Long COVID and Health Inequities: The Role of Primary Care

Policy Points

• An estimated 700,000 people in the United States have “long COVID,” that is, symptoms of COVID‐19 persisting beyond three weeks.
• COVID‐19 and its long‐term sequelae are strongly influenced by social determinants such as poverty and by structural inequalities such as racism and discrimination.
• Primary care providers are in a unique position to provide and coordinate care for vulnerable patients with long COVID.
• Policy measures should include strengthening primary care, optimizing data quality, and addressing the multiple nested domains of inequity.

The pandemic has highlighted and exacerbated health inequities in both acute coronavirus disease 2019 (COVID‐19) and its longer‐term sequelae. ¹ , ² , ³ , ⁴ Symptoms of COVID‐19 persist in approximately one in 10 patients. ⁵ Acute symptoms include shortness of breath, cough, myalgias, disturbances in the sense of taste and smell, fatigue, fever, chills, and, less commonly, rhinitis and gastrointestinal symptoms. By contrast, the term “long COVID,” coined by patients, refers to both postacute symptoms (lasting more than three weeks) and chronic symptoms (lasting more than 12 weeks). ⁶ Long COVID is a multisystem disease of unknown cause whose manifestations, while partially overlapping the acute presentation, vary widely among patients and are exacerbated by comorbidities and vulnerabilities (Box 1). It occurs in adults who were hospitalized and those who were not ⁶ , ⁷ , ⁸ and (more rarely) in children. ⁹ At the time of this writing, the United States had more than 17 million diagnosed cases of COVID‐19, ¹⁰ , ¹¹ which translates into approximately 1,700,000 people with long COVID. This does not include the likely underreporting of COVID‐19 cases, the proportion of which in one study ranged from one in three to one in 406. ¹² The implications for health services are substantial. Given the heterogeneity in definitions of long COVID and the lack of centralized registries of patients with the disease, those who might suffer from long‐term symptoms might mistakenly be recorded as recovered.Box 1Some of the Many Manifestations of Long COVID ⁶ , ¹³ , ¹⁴ , ¹⁵

The Structure and Financing of Health Care Systems Affected How Providers Coped With COVID‐19

Policy Points

• We compared the structure of health care systems and the financial effects of the COVID‐19 pandemic on health care providers in the United States, England, Germany, and Israel: systems incorporating both public and private insurers and providers.
• The negative financial effects on health care providers have been more severe in the United States than elsewhere, owing to the prevalence of activity‐based payment systems, limited direct governmental control over available provider capacity, and the structure of governmental financial relief.
• In a pandemic, activity‐based payment reverses the conventional financial positions of payers and providers and may prevent providers from prioritizing public health because of the desire to avoid revenue loss caused by declines in patient visits.

Financial distress in the health care sector is a nonintuitive consequence of a pandemic. Yet, in the United States, the budgets of health care providers are under considerable strain as the COVID‐19 pandemic continues.Analysts anticipate that these continuing financial challenges will generate a wave of consolidation among hospitals and physician practices through 2021. ¹ Critical access hospitals, hospitals serving vulnerable populations, and independent primary care practices are particularly threatened. ² , ³ These dire financial outcomes arose through the interaction of the public health measures taken in response to the COVID‐19 epidemic, particularly the shutdown of elective procedures, along with the underlying structure of US health care financing and the US government''s emergency response.But COVID‐19 is a global epidemic. The twin effects of COVID‐19 treatment and reduced non‐COVID treatment have dramatically changed the number and case mix of patients treated in similar ways across high‐income countries. In all countries, the number of acutely ill patients with COVID rose while the number of patients with other conditions fell. The effects of these changes on health care providers’ finances have varied, however, depending on how health care systems are ordinarily structured and financed and to what extent government actions protected health care providers. By comparing the financial effects of the COVID‐19 pandemic in the United States and three other health care systems (England, Germany, and Israel) that incorporate both public and private insurers and providers, we can identify the governmental and policy factors that contributed to the severity and distribution of the effects of COVID‐19 on US providers.In all four countries, the impacts of COVID on the utilization of health care were similar. During infection surges, the number of COVID patients stressed hospitals, and as a result, nonurgent services for non‐COVID patients were postponed or forgone. The governments of all four countries directly supported health care providers with funding for increased COVID‐related expenditures (such as for personal protective equipment). The governments of all four countries also protected and compensated health care providers for their financial losses, but they did so in different ways, reflecting the structure of their health systems. In Israel, which uses relatively little activity‐based financing, the government saw less need for dedicated financial assistance. The governments of Germany and England shifted the form of payment away from activity‐based financing toward budgets to provide financial protection to health care providers, particularly in hospitals. Finally, in the United States, where activity‐based payment is prevalent and the health care–financing system is far too fragmented to permit a rapid switch in the method of payment, the government directly compensated providers for lost revenue.     

