Where will poorer countries stand in the queue for a Covid-19 vaccine?

The lion’s share of the potential Pfizer vaccine is already claimed by high-income nations

The Sinovac vaccine factory in China, which has signed up to the Covax facility.
The Sinovac vaccine factory in China, which has signed up to the World Health Organization’s Covax facility. Photograph: Ng Han Guan/AP
The Sinovac vaccine factory in China, which has signed up to the World Health Organization’s Covax facility. Photograph: Ng Han Guan/AP

Last modified on Thu 12 Nov 2020 03.20 EST

The news that joint efforts by the US pharmaceutical company Pfizer and the German biotech company BioNtech have produced a vaccine that is 90% effective at protecting people from Covid-19 has been understandably applauded – in spite of the caveats. Pfizer states that it can manufacture up to 50m doses by the end of 2020 and up to 1.3bn doses in 2021.

Given the desire to get life back to normal, these doses will be in incredibly high demand. Some governments around the world, including the UK, have already begun to indicate to their populations that they will receive a vaccine by Christmas. But how will the distribution of this finite number of vaccines work when we only have enough for one seventh of the global population?

At least 500m doses of the vaccine have been reserved by high-income countries including the US, UK, Canada, Australia and the European Union, with the potential for this to rise to more than 1bn doses through advanced purchase agreements. These agreements work by countries paying to reserve doses at an agreed cost in an attempt to guarantee priority access.

During the 2009 “swine flu” pandemic, the use of these agreements was widespread to such a degree that the majority of vaccine manufacturers said they were unable to provide 10% of vaccine stock to United Nations agencies because of their pre-existing commitments to fulfil agreements with wealthy countries. In this sense, “vaccine nationalism” – the dynamic that we’ve seen in action this year, as nations pursue self-interest rather than the global common good – is not new.

Low- and middle-income countries have lobbied for equity in access to treatment and vaccines for years – they know well that the market-based agreements on which global health agreements rest favour governments with the largest pockets. This was most acutely seen over access to antiretroviral treatments for HIV in the 1990s, and the Indonesian viral sovereignty dispute of 2007.

The prospect of rich countries getting their hands on a vaccine first is always on the cards. That’s why the public-private health partnership GAVI, the CEPI foundation and the World Health Organization established Covax earlier this year. Covax was created to support an equitable distribution of a Covid-19 vaccine through pooled purchasing agreements, allowing all countries, regardless of means, to buy vaccines; it is funded both through direct purchasing from high-income countries and through overseas development assistance and philanthropic contributions.

Covax aims to procure sufficient vaccines so that participating countries can immunise at least 20% of their population. High-income countries contributing to Covax are doing so as an insurance policy if other commercial agreements they have in place do not come to fruition. Lower-income countries see Covax as a lifeline to be able to access any vaccines at all.

However, the promising Pfizer vaccine is not currently part of Covax (although there is an “an expression of interest for possible supply”). While GAVI has agreements for the supply of nine potential vaccine candidates, including the promising AstraZeneca/University of Oxford vaccine, the apparent success of the Pfizer vaccine raises deeper questions about how successful vaccines can be accessed by low- and middle-income countries.

Even if Covax were to negotiate with Pfizer now, it is not clear how much would be available for the rest of the world, given most of the potential supply is taken, or whether supply to wealthy countries with advance purchase agreements would be given priority.

Key questions remain: how will doses procured through advance-purchase agreements be allocated, who will get the first batches and how will the rest be shared? Might practical considerations such a country’s ability to provide an ultra-cold chain – a network of sub-zero refrigeration that ensures the vaccine doesn’t perish – affect considerations so doses are not wasted?

As wealthy countries scramble to the front of the queue, we need to be asking how Covax will ensure it can supply healthcare workers in the world’s poorest locations who are on the frontlines right now.

It is important not to forget that this vaccine is not the only one in the pipeline: there are 10 currently in phase 3 trials. Indeed, within 24 hours of the Pfizer announcement, the Russian government declared its Sputnik V vaccine to be also over 90% effective; China has similarly rolled out emergency-use vaccines of its leading candidates on a voluntary basis.

Some political commentary has cast this as a global race for a vaccine akin to the space race, but we need to move beyond these outdated cold war analogies. Firstly, such analysis misses the vital role being played by middle-income states in vaccine development: some of the leading biotech firms and manufacturing capacity are in Brazil and India. Secondly, there’s a difference between state-sponsored vaccine candidates (in Russia and China) and those of multinational corporations like Pfizer and AstraZeneca. Thirdly, the real race isn’t about who makes the vaccines, but who can access them once made.

Sadly, although the current pandemic has made the fact of our global interdependence clear to everyone, it appears that poorer populations continue to lose out.

  • Clare Wenham is assistant professor of global health policy at the LSE. Mark Eccleston-Turner is a lecturer in Global Health Law at Keele University

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