If the world is to beat COVID-19, we will need to develop one or more vaccines to protect us from it. And with thousands of people dying each week, not to mention an estimated US$ 2 trillion per year in lost economic activity, the pressure to protect the population and return life to normal has never been greater.

The positive news is that the global response in terms of vaccine development has been historic. Today, over 80 preclinical candidates are in development and seven have already progressed to human trials. This could well give us a better chance of getting more than one COVID-19 vaccine introduced in record-breaking time. However it also shines a light on another critical challenge: how to ensure that once a vaccine is available, it is accessible to everyone that needs it. We can only stop the pandemic if it is under control everywhere.

What is an advance market commitment?

History has shown us that “market failures” can occur when vaccines are developed but they are either unsuitable or too expensive to be widely rolled out. A classic example is the vaccine that protects against pneumococcus bacterium, which is the leading cause of severe pneumonia. While a pneumococcal conjugate vaccine (PCV) was developed in the twentieth century, it was tailored for use in the developed world and was not optimised for developing countries where, ironically, the death toll was greatest.

Gavi’s Pneumococcal Advance Market Commitment changed that in 2009. By agreeing to buy large quantities of vaccines at established prices once the vaccine was licensed, the mechanism effectively created healthy market dynamics, providing pharmaceutical companies with an incentive to develop and produce suitable vaccines and guaranteeing a sustainable price to provide coverage for anyone that needed it. The AMC has been a huge success over the last decade and has prevented 700,000 children’s deaths in 60 developing countries.

Could an AMC for COVID-19 be exactly the same?

This experience with PCV, and again a similar approach used more recently with Ebola vaccines, proves that such a concept can mean the difference between failure and success. In the case of Ebola, it reduced a 5-6 year horizon to just two. Given the huge size of the response necessary to defeat COVID-19, any new AMC would need to be augmented. Instead of only using  the ‘pull’ of incentivising manufacturers through guaranteed demand, it would also need to ‘push’, whereby public funds would be necessary during development to invest in manufacturing capacity, secure vital raw materials, and start enabling the transfer of technology from the lab to a distributed network of global manufacturers.

Who would make the vaccines?

A growing community of stakeholders now agrees that any future vaccine should be treated as a global public good, made available on public health grounds to those that need it most rather than limiting supply to those countries that make it or can afford to pay the highest price for it. To this end, manufacturers would work together, with no one company controlling the market. By involving a large community of manufacturers, including those in the global south, a side effect of the AMC would be the stimulation of a more diverse vaccine market.

What about vaccine development?

An AMC would not be used to fund development of vaccines. Instead, push and pull mechanisms would accelerate availability by ramping up production and procurement, in advance while the most promising and suitable vaccines were still in development. Other financial instruments can be used to help vaccine development, such as Gavi’s IFFIm (it stands for International Finance Facility for Immunisation), which has been issuing vaccine bonds in the world’s capital markets since 2006.

Who would run it?

COVID-19 will not be solved without a concerted and collaborative global effort. The Vaccine Task Force is one of three, alongside therapeutics and diagnostics, that were announced on 24 April 2020 as part of the Access to COVID-19 Tools (ACT) Accelerator. The Task Force will include many of Gavi, the Vaccine Alliance’s existing members – governments from low- and middle-income countries, industry and civil society, the WHO, UNICEF and the World Bank. CEPI, the Coalition for Epidemic Preparedness Innovations, will be another leading partner in this task force.

How much would it cost?

Immunising the whole world will cost tens of billions of dollars. However, Gavi estimates that an initial investment of US$ 2 billion would enable 20 million health care workers to be vaccinated, create a stockpile necessary to deal with emergency outbreaks, and start establishing production capacity to vaccinate additional high-priority groups. In other words, given the economic cost incurred by the ongoing crisis, any response would pay for itself in weeks if not days.

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