The Commercial Determinants of Three Contemporary National Crises: How Corporate Practices Intersect With the COVID‐19 Pandemic,Economic Downturn,and Racial Inequity

Policy Points

•  The United States finds itself in the middle of an unprecedented combination of crises: a global pandemic, economic crisis, and unprecedented civic responses to structural racism.
•  While public sector responses to these crises have faced much justified criticism, the commercial determinants of these crises have not been sufficiently examined.
•  In this commentary we examine the nature of the contributions of such actors to the conditions that underpin these crises in the United States through their market and nonmarket activities.
•  On the basis of this analysis, we make recommendations on the role of governance and civil society in relation to such commercial actors in a post‐COVID‐19 world.

The united states finds itself amid three concurrent and interrelated crises. First, at the time of writing, the United States has reported more than 27 million confirmed COVID‐19 cases and more than 500,000 Americans have lost their lives. ¹ Second, in part as a consequence of the physical distancing measures enacted to slow the spread of the pandemic, the United States has faced record unemployment, a rise in the number of Americans unable to afford medical insurance, an end to federal support measures, and an uncertain economic outlook. According to the US Department of Labor, more than 50 million Americans have filed for unemployment benefits since the COVID‐19 pandemic started; more than 10 million Americans remain on state unemployment benefits. ² Third, the country is still contending with how to respond to mass civil protests in 2020 unlike any seen in half a century, triggered by the killing of George Floyd at the hands of police in Minneapolis. This civil unrest reflects centuries of structural racism and has brought unprecedented attention to this problem. ³ , ⁴ , ⁵ In each of these three concurrent crises, the pandemic, ongoing large‐scale unemployment, and civil protests, ⁶ the US federal response has been criticized as being delayed and poorly coordinated, involving downplaying the threat posed by the pandemic and building on longer‐term failures by previous administrations to make investments in public goods that may have facilitated a more robust and effective collective response.By contrast, it would appear that some of the largest entities in corporate America have responded more rapidly to each of the ongoing crises than the federal government has. A number of large companies have engaged in activities that responded to needs emerging from the pandemic, such as producing hand sanitizer, ⁷ setting up COVID‐19 testing sites, ⁸ and partnering on contact tracing. ⁹ Most notably, the pharmaceutical sector has contributed to an unexpectedly and unquestionably successful vaccine development process for SARS‐CoV‐2, with almost 200 million shots already distributed. ¹⁰ In response to the economic downturn, many companies have been adapting their business practices to supply essential services in a time of great disruption. For example, food and other essential businesses have largely kept supply chains for essential goods open, ¹¹ through extending working hours, hiring additional staff, and implementing new means of operating. Several large employers have responded to changing circumstance, aiming to keep as many employees working as possible, often through an embrace of remote working and implementing more permanent shifts into patterns of working. ¹² In response to the global protests around structural racism that erupted in 2020, a number of large companies, including Nike, Reebok, Twitter, and Citigroup, have publicly aligned themselves with the Black Lives Matter movement, ¹³ including committing more than a billion dollars in pledged donations. ¹⁴ In a moment of great national turmoil, when government seems not up to the task, private sector actors have appeared, by contrast, to be better positioned to address the three crises of the moment. This plays neatly into a private sector–centric narrative, and there is little question that much good has come from elements of the private sector during this time.It is certainly true that these visible private sector efforts have contributed to helping populations deal with the consequences of an unprecedented global pandemic. But, given the emerging evidence about the populations at risk for COVID‐19, and why that risk exists to begin with, it is legitimate to ask: in the case of COVID‐19, what was the contribution of the private sector in creating the conditions that made us vulnerable to the pandemic and its consequences to begin with? And, by extension, how can private sector actions align with a durable set of solutions to the crises that characterize this moment?We already know that large, consolidated corporate entities, particularly those that manufacture harmful products, can have profound effects on population health. ¹⁵ , ¹⁶ , ¹⁷ The most obvious way in which this manifests is through “market activity,” that is, the direct consequences of manufacturing and marketing particular products. For example, it is easy to recognize that marketing of cigarettes harms health. However, such actors also influence population health through a range of “nonmarket” activities that shape the political, social, and cultural environments that they operate in. ¹⁸ Examples of this activity include political donations, lobbying, corporate social responsibility initiatives, and legal activity. These activities, often seen as intrinsic to corporate practice, support and protect commercial interests, yet do not necessarily promote population health or structures of governance. Bearing this in mind, it is worth understanding how such activities, both market and nonmarket, have contributed to the vulnerability of the United States to the three crises we now face.     

