How important is international cooperation in the vaccine rollout?

Early procurement and stockpiling of doses by wealthier countries has led to inequality in the vaccine rollout. International coordination and initiatives such as COVAX may offer a path to close the gap.

The development of several safe and effective vaccines has been key in the global fight against Covid-19. In many countries, it has reoriented policy towards medically-induced herd immunity and away from non-pharmaceutical interventions, such as lockdowns and social distancing measures. Many European countries have now wound down restrictions, as have Canada, South Korea, Chile and Israel. The results of these policy changes have been mixed.

But while many developed nations still have some restrictions in place, it is concerning that the policy debate appears to have focused on the pace of vaccine rollouts, and a ‘race’ between developed nations to be the first to vaccinate their populations. Covid-19 is a global problem, and while success stories such as that of Israel or the UK have raised hopes that the pandemic is in its last stages, the picture globally remains uncertain.

As has been highlighted throughout the pandemic, we are only as strong as the weakest link. Success at a global level depends on the efforts (or success) of those countries that do, or are able to do, the least (Barrett, 2007). For example, if all countries bar one eradicates a disease, then there is the potential for renewed spread from the one country where the disease persists to the rest of the world.

In an ideal world, global coordination across all stages of vaccine research, development and distribution might have overcome some these current challenges. Coordination helps ensure that resources are spread across many viable vaccine candidates, that production and supply chains run smoothly, and that competition for scarce vaccines does not leave any country without doses while others stockpile them.

It is worthwhile differentiating two possible views on the sharing of vaccines with lower- and middle-income countries by wealthier nations. In one view, the pandemic is an economic and health crisis that is local to different countries. Viewed this way, sharing vaccines becomes an extension of foreign aid – like that offered to countries experiencing famines, civil war or natural disasters.

The alternative view recognises the interconnected nature of the pandemic. Just like a national Covid-19 response must work to control the disease in each part of a country, a global strategy must ensure that each individual country effectively controls the local pandemic. Viewed this way, sharing vaccines with others becomes an act of self-interest.

Deaths from Covid-19 have been recorded in close to 200 countries. “A global pandemic,” Ursula von der Leyen, President of the European Commission, noted in a recent opinion piece, “requires a world effort to end it – none of us will be safe until everyone is safe”. While countries may recognise some of the national benefits from sharing vaccines internationally, this may still lead to insufficient sharing and coordination globally. This is because of the presence of positive externalities in the vaccine development and rollout process.

Are countries working together to deliver Covid-19 vaccines?

As a result, in addition to pragmatism, many argue that for both humanitarian and narrowly self-interested reasons, high income countries should assist lower- and middle-income countries.

Accordingly, governments in wealthy countries have made pledges to do so via several different routes, such as the COVAX facility or by uncoordinated direct assistance to specific countries, sometimes linked to the donor country by history or geography. For example, the UK has recently pledged to donate five million vaccine doses to COVAX and a further four million directly to specific Asian and Commonwealth nations.

How then, has the world fared in rolling out vaccines? Which countries are immunising their populations faster and are the vaccines shared across countries in an equitable manner? Figure 1 shows the relationship between GDP per capita (average income) and total vaccinations per capita on two dates: 1 March 2021 (early in the vaccine rollout) and 1 July 2021. As can be seen on the first panel of the graph, the rollout of vaccines was extremely unequal at the early stages.

It shows that the countries with the highest GDP per capita were often the most advanced in terms of delivering doses of the vaccine. If vaccines had been allocated without regard to income, then the observations on the plot would have been located within a tight vertical band. Instead, the data show that, overall, it is the relatively poor countries who experienced initial delays in rolling out the vaccine. As shown in a recent study, the speed of the vaccine drives seems not to have been related to the severity of the epidemic in the different countries. This suggests it can be explained in terms of availability and a country’s purchasing power rather than in terms of need (Auld and Toxvaerd, 2021).

