Vaccinating the World: The Successes and Shortcomings of the COVAX Mechanism

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25 November 2021, 8:10 a.m.

Disponible en français.

In May 2020, only months into the COVID-19 pandemic, António Guterres, the United Nations Secretary-General, stressed the need for a united, global response. “In an interconnected world, none of us is safe until all of us are safe,” he said. Mr. Guterres also praised the launch of the Access to COVID-19 Tools (ACT) Accelerator, calling it “a landmark global collaboration to speed up the development, production and equitable access to new COVID-19 diagnostics, therapeutics and vaccines.”

A year and a half later, and despite 53.4% of the world’s population having received at least one dose of a COVID-19 vaccine, only 5.1% of people in low-income countries have received their first shot. Moreover, many countries have started administering “booster” doses. That inequity has led some observers to conclude that the vaccine pillar of the ACT Accelerator, COVAX, is failing. It has also led to more scrutiny of the mechanism and intensified calls for expanding and accelerating dose donations from countries more advanced in their vaccination programs.

Figure 1– Share of the Population that is Fully and Partially Vaccinated Against COVID-19

Figure 1 shows the share of the eligible populations in Canada, in the world and in low- and high-income countries – as defined by the World Bank’s income classification system – that have been partially or fully vaccinated against COVID-19. Canada’s vaccination rate is greater than the vaccination rate in high-incomes countries, which is itself higher than that of the average global vaccination rate. Only a small percentage of low-income countries has been vaccinated.

Note: Low-income countries are those with a gross national income (GNI) per capita of US$1,045 or less in 2020, while high-income countries are those with a GNI per capita of US$12,696 or more in 2020. See The World Bank, “World Bank Country and Lending Groups,” Country Classification.
Source: Figure prepared by the Library of Parliament using data obtained from Our World in Data, “Coronavirus (COVID-19) Vaccinations,” Database, accessed 23 November 2021.

What is COVAX?

COVAX is coordinated by the World Health Organization (WHO), Gavi, the Vaccine Alliance, and the Coalition for Epidemic Preparedness Innovations, with the United Nations Children’s Fund (UNICEF) as a delivery partner. It combines the resources and purchasing power of more than 180 participant economies in a global procurement mechanism known as the COVAX Facility. The COVAX Facility includes higher income self-financing participants, and low- and middle-income economies whose participation is supported by the COVAX Advance Market Commitment (AMC), a donor-financing mechanism.

COVAX was premised on the idea that its ability to offer large-volume guarantees to vaccine manufacturers would enable it to negotiate competitive prices. To increase its probability of success, COVAX invested in a large portfolio of vaccine candidates. For countries able to finance their own procurement, COVAX was intended as an insurance policy, in case the vaccine candidates they supported through bilateral deals did not receive regulatory approval. Meanwhile, for low-income countries, COVAX was intended as a lifeline, assuring access to vaccines that would otherwise have been unattainable.

Figure 2 – Current COVAX Supply Agreements

Figure 2 shows the names of the 11 vaccine manufacturers with which COVAX has signed supply agreements. Seven vaccines have received World Health Organization (WHO) emergency use approval. They are those produced by Oxford/AstraZeneca, Janssen, Moderna, Pfizer/BioNTech, Serum Institute of India (Covishield), Sinopharm and Sinovac. Four vaccines still require WHO emergency use listing. They are those by Clover Biopharmaceuticals, Novavax, Sanofi/GSK and the Serum Institute of India (Covovax).

Source: Figure prepared by the Library of Parliament using data obtained from Gavi, The Vaccine Alliance et al., COVAX Global Supply Forecast, 8 September 2021, p. 8; and McGill COVID19 Vaccine Tracker Team, “World Health Organization (WHO),” COVID19 Vaccine Tracker, Database, accessed 22 November 2021.

The WHO established overarching principles to guide the allocation of COVID-19 vaccines. Under phase one of COVAX’s allocation framework, all participants – whether high- or low-income – are eligible to receive doses to cover up to 20% of their total population (or fewer doses, if requested). Once all participants have achieved 20% coverage, countries will receive doses at varying rates based on factors that include the risk that COVID-19 poses in specific national contexts.

Supply and Distribution Challenges

Lawrence Gostin, a professor of global health law at Georgetown University and WHO adviser, considers the idea of COVAX an “A+” but its implementation a “C.” COVAX’s procurement of vaccines was slow to begin, as manufacturers struggled to ramp up production owing to limited production facilities and shortages of critical components and trained personnel.

