Last September, the World Health Organization and the United Nations laid out a roadmap to end the pandemic. The key goal: having every country in the world achieve at least 40 percent vaccination coverage against Covid-19 by the end of 2021, and 70 percent by mid-2022.
One major player in that effort has been Covax. A global vaccine distribution project co-led by the WHO, Covax was billed by one sponsor as the “world’s best hope of bringing the acute phase of this pandemic to a swift end.” However, it has been plagued with problems since its inception — namely insufficient funds, insufficient supply, and insufficient willingness from rich countries to share vaccines. These struggles have hampered the global fight against Covid-19.
But there’s a glimmer of hope. Covax ended the year strong: December brought a last-minute surge of deliveries, with about 300 million doses of Covid-19 vaccines shipped to 144 mostly low- and middle-income countries. That is roughly a third of the total of vaccine doses Covax delivered in 2021 — in only one month.
As the Washington Post reported, much of this surge can be attributed to an increase in the supply of vaccine doses to Covax, particularly with long-delayed donations from high-income countries and pharmaceutical companies like Johnson & Johnson, Moderna, Pfizer, and BioNTech.
That’s welcome news, not just for the countries that received them, but also for the world. Vaccine equity would most directly prevent sickness and death in low- and middle-income countries, but it would also give the virus fewer opportunities to mutate and produce variants like delta and omicron.
Even with the late surge, though, the total number of vaccines delivered in 2021 — 900 million — amounts to less than half of Covax’s original target of sending at least 2 billion doses by the end of 2021. “We’re very far from the 70 percent vaccination rate in low-income countries,” says Amanda Glassman, a senior fellow at the Center for Global Development, adding that reaching that level soon would require a “huge lift” in terms of financing for booster doses and delivery. “We’re still not serious as a world about paying for the stuff and getting it done.”
Almost three-fourths of all Covid-19 vaccine shots administered thus far have gone into the arms of people in high- and upper-middle-income countries, with more booster doses in high-income countries having been administered than total doses in low-income countries. While 59.4 percent of the global population has received at least one dose so far, only 9.5 percent of people in low-income countries have received that much coverage. Experts have denounced this state of affairs as the product of nationalism and extreme global inequality.
Nevertheless, this late 2021 surge in vaccine deliveries could be a hopeful sign that a key vessel for global vaccination efforts is finally righting itself. With improvements in supply and delivery, Covax has the potential to help the world reach greater vaccination coverage. But all of this hinges on Covax getting this right — and that few further storms appear on the horizon for the project.
Covax is an initiative led by three groups. There’s the WHO; Gavi, a public-private group that works on getting people in developing countries vaccinated; and the Coalition for Epidemic Preparedness Innovations, a project co-founded by the Gates Foundation that seeks to make vaccines available in the event of outbreaks. The United Nations Children’s Fund (UNICEF) is also organizing the delivery of vaccines.
Rich countries were supposed to pool funding through Covax to negotiate deals for and finance multiple vaccine candidates, increasing the chances of effective ones being developed. At the same time, some of that financing was intended to allow Covax itself to purchase vaccines for poorer countries that couldn’t afford them. In addition, Covax was also supposed to gather vaccines via donations from nonprofits, businesses, and countries, in order to further shore up its supply.
But all that didn’t quite pan out. Rich countries not only faltered in their funding commitments to Covax, they also struck their own bilateral deals with pharmaceutical companies, even as Covax was still fundraising. That left the group with little supply to buy once it did raise funds. And even when rich nations amassed more vaccines than they needed, they were slow to donate the extras.
Pharmaceutical companies similarly underdelivered on the commitments they had made to Covax. A report by the People’s Vaccine Alliance — a coalition of organizations and activists campaigning for the sharing of knowledge and technology related to Covid-19 vaccines, treatments, and tests — found that neither AstraZeneca, Pfizer/BioNTech, Moderna, nor Johnson and Johnson “have sold more than 25 percent of their vaccine supply (agreed through contracts)” to Covax as of October 2021.
Groups like Oxfam International suspect this is because these companies “put their rich customers at the front of the line.” And when vaccine doses finally did make it to poorer countries, too many of them were close to expiration, leaving little time to get shots into arms. A joint investigation in October by the Bureau of Investigative Journalism and Stat News also found that Covax had contributed less than 5 percent of all vaccines administered globally.
“The reality is that Covax purchased a bit later than the high-income countries, and bet on Indian manufacturers given their limited resources,” Glassman says. When those Indian vaccines failed to pan out because of the devastating delta surge in that country, another expected source of doses dried up. “It’s not surprising that they didn’t get the deliveries they hoped for during .”
What the year-end surge means
But if Covax’s performance to date has been underwhelming, the surge in activity in late 2021 has renewed hopes that it’s turned the corner.
