How will the world's poorest people get a coronavirus vaccine?

https://www.theguardian.com/commentisfree/2020/jun/24/worlds-poorest-people-coronavirus-vaccine-gavi

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Rich countries’ governments are putting all their trust in a marriage of markets and philanthropy called Gavi, say Achal Prabhala and Kate Elder

Vaccines for Covid-19 are coming. Billions of dollars are flowing in, over 100 efforts are under way, and at least 13 leading candidates are already being tested on humans. But how will these vaccines reach the poorest people on the planet? This question haunts the fate of more than half the world’s population. It is the central question of our time. The failure to address this question in the past has resulted in millions of unnecessary deaths – and yet, some believe there is a simple answer. Ask pharmaceutical corporations about how they will ensure access to Covid-19 vaccines, and they say “Gavi”. Ask the wealthiest governments in the world what they are doing to ensure global equity, and they too say “Gavi”.

Gavi, the Vaccines Alliance, is a 20-year old public-private partnership that believes the marriage of markets and philanthropy will bring vaccines to everyone in the world. The numbers are impressive: every year, Gavi sends out 500 million vaccine doses against 17 different diseases. The sums of money pumped into Gavi are equally impressive. At the Global Vaccine Summit held earlier this month, Gavi raised a record-breaking $8.8bn. With £330m committed annually for the next five years, the British government is their single largest donor, alongside other wealthy countries and the Gates Foundation. At the summit, Gavi launched its newest initiative, a fund for future Covid-19 vaccines – the Covax Facility – which invites countries to invest in a wide portfolio of potential vaccines, pool their risk, and gain dedicated access to eventual products.

Gavi heavily publicised a unit of the Covax Facility called the Covax Advance Market Commitment (or AMC, and yes, it’s confusing) that deals with the access side of things. The first deal – a US$750m agreement with AstraZeneca for 300 million doses of the potential Oxford University vaccine – was heralded as a commitment by industry to meet the needs of the world’s poorest countries. But it came at a high price, representing only a minor discount over the full price paid by the US government. The problem is, we know very little about this deal because the agreement isn’t public, despite all the public money involved. We don’t know if, for example, AstraZeneca gets to keep the money if its vaccine fails. We don’t even know for a fact that all the vaccines bought are intended for use in poor countries. We asked AstraZeneca about this but did not receive a response in time for publication.

At the summit, Gavi devoted considerably less attention to decisions made within the Covax Facility to make the fund attractive to rich countries. For instance, there is consensus that the most vulnerable people in the world be given the vaccines first and in a fair and equitable way, and the World Health Organization’s forthcoming Global Allocation Framework will specify how that can be done. And yet, a report prepared for the Gavi board meeting that starts this week, and circulated ahead by Gavi to stakeholders, including civil society organisations, proposes that rich countries can ignore the WHO framework, with only poor countries having to abide by it. According to the document, it seems Gavi will allocate rich countries enough vaccines for a fixed percentage of their population, which their “national advisory bodies” will decide. Poor countries, meanwhile, will only get vaccines for their highest priority people, after demonstrating proof.

Rich countries are “encouraged (but not required)” to donate vaccines if they have more than they need, but we do not know when poor countries will get these donated vaccines: will it be at the same time as the rich countries, or only after they have used up all the vaccines they need? We put the questions raised by this document to Gavi, but it was unable to provide answers before this week’s board meeting.

The prospect of a two-tiered system puts into question the fundamental issue that Gavi was founded to address: equitable access to vaccines. In many ways, Gavi has helped create the problem it is now trying to solve. Three decades of getting medicines and vaccines to poor people have revealed the problem and the solution: monopolies over vaccines in the pharmaceutical industry, enforced through patents which, when suspended, result in prices going down and supply going up. The rich countries and organisations who fund Gavi are equally culpable: the US, UK and EU have committed billions towards vaccine research, almost all of which has gone to private pharmaceutical companies – without any conditions to prevent them from monopolising their vaccines.

All these countries have further stockpiled future vaccines by making direct deals with manufacturers, again without any access conditions whatsoever. In failing to challenge the most perverse feature of the pharmaceutical industry – monopolies that block access to their products – Gavi is in step with the governments who fund it. At best, Gavi has failed at negotiating control over the vaccines it funds. At worst, it believes that pharmaceutical monopolies, which have thwarted equitable access, are somehow essential to achieving it.

And unaffordable prices are only one part of the monopoly problem; in this pandemic, expanding supply is a major challenge. We have a shot at making enough vaccines for everyone, everywhere, if we put the planet’s full manufacturing capacity to use. But that can only happen if the vaccines are set free. Gavi’s inability to consider this problem, or use its leverage to force a solution, is baffling.

Pharmaceutical companies say they will make no money off the pandemic, that they will supply vaccines at a cost. Yet, they have already seen multibillion dollar increases in their market capitalisation, and are unwilling to relinquish the monopolies that drive their outsize profits. Leaders of rich countries (apart from the US) have said all the right things about equitable access to vaccines. Yet they are entering into multiple advance deals to stock up on possibly far more vaccines than they will ever need. They cannot have it both ways, and neither can Gavi. Seth Berkley, the Gavi CEO, cannot claim to want “the world to come together” with “no barriers” while failing to tackle both rich country nationalism and pharmaceutical industry greed.

Gavi can change the rules of the game and turn the Covid-19 vaccine into a global public good. It can ask far more of the pharmaceutical companies it is funding, and it can force the entire vaccine ecosystem to join a cooperative, collaborative and monopoly-free mechanism like the WHO’s Covid-19 Technology Access Pool. This would be the right move to make, and in doing so, Gavi could finally deliver on the promise it made to the world 20 years ago.

Achal Prabhala is the coordinator of the AccessIBSA project, which campaigns for access to medicines in India, Brazil and South Africa. Kate Elder is the senior vaccines policy adviser at the Médecins Sans Frontières Access Campaign