The second panel of Figure 1 shows the same relationship in July 2021. Although the data show that the rollout is no longer limited to wealthy countries, the distribution is still unequal. In addition, these data mask the fact that many lower- and middle-income countries have been forced to rely on vaccines that have not been approved for use in wealthy countries, such as those in the European Union. For example, Peru has scrambled to source vaccines from several different suppliers, including Russia and China.

Figure 1: Vaccination rate versus GDP per capita, March 2021 and July 2021

Panel A: March 2021

Panel B: July 2021

Source: Our World in Data
Note: GDP in thousands of 2019 US dollars; blue lines show linear best fit

Could COVAX be the answer?

The Covid-19 Vaccines Global Access – or COVAX – was set up in April 2020, with the goal of providing equitable access to vaccines, by reducing ‘vaccine nationalism’ and encouraging countries to purchase their vaccines in partnership.

COVAX is jointly run by The Vaccine Alliance (GAVI), the Coalition for Epidemic Preparedness Innovations (CEPI) and the World Health Organization (WHO), and through donor funding can provide vaccines to 92 low- and lower-middle income countries. The aim is to provide enough vaccines for 20% of every country’s population by the end of 2021 and 30% in 2022. But as of 12 August 2021, only 1% of people in low-income countries had been vaccinated, compared with 57% in high income countries, 39% in upper middle-income and 21% in lower-income.

COVAX is currently failing to meet its targets for a combination of reasons. One is that many of the vaccines it has purchased – such as those manufactured in India– are subject to export bans, and so their supply has been heavily disrupted.

COVAX was set up partly because concentrating expertise in one procurer and market scales was thought to make negotiating easier: rather than 91 countries embarking on 91 separate negotiations it could be more efficient to centralise decisions and the expertise needed to carry them out.

For similar reasons, the African Union (AU) and the European Union (EU) have procured vaccines centrally, as have national governments that don’t usually do health procurement (such as the United States and Canada).

While most COVAX vaccines are now funded by the organisation itself, it has taken time to raise these funds. Initially, a $12 billion loan facility from the World Bank was created to allow countries to purchase vaccines from COVAX. This made it difficult for COVAX to negotiate agreements with companies, as it could not guarantee that countries would be willing to purchase the vaccines it was obtaining, and it did not have the funds to purchase the vaccines directly and then re-sell them.

In addition, the availability of vaccines has been limited by production bottlenecks and stockpiling by wealthier countries. While production short-falls have been widely reported and discussed in the media in the context of vaccine nationalism, much less is known about stockpiling – in part because governments have sought to keep such information out of the public eye.

Stockpiles can serve many purposes. First, some governments ‘bet early’ on several vaccine candidates and ensured ample supplies of multiple vaccines to increase the chances that at least one would be effective. When supplies of several vaccine candidates materialised, some countries (notably the United States) ended up with surplus vaccines.

Second, as the virus mutates, there is a possibility that some vaccines will offer more effective protection against new variants than others. So, having a stockpile of alternative vaccines may offer flexibility in the future, should it become necessarily to roll out alternatives. Finally, some countries may keep vaccines in reserve in case they are needed to provide booster vaccines at a later stage.

Stockpiling by wealthier nations has created anger and resentment in countries that are still not adequately covered by vaccines. Namibia and Kenya have called the current situation ‘vaccine apartheid’.

There was pressure to delay programmes in some countries to help those further behind. For example, the WHO urged the UK to pause vaccinations after the most vulnerable had been jabbed. It has been argued that it is immoral for wealthy countries to not only vaccinate their own populations first, but to also hamper the rollout in other countries by sitting on unused vaccine stockpiles.

This political pressure has led some governments to partially change course and offer a limited supply of vaccines from their reserves. The United States has shared surplus vaccines with India and the UK has been under pressure to offer vaccines surplus stocks to COVAX.

Despite pronouncements from leaders of wealthy nations on the importance of coordination and initiatives like COVAX, to date the global vaccine rollout has been unequal and driven by the needs and availability of vaccines in individual countries. A coherent global policy has not been at the forefront of decision making.

While it may be difficult now to undo the damage caused by this approach, there is hope that the reduced urgency in wealthier nations will allow politicians and policy-makers to refocus their efforts.