Policy Points Equitable access to a COVID-19 vaccine in all countries remains a key policy objective, but experience of previous pandemics suggests access will be limited in developing countries, despite the rapid development of three successful vaccine candidates. The COVAX Facility seeks to address this important issue, but the prevalence of vaccine nationalism threatens to limit the ability of the facility to meet both its funding targets and its ambitious goals for vaccine procurement. A failure to adequately address the underlying lack of infrastructure in developing countries threatens to further limit the success of the COVAX Facility. Context Significant effort has been directed toward developing a COVID-19 vaccine, which is viewed as the route out of the pandemic. Much of this effort has coalesced around COVAX, the multilateral initiative aimed at accelerating the development of COVID-19 vaccines, and ensuring they are equitably available in low- and middle-income countries (LMICs). This paper represents the first significant analysis of COVAX, and the extent to which it can be said to have successfully met these aims. Methods This paper draws on the publicly available policy documents made available by the COVAX initiatives, as well as position papers and public statements from governments around the world with respect to COVID-19 vaccines and equitable access. We analyze the academic literature regarding access to vaccines during the H1N1 pandemic. Finally, we consider the WHO Global Allocation System, and its principles, which are intended to guide COVAX vaccine deployment. Findings We argue that the funding mechanism deployed by the COVAX Pillar appears to be effective at fostering at-risk investments in research and development and the production of doses in advance of confirmation of clinical efficacy, but caution that this represents a win-win situation for vaccine manufacturers, providing them with opportunity to benefit regardless of whether their vaccine candidate ever goes on to gain regulatory approval. We also argue that the success of the COVAX Facility with respect to equitable access to vaccine is likely to be limited, primarily as a result of the prevalence of vaccine nationalism, whereby countries adopt policies which heavily prioritize their own public health needs at the expense of others. Conclusions Current efforts through COVAX have greatly accelerated the development of vaccines against COVID-19, but these benefits are unlikely to flow to LMICs, largely due to the threat of vaccine nationalism.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/1468-0009.12503

International Collaboration to Ensure Equitable Access to Vaccines for COVID-19: The ACT-Accelerator and the COVAX Facility.

Global COVID-19 vaccine inequity: The scope, the impact, and the challenges.

The development of COVID-19 vaccines does not imply the end of the global pandemic as now countries have to purchase enough COVID-19 vaccine doses and work towards their successful rollout. Vaccination across the world has progressed slowly in all, but a few high-income countries (HICs) as governments learn how to vaccinate their entire populations amidst a pandemic. Most low- and middle-income countries (LMICs) have been relying on the COVID-19 Vaccines Global Access (COVAX) Facility to obtain vaccines. COVAX aims to provide these countries with enough doses to vaccinate 20% of their populations. LMICs will likely encounter additional barriers and challenges rolling out vaccines compared HICs despite their significant experience from the Expanded Programme on Immunisation (EPI). This study explores potential barriers that will arise during the COVID-19 vaccine rollout in lower-middle-income countries and how to overcome them. We conducted sixteen semi-structured interviews with national-level stakeholders from Ghana and Bangladesh (eight in each country). Stakeholders included policymakers and immunisation programme experts. Data were analysed using a Framework Analysis technique. Stakeholders believed their country could use existing EPI structures for the COVID-19 vaccine rollout despite existing challenges with the EPI and despite its focus on childhood immunisation rather than vaccinating the entire population over a short period of time. Stakeholders suggested increasing confidence in the vaccine through community influencers and by utilising local government accredited institutions such as the Drug Authorities for vaccine approval. Additional strategies they discussed included training more health providers and recruiting volunteers to increase vaccination speed, expanding government budgets for COVID-19 vaccine purchase and delivery, and exploring other financing opportunities to address in-country vaccine shortages. Stakeholders also believed that LMICs may encounter challenges complying with priority lists. Our findings suggest that COVID-19 vaccination is different from previous vaccination programs, and therefore, policymakers have to expand the EPI structure and also take a systematic and collaborative approach to plan and effectively rollout the vaccines.

