NEW YORK — As the wealthiest governments sink billions of dollars into their own COVID-19 vaccinations, public health officials warn that "vaccine nationalism" could leave behind the poorest countries. A new COVAX Global Vaccines Facility may offer the best hope for ensuring the world’s most vulnerable people receive vaccines once they are available.
The facility is jointly administered by Gavi, WHO, and the Coalition for Epidemic Preparedness Innovations, and is convening countries to jointly support and distribute future COVID-19 vaccines.
“COVAX is the only truly global solution that has the capability to end the acute stage of COVID-19 pandemic. It does this by ensuring fair and equitable access for all countries, thus avoiding the mistakes of the past when a small number of countries have been able to secure a disproportionate amount of the worldwide supply,” a Gavi spokesperson wrote in an email to Devex.
“But it will only succeed if we start investing in manufacturing now so that vaccines are ready to be shipped the day the gain licensure.”
It won’t be an easy task. Apart from securing sufficient funding, the facility will face many complicated policy decisions: Which vaccines should countries preemptively fund, knowing that not all vaccine candidates will pass the test of efficaciousness and safety? And who should be the first to receive a vaccine once it is available?
“Donor countries would have to walk the talk and put the money into the facility. There are a lot of decisions that are needed and those decisions cannot be made before we know how big the pool of resources is,” PATH CEO Nikolaj Gilbert told Devex in a recent interview.
“There's so much that needs to be done to basically work for this vision to become a reality. But I do believe it's a grand vision and we need that right now. So obviously, we are doing our best to support it. But the world will need to remain committed for the long run, this one,” Gilbert continued.
Gavi announced the COVAX facility as the first “building block towards a global mechanism to ensure equitable access to future COVID-19 vaccines” during its replenishment meeting in June.
The facility acts as a risk management mechanism that is designed to increase the chance of a successful vaccine, or vaccines, that can be produced in large quantities shortly after regulatory approval. Participating governments jointly invest in nine vaccine candidates, as an advance market commitment, or AMC, and agree to equitably distribute the vaccines among their countries. Health care workers will receive first priority, and then access will be expanded to the most vulnerable 20% of the population of every country that participates.
Some 92 low- and middle-income countries are eligible for accessing vaccines for free through COVAX, Gavi’s board of directors announced at the end of July. Another 81 high- and middle-income countries have expressed interest in joining as self-funded members, making upfront payments that will be critical to filling COVAX’s coffers.
The level of interest shows that countries understand the benefits of the facility, according to the Gavi spokesperson.
“It’s also a sign that countries are seeing that equitable access isn’t just the right thing to do, it’s in all our interests. The urgent need is for as many countries as possible to sign up for the Facility and to finance the COVAX AMC. We need to work together,” the spokesperson said.
COVAX will require $2 billion in seed funding by the end of the year to guarantee doses for the eligible low- and middle-income countries, according to Gavi. So far, the facility has raised $600 million. An additional $3.4 billion would then be needed to procure around 1 billion doses by the end of 2021.
“There will be a lot of failures among these portfolios of vaccines. If we're lucky, there will be one or two that CEPI has in the portfolio that will succeed….So someone needs to make that decision to say, OK, do we go forward with all of these? With five of them? With seven of them? And who are those people that will make those decisions?” Gilbert said.
But a global response to fully vaccinate against COVID-19 is expected to take years and will require billions and billions of doses, according to Peggy Hamburg, a board member of Gavi. Hamburg spoke during an August webinar hosted by the Center for Strategic and International Studies about the COVAX facility.
“All of this sounds good, but it requires the resources, importantly dollar resources, but political and human as well, to estimate the goals,” Hamburg said. “This is a critical gap in funding.”
WHO chief Tedros Adhanom Ghebreyesus called for wealthier nations to join the facility ahead of the Aug. 31 deadline issued by the health organization.
A handful of wealthy countries such as Canada, New Zealand, Singapore, Saudi Arabia, and the U.K. have agreed to join. But the U.S. and China — two of the largest possible vaccination producers — are notably absent.
As the European Union, United Kingdom, Switzerland, and the United States have all struck their own deals with pharmaceutical companies developing vaccines, Tedros called for a need to prevent vaccine nationalism during a media briefing in mid-August.
“Sharing finite supplies strategically and globally is actually in each country’s national interest,” Tedros said.
Jointly investing in a greater number of vaccines could improve the chances of backing a vaccine that will prove effective. Avoiding bidding wars on a vaccine, meanwhile, could lower the cost of procurement by a factor of 13, according to research by Kendall Hoyt, assistant professor of Dartmouth’s Geisel School of Medicine.
“Competition is sort of a time-honored way to generate innovation, but it might hinder efforts to develop a COVID vaccine and to make it equitably available,” Hoyt explained during the CSIS webinar.
But even if proper funding is secured to support the COVAX facility, and successful vaccine candidates are selected, many big questions remain unanswered.
“Who gets the vaccines in the countries?” asked Gilbert. “Who gets that 20%? Also, in all countries around the world, who decides that? But also, how do those then become distributed in an equal way across the country, not depending on the political agenda or whatever the dynamics are in that country. And that's another challenge that needs to be addressed.”
Initially, there will not be enough supply of successful COVID-19 vaccines to match the large demand, in part because of the manufacturing time required to produce billions of doses.
“You add the scarcity of COVID-19 doses, which will make this so much more political. Geopolitics is going to play in, money is going to play in. You know the story. It's probably not going to be beautiful, what will happen,” Gilbert said.
But the facility still offers hope as a model of global cooperation and potential progress on developing and distributing vaccines, according to Gilbert.
"If we can continue that spirit when it comes to also access to every person around the world, then yes, then we will be successful,” Gilbert said.