Co-chairs Dr Caroline Schmutte, Head of European Government Relations at Wellcome Trust, and Elhadj Al Sy, Chair of the Board of the Kofi Annan Foundation, facilitated a thought-provoking discussion on vaccine equity, with senior representatives from GAVI, the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), the Coalition for Epidemic Preparedness Innovations (CEPI), and the governments of Ethiopia and Germany. Inviting panellists to critically review the pandemic response to date, Mr Al Sy asked: ‘Have we passed the test of preparedness? Have we passed the test of delivering for people? Have we passed the test of equity? Have we passed the test of solidarity?’

First targets have been missed

The international community has signed up to ambitious global vaccination coverage targets of 40% of every country, economy and territory by the end of this year and 70% by mid 2022. The first of these targets – 10% coverage by the end of September – has already been missed. Thirty of the world’s poorest countries have fully vaccinated only approximately 2% of their populations, while 90% of vaccine doses are going to just 10% of countries. These statistics lay bare the high degree of vaccine inequity. The slow rate of vaccination rollout in poorer countries leaves them vulnerable to new COVID-19 variants and successive waves of the virus, as well as slower recovery, with far-reaching effects for their societies and economies. So what has gone right and what has gone wrong? And how can the world get back on track? 

And yet: From zero to 25 vaccines in under two years

CEO of GAVI, Dr Seth Berkley reminded everyone that we have come a long way in a very short space of time, ‘When we set up COVAX, we had no idea whether any of these vaccines was going to work. Was it even possible to have a vaccine? It took just 327 days for the first vaccine to be developed and used in a patient off clinical trial, and now we have 25 vaccines in use’. Furthermore, the first COVAX vaccine was delivered just 39 days after the original injection in a high-income country. Although there have been obstacles in the development and approval of some of the vaccines which COVAX invested in early on, the focus on building a broad and diverse portfolio is now showing results – COVAX has a portfolio of 11 approved vaccines, making it the largest in the world. 

Broken commitments and promises

So what went wrong after this promising start? Few would say that COVAX has not been without its challenges. Vaccine manufacturers supplying COVAX have repeatedly downgraded delivery timelines, trade restrictions have halted the export of vaccines to COVAX by major suppliers, and rich countries have simply failed to honour their commitments. Of 1.3 billion doses promised to COVAX, only 150 million have been delivered so far.

And CEPI – the global partnership for vaccine development launched in 2017 – has faced its own challenges, as described by Jane Halton, Chair of the CEPI board, who called in particular for increased transparency in vaccine contract negotiations and improvements in the predictability of vaccine supplies. She said, ‘we have to be able to translate our investments in research, first into the rights to purchase those vaccines and then on to more equitable distribution’.

Moving from vaccine shortages to inequitable distribution

Thomas Cueni, Director General of IFPMA, explained that the situation has shifted from what he calls ‘the big shortage problem’ – referring to challenges with the supply of raw materials, trade barriers and the like – to one of over supply and inequitable distribution. There are now around 1.2 billion excess doses in the world and the real problem is that these excess vaccines are not reaching countries and peoples who need them most. Dr Berkley highlighted significant difficulties in getting vaccines to stateless people and those living in refugee camps and conflict zones, who are missing from national vaccination plans. 

Hoarding of vaccines by countries is a particularly thorny issue. Mr Al Sy put his finger in the wound when he said, ‘we are seeing irrational behaviours with boosters and hoarding of vaccines – what we call vaccine nationalism, which is too polite a way to describe these behaviours that have such far-reaching consequences’. 

When very few doses arrive, this leads to erosion of trust

Not only do such behaviours deprive poorer countries of the vaccines they need, they also bolster anti-vaccination campaigns. Her Excellency Dr Lia Tadesse Gebremedhin, Ethiopia’s Minister of Health, explained how receiving fewer doses than had been promised has had a critical impact on people’s motivation to be vaccinated. Ethiopia, which has administered just over four million doses at the time of writing, had hoped to fully vaccinate at least 20% of its 118 million citizens by now. She said ‘when very few doses arrive and the demand is very high, this leads to frustrations and erosion of trust – it is very challenging to maintain the momentum of the campaign’.

So, what will it take to strengthen vaccine equity?

Before turning to Prof Dr Lars-Hendrik Röller, Director General for Economic and Financial Policy in Germany’s Federal Chancellery, Mr Al Sy saluted the leadership of Chancellor Merkel and Germany’s contributions to the key institutions and partnerships for fighting the pandemic. He asked Prof Röller – from a political perspective – what the G20 and Germany’s incoming new government can do to ensure a more equitable access to vaccines in the very near future. 

 Prof Röller, who is attending the G20 meeting in Rome this week, raised three issues. Firstly, the need to maintain health at the very heart of political discourse –something which Germany has always pushed hard for, even in the face of opposition from other leaders during Germany’s G20 presidency. Secondly, the need to follow through on promises made by the G7, for example regarding the sharing of doses and financial compensation to COVAX and ACT-A, which works to accelerate development, production, and equitable access to Covid-19 tests, treatments, and vaccines. 

And thirdly, the need for successful negotiations at the G20 meeting where the two main issues on the agenda are climate finance and health. Prof Röller said, “On both of these issues, the world will be looking towards Rome and thinking how we can bridge the equity gap. Localised production, trade restrictions, following through on commitments – in short, all the things we are discussing today will be smack in the middle of the G20 discussions.”

Investing in more resilient national health systems

Mr Al Sy then asked Dr Tadesse what countries like Ethiopia can do themselves to ensure that vaccines get to those who need them most. Dr Tadesse highlighted three key requirements that will resonate with many countries: the need for more robust leadership and political commitment; advocacy to counteract vaccine hesitancy; and, investing in more resilient health systems. While poor predictability of vaccine deliveries and short vaccine shelf lives complicate the logistics of distribution in a country as large and diverse as Ethiopia, there are also considerable challenges in the underlying health system. Inequitable access to broader health services, problems in the supply chain and poor quality data are just a few of the challenges which contribute to a situation where not all of the doses that arrive in country get into people’s arms. Investing to strengthen health systems now will have long-term benefits post-covid.

Boosting local manufacturing capacities and more equal partnerships

In the long-term, panellists all agreed on the need to strengthen local vaccine manufacturing capacities, particularly in Africa. And while local production is key, a more equitable ownership of that production is also critical for the development of sustainable and resilient systems to fight the next pandemic. And as Ms Halton emphasised, equity needs to be embedded from the very start of a pandemic response and not addressed once the problem becomes visible. This requires more upfront investment by richer countries.

From inequity and egoism to effective partnerships and collaboration

As Germany looks towards 2022 and the G7 leadership, Mr Al Sy skilfully summed up everyone’s thoughts when he said ‘these shocks, hazards and pandemics reveal many things about us. They reveal the worst in us – the exclusion, the nationalism and egoism, the inequalities that we have been discussing all morning. But, importantly, they also reveal the best in us – partnership, and sharing of knowledge, resources and information, and sometimes even of power. Our wish is that the best in us can prevail over the worst in us.’

Corinne Grainger, October 2021