Medicare Advantage for Most

Policy Points

• Fixing the ACA requires real cost containment in addition to better subsidies.
• Private Medicare (Medicare Advantage) plans are uniquely empowered to control costs and deliver good care.
• Medicare Advantage plans should serve as the public option on the ACA Marketplace.
• Medicare Advantage plans can also be deployed to voluntarily raise minimum employer‐sponsored benefits and contain their costs.

Covid‐19 highlights one of the major problems with America''s hybrid arrangement for financing health care. While the Affordable Care Act (ACA) improved financial access and reduced racial disparities in coverage, ¹ , ² it has proved inadequate in the face of the pandemic''s disruption of employer‐sponsored insurance (ESI). The number of uninsured persons, almost 30 million in 2019, jumped by 5 million or more in spring 2020. ³ , ⁴ The ACA also cannot do much to control private health care spending. As deductibles and coinsurance rise, tens of millions of insured Americans face a growing share of rising total costs. In 2018, an estimated 42% of those with individual insurance and 28% of those with ESI met the Commonwealth Fund''s definition of underinsurance. ⁵ Decreasing coverage, climbing costs, and the mounting public anxiety about both may well reenergize serious health reform. When the legislative standoff that has blocked improvements to the ACA ends, reform should not only improve enrollment and benefits but actually make care affordable, that is, both adequately subsidize decent coverage and control the total cost of care. Fortunately, the foundation has been laid for ambitious reform without major disruptions.Although the ACA established a framework for achieving near‐universal coverage, premium subsidies have not been adequate, and counterattacks by Republicans have dented the structure. Linda Blumberg and her colleagues at the Urban Institute proposed a package of fixes for the ACA, ⁶ many of which have been incorporated into both HR 1425, the Patient Protection and Affordable Care Enhancement Act, and President‐elect Joe Biden''s campaign proposals. ⁷ The ACA''s expansion of Medicaid eligibility has proven very effective in the 34 states that are participating. ⁸ With sophisticated ballot campaigns for Medicaid expansion in 10 holdout states—some of which have already succeeded—and full federal funding for states newly expanding Medicaid, millions more people would be cut from the uninsurance rolls. ⁹ , ¹⁰ To make the ACA''s Marketplace coverage decent and premiums affordable, Blumberg and colleagues propose increasing the ACA''s premium tax credits so that no household would pay a premium of more than 8.5% of their income for the benchmark plan and increasing that benchmark from covering 70% to covering 80% of expected claims. They would also restore tax penalties for the individual mandate and add a federal reinsurance program, autoenrollment, and a public option.The incremental federal outlays for these fixes would be relatively modest. Blumberg and colleagues estimate that these enhancements (Scenario 4) would have increased 2020 federal outlays by $45.6 billion. ¹¹ The Congressional Budget Office''s projection for HR 1425 is slightly higher, nearly six hundred billion over 10 years. ¹² As Sherry Glied pointed out, “What is impressive is how far these relatively modest proposals could take us . . . bring[ing] the national uninsurance rate among non‐elderly legal residents of the US down to 3.1 percent, counting those eligible for Medicaid as effectively insured.” ¹³ Controlling health care spending is a tougher challenge, one that has eluded US health policy for more than a half century. However, as I describe later, Medicare Advantage could be deployed to invite most privately insured Americans into good, truly affordable coverage without disrupting existing sources of employer funding. To understand how, it is important to recognize that Medicare is no longer simply a public program but a hybrid that includes a robust private segment, Medicare Advantage (MA) health plans. MA plans now cover 36% of beneficiaries, continue to grow rapidly, ¹⁴ and offer many of the advantages of social insurance with considerably more flexibility. They could be adapted to enlarge benefits and provide a peculiarly American response to relentlessly rising health care costs.     

