Covid and COVAX, lessons being learned for the next pandemic

 From the Lancet:

A beautiful idea: how COVAX has fallen short by Ann Danaiya Usher, June 19, 2021DOI:https://doi.org/10.1016/S0140-6736(21)01367-2

"At the pledging summit for COVAX on June 2, 2021, hosted by Japan, Gavi finally reached its US$8·3 billion ask for the procurement and delivery of vaccines for the 92 eligible low-income and middle-income countries (LMICs) this year. However, even with full financing, the COVAX roll-out has moved much more slowly than that in high-income countries (HICs). Speaker after speaker at the summit lamented the gross inequity in access to vaccines. “Today, ten countries have administered 75% of all COVID-19 vaccines, but, in poor countries, health workers and people with underlying conditions cannot access them. This is not only manifestly unjust, it is also self-defeating”, UN secretary general António Guterres told the gathering. “COVAX has delivered over 72 million doses to 125 countries. But that is far less than 172 million it should have delivered by now.” Of the 2·1 billion COVID-19 vaccine doses administered worldwide so far, COVAX has been responsible for less than 4%.

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"COVAX, managed by Gavi, along with the Coalition for Epidemic Preparedness Innovations and WHO, was designed to stand on two legs: one for HICs, which would pay for their own vaccines, and the other for 92 lower-income countries, whose doses would be financed by donor aid.

"In the so-called self-financing leg of COVAX, HICs were asked to pay upfront by mid-September, 2020, for the option to buy vaccines for their own populations. The UK, for example, paid £71 million for 27 million doses from COVAX, and Canada paid CA$220 million for 15 million doses. Australia, New Zealand, Norway, and South Korea also bought vaccine options from COVAX as self-financing countries.

"In the other leg of COVAX, vaccines for lower-income countries would be financed with donor grants through an Advance Market Commitment (AMC). The poorest of the 92 countries would receive them at no cost. Team Europe (led by Germany) and the USA have together provided US$5 billion to the COVAX AMC, Japan has given US$1 billion, and the UK, US$735 million. Most of these funds have been pledged only in the past few months.

"The grand idea of COVAX was that the combination of these two funding streams—the self-financed part and the aid-financed AMC—would give the facility the means to invest in research and development of several promising vaccine candidates. Additionally, as a pooled procurement mechanism, COVAX would have the financial muscle as a buyer to drive down prices for all participants. Once any of the COVAX portfolio vaccines had successfully undergone clinical trials and proved themselves to be both safe and effective, both self-financing and AMC countries would be allocated vaccines at the same rate, proportional to their total population size.

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"Everyone knew that rich countries would enter into bilateral vaccine deals, Yamey said. But it was hoped that they would also buy into COVAX as insurance in case some vaccine candidates did not prove successful. Most of them did not. In the end, “three dozen countries bypassed COVAX and made huge deals directly with manufacturers. They were very lucky that the vaccines worked out. And since they cleared the shelves, there were not enough doses left for COVAX”, he said.

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"The report of the Independent Panel for Pandemic Preparedness and Response also pointed to the harm caused by the slow mobilisation of resources for COVAX: “Had COVAX had sufficient and readily available early funding it would have been better able to secure enough immediate supply to meet its aims”, it states.

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"The original notion of a global vaccine hub more or less collapsed, and COVAX ended up using a traditional aid-financed approach, which has left lower-income countries wholly at the mercy of wealthy nations and profit-driven companies.

“It is still this model of seeing how much money you can bring in and then seeing what you can negotiate with industry based on that money”, said Elder. “The promise of COVAX from the beginning that it would be the most attractive buyer for industry because it represented the ‘global need’ obviously did not pan out.” For any future iterations of COVAX, Taylor has argued that since national leaders have a responsibility to protect their own populations, vaccine nationalism is inevitable and this should be integrated into the design from the start.

"Several global health experts point to the failure to recognise supply constraints as a major obstacle to global vaccination and emphasise diversifying and scaling up manufacturing from the beginning. This lack of recognition was a serious flaw in the COVAX design, said Gostin. “Supply shortages should have been anticipated and ramping up supplies should have been baked into the design of COVAX from the start.”