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.