Politics and the Public Health Workforce: Lessons Suggested from a Five-State Study

Policy Points

• The United States public health system relies on an inadequate and inefficient mix of federal, state, and local funding.
• Various state-based initiatives suggest that a promising path to bipartisan support for increased public health funding is to gain the support of local elected officials by providing state (and federal) funding directly to local health departments, albeit with performance strings attached.
• Even with more funding, we will not solve the nation's public health workforce crisis until we make public health a more attractive career path with fewer bureaucratic barriers to entry.

     

The Perils of Medicalization for Population Health and Health Equity

Policy Points

• Medicalization is a historical process by which personal, behavioral, and social issues are increasingly viewed through a biomedical lens and “diagnosed and treated” as individual pathologies and problems by medical authorities.
• Medicalization in the United States has led to a conflation of “health” and “health care” and a confusion between individual social needs versus the social, political, and economic determinants of health.
• The essential and important work of population health science, public health practice, and health policy writ large is being thwarted by a medicalized view of health and an overemphasis on personal health services and the health care delivery system as the major focal point for addressing societal health issues and health inequality.
• Increased recognition of the negative consequences of a medicalized view of health is essential, with a focus on education and training of clinicians and health care managers, journalists, and policymakers.

     

US State Polarization,Policymaking Power,and Population Health

Policy Points

• Explanations for the troubling trend in US life expectancy since the 1980s should be grounded in the dynamic changes in policies and political landscapes. Efforts to reverse this trend and put US life expectancy on par with other high‐income countries must address those factors.
• Of prime importance are the shifts in the balance of policymaking power in the United States, the polarization of state policy contexts, and the forces behind those changes.

The troubling trend in us life expectancy and the widening disparities in life expectancy across the United States have deep roots. This article posits that both trends are grounded in the dynamic changes in the policy and political landscapes since the 1980s. It first briefly describes the trends and the importance of excavating their structural roots. It then builds the case that changes in state policies and politics, as well as the forces behind those changes, are key explanations for both trends.     

Child Poverty and Health: The Role of Income Support Policies

Policy Points

• Child poverty is associated with both short- and long-term health and well-being, and income support policies can be used to improve child health.
• This article reviews the types of income support policies used in the United States and the evidence of the effectiveness of these policies in improving child health, highlighting areas for future research and policy considerations specific to income support policies.

     

The Communication Infrastructure as a Social Determinant of Health: Implications for Health Policymaking and Practice

Policy Points

• Persistent communication inequalities limit racial/ethnic minority access to life‐saving health information and make them more vulnerable to the effects of misinformation.
•  Establishing data collection systems that detect and track acute gaps in the supply and/or access of racial/ethnic minority groups to credible health information is long overdue.
• Public investments and support for minority‐serving media and community outlets are needed to close persistent gaps in access to credible health information.

     

Abortion Policy in the United States: The New Legal Landscape and Its Threats to Health and Socioeconomic Well-Being

Policy Points

• The historic 2022 Supreme Court Dobbs v Jackson Women's Health Organization decision has created a new public policy landscape in the United States that will restrict access to legal and safe abortion for a significant proportion of the population.
• Policies restricting access to abortion bring with them significant threats and harms to health by delaying or denying essential evidence-based medical care and increasing the risks for adverse maternal and infant outcomes, including death.
• Restrictive abortion policies will increase the number of children born into and living in poverty, increase the number of families experiencing serious financial instability and hardship, increase racial inequities in socioeconomic security, and put significant additional pressure on under-resourced social welfare systems.

