Strengthening Gavi is a way forward for global vaccine equity

The Biden administration’s upcoming Covid-19 summit will shine a spotlight on the global failure to achieve vaccine equity. Although nearly 12 billion doses of Covid-19 vaccines have been administered globally and 80% of people in high-income countries vaccinated, as I write this, in low-income countries, only 16% of people have received a vaccine.

Poor countries have been left behind for multiple reasons: Rich and vaccine-producing countries jumped the queue, the costs and challenges of vaccine delivery were vastly underestimated, international coordination failed, and more.

This is not the first time that a global effort to reach people equitably with vaccines has required a new way of doing business. A transformation that occurred more than 20 years ago gives hope that it can happen again.

In the late 1990s, the world was suffering from stagnating childhood immunization coverage, and new vaccines were not reaching low-income countries. The Global Alliance for Vaccines and Immunization (now known as Gavi, the Vaccine Alliance), was created to solve this problem. By purchasing vaccines on behalf of all low-income countries, Gavi addressed the needs of countries by negotiating lower prices and also offered opportunities for pharmaceutical companies because bulk orders offered predictable business and economies of scale. (Full disclosure: I worked for Gavi from 2007 to 2014 and served on its evaluation advisory committee from 2019 to 2021, but have no current engagement with the organization.)

Based on Gavi’s phenomenal success in reaching more than 900 million children with vaccines against multiple disease and raising more than $21 billion for routine childhood immunization since is its launch in 2000, the world assumed that the same model could be applied when Covid-19 emerged. Gavi, together with the World Health Organization and the Coalition for Epidemic Preparedness Innovations (CEPI), co-launched COVAX, a global initiative to supply Covid-19 vaccines to low-income countries in April 2020, just months after the pandemic emerged and well before the first vaccines were developed. But the model has proved woefully inadequate for the challenges at hand.

Beyond bulk procurement and limited advance payment for companies, COVAX offered no solutions to the reality that as with most vaccines, the production and supply is centered in just a few countries. Manufacturers made profits a priority by selling at the highest prices to the countries in which they are based, and some governments imposed export bans. COVAX also vastly underestimated the delivery costs and logistical challenges of reaching 70% of the population in every country, and catch-up efforts have been too little and too late.

These challenges were foreshadowed years earlier, when the global introduction of human papillomavirus (HPV) vaccines to prevent cervical cancer stumbled. As would happen with Covid-19 vaccines, countries were unprepared to meet the delivery challenges for HPV vaccines. And despite promises to supply vaccines to low-income countries, pharmaceutical companies prioritized sales to rich countries, leaving poor ones without vaccines.

Instead of pointing fingers, the world has the opportunity to learn from the successes in childhood vaccination and the failures of Covid-19 to design a new way forward for vaccine procurement and delivery.

First and foremost, it is time for a new global contract with the pharmaceutical companies that make vaccines. Instead of just agreeing to buy large quantities of vaccines to be distributed in low-income countries, Gavi and others should also insist that equity provisions be written into procurement contracts with product innovators. These would include commitments to sharing intellectual property, technology, and vaccine manufacturing knowledge, and support for training manufacturers in nascent vaccine-producing regions in areas that include vaccine production, quality assurance, and regulatory affairs.

While there have been some reports of production collaboration on Covid-19 vaccines — for example Pfizer/BioNTech in South Africa and in Brazil, Moderna in Kenya, and J&J in South Africa — the details are hazy. Working in partnership with the African Union and others, much more can be done by countries and international agencies procuring vaccines to encourage manufacturers to increase transparency on production and prioritize low-income countries in the distribution queue. These changes are about shifting away from a model of providing charity to countries and instead helping them become self-reliant.

Second, doubling down on vaccine delivery is essential. Before Covid-19, most vaccine delivery was focused on children. This pandemic has made it clear that the world needs systems ready to reach entire populations. The pandemic also hammered home the long-ignored message that structural determinants like race, gender, and economic status, among others, affect whether people have access to and accept vaccination. It’s not enough to adequately finance vaccine delivery programs — they must be driven by the people they aim to serve.

Even before the Covid-19 pandemic, many countries faced challenges in reaching every child with routine vaccines. Reaching so-called “zero dose” children, who have never received any vaccine, requires engaging communities, in particular the women who are most often responsible for day-to-day care of children. It also requires gender- and rights-based programming and reporting that hold governments accountable for the coverage targets they set. Reporting data broken down by sex, for example, should be a non-negotiable condition for a country to receive global vaccination financing.

Third, the composition of decision-making structures must be rebalanced to give more weight to voices from low-income countries and the Global South and support the development of local innovations, partnerships, and solutions. As an alliance, Gavi already brings together in one boardroom representatives from various countries; donors; manufacturers; non-state actors like community groups, nongovernmental organizations, faith-based organizations, and the like; and the U.N. system. But once there, opinions are not considered equally.

The story that COVAX was conceived in a bar in Davos, Switzerland, is a frightening example of how decision-making in global health is often concentrated in elite settings. Important stakeholders, including the Africa CDC, were noticeably missing in the early days of COVAX, and questioning voices of community organizations were silenced. Ensuring greater representation of regional and community organizations in vaccination programs and policy decision-making can begin to shift power away from Geneva and toward the Global South.

While the global Covid-19 summit will not solve these problems, it stands as a reminder of the urgency to act boldly. The world is in crisis. There is war in Europe exacerbating a global food shortage, nearly one-third of the world’s residents are completely unvaccinated against Covid, and 23 million children have missed out on basic vaccines because of the pandemic. The global conversation needs to shift from one-off commitments to new ways of doing business.

Omicron will not be the last Covid-19 variant. Another mystery disease will someday emerge. Gavi has a key role to play in pandemic-proofing countries around the world and can lead the way on holding industry to account, staying ahead of the curve on delivery, and empowering stakeholders from the Global South. Leveraging its power and influence as an alliance and building on lessons learned, Gavi can get global vaccination back on track while shaping a new model to enable equitable global vaccination.

Nina Schwalbe is a principal visiting fellow at the United Nations University International Institute for Global Health, an adjunct assistant professor of population and family health at Columbia University’s Mailman School of Public Health, and the former director of USAID’s Covid-19 Vaccine Access and Delivery Initiative, which is responsible for executing the Biden administration’s donation of 1 billion vaccines to COVAX. She was managing director for policy and performance at Gavi from 2007 to 2014 and a member of its evaluation advisory committee, which helps the board fulfill its responsibilities regarding the oversight of Gavi’s organizational and programmatic evaluation activities, from 2017 to 2021.