The national vaccine procurement strategies of high-income countries also contributed to supply shortages, a situation COVAX has been criticized for failing to foresee. As noted above, participation in COVAX does not preclude countries from signing bilateral deals with vaccine manufacturers, and many high-income countries did so as early as July 2020. As a result, when COVAX was still securing funding, high-income countries were obtaining access to doses at the front of the manufacturing queue.

A report published by the Organisation for Economic Co-operation and Development indicated that as of mid-March 2021, “high-income countries (16% of the global population) had negotiated supply agreements amounting to approximately half of the world’s vaccine supply, leading to allegations of ‘vaccine nationalism.’”

Export restrictions enacted by India also contributed to vaccine shortages. The Serum Institute of India – the world’s largest vaccine manufacturer and leading supplier of the Oxford/AstraZeneca vaccine to COVAX – halted exports in March 2021 following a surge of COVID-19 cases in India. Though India resumed vaccine exports in October 2021, its export restrictions raised questions as to why COVAX was relying so heavily on one manufacturer.

Logistical challenges also complicated COVAX’s rollout. Some vaccines require ultra-cold boxes for transport and storage. Powering “cold chain” equipment demands reliable sources of energy, which many low-income countries struggle to provide, particularly in rural areas.

In addition, delays in shipping, vaccine hesitancy, poor planning and weak public health systems have affected the ability of some recipient countries to quickly administer vaccines. In several cases, thousands of doses expired before they could be used. In response, the WHO deepened its investment in tools and strategies aimed at helping countries prepare to receive vaccines. COVAX has also launched a campaign to deliver hundreds of new ultra-cold freezers to more than 45 countries by the end of 2021.

Delivery Targets

These and other supply and distribution challenges prompted COVAX to revise its 2021 delivery targets. COVAX’s September 2021 global supply forecast indicated that 1.4 billion doses would be available for delivery in 2021. This projection is down from an earlier goal of making available two billion doses by the end of 2021. However, it is unclear whether COVAX will be able to achieve even that revised target. As of 23 November 2021, approximately 531 million doses had been shipped to 144 countries through COVAX. Of these doses, 431 million have gone to AMC participants.

Recognizing the disparity in vaccination rates among participants, COVAX agreed to earmark its October 2021 supply for those countries with low vaccine coverage and for whom COVAX was the only or primary source of COVID-19 vaccines. This decision deviated from COVAX’s original allocation framework, which did not take into account doses that participants may have obtained outside the COVAX Facility, including via donation or bilateral procurement.

Accelerating Global Vaccination Efforts

At a global COVID-19 summit in September 2021, U.S. President Joe Biden and other world leaders committed to the WHO’s goal of fully vaccinating at least 70% of the global population by September 2022. That is the minimum coverage many public health experts estimate will be needed to achieve herd immunity and end the pandemic.

To that end, the U.S., Canada and other countries agreed to make additional contributions to COVAX. The U.S. intends to provide a total of 1.1 billion doses through the mechanism, while Canada has contributed $545 million to the COVAX AMC and has pledged to donate the equivalent of at least 200 million doses to COVAX by the end of 2022.

While COVAX partners have stressed that “deliveries to countries are accelerating and will continue to ramp up dramatically through the end of year,” they have also acknowledged that significant risks remain to its supply forecast.

As a result, they issued an urgent call to donors and manufacturers in September 2021, in which they appealed to countries that have high vaccination coverage and that are ahead of COVAX in manufacturing queues to give up their spots. They also urged donor countries to provide vaccine doses in larger and more predictable volumes with longer shelf lives in order to reduce the burden on countries preparing for deliveries.

In addition, Dr. Tedros Adhanom Ghebreyesus, Director-General of the WHO, has called for a global moratorium on booster doses until the end of 2021 to enable all countries to vaccinate 40% of their populations.

Additional Resources

Brown, Stephen, COVID-19 : Apartheid vaccinal et échec de la coopération internationale, Institut d’études internationales de Montréal, 13 September 2021 [en français].

Chelpi-den Hamer, Magali, COVAX : faut-il continuer à financer un échec? iD4D, 30 August 2021 [en français].

Gavi, The Vaccine Alliance, COVAX AMC.

Randolph, Haley E. and Luis B. Barreiro, “Herd Immunity: Understanding COVID‑19,” Immunity, Vol. 52, 19 May 2020.

Statement by UN Human Rights Experts Universal access to vaccines is essential for prevention and containment of COVID-19 around the world, Office of the United Nations High Commissioner for Human Rights, 9 November 2020.

Usher, Ann Danaiya, “A beautiful idea: how COVAX has fallen short,” The Lancet, World Report, Vol. 397, Issue 10292, 19 June 2021.

Authors: Brian Hermon and B. J. Siekierski, Library of Parliament

Categories: COVID-19, Health and safety, International affairs and defence

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