     

Upstream Policy Changes to Improve Population Health and Health Equity: A Priority Agenda

Policy Points

• Upstream factors—social structures/systems, cultural factors, and public policy—are primary forces that drive downstream patterns and inequities in health that are observed across race and locations.
• A public policy agenda that aims to address inequities related to the well-being of children, creation and perpetuation of residential segregation, and racial segregation can address upstream factors.
• Past successes and failures provide a blueprint for addressing upstream health issues and inhibit health equity.

     

Public Health Emergency Preparedness After COVID-19

Policy Points

• The critical task of preparedness is inseparable from the regular work of advancing population health and health equity.

     

A Population Health Impact Pyramid for Health Care

Policy Points

• To meaningfully impact population health and health equity, health care organizations must take a multipronged approach that ranges from education to advocacy, recognizing that more impactful efforts are often more complex or resource intensive.
• Given that population health is advanced in communities and not doctors’ offices, health care organizations must use their advocacy voices in service of population health policy, not just health care policy.
• Foundational to all population health and health equity efforts are authentic community partnerships and a commitment to demonstrating health care organizations are worthy of their communities’ trust.

     

The Role of Primary Care in Improving Population Health

Policy Points

• Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure.
• Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges.
• Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.

     

COVID‐19: The Time for Collaboration Between Long‐Term Services and Supports,Health Care Systems,and Public Health Is Now

Policy Points

• To address systemic problems amplified by COVID‐19, we need to restructure US long‐term services and supports (LTSS) as they relate to both the health care systems and public health systems. We present both near‐term and long‐term policy solutions.
• Seven near‐term policy recommendations include requiring the uniform public reporting of COVID‐19 cases in all LTSS settings; identifying and supporting unpaid caregivers; bolstering protections for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing barriers to telehealth in LTSS; and providing incentives to care for vulnerable populations.
• Long‐term reform should focus on comprehensive workforce development, comprehensive LTSS financing reform, and the creation of an age‐friendly public health system.

ContextThe heavy toll of COVID‐19 brings the failings of the long‐term services and supports (LTSS) system in the United States into sharp focus. Although these are not new problems, the pandemic has exacerbated and amplified their impact to a point that they are impossible to ignore. The primary blame for the high rates of COVID‐19 infections and deaths has been assigned to formal LTSS care settings, specifically nursing homes. Yet other systemic problems have been unearthed during this pandemic: the failure to coordinate the US public health system at the federal level and the effects of long‐term disinvestment and neglect of state‐ and local‐level public health programs. Together these failures have contributed to an inability to coordinate with the LTSS system and to act early to protect residents and staff in the LTSS care settings that are hotspots for infection, spread, and serious negative health outcomes.MethodsWe analyze several impacts of the COVID‐19 pandemic on the US LTSS system and policy arrangements. The economic toll on state budgets has been multifaceted, and the pandemic has had a direct impact on Medicaid, the primary funder of LTSS, which in turn has further exacerbated the states’ fiscal problems. Both the inequalities across race, ethnicity, and socioeconomic status as well as the increased burden on unpaid caregivers are clear. So too is the need to better integrate LTSS with the health, social care, and public health systems.FindingsWe propose seven near‐term actions that US policymakers could take: implementing a uniform public reporting of COVID‐19 cases in LTSS settings; identifying and supporting unpaid caregivers; bolstering support for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing the barriers to telehealth in LTSS; and providing incentives to care for our most vulnerable populations. Our analysis also demonstrates that our nation requires comprehensive reform to build the LTSS system we need through comprehensive workforce development, universal coverage through comprehensive financing reform, and the creation of an age‐friendly public health system.ConclusionsCOVID‐19 has exposed the many deficits of the US LTSS system and made clear the interdependence of LTSS with public health. Policymakers have an opportunity to address these failings through a substantive reform of the LTSS system and increased collaboration with public health agencies and leaders. The opportunity for reform is now.     

