Equitable access to COVID-19 vaccines: cooperation around research and production capacity is critical

David G Legge and Sun Kim

The COVID-19 pandemic has devastated families and communities and disrupted society and the economy; it has caused over 1 million deaths globally and left a disturbing burden of chronic morbidity. The prompt availability of effective and affordable vaccines against the SARS-2-coronavirus offers the most promising path out of the disease and disruption that the pandemic has wrought.

From the beginning the WHO Director General was emphasising ‘solidarity’ as the key to the global response. Solidarity was reflected in the early publication of the genome sequence and the sharing of protocols for the nucleic acid test. However, the proposal that vaccine technologies be pooled to accelerate vaccine development and production was a step too far for pharma and its nation state sponsors.

WHO’s proposed ‘solidarity vaccine trial’ which would yield comparative data about efficacy, safety and cost was likewise boycotted by pharma. From late March negotiations toward global cooperation for diagnostics, medicines and vaccines moved from WHO to the G20 sponsored ‘Access to COVID-19 Tools Accelerator’, a new ‘multi-stakeholder public private partnership’. The ‘vaccine arm’ of the Accelerator was the Covax Facility which would enter into advanced purchase commitments for selected candidate vaccines for participating countries. Covax also provided for the mobilising of donor funds to pay for vaccine supplies for low and lower middle income countries. Covax was designed to deliver vaccines for the priority fraction of countries’ populations (up to 20%). After this, countries would return to bilateral purchasing in the open market.

By July however, it was becoming clear that massive bilateral advanced purchase agreements, in particular, by the US, UK and EU, would reserve most of the early supply of effective vaccines and jeopardise the fund-raising for Covax. The rejection of technology pooling, the rise of ‘vaccine nationalism’, and the underfunding (and under-supply) of Covax all look set to produce highly inequitable outcomes in terms of access to vaccination, particularly during the first year or so after the first vaccine is approved.

Drawing on a review of access-to-medicines debates over the last two decades, an analysis of the evolving business model of transnational pharma, and taking into account the rising call for universal health cover, we propose a policy platform to promote a more equitable roll out of vaccines in the context of the COVID-19 pandemic.

Core elements of such a platform include:

• Full funding of the concessional component of Covax;
• Rapid expansion of local production of vaccines in low and middle income countries (L&MICs) supported by an organised program of technology transfer as appropriate;
• An immediate waiver of key provisions of the TRIPS Agreement to facilitate access to intellectual property and technical knowhow necessary for vaccine development and production;
• Full transparency regarding key aspects of vaccine development and production, including clinical trial data, production costs, and patent and market approval status; and
• A moratorium on national debt servicing and repayment for highly indebted L&MICs.

Policy initiatives directed at a more equitable and efficient response to the next pandemic need to be put in place now, including:

• Scaling up public sector innovation and manufacturing capacity in L&MICs;
• Regional and plurilateral agreements on biopharmaceutical technology transfer and capacity building;
• Reforming the TRIPS Agreement to facilitate technology pooling in future pandemic emergencies;
• Reforming the International Health Regulations to give WHO the power to trigger mandatory technology pooling and mandatory participation in comparative clinical trials (‘Solidarity trials’) in pandemic emergencies; and
• Continued mobilisation around delinking and the creation of a global research and development treaty.

Critical to achieving progress in the implementation of this platform will be:

• Institutional reform at the national level including legislation for the full deployment of TRIPS flexibilities and for the imposition of conditionalities on public funding of research (open licensing) and the funding of private pharma (transparency);
• Protection of the multilateral member-state fora such the UN and the WHO where L&MIC voices can be heard and which can provide leadership in institutional reform; and
• Community mobilization around single payer UHC and equitable access to affordable, effective medicines and vaccines.

Keywords

COVID-19, Access to COVID-19 Tools Accelerator (ACT-A), Covax, vaccines, vaccine development, vaccine production, equity, access, TRIPS Agreement, compulsory licensing, Solidarity Clinical Trials, universal health cover (UHC), pharmaceutical industry, COVID-19 Technology Access Pool (C-TAP).