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The global approach to vaccine equity is failing: additional steps that would help

A roll of stickers printed with the words "I got my COVID-19 vaccine"
Paul Hennessy/SOPA Images/LightRocket via Getty Images

Accusations abound of vaccine nationalism against states that stockpile vaccines and of vaccine apartheid, as COVID-19 vaccines become concentrated in rich countries. Calls for vaccine equity or justice demand vaccine allocation on account of need, based on the idea that no one is safe until everyone is safe.

At stake is our ability to ensure an end to the pandemic and restoration of the global economy via an end to border restrictions.

Efforts to address vaccine equity have focused on multilateral solutions such as the COVAX scheme and the suspension of intellectual property rights through the World Trade Organisation (WTO).

These initiatives differ in approach. But each is committed to pursuing solutions through global institutions.

Based on our work in global health and world trade governance, we question whether vaccine equity can be addressed via global institutions alone. All existing multilateral approaches have their limits: they are charitable, and depend on the alignment of powerful state interests. They also don’t address the central problem of how vaccines are manufactured and delivered around the world: supply chain governance.

We argue, therefore, that the fight for vaccine equity needs to stop looking to multilateral institutions for permission and instead focus on the policy tools that are already available to states.

Shortcomings of COVAX

COVAX is a joint initiative by various global health bodies including the GAVI Alliance and the World Health Organisation. It has two primary functions: to generate development of COVID-19 vaccines; and to ensure vaccine equity by providing doses for 20% of the population of all the 190 eligible countries.

COVAX incentivises the research and development of COVID-19 vaccines and negotiates the price paid for them, helping to secure a better deal by negotiating as a bloc. COVAX is currently supporting the development of nine vaccines.

Getting the vaccine is only part of the issue. COVAX then commits to ensure equitable access to these vaccines. This is done through self-financing states who pay in to the model and can then draw from it to secure vaccines for 10-50% of their population; and through funded states where official development assistance is used to support the COVAX Advance Market Commitment mechanism that ensures the 20% doses figure for low- and middle-income states.

For high-income countries that participate in the scheme, COVAX provides an insurance mechanism should their bilaterally-agreed supplies fall short. For low-income countries, COVAX is a vaccine lifeline when the prices of bilateral agreements become too high.

Global health institutions and state leaders celebrate images of COVAX vaccines arriving in poor countries as evidence that this approach is fast moving, results-based and equitable. But these images mask several vaccine equity issues.

It is unclear that COVAX can secure the investment required to reach its goal of securing 2 billion doses by the end of 2021. COVAX itself has warned of a US$27 billion gap needed to meet this ambition. Furthermore, doses for 20% of a population are insufficient.

When states are challenged on vaccine hoarding, priority deals, and bilateral price negotiations, they often point to COVAX as evidence of commitment to vaccine equity. Our criticism of COVAX is more than that it is just charity: COVAX is serving as a smokescreen to cover up vaccine nationalism.

Intellectual property

The cost of medicines is seen as the root problem of access to vaccines and technology. Hence the campaign for a temporary suspension (waiver) of intellectual property rights protected under the Trade Related Intellectual Property Rights (TRIPs) agreement of the WTO for all medical products required to fight the pandemic.

South Africa and India put forward a proposal for a vaccine waiver supported by developing countries and civil society campaigns. However this was blocked by the EU, US, UK, and Switzerland among other high-income states.

Advocates argue that current intellectual property rights arrangements stifle competition, and keep essential and affordable medicines and other medical products out of the hands of those who need them most.

However, existing rules already allow countries to suspend the application of intellectual property rights in a public health emergency. The 2001 Doha Declaration on TRIPs and public health reaffirmed that countries can determine what constitutes a national emergency, and issue compulsory licences “under any conditions they deem appropriate”.

Compulsory licences allow private corporations or governments to produce and distribute a generic version of a patented product without the permission of the patent holder. An amendment passed in 2005 also allowed countries without domestic manufacturing capacity to import generic medicines in times of national emergency.

So issuing compulsory licences is one feasible strategy for speeding access to vaccines.

Most states won’t do this. They perceive themselves as having a lot to lose – damage to international reputation, and criticism from global health actors who put a premium on playing by their rules.

Some states such as Chile have mooted the idea of compulsory licences for COVID-19 vaccines. No state has issued them to date. But the combination of past precedent and the growth of the pandemic in low-income countries could bring new attention and urgency to the option.

Supply chains and global governance

While supply chains are truly global, their reach and control remains outside the realm of multilateral institutions.

COVID-19 vaccines and other medical products are supplied through highly complex transnational supply chains often spanning continents. Manufacture of vaccines requires the procurement of raw materials, consumables and reagents. This involves multiple suppliers from across the world. For example, AstraZeneca works with 20 partners from over 15 countries and 20 testing sites in the development of its COVID-19 vaccine.

These supply chains are set up, managed and coordinated through core corporations that are typically the intellectual property rights holders in the chain.

The set-up of supply chains for vaccines and other medical products affects their global distribution. Smaller corporations in the chain are dis-incentivised from undermining the commercial interests of the core corporation. Smaller corporations in low-income states are fearful of undermining the intellectual property rights system as it may affect their future revenue. Their states, however fearful they may be, need to be bold and provide the necessary cover by compelling the production of generic vaccines under a compulsory licence.

What to do?

To secure universal access to vaccines, states must take up the fight by using the existing rules to their advantage. These include:

  • Issuing compulsory licences to produce their own vaccines.

  • Setting up bilateral agreements with those states that have production capacity.

  • Building vaccine blocks to negotiate and supply vaccines to territories.

  • Being prepared to disrupt power relations within supply chains by breaking confidentiality clauses in contracts and publishing what pharmaceutical companies want them to pay – or at least leak these contracts.

Controversial, yes, but as previous cases such as the Indonesia virus sample sharing controversy shows, these controversies are produced by gross inequities within the system.

If countries want to solve the problem of vaccine equity they should stop seeing COVAX as the solution, and see it as the charity it is. And they should share vaccine intellectual property and technology without waiting for multilateral institutions to offer permission when the rules already make allowances for this.

Multilateral institutions rest on rules and norms. These exist for order and discipline, but on occasion can be used for justice when states do something brave.

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