A Commons for a Supply Chain in the Post-COVID-19 Era: The Case for a Reformed Strategic National Stockpile

Policy Points

• Reflecting on current response deficiencies, we offer a model for a national contingency supply chain cell (NCSCC) construct to manage the medical materials supply chain in support of emergencies, such as COVID‐19. We develop the following:
  • a framework for governance and response to enable a globally independent supply chain;
  • a flexible structure to accommodate the requirements of state and county health systems for receiving and distributing materials; and
  • a national material “control tower” to improve transparency and real‐time access to material status and location.

ContextMuch of the discussion about the failure of the COVID‐19 supply chain has centered on personal protective equipment (PPE) and the degree of vulnerability of care. Prior research on supply chain risks have focused on mitigating the risk of disruptions of specific purchased materials within a bounded region or on the shifting status of cross‐border export restrictions. But COVID‐19 has impacted every purchase category, region, and border. This paper is responsive to the National Academies of Sciences, Engineering and Medicine recommendation to study and monitor disasters and to provide governments with course of action to satisfy legislative mandates.MethodsOur analysis draws on our observations of the responses to COVID‐19 in regard to acquisition and contracting problem‐solving, our review of field discussions and interactions with experts, a critique of existing proposals for managing the strategic national stockpile in the United States a mapping of the responses to national contingency planning phases, and the identification of gaps in current national healthcare response policy frameworks and proposals.FindingsCurrent proposals call for augmenting a system that has failed to deliver the needed response to COVID‐19. These proposals do not address the key attributes for pandemic plan renewal: flexibility, traceability and transparency, persistence and responsiveness, global independence, and equitable access. We offer a commons‐based framework for achieving the opportunities and risks which are responsive to a constellation of intelligence assets working in and across focal targets of global supply chain risk.ConclusionsThe United States needs a “commons‐based strategy” that is not simply a stockpile repository but instead is a network of repositories, fluid inventories, and analytic monitoring governed by the experts. We need a coordinated effort, a “commons” that will direct both conventional and new suppliers to meet demands and to eliminate hoarding and other behaviors.     

Making Communities More Visible: Equity-Centered Data to Achieve Health Equity

Policy Points

• Despite decades of research exposing health disparities between populations and communities in the US, health equity goals remain largely unfulfilled. We argue these failures call for applying an equity lens in the way we approach data systems, from collection and analysis to interpretation and distribution. Hence, health equity requires data equity.
• There is notable federal interest in policy changes and federal investments to improve health equity. With this, we outline the opportunities to align these health equity goals with data equity by improving the way communities are engaged and how population data are collected, analyzed, interpreted, made accessible, and distributed.
• Policy priority areas for data equity include increasing the use of disaggregated data, increasing the use of currently underused federal data, building capacity for equity assessments, developing partnerships between government and community, and increasing data accountability to the public.

     

International Collaboration to Ensure Equitable Access to Vaccines for COVID‐19: The ACT‐Accelerator and the COVAX Facility

Policy Points

• Equitable access to a COVID‐19 vaccine in all countries remains a key policy objective, but experience of previous pandemics suggests access will be limited in developing countries, despite the rapid development of three successful vaccine candidates.
• The COVAX Facility seeks to address this important issue, but the prevalence of vaccine nationalism threatens to limit the ability of the facility to meet both its funding targets and its ambitious goals for vaccine procurement.
• A failure to adequately address the underlying lack of infrastructure in developing countries threatens to further limit the success of the COVAX Facility.

