The COVID-19 pandemic laid bare brutal inequities in access to medical breakthroughs between Global North and South. A high-level panel debates how this can be changed.

In this session, the three co-hosts, namely the German Federal Ministry for Economic Development and Cooperation (BMZ), the Global Fund to fight AIDS, Tuberculosis and Malaria, and Gavi, The Vaccine Alliance, engaged in a lively debate on global health inequities with a government representative from Malawi and a civil society representative from Kenya. 

The discussion took place against the backdrop of a world still reeling from the unprecedented effects of the COVID-19 pandemic, where difficulties in ensuring a sufficient global supply of the life-saving new mRNA vaccines revealed the vulnerability of low- and lower middle-income countries. Rather than hastening to ‘turn the page’, the five panellists were in agreement that now is the time to shed light on what lessons can be learned from failures during the pandemic, to be better prepared in the future.  

The dangers of dependency

Most health commodities, technical innovations and vaccines are developed and produced in the Global North, obliging most low- and lower middle-income countries to import the products required to maintain a ‘modern’ standard for their healthcare systems. In 2021 only 1% of the vaccines needed in Africa were produced on the African continent. Low demand and high costs (including for imported ingredients) are constraints that discourage many African manufacturers from venturing into vaccine production.

The worldwide COVID crisis revealed the danger of this dependency, as Dr Githinji Gitahi of Kenya, Global CEO of Amref Health Africa, testifies: ‘My country borrowed US$ 150 million for vaccines, but they were not available….’

Malawi’s Minister of Health, Hon. Khumbize Kandodo Chiponda, shares her concern about health innovation inequities. While shecelebrates the rapid development of the COVID-19 vaccines, she is concerned that regional issues, such as a cholera outbreak extending to neighbouring countries, and national health issues such as an unexpected polio resurgence, have not received the same international attention. As a consequence, the development of vaccines for these diseases – which, in her view, could be game-changers – proceeds at a much slower pace. 

The challenge of communicating on an equal footing

Dr Githinji Gitahi pointed at African governments’ limited financial means for health and the low density of the continent’s health workforce as two of the factors contributing to the continent’s lack of access to important health innovations. This is compounded by the security of commodities (only 1% of commodities are manufactured in Africa, so availability is dependent on forecasting by actors outside the African continent). Another challenge for African stakeholders, however, is communicating on an equal footing with large international health initiatives such as Gavi and the Global Fund. Dr Githinji related his personal experience of moving from a sense of powerlessness through lack of control over the finances and the structures of power to increasing familiarity with global giants such as Gavi and PEPFAR the more he engages with them.  He addressed this sensitive topic with humour, eliciting laughter from spectators and panellists alike.

When we started talking about injustice, we were in a position of disempowerment. With Gavi and Global Fund, we’ve gone through a whole courtship process, now we are bonding, and I think we are moving to commitment – so our dating is going to a full marriage!

Dr Githinji Gitahi, Global CEO of Amref Health Africa (Kenya)

Germany’s focus: tackling the bottleneck of regional manufacturing capacity

Ariane Hildebrandt, Director General at BMZ, reacted to the inequities evoked by the previous speakers, reminding the panellists of Germany’s long-standing engagement for global health. Germany is a strong partner of the Global Fund and the third largest contributor to Gavi, The Vaccine Alliance, as well as being a founding member of the Pandemic Fund hosted by the World Bank. Germany is also a strong supporter of WHO’s Pandemic Agreement, which promises to be another important tool for worldwide coordination and greater equity in dealing with future pandemics.

These inequalities in diagnostics, vaccines and therapeutics must be addressed. The Pandemic Agreement must become a powerful legal tool – we must conclude this Agreement and regain lost trust in our partner countries.

Ariane Hildebrandt, Director General, BMZ

Since the pandemic, a major new focus of German support is on regional and local vaccine and pharmaceutical manufacturing in Africa, to reduce dependency on foreign sources of health commodities. Germany, as part of Team Europe, and in partnership with the African Union and several of its member states, has committed over EUR 550 million to supporting the African Union’s goal of expanding local vaccine production from currently only 1% to cover 60% of the African demand for vaccines by 2040. 

Ms. Hildebrandt explained that major facets of the support include workforce development (with an emphasis on gender equity) and capacity building for regulation authorities, to ensure high-quality products that will be trusted by African consumers. A challenge for African manufacturers is that, to be competitive, they require sufficient demand for their products. Therefore, Germany works closely with Gavi and the Global Fund, which are among the world’s biggest buyers of medical products, to shape global pharmaceutical markets, for instance supporting a new Gavi financing mechanism to improve the competitiveness of African manufacturers by initially paying higher prices to cushion the high costs of manufacturing in Africa.