Olly Cann, director of communications at Gavi, believes that the end-of-year surge in shipments is indeed a hopeful sign that the pace of vaccine distribution will pick up for Covax this year. “We do have genuine momentum when it comes to delivering doses into the countries that we serve,” he says. “We’re now in a situation where we can now meet the demand” of the low- and middle-income countries that Covax is prioritizing.
A major reason for that optimism is in seeing positive signs in India, a major vaccine producer and the main supplier of vaccines to Covax. Due to the devastating second wave of Covid-19 that hit India last spring, the country focused its efforts on vaccinating its own citizens and had banned exports of doses, which Cann notes was “a severe blow to us at the time.”
The country finally resumed exports to Covax at the end of November. Along with the WHO’s long-awaited emergency approval of the vaccine developed by US-based Novavax, whose manufacturing partner for Covax is the Serum Institute of India. and which doesn’t require the cold storage needed by mRNA vaccines from Moderna and Pfizer/BioNTech, Covax is “back in business,” Glassman says.
She expects India’s shipments to Covax to continue for the next three months at least, adding that even with Omicron, India may not need to resort to export bans again now that 62 percent of Indians have received at least one dose.
Another problem with Covax is that it was initially developed as a procurement and shipping effort for vaccines, but not a delivery effort — meaning actually getting shots into arms. “Waiting for a delivery is a big deal, obviously, because the longer the wait, the more disease and deaths there will be,” Glassman says.
But Covax deliveries are now ramping up, as shipments from India are finally reaching recipient countries and also because the international community is finally starting to address this problem of delivery. Glassman also notes that last month, Covax’s leadership appointed Ted Chaiban, the regional director for the Middle East and North Africa for Unicef, to serve as the organization’s global coordinator for vaccine readiness and delivery. In her view, this reflects a shift in Covax’s strategy toward actually administering vaccines in recipient countries.
Can Covax help achieve 70 percent global vaccination by the middle of 2022?
Despite the recent good news, it’s highly unlikely that Covax will enable the WHO to reach its goal of 70 percent global vaccination by mid-year. While supply constraints have eased, financing is still a challenge, as high-income countries have remained unwilling to share enough funds or resources for low- and middle-income countries to acquire or make the vaccines themselves.
But there are also questions about how practical that 70 percent vaccination coverage threshold is — both for the rich nations meant to be funding Covax and the poorer countries meant to receive vaccines. Governments in lower-income countries with younger populations (who are less susceptible to hospitalization and death from Covid-19) are overwhelmed by many competing priorities, such as poverty, hunger, and other diseases like HIV/AIDS and malaria. Glassman and Cann both mentioned that the 70 percent vaccination goal may not just be out of reach, but also simply not the best allocation of limited resources.
Cann also notes that Covax was never meant to be the solitary silver bullet to solve the issue of vaccine equity.
“What we were set up to do was to cover the most vulnerable groups as quickly as possible,” Cann says. “That’s why we initially focused on the 20 percent coverage of the [highest priority low- and middle-income recipient] countries. This is roughly 950 million doses. We’re actually quite close to this now, and we’ll have delivered that number in the coming days, if not weeks.”
Meeting its goals will also depend on whether Covax will be pushed down the priority list again in favor of high-income countries, as the latter now aim to shore up supplies of vaccines to administer booster shots for their populations.
“The big problem we’ve had, and still to a degree do, is that it’s been very, very hard to get transparency from manufacturers on when doses are going to be coming to us,” Cann says. “It’s difficult for us to be confident that we’re not being pushed to the back of the queue, or being deprioritized over bilateral deals.”
Ultimately, Glassman believes that the optimistic scenario is that there are “orders in place, there’s manufacturing under way to meet those orders, and then it’s just a matter of time and effort for the shots to get from airports into arms.”
Covax has a long way to go though if it wants to achieve the WHO’s goal, and it’s likely the poorest countries in the world won’t achieve 70 percent vaccination until 2023 at current rates of delivery.
That said, countries in the Global South also may not need to keep waiting on Covax. They are already pursuing other avenues to vaccinate their populations, from pushing for a patent waiver at the World Trade Organization to encourage technology transfer, to shoring up their own domestic manufacturing capabilities (including for mRNA vaccines) to seeking out other vaccine sources.
And there was one more development of note at the very end of 2021: CORBEVAX, a vaccine created by Texas Children’s Hospital Center for Vaccine Development and Baylor College of Medicine in Houston, was licensed for use without patents and had its technology transferred immediately to Biological E. Limited, an Indian pharmaceutical manufacturer. One of the key people behind the project, Dr. Peter Hotez, claimed available CORBEVAX doses will soon surpass in number the vaccine doses donated so far by the US government or any other G7 country.
Given the enormous need — both to protect vulnerable people in the poorest nations and prevent the rise of new variants — the world must pursue every possible channel to get shots into arms and truly end the Covid-19 pandemic. Though Covax is showing signs of turning the corner, it may end up playing a smaller role than what the international community had originally envisioned for it in 2020.