ContextSignificant effort has been directed toward developing a COVID‐19 vaccine, which is viewed as the route out of the pandemic. Much of this effort has coalesced around COVAX, the multilateral initiative aimed at accelerating the development of COVID‐19 vaccines, and ensuring they are equitably available in low‐ and middle‐income countries (LMICs). This paper represents the first significant analysis of COVAX, and the extent to which it can be said to have successfully met these aims.MethodsThis paper draws on the publicly available policy documents made available by the COVAX initiatives, as well as position papers and public statements from governments around the world with respect to COVID‐19 vaccines and equitable access. We analyze the academic literature regarding access to vaccines during the H1N1 pandemic. Finally, we consider the WHO Global Allocation System, and its principles, which are intended to guide COVAX vaccine deployment.FindingsWe argue that the funding mechanism deployed by the COVAX Pillar appears to be effective at fostering at‐risk investments in research and development and the production of doses in advance of confirmation of clinical efficacy, but caution that this represents a win‐win situation for vaccine manufacturers, providing them with opportunity to benefit regardless of whether their vaccine candidate ever goes on to gain regulatory approval. We also argue that the success of the COVAX Facility with respect to equitable access to vaccine is likely to be limited, primarily as a result of the prevalence of vaccine nationalism, whereby countries adopt policies which heavily prioritize their own public health needs at the expense of others.ConclusionsCurrent efforts through COVAX have greatly accelerated the development of vaccines against COVID‐19, but these benefits are unlikely to flow to LMICs, largely due to the threat of vaccine nationalism.

A vaccine is viewed as the key to bringing about the end of the COVID‐19 pandemic. The sooner a vaccine is available, the sooner the world can begin to escape the acute phase of the pandemic, suppressing mortality and morbidity caused by infection and restoring a degree of normality to social life and the global economy. Not only is global equitable access to a COVID‐19 vaccine an important public health tool, but it is also necessary to ensure that all countries can discharge their human rights obligations. ¹ In an attempt to accelerate the availability of vaccines and other tools to combat COVID‐19, the World Health Organization (WHO) established the Access to COVID‐19 Tools (ACT) Accelerator, a global initiative designed to harbor international cooperation and knowledge regarding the pandemic. Specifically, the ACT‐Accelerator is focused on accelerating development in four areas, or pillars: diagnostics, therapeutics, vaccines (called COVAX), and health systems strengthening.Although efforts to develop a vaccine are starting to prove successful, with the development of successful candidates from Pfizer, Moderna, and AstraZenica/University of Oxford all receiving emergency regulatory approval in late 2020, key questions remain about which countries will have access to these vaccines, when they will get access, and in what quantities. During the 2009 H1N1 influenza pandemic, procurement of pandemic vaccines was dominated by developed countries, which used advance purchase agreements to reserve doses ahead of production. This severely limited the number of doses available in developing countries. ² In addition to accelerating research and development (R&D) through the ACT‐Accelerator, and in an attempt to ensure more equitable access to vaccines for COVID‐19, the Coalition for Epidemic Preparedness Innovations (CEPI); Gavi, the Vaccine Alliance; and the WHO formed the COVAX Facility in early 2020. The COVAX Facility is designed to address the issues encountered by developing countries during the 2009 H1N1 pandemic by using significant advance market commitments to secure access to vaccines on their behalf. It also encourages multilateral cooperation to increase access to vaccines in all participating countries.This paper argues that the funding mechanism deployed by the COVAX pillar appears to be effective at fostering at‐risk investments in R&D and the production of doses in advance of confirmation of clinical efficacy. Indeed, the development of two vaccine candidates funded by the ACT‐Accelerator is testament to this fact. However, this comes with a caution that the mechanism heavily favors pharmaceutical companies, for which up‐front investment from the COVAX pillar represents a win‐win situation and an opportunity to benefit regardless of whether their vaccine candidate ever goes on to gain regulatory approval. The paper then discusses the COVAX Facility, arguing that, like any multilateral purchasing system, securing a sufficient degree of interest and participation is essential to its success. It argues that the COVAX Facility has so far failed to do this, primarily as a result of the prevalence of vaccine nationalism, whereby countries adopt policies that heavily prioritize their own public health needs at the expense of others, and that its success is therefore likely to be limited. The paper concludes by arguing that the Global Allocation System, designed by the WHO, fails to address the issues experienced by the Vaccine Deployment Initiative during the 2009 H1N1 pandemic, specifically the delays in deploying vaccine in developing countries owing to a lack of preparedness and vaccine utilization infrastructure. It argues that, if these issues are not addressed, the COVAX Facility will fail to secure equitable access to vaccines in developing countries, despite the rapid development of successful vaccine candidates, because the allocation framework will be unable to operate as intended.