The Global Fund’s focus: reducing costs and increasing access – not hoping for a ‘silver bullet’

Peter Sands, CEO of the Global Fund to Fight AIDS, Tuberculosis and Malaria, picked up on the topic of market shaping for health commodities. Last year alone, he explained, the Global Fund spent over US$ 2 billion on medical commodities, seeking as always, the best ‘value for money’: Reducing costs enables buying in greater volume, thus increasing accessibility of the product. The Fund has in some cases contributed to astronomical reductions in the cost of essential medical commodities, for instance for Anti-Retroviral (ARV) treatment for HIV patients:

This August we secured a 20% reduction in the price of ARV treatment, to US$ 45 per year – when you think that when the Fund was created, we were talking 10,000 a year.

Peter Sands, CEO, Global Fund

The Global Fund is now, like Germany, increasingly focussed on decentralising manufacturing, for instance planning tenders for African-based manufacturing of HIV diagnostics and potentially ARVs. It is careful to target areas where there is sustainable demand to reduce risks for the enterprises concerned.

But having the products is not enough, says Sands – the other challenge is getting them to the people who need them. Barriers to access increasingly include conflicts, as well as policies and laws that stigmatise the most vulnerable: ‘Even if the products and the health facility are there, patients don’t go, because they are afraid of being arrested.’ 

Concerning innovations in the fight against AIDS, Tuberculosis and Malaria, Sands cautions against hoping for a ‘silver bullet’ that will singly wipe out these tenacious diseases. He cites rather the relevance of more effectively using an array of existing and new tools. For combatting HIV, a choice tool is PrEP (pre-exposure ARV prophylaxis for seronegative at-risk people), another will be a vaginal ring dispensing an ARV to protect its wearer. For preventing malaria, in addition to the new vaccine, the Dual Active Ingredient Bednet will protect against mosquitoes that have become resistant to the insecticides used to date. The challenge, though, reminds Sands, is getting these new tools to those who need them.

Gavi, The Vaccine Alliance: partnering with countries to develop local markets

Marie-Ange Saraka-Yao, Managing Director for Resource Mobilization, Private Sector Partnerships and Innovative Finance at Gavi, The Vaccine Alliance, concurs with the preceding speakers that just as important as financing the products is developing good market conditions to stimulate local producers by reassuring them that there is a sustainable demand for their products. She compares vaccine manufacturing to the construction industry: very capital-intensive and subject to high scrutiny, e.g. for regulatory quality – authorisation is a complex and usually lengthy procedure. It is also essential to take measures to ensure consumer acceptance of locally produced vaccines and other medical commodities – all the more now that rumours easily run rampant on social media.

Due to its close partnership with individual countries, Gavi is well-placed to make prognoses on the demographic progression in a country and the consequent need for vaccines, factoring in the risk of an outbreak, so that in case of need the vaccines will already have been manufactured in the country or the region. Co-financing with countries is important for increased country ownership: For instance, over the last ten years Malawi’s share in financing vaccines with Gavi has risen from 8% to 41%.

Looking to the future, Marie-Ange Saraka-Yao notes an increased demand for vaccines that respond to the needs of specific regions and countries.

One of the things we learned during the pandemic is that while we worked a lot to create global markets, it didn’t work so well because borders were closed and restricted the ability of products to move. We now look to regional manufacturing because in a sense it’s about supply resilience. We also need to project ourselves and look at what type of new products we need.

Marie-Ange Saraka-Yao, Gavi

The call for new vaccines creates even more market opportunities and strengthens the business case for regional manufacturing. But, she cautions, one needs to assess the risk of investing in innovation. Regional manufacturing needs to be carefully engineered, since it means ‘plugging African manufacturers into a competitive global system.’ Gavi is therefore considering introducing a ten-year African Vaccine Manufacturing Accelerator to financially support the entry of competitive African products into the global market. ‘What you don’t want is to distort the market: For instance, the vaccine package for children recommended by WHO that we procure at Gavi costs US$ 24 versus 1300 in the US.’ 

A need to restore trust through authenticity and respectful partnerships

In a closing round, all panellists underlined the importance of working together. Marie-Ange Saraka-Yao of Gavi pointed out the need to share in at-risk financing to enable the development of future innovations. Peter Sands of the Global Fund emphasised the need for risk reduction – on the one hand for local manufacturers by streamlining regulatory approval mechanisms for new products, and on an international scale he evoked the need to keep an eye on the risk that accelerating scientific discoveries in medicine and in artificial intelligence could potentially pose for equitable access to these innovations. Malawi’s Minister of Health, Hon. Khumbize Kandodo Chiponda, strongly argued in favour of developing joint country health plans, with complementary roles for all partners, to reduce fragmentation and the skewed effects of vertical, partner-led programmes. Dr Githinji Gitahi of Amref underlined that ‘trust, authenticity and respectful partnerships’ are the foundation for collaboration between South and North. It must be ‘a collaborative effort to see that actually we can build this capacity for future together.’ 

Ariane Hildebrandt agreed, saying that the pandemic had made it clear to her that global challenges need joint solutions. ‘Before the backdrop of the ongoing crises in the world, all of us – government, civil society, private sector, multilateral and technical partners – can only make progress together.’

October 2023