Middle-income countries are caught in a COVID-19 financing gap

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Workers unload boxes of COVID-19 vaccines shipped under the COVAX scheme at an airport in Abidjan, Côte d'Ivoire. Photo by: Luc Gnago / Reuters

Mongolia’s COVID-19 response has been one of the most successful in the world. The country of 3.3 million people has recorded roughly 3,300 coronavirus infections and only four deaths.

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Davaadorj Rendoo, who heads the country’s Department of Public Health Surveillance and Emergency Operations, told Devex he credited a policy of universal mask-wearing and the government’s willingness to lock down at the hint of a transmission spike.

But Mongolia’s success has come at a cost. Its export-driven economy has stalled, and the government has been forced to take on debt. Rendoo said the government is now moving to open up the economy while keeping transmission down. Vaccines would make it easier to strike that balance — but it’s unlikely they will be arriving at anywhere close to the necessary scale anytime soon.

Mongolia isn’t an isolated case. Middle-income countries from Georgia to Belize find themselves in a maddening bind, unable to afford the kinds of bilateral deals with vaccine manufacturers that have fueled the massive immunization campaigns in the United States and the United Kingdom but overlooked by activists and development actors desperately trying to get vaccines to the lowest-income nations. In the scramble to vaccinate, experts in middle-income countries worry their nations risk being left behind.

High-income countries dominated the early rush to immunize. Of the first 128 million doses administered, three quarters went to people living in just 10 countries. Combined, those countries represent 60% of the world’s gross domestic product.

“It will be the middle-income countries without the money to make good arrangements and without the possibility of getting more help, whether from donors or from other countries.”

— Florencia Luna, principal researcher, Argentina’s National Scientific and Technical Research Council

“Few of the wealthy countries have really stepped up to whatever obligations they have for global justice toward the rest of the world,” said Ruth Faden, the founder of the Johns Hopkins Berman Institute of Bioethics. “They have actually gotten in the way and and, in some cases, pursued a national advantage at the expense of COVAX,” she said, referring to the global facility aimed at ensuring equitable access to vaccines.

Nevertheless, COVAX was able to begin distribution last month. Faden is hopeful it may help to right the inoculation imbalance.

But with COVAX only guaranteeing enough doses to immunize 20% of each member country’s population, Florencia Luna, a principal researcher at the National Scientific and Technical Research Council of Argentina, warned that access disparities appear bound to persist.

“It will be the middle-income countries without the money to make good arrangements and without the possibility of getting more help, whether from donors or from other countries,” she told Devex.

Middle-income nations have seen nearly half of the total cases of COVID-19 globally, according to research published in mid-February by the Council on Foreign Relations’ Think Global Health initiative, but have only administered about a third of global vaccine doses. The disparity becomes even starker when you remove China, an upper-middle-income country, from the equation: The remaining middle-income countries still reflect nearly half of all global infections but have administered just over 17% of all doses.

Low-income countries have about 0.5% of reported cases, in comparison, though virtually none of the vaccinations.

Ethicists say the goal now is to refocus attention on how new or existing mechanisms, beginning with COVAX, might ethically distribute what is available.

Ninety-two low- and lower-middle-income countries, including Mongolia, were eligible for free vaccines through COVAX’s advance market commitment, or AMC. Just because other middle-income countries didn’t qualify, though, does not mean governments such as those in South Africa, Guatemala, and Armenia are in a position to fully fund their own responses.

“In a country that was just above the cutoff, they aren’t really enough better off that they can handle the whole thing on their own,” Faden said.

Such countries were able to join COVAX and self-finance their vaccine purchases through the facility. Dozens did, recognizing that at least COVAX could leverage the size and purchasing power of all of its member countries to engage pharmaceutical companies that would otherwise prioritize higher-income nations. The question of how to secure and pay for the remaining doses they need remains unanswered.

Within the AMC countries, COVAX has pledged to follow a proportional allocation model in distributing doses to the first 20% of populations. But even this raises questions about prioritization.

“Committing to distributing or allocating vaccines in a fair or equitable way, that’s an important step,” Luna said. “But it’s also about how you define that equitable way.”

COVAX’s allocation does not consider whether some of those countries have older populations, who might be at higher risk of serious illness, or higher numbers of front-line health workers, who are repeatedly facing exposure as they treat patients. Those groups are more likely to make up a larger proportion of the populations in eligible lower-middle-income countries than in the world’s lowest-income nations.

Interactive: Middle-income countries rush to get Russian COVID-19 vaccine

Over 30 countries and territories have given emergency approval to use the vaccine.

Luna was part of a group of ethicists who proposed a different allocation process, called the “fair priority model,” which asked allocators to consider “where a vaccine’s harm-reducing powers are most urgently needed.” That might lead to a redistribution toward countries with larger risk groups but also to nations where transmission is more rampant.

The fair priority model attracts its own doubters. Countries that successfully deployed extraordinary measures to control the spread of the coronavirus would initially be deprioritized under a model that considers transmission rates. It’s a profile that fits many middle-income countries, including Mongolia but also Vietnam and Malaysia.

The model does account for economic harms created by lockdowns and other measures in its second distribution phase, but that does little to alleviate the sense in some countries that even if they did everything right, they are slated to fall behind.

Against this landscape, both low- and middle-income countries are looking to purchase vaccines created in Russia, China, and India for relief.

In Mongolia, the government was able to launch immunizations with 150,000 doses of the vaccine developed by AstraZeneca and the University of Oxford that it received from the Serum Institute of India, and the country is scheduled to receive nearly 140,000 more vaccine doses through COVAX before the end of May. That still leaves it far short of the 2 million people Rendoo said the government plans to vaccinate.

Mongolia is now looking to purchase the remaining doses, probably from Russia, China, and India, even though Rendoo said much of the population distrusts the latter two. It will rely in part on $50.7 million in new World Bank financing to do so. According to the loan documents, while development agencies have expressed interest in supporting Mongolia, no agreements have been formalized.

About the author

  • Andrew Green

    Andrew Green is a Devex Contributing Reporter based in Berlin. His coverage focuses primarily on health and human rights and he has previously worked as Voice of America's South Sudan bureau chief and the Center for Public Integrity's web editor.