Gavi Covax AMC: An Internationally Employed Financing Strategy Aimed at Promoting Equitable Distribution of Future COVID-19 Vaccines

The COVID-19 pandemic is without doubt the most devastating public health crisis since the H1N1 outbreak in 2009. Yet, despite the exponential growth in healthcare technology and access, we remain in the shadow of certain social disparitiestied to race and income we ought to have eliminated by now. Specifically, issues with the equitable distribution of critical pandemic vaccines pose as much of a challenge now as they did 11 years ago with the Swine Flu.

In early 2010, during the massive global rollout of the H1N1 vaccine, the World Health Organization (WHO) itself criticized the large advanced orders placed by developed nations and neglect of vaccine demand in developing countries. The WHO attempted to negotiate with manufacturers and first-world nations to reserve some vaccine supply for the developing world and partnered with the United Nations (UN) to collect monetary donations as well. However, success was limited and developed nations saw an excess of vaccine supply, even after the end of the pandemic, while developing countries struggled with their limited resources[1]. The WHO committed to a goal of supplying only 10% of the populations of 95 developing nations with the H1N1 vaccine, amounting to 200 million total doses [2].To put this in perspective, in 2009 the United States alone advance ordered 250 million units of the vaccineenough to vaccinate about 81% of its population [3], [4]. Despite many proposed actions having targeted this inequity over the years, the COVID-19 pandemic once again places it under the spotlight and highlights the demand for a more innovative solution.

Unfortunately, this disparity in vaccine distribution boils down to governing principles that are too often socioeconomically discriminating. Governments themselves don’t possess the infrastructure necessary to develop and manufacture vaccines and instead resort to funding private pharmaceutical companies to do so. This renders potential vaccines as make-or-break business opportunities, where private corporations construct distribution and pricing plans based largely on financial incentives. Specifically, the risks and resources involved in developing such vaccines so rapidly promote high prices and limited access. However, unlike with the relatively small scale H1N1 outbreak, it is clear that financially targeting vaccines to those wealthy enough to purchase them won’t end the current Coronavirus pandemic. Experts contend that at least 70% of the globe must be vaccinated to achieve herd immunity and effectively halt the spread of the virus[5].How, then, have nations addressed these issues? What is being done to ensure that COVID-19 vaccines will be distributed evenly across the world both at reasonable costs, to both the disadvantaged and advantaged, and without financially hurting pharmaceutical developers?

An interesting initiative that has gained significant traction is the Gavi Covax Advanced Market Commitment (Covax AMC). The goal of the Covax AMC is first to construct a coalition of nations willing to aid in the equitable distribution of future COVID-19 vaccines. It’s focused on raising $2 billion from participating countries around to world to immunize health care workers and high-risk individuals in developing nations. Furthermore, the Covax AMC hopes to provide volume guarantees to all nations for multiple vaccine candidates before they are licensed, similar to what the United States did in 2009 with H1N1. To accomplish this, Gavi has preordered large, set amounts of vaccines from different pharmaceutical companies that the WHO can later decide where to administer. This incentivizes pharmaceutical companies to invest in manufacturing, increasing supply availability and reducing prices as well as the amount of time it takes for vaccines to become available. In effect, this strategy promotes abundant vaccination resources for all nations while de-risking the costs, for pharmaceutical companies, of investing in manufacturing large amounts of product when the outcomes of the vaccines are yet to be known [6].As of August 24th, 2020, 172 nations are participating in the Covax alliance[7].

The Gavi model has proved successful before with the Pneumococcal vaccine (PCV AMC). This alliance helped vaccinate 225 million children across 60 low and lower-middle income countries against the leading cause of childhood pneumonia. Launched in 2009, it now ships over 160 million doses of PCV to developing countries annually [6]. However, despite this success, the Covax AMC model faces a much more significant challenge and needs to address certain underlying issues.

A major obstacle for the Covax AMC is deciding which vaccine candidates to invest in. Do they concentrate their funding on a select few or a wide distribution? The scale of the
Coronavirus pandemic has spurred waves of vaccine development in comparison to the PCV, and there are many promising candidates. However, none are proven. The main strategy of the Covax AMC is to invest in vaccine candidates ahead of time, a principle that in effect locks the coalition into their vaccine selections. If vaccine candidates show impactful variations in efficacy after phase 3 trials or some perhaps have dangerous side effects, this could reduce supplies to developing nations and pose a large financial risk for Gavi. The situation would revert to that seen in the H1N1 pandemic where the Covax AMC would lose investments and vaccine supplies while wealthy nations could forfeit the alliance and revert to their own national funding to quickly order functional vaccines. Vaccine supplies would then again prove limited to developing nations.

A more long-term issue is determining whether Covid-19 fits the Pneumococcal model Gavi has developed for continued shipment of vaccines years from the start. There is a possibility for companies to invest in developing seasonal Coronavirus vaccines to prevent another pandemic. If they do so, Gavi would have to outline plans to continue funding vaccine orders. Furthermore, seasonal Coronavirus vaccines may prove less necessary than, for example, the PCV (Coronaviruses tend to cause mild illnesses) and it may not be feasible for Gavi to continue the Covax AMC. In this situation, access to seasonal Coronavirus vaccines in third world countries would diminish, as lower demand would raise prices. This may leave the developing world more susceptible to a new Coronavirus pandemic or epidemic, as the inaccessible seasonal vaccines may offer partial immunity against new highly virulent or deadly strains to wealthy, developed nations only.

The Gavi Covax initiative is a unique effort that showcases the benefits of all nations, rich and poor, working collectively to eradicate a common threat. However, unlike past epidemics and pandemics, the scale and timetable of the COVID-19 outbreak introduces many economic and technological risk factors and uncertainties. While the current pandemic has clearly fostered efforts to promote health equity with respect to vaccine access, can we really expect to share our resources and developments to third world nations if we ourselves are uncertain of our own future? At the end of the day, luck is still involved. Our vaccines still need to work. If the Covax alliance succeeds, the Gavi model may hold the key to future healthcare investments in developing nations. However, if it fails, we could see rising disparity on a devastating scale.