/pdf/covid-19-vaccination-in-lower-middle-income-countries-3208tus6av.pdf

COVID-19 Vaccination in Lower-Middle Income Countries: National Stakeholder Views on Challenges, Barriers, and Potential Solutions.

There is growing need for a safe, efficient, specific and non-pathogenic means for delivery of gene therapy materials. Nanomaterials for nucleic acid delivery offer an unprecedented opportunity to overcome these drawbacks; owing to their tunability with diverse physico-chemical properties, they can readily be functionalized with any type of biomolecules/moieties for selective targeting. Nucleic acid therapeutics such as antisense DNA, mRNA, small interfering RNA (siRNA) or microRNA (miRNA) have been widely explored to modulate DNA or RNA expression Strikingly, gene therapies combined with nanoscale delivery systems have broadened the therapeutic and biomedical applications of these molecules, such as bioanalysis, gene silencing, protein replacement and vaccines. Here, we overview how to design smart nucleic acid delivery methods, which provide functionality and efficacy in the layout of molecular diagnostics and therapeutic systems. It is crucial to outline some of the general design considerations of nucleic acid delivery nanoparticles, their extraordinary properties and the structure–function relationships of these nanomaterials with biological systems and diseased cells and tissues. In this Primer, Conde and colleagues explain how to design smart nucleic acid delivery methods, which provide functionality and efficacy in the layout of molecular diagnostics and therapeutic systems. 

/pdf/nanodelivery-of-nucleic-acids-2d1fqs6w.pdf

Nanodelivery of nucleic acids

COVAX, the vaccines pillar of the Access to Covid-19 Tools Accelerator (ACT-A), has been promoted as 'the only global solution' to vaccine equity and ending the Covid-19 pandemic. ACT-A and COVAX build on the public-private partnership (PPP) model that dominates global health governance, but take it to a new level, constituting an experimental form that we call the 'super-PPP'. Based on an analysis of COVAX's governance structure and its difficulties in achieving its aims, we identify several features of the super-PPP model. First, it aims to coordinate the fragmented global health field by bringing together existing PPPs in an extraordinarily complex Russian Matryoshka doll-like structure. Second, it attempts to scale up a governance model designed for donor-dependent countries to tackle a health crisis affecting the entire world, pitting it against the self-interest of its wealthiest government partners. Third, the super-PPP's structural complexity obscures the vast differences between constituent partners, giving pharmaceutical corporations substantial power and making public representation, transparency, and accountability elusive. As a super-PPP, COVAX reproduces and amplifies challenges associated with the established PPPs it incorporates. COVAX's limited success has sparked a crisis of legitimacy for the voluntary, charity-based partnership model in global health, raising questions about its future.

COVAX and the rise of the 'super public private partnership' for global health.

A vaccine is key to the COVID-19 global response strategy. However, it is not yet clear how any COVID-19 vaccine will or ought to be distributed, despite the significant issues of fairness, equity, and justice this raises. The 2009-H1N1 pandemic demonstrated that without a robust mechanism at the international level to ensure fair allocation, developing countries will either not receive the vaccine at all, or receive it significantly later than developed countries. Using procurement of vaccines during 2009-H1N1 as a case study, this chapter explores how developing states may procure a COVID-19 vaccine, if one is developed. It considers both direct procurement of vaccines by developing countries, and procurement by international organizations on behalf of developing states. The chapter outlines some of the unique challenges associated with manufacturing and procuring vaccine, and argues that without strong and meaningful commitments from developed countries to donate vaccine to their developing neighbours, then developing countries are likely to be unable to procure this vital medical resource. Drawing on procurement of vaccine during 2009-H1N1 pandemic this chapter argues that developed states with the capacity to manufacture a COVID-19 vaccine are likely to utilise compulsory requisition and other regulatory measures such as government indemnification of vaccine manufacturers for failure to meet contractual obligations, export control measures, and other parallel regulatory measures in order to delay or prevent the export of a COVID-19 vaccine.

Harry Upton

Papers

International Collaboration to Ensure Equitable Access to Vaccines for COVID-19: The ACT-Accelerator and the COVAX Facility.

The procurement of a COVID-19 vaccine in developing countries: Lessons from the 2009-H1N1 pandemic