As of early July 2021, over 181 million cases of COVID-19 and over 3.9 million deaths have been reported globally, Sharma K, Koirala A et al 2021 reported. The impacts of the pandemic have been felt unequally around the world, with varying public health strategies leading to different epidemic trajectories. Many countries are struggling with successive waves of COVID-19, and the goal of global elimination of SARS-CoV-2 has been abandoned and replaced with that of transition to endemicity. A year ago, over 100 COVID-19 vaccines were under development, but none were approved for use, it has been reported in many different platforms. Within 12 months several highly effective COVID-19 vaccines have achieved widespread use with over 3.04 billion doses administered, although unfortunately not equitably distributed. Of the global population, 23.4% have received at least one dose of a COVID-19 vaccine while only 0.9% of people in low-income countries have done so, see Sharma K, Koirata A et al 2021. There are currently 105 COVID-19 vaccines in clinical trials, and 184 in pre-clinical development.
It is evident from the global covid-19 vaccine roll out has led to inequity thus signalling a wakeup call especially in Africa, more so with faced with the high burden of infectious diseases, weak health systems and poverty are some major factors which particularly make the continent one of the most vulnerable to this current pandemic. There are growing concerns that shortages in many African countries are holding back the continuity rollout of their vaccination programmes which has come mainly as a result if vaccine nationalism leading to its dependency through vaccine diplomacy.
The World Health Organisation have also acknowledged that a large number of poorer countries relying on the global vaccine sharing scheme COVAX do not have enough doses to continue vaccinating. The UN and the Africa Centre for Disease (CDC) have already urged countries with surplus supplies to donate them to parts of Africa where they are needed. Most African countries got their vaccines under the COVAX scheme, and these were largely sourced from the Serum Institute India. However, India halted vaccine exports in response to its own needs and manufactures faced issues with ramping up production in a short space of time. Botswana started the vaccination rollout with its “Arm ready” campaign on 26th March 2021 with the first doses from covishield known as AstraZeneca. Botswana has to date received a consignment of 19890 doses of PFIZER covid-19 vaccines procured by government through the COVAX facility. This was after the country received 30 000 doses in March 9, 2021, from Serum Institute of India the largest vaccine manufacturer in the world. Moreover, the country received its second batch of Astra Zeneca / Oxford manufactured in South Korea through the COVAX initiative on March 28th, 2021, it has been reported.
The inequity in the global vaccine roll out and the COVAX facility has led to heated debates and exchanges leading to some even suggesting that COVAX facility was a global health scam. For instance, in challenging Ann Usher’s inaccuracies that COVAX Facility was a hoax and that it was a ship that was being built as it set sail, Chief Executive of GAVI Alliance, Seth Berkley stated that “Usher wholly missed the point by submitting his claim that it was a ship that is still sailing”. According to Berkley despite the challenges, COVAX is still more or less on track to deliver on its original promise by shipping 2·2 billion doses of COVID-19 vaccines by January 2022. Berkley noted that this delivery will go a long way towards starting to address the appalling global inequities in COVID-19 vaccine distribution that we are currently witnessing. The point is that this grim scenario according to Berkley would not only be considerably worse without COVAX but would most likely persist.
Berkley further challenged Usher by stating It was also inaccurate for him to suggest that COVAX failed to anticipate the initial supply constraints of COVID-19 vaccines, however, on the contrary, this inevitability is one of the reasons COVAX was created submitted Berkley. Furthermore, Berkley presented that contrary to claims submitted that time was lost negotiating with wealthy nations; this was however not the case, rather this was necessary to build a consensus for global and equitable supply, and to raise the funds needed to secure doses argued Berkley. According to Berkeley, the principal reason they faced were as a result of the initial delays due to the early supply being bought by a small group of wealthy countries and the unfortunate epidemiological situation in India and its effect on one of our largest early suppliers.
In supporting his submissions, Berkeley noted that the meaning of equitable access appears to be misunderstood and submitted claims that the vast majority of COVAX doses will go to low- income countries, with the rest largely going to self-financing upper-middle- income countries, and a small amount to some high-income countries too. These wealthier nations can afford to pay, but, like low-income countries, they would still struggle to get doses without COVAX. This has become a subject of debate.
But what really is the COVAX Facility?
COVAX Facility was launched in 2020 and was conceived as an “unparalleled and ambitious” attempt to create a global procurement mechanism to supply COVID-19 vaccines to all countries in the world. At the time of its inception COVAX was considered a beautiful idea, born out of solidarity. “Unfortunately, it didn’t happen…Rich countries behaved worse than anyone’s worst nightmares, noted Usher. COVAX, managed by Gavi, along with the Coalition for Epidemic Preparedness Innovations (CEPI) and WHO, was designed to stand on two legs, one for High Income Countries 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, High Income Countries (HIC) according to the literature, 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, (Lancet, 2021). 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 according to the literature is that it 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, (Lancet, 21).
The expectation was such that COVAX would be “quite literally a lifeline” for self-financing countries that had not made any bilateral deals with vaccine manufacturers, according to Seth Berkley. However, this was not the case, for instance by August 2020, the USA had already entered seven bilateral deals with six companies for more than 800 million doses, enough to vaccinate 140% of its population. The United States thus became a key player in the Covid-19 vaccine manufacturing race. It awarded pharmaceutical company Astra Zaneca $1 billion to develop an adenovirus vaccine through a partnership between Astra Zaneca and the University of Oxford.
During the Covid-19 Pandemic, GAVI entered into procurement agreement reserving vaccine doses to populations in both developing and developed countries. It did so through the formation of the Covid-19 Vaccine Global Access Facility (COVAX), which in addition to procurement mechanism, functions as a resource pooling, risk sharing & push financing on a nearly global level. COVAX is integrated into a broader structure in which CEPI and WHO play separate but complementary roles. This structure is known as the vaccine pillar of the Access to COVID-19 Tools (ACT) Accelerator. The vaccine pillar is divided into three work streams, CEPI whose role is the coordination of vaccine development and manufacturing, the WHO oversees policy and allocation issues and GAVI is responsible for procurement and delivery scale, (GAVI, Briefing on the COVAX Facility). COVAX is housed under GAVI’s workstream
Initially, all countries were to receive equal treatment by COVAX. They would have access to vaccines at the same time and participants would be allowed to purchase enough doses to cover 20% of their populations. As to whether COVAX is a beautiful idea, the situation on the ground speaks to the contrary leading to anxiety, high mortality rates and at times just mere state of confusion in Africa.
Thabo Lucas Seleke is a Researcher & Scholar, Global Health Policy (LSHTM)
