a single dose.
On one side are examples like the EU and the U.K., where over 11 million doses of vaccines have already been administered. In total, the EU has signed contracts for 2.3 billion doses, while the U.K. has secured 367 million. If all those vaccines are approved, their populations will be able to be vaccinated almost three times over.
Wealthy countries are also setting ambitious targets for September: The British government aims to administer to all adults their first dose; Belgium plans to have vaccinated 70 percent of its population; and Germany has set its sights on the 60 percent mark.
But on the other side are the less-wealthy nations, where national vaccination campaigns have yet to begin.
It’s the nightmare that global health experts had long warned about.
COVAX, the joint effort to ensure equitable distribution of vaccines managed by the World Health Organization (WHO); Gavi, the Vaccines Alliance; and the Coalition for Epidemic Preparedness Innovations (CEPI), was meant to solve so-called vaccine nationalism, but it has struggled to get off the ground. Although it has secured around 2 billion doses — with the goal of covering 20 percent of participant countries’ populations by the end of 2021 — none have been delivered.
And while its backers say the facility is “on track,” it’s still short of about $2.8 billion for 2021.
Those most in need of support from COVAX are countries that can’t afford to buy vaccines on their own, which total 92. These include places such as Afghanistan, Ethiopia, Uganda and Zimbabwe. However, many other countries that are paying for doses themselves, such as South Africa, had also pinned their hopes on the facility.
“How can we claim that we’re having equity now? We can’t,” said Kate Elder, senior vaccines policy adviser at Doctors Without Borders.
Even the WHO’s director general, Tedros Adhanom Ghebreyesus, has admitted things aren’t going as planned. On Monday, he disclosed that over the past couple of weeks, member countries have asked when COVAX will get the vaccines it needs.
“The world is on the brink of a catastrophic moral failure and the price of this failure will be paid with lives and livelihoods in the world’s poorest countries,” was Tedros’ stark warning. It followed his previous call for countries to stop making bilateral deals at the expense of COVAX.
Some of the rich countries arguably targeted by Tedros’ words are also criticizing COVAX. In a statement to the WHO executive board Monday, speaking on behalf of Austria, Clemens Martin Auer said that COVAX “has to do a better job.”
“The glass of delivering [vaccines] is not even half full,” he said. He called on Gavi, the organization responsible for COVAX’s day-to-day running, to make public detailed delivery plans.
Gavi has defended itself, pointing to the fact that COVAX is trying to do this all at “unprecedented speed.”
“Nothing like this has ever been attempted before in such a short time frame and we are working round the clock to ensure it is a success,” said a Gavi spokesperson.
From its inception, COVAX has been on the back foot, with wealthy countries wasting no time in negotiating secret deals with drugmakers. For months, backers of COVAX pleaded with rich countries to get on board. Eventually, the funding promises and sign-ups started to come in.
The EU is now contributing €500 million to support rollout in low- and middle-income countries. Other countries and charitable foundations have also pledged substantial amounts — France and Germany are both giving €100 million each, while Canada is contributing $246 million.
But the bilateral vaccine deals — which COVAX initially accepted — continue to proliferate, and countries continue to purchase hundreds of millions of doses from a very limited global supply. The chief concern about such agreements is that they let rich countries snap up more doses of a scarce resource, rather than bargain collectively to allow a more equitable distribution.
During his Monday speech, Tedros lambasted countries that “even as they speak the language of equitable access … continue to prioritize bilateral deals.”
He said that these deals, of which at least 12 have been signed in 2021 alone, are driving up prices as countries attempt to “jump to the front of the queue.”
High-income countries are securing vaccines that “could potentially be then at the expense of COVAX,” explained Kirsten Mathieson, head of policy and advocacy as well as health and nutrition at Save the Children International. “They’re kind of competing for the same advance purchase commitments.”
In defense, the EU has pointed to its sizeable contributions to COVAX. In particular, Commission President Ursula von der Leyen has repeatedly highlighted the fact that “Team Europe” (including member country contributions) is the largest contributor to the COVAX Facility.
But that still leaves the problem that COVAX doesn’t enjoy real buy-in from wealthier countries, says Jaume Vidal, senior policy adviser at Health Action International. He argues these countries “never really supported COVAX.” Notably of the €500 million provided by the EU, the lion’s share — €400 million — is a loan from the European Investment Bank.
One possible bright spot is the U.S., which didn’t commit to COVAX under the Trump administration. The U.S. Congress has appropriated $4 billion to go to Gavi, which is expected to go directly to its work on COVAX. This needs to be clarified by the Biden administration, however.
