As the board of Gavi, The Vaccine Alliance is set to meet this Wednesday and Thursday, the COVAX global vaccine facility – a cornerstone of the global health sector response on vaccine access – is coming under increased fire for its shortcomings.

A bitter opinion piece by Médecins Sans Frontières, published today, has called for a “drastic change of model” in the global procurement mechanism “that was supposed to deliver COVID-19 vaccine equity.”

Co-launched by a range of partners, including WHO, the COVAX facility is legally administered by GAVI. What started out with a much-trumpeted bang of vaccine distributions across African nations has fizzled after the primary vaccine supplier, the Serum Institute of India, began redirecting its available COVID doses to domestic vaccine needs.

Massive commitments by rich countries for further vaccine sharing, made at the recent G-7 meeting, are supposed to be funnelled through COVAX. Yet most of those donations will likely only be realized in the latter part of 2021 or early 2022, leaving the current shortfalls over the summer, as Africa faces yet another COVID wave.

“COVAX is currently grossly behind on achieving its goals,” said MSF’s Katie Elder, senior vaccines policy advisor. “COVAX had aimed to provide 2 billion doses by the end of 2021, but so far has only distributed 88 million (the goal by the end of June was to distribute around 337 million). Less than half of one percent of total populations of COVAX countries have received at least a first dose of vaccine through COVAX.”

She blames the fundamental model of the facility – in which it has been forced to compete on the open market for COVID vaccines – which were still often subsidized by public and government players – for the failings.

Not Set Up to Succeed

“COVAX was not set up to succeed,” she said. “It was constructed to work within the current parameters of the pharmaceutical market, where you see how much money you can raise and then see what you can negotiate with industry for it. 

“Loud calls early in the pandemic to depart from a business as usual approach were ignored—pharmaceutical corporations developing vaccines received billions in government money without any strings attached, so were free to charge prices they chose and to sell to the highest bidder. Unsurprisingly, this led to the very same governments that had touted the importance of equity …. and the governments that Gavi spent so much time courting to join the COVAX Facility – ultimately pursuing national interests and securing the bulk of future promised vaccines.

“COVAX was left behind as wealthy governments secured their doses through bilateral deals with an industry that acted as expected: selling doses first to the buyers who could afford to pay the most.”

The net result now leaves the Gavi Board struggling with how to continue the participation of upper income countries in the facility at all.

“The fact that Gavi’s board is now reviewing the way in which wealthier countries (so called ‘Self-financing participants’) can continue to participate in the facility is in part a recognition that the set up does not work,” she added. “Allowing wealthy countries so much flexibility to decide how they join COVAX and how many vaccines they procure, has caused delays and undermined its objectives. A more equitable model would have encouraged regional leadership with decentralized methods of procurement at their core. In the future, we must support these regional initiatives that aim for self-sufficiency and self-determination.”

A Beautiful idea: How the COVAX has Fallen Short

The result has been an awkward legal situation for the facility which is still required to provide 20% of its doses for higher income countries – even though most have now met their vaccine needs and hoarded even more, notably Canada, which bought enough vaccine doses to cover its population four times over.

“The failure to entice wealthy countries to join COVAX in large numbers has left the managers of the facility in an awkward situation,” said global health journalist Ann Aanaiya Usher in a critique published by The Lancet.

“On one hand, not enough self-financing participants joined COVAX to give it the massive buying power that was hoped. On the other, even though COVAX is desperately short of vaccines, the facility is now contractually obliged to reserve one in five doses for a few rich countries, she said, adding that so far, COVAX has distributed 80 million doses to LMICs and over 20 million doses to high-income countries (HICs), including the UK and Canada.

She slams the COVAX facility for its “naive” set-up that failed to anticipate widespread vaccine nationalism that has locked up most of the vaccine doses that are available. 

“It was a beautiful idea, born out of solidarity”, Duke University’s Gavin Yamey was quoted as saying. “Unfortunately, it didn’t happen…Rich countries behaved worse than anyone’s worst nightmares.”

COVAX should have also diversified its portfolio earlier on, in anticipation of supply shortages that crippled the facility after India’s Serum Institute halted vaccine exports to fend off a tragic second wave on the subcontinent that has claimed the lives of almost 400,000 people.  

“Supply shortages should have been anticipated and ramping up supplies should have been baked into the design of COVAX from the start,” observed Georgetown University’s Lawrence Gostin.

He added, however, that it would be “literally impossible” to ramp up vaccine supplies without greater investments in manufacturing hubs in lower-income countries, as well as broad waiver on intellectual property rights to vaccine know-how. 

In its struggle to get rich countries to sign up, the COVAX facility’s offer to allow rich countries to choose which vaccines they would receive has also drawn widespread criticism for leading to “double standards” – which seemingly defy the very purpose of the facility, critics have said.

A beautiful idea: how COVAX has fallen short https://t.co/QpG6o5zbqt This is the most complete & readable analysis of COVAX I have seen. The title says it all. COVAX was a beautiful idea & we must make it better & permanent

— Lawrence Gostin (@LawrenceGostin) June 18, 2021

Facility Needs Equity Funds to Compete in the Marketplace

Even Gavi, the Vaccine Alliance, has acknowledged that its slow mobilization of resources has hampered its ability to quickly procure, and thus deliver as many doses as possible to those who need them most. 

“If we had secured financing earlier, then we could have locked in doses earlier, as opposed to the second half of this year when COVAX’s volume will start ramping up,” a Gavi spokesperson said. The spokesperson was referring to the fact that most of the funds to procure and distribute vaccines for the 92 low- and middle-income countries (LMICs) that signed up for the scheme were pledged in late December or early 2021 – after high-income countries had already snapped up large vaccine pre-orders.   

That is a point of view shared by some independent observers as well as industry leaders, who maintain that the facility needs fine-tuning for the next pandemic. 

“Had COVAX had sufficient and readily available early funding it would have been better able to secure enough immediate supply to meet its aim,” said the Independent Panel for Pandemic Preparedness said, which reviewed the global pandemic response, under a mandate from the World Health Organization. 

Going forward, what COVAX needs is a “pot of money” to be able to pre-order vaccine doses earlier on in a global health emergency, said Thomas Cueni, director general of the International Federation of Pharmaceutical Manufacturers and Associations, in a recent Q&A with Health Policy Watch. That, he maintains, would allow the global facility to compete on a more equal footing with rich countries in the vaccines marketplace.  

Added Peter Hotez, a prominent vaccine scientist and dean at Baylor College of Medicine in Texas: “I think it’s important that we don’t sell COVAX short.  It still has a lot going for it, and is innovative in its design. But it needs more vaccines to share,”

Asked for comment by Health Policy Watch, GAVI did not respond.

Image Credits: UNICEF, WHO, WHO.