As for when vaccines will start to be distributed through the mechanism, COVAX has pinned February as the month rollout will begin. But those who’ve been closely following the facility since it was first floated in May 2020 are concerned.
“We are not in a good place,” said Vidal, who fears the first doses for some countries may not even arrive until 2022. “We’re getting into a situation that COVAX was created to avoid … a race to get vaccines.”
Elder is also pessimistic, saying that things are looking “a little bit tenuous at the moment” with concerns about the volumes secured, the prices paid and the time frames for delivery.
A central concern is that many of COVAX’s deals are not advance-purchase agreements with drugmakers, where actual cash exchanges hands. The only exceptions are the 170 million doses of Oxford/AstraZeneca vaccine and another 200 million doses of that same vaccine (or the Novavax candidate) that are secured through an agreement with the Serum Institute of India. But COVAX’s other deals are less clear cut.
For example, its agreement for 500 million doses of the Janssen candidate vaccine is in the form of a memorandum of understanding, while its 200 million doses of Sanofi/GSK vaccine are through a statement of intent.
Some self-financing countries have also had difficulties in coming up with the money needed to make down payments. South Africa, for example, missed its initial deadline for its R283 million (about €16 million) down payment.
These down payments were a “huge problem for many, many countries” said Alain Alsalhani, vaccines and special projects pharmacist at Doctors Without Borders. Countries have found it difficult to justify enormous sums of money being put towards vaccines that had yet to materialize. “This created huge legislative problems in many self financing countries and it also created huge delays to the COVID facility,” he explained.
Another major holdup has been regulatory approval. For a coronavirus vaccine to be distributed through the COVAX facility, it needs to have emergency-use listing from the WHO. So far, only the BioNTech/Pfizer vaccine has received this — a vaccine not in COVAX’s portfolio. In exceptional circumstances, regulatory approval from a national regulator such as the U.S. or the U.K. could suffice. But among COVAX’s agreed vaccine deals, only the Oxford/AstraZeneca vaccine has secured national approval. Even after this green light, other hurdles follow, including local regulatory sign-off.
Tedros has placed the blame for the delay on drugmakers, arguing they “prioritized regulatory approval in rich countries where the profits are highest, rather than submitting full dossiers to WHO.”
Doling out doses pro bono?
The other option is for wealthy countries to donate excess doses after vaccinating their own citizens.
Canada has pledged to donate these excess doses “once its population is inoculated.” The Commission itself has said that member countries are able to do this, and it’s working to set up a scheme to distribute excess doses. On Wednesday, von der Leyen elaborated on the scheme, saying that it would either channel excess vaccines through COVAX or send them directly to countries in need.
However, in those cases to date when EU members haven’t taken up the full allocation of doses they were eligible for, countries such as Germany have quickly bought up the excess, as was the case with the Moderna jab.
For now, there isn’t yet evidence of countries actually redistributing doses, Mathieson said: “It’s not about waiting till the end of the year when the whole population is vaccinated and then deciding, okay, now we don’t need them.”
For Doctors Without Borders’ Elder, the idea of countries holding out for donations is “absolutely abysmal.”
“[It just] illustrates how dire the global situation is, in terms of equity that people might be talking [as if] that is one of the main strategies for getting doses to the developing world,” she said.
In the wake of reports that the EU could donate doses directly to poorer countries, instead of through COVAX, Gavi published guidance on dose sharing. It calls for doses to be made available “as soon as possible and ideally concurrently by the sharing country as it receives vaccines.” Doses themselves should be un-earmarked, state the principles.
So far, Denmark appears to be the only country explicitly promising to do this, with its Minister of International Development Dag Inge Ulstein tweeting Tuesday that it would donate doses to COVAX in the “early stages of vaccination.”
Meanwhile, as rich countries look inward and focus on protecting their own populations, Russia and China have snatched up the chance to exert vaccine diplomacy.
For many countries that would otherwise be without a single dose, the lifeline offered in the form of Russia’s Sputnik V and China’s Sinovac or Sinopharm has been gladly taken up.
The Sinovac jab is already being rolled out in Turkey and Indonesia, despite questions around its efficacy. The company has also made deals with several other countries, including Brazil, Thailand and the Philippines. As for Russia’s Sputnik V, Argentina and Belarus have started to use the vaccine.
The fact that these vaccines are getting bought up before their efficacy is proved is merely an indicator of countries’ desperation, says Elder.
“Any government that has the financial means and the political clout to find alternatives to the COVAX facility is trying to do it,” she said.
This story has been updated to clarify Jaume Vidal’s expectation of when vaccines will arrive for COVAX recipients.
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