To end the pandemic, we don’t just need a COVID-19 vaccine, we’ll need lots of them. It will take literally billions of doses to protect enough people across the world to beat this virus. Individual governments, duty-bound to make the protection of their citizens their first priority, are keen to secure doses even before they have been developed. But even with more than 100 vaccine candidates currently in development, the vast majority are likely to fail. And, even if one or more vaccine candidates does prove to be both safe and effective, the chances are that no single manufacturer will be able to produce more than a few hundred million doses, at least initially. So, what can governments do to increase their chances of backing a successful vaccine, to ensure they have enough doses for their citizens, without everyone else missing out?
By far, the best solution is for all governments to pool their resources. By working together with others, individual governments will be able to support the development of far more vaccine candidates than they could alone. This not only makes it more likely they will back a winner, but will also ensure that there will be enough doses to go around. This is precisely what the COVID-19 Vaccine Global Access Facility (COVAX Facility) and Gavi Covax Advance Market Commitment (AMC) were set up to achieve. By supporting these mechanisms, individual governments will not only increase their chances of getting a successful vaccine, and the doses they need to protect for high-risk populations and kickstart their economies, but it will also help ensure that people in the world’s poorest nations also get access, which will ultimately bring this crisis to a far swifter conclusion.
But first, why do we need it?
Why doing it alone won’t work
So far, the novel coronavirus has killed more than 400,000 people, and infected over 7 million; it has devastated livelihoods, businesses and industries. According to the International Monetary Fund, it is predicted to cost as much as US$ 9 trillion in cumulative global economic losses by the end of 2021. To protect their citizens and economies, some governments, or groups of governments, are seeking bilateral agreements with individual manufacturers developing COVID-19 vaccines to secure the doses once the vaccine is licensed.
"But what about if we get lucky and one or more of the vaccine candidates does succeed?"
However, this approach is risky. There is no guarantee that any vaccine will actually succeed. Based on historic evidence, vaccine candidates that have not yet entered human trials have a probability of just 7% of success, odds that rise to 17% once they reach human trials. Even the wealthiest governments would only likely be able to fund a handful of vaccine candidates, at most. This means that the chances of backing an unsuccessful vaccine are significant, and despite considerable investment, individual governments could still end up without any COVID-19 vaccines.
Another grim scenario is that we end up without a COVID-19 vaccine because the wrong candidates have been backed. It is possible that one or more promising candidates fail to get the funding they need to go to clinical trials, because governments focus their resources on other candidates, perhaps because they have manufacturing facilities on home soil.
Why the market won’t work on its own
But what about if we get lucky and one or more of the vaccine candidates does succeed? If individual governments go it alone, or perhaps club together with their neighbours, to strike bilateral deals with manufacturers, then a winner-takes-all scenario seems likely, where a small number of countries benefit, while the rest of the world goes without.
"By working together and pooling resources, governments can invest in the development of a larger number of vaccine candidates, and in the scaling-up of manufacturing facilities even before any are approved."
Some governments may have enough confidence in the vaccine candidates they are backing to believe this is a gamble worth taking, that they are likely to emerge as a winner. But even if they do, the benefits of securing vaccines will only be short-lived if the coronavirus is allowed to continue to cause havoc elsewhere. Because unless the vaccine offers lifelong protection – which is by no means a given – and unless everyone susceptible is protected, including newborns, then even countries that have successfully eliminated the disease will face the risk of resurgence.
Another issue with going it alone is that it will push up the price of COVID-19 vaccines. Even if successful manufacturers are able produce hundreds of millions of doses, and even if individual governments, or groups of governments haven’t hoarded most of them, if left to market dynamics alone, then competition is likely to be fierce. This will inevitably drive the price up, putting COVID-19 vaccines even further beyond the reach of most people.
In time, manufacturers may invest in creating larger facilities, capable of producing more doses. But given that a single vaccine manufacturing plant can cost half a billion dollars, they are unlikely to do so until they are certain they will have a successful product. This delay will create shortages, costing lives and prolonging economic misery.
Why there is safety in numbers
The best way to avoid these scenarios is to collectively hedge our bets. By working together and pooling resources, governments can invest in the development of a larger number of vaccine candidates, and in the scaling-up of manufacturing facilities even before any are approved. This would not only increase the chances of success but also the likelihood that we have enough doses for everyone as soon as a vaccine is licensed. It wouldn’t remove the risks associated with backing candidates that don’t succeed, but it does allow those risks to be shared, along with the benefits, if a successful vaccine transpires.
"In addition to providing access to successful COVID-19 vaccines, the COVAX Facility is designed to reduce the chances of countries facing immediate shortages by ensuring that we hit the ground running."
In practical terms, this means first identifying the most promising candidates – based on the scientific evidence, as well as their suitability for large-scale manufacturing and deployment across the world and across different demographics – and then funding their development. At the same time, it means increasing or creating manufacturing facilities for those same candidate vaccines, so that manufacturers are able to produce and make available billions of doses, as soon as the vaccines get regulatory approval.
Organisations like the Coalition for Epidemic Preparedness Innovation (CEPI) have started the first part of this process, by assessing and funding nine candidate vaccines, although more may warrant backing. The COVAX Facility would act like an insurance policy for countries, giving them access to these vaccines if they prove successful. As an element of the COVAX Facility, the Gavi Covax AMC will serve as an innovative finance instrument that uses donor funding to secure supply specifically for developing countries, to ensure everyone gets access to these vaccines, no matter where they live and to help the Facility get to scale.
How exactly will the COVAX Facility and Gavi Covax AMC help?
In addition to providing access to successful COVID-19 vaccines, the COVAX Facility is designed to reduce the chances of countries facing immediate shortages by ensuring that we hit the ground running. It will do this by encouraging manufacturers to build up production capacity for their vaccine candidates, even before it is known if the vaccines will work. This will be achieved by making commitments in advance to purchase vaccines when they’re available. This will be in addition to direct support through CEPI to help finance the scaling-up.
"AMCs are not a new idea. Gavi has already used an AMC very successfully to address market failures that were preventing children in developing countries from getting access to pneumococcal conjugate vaccines (PCV), which prevents the biggest killer of under-fives, pneumonia."
At the same time the Gavi Covax AMC will provide incentives for manufacturers to scale-up vaccine production capacity for developing countries, by making commitments to purchase substantial volumes of vaccines, if their vaccine is successful. Both of these approaches are designed to help remove some of the risks that might otherwise deter manufacturers from making the necessary investments in scaling-up or expanding their facilities. It will also be open to all manufacturers, encouraging third party contract manufacturers to get involved too. And while the Gavi Covax AMC will help all participating countries secure doses, it is being created with the specific aim of ensuring that developing countries in particular get the doses they need.
None of this guarantees any of the prioritised vaccines will be successful or that there will be enough doses for everyone. But it does increase the chances of success for all and will make sure that every country gains access to the available doses. A certain proportion of available doses will be ring-fenced for countries that are paying for their own doses, and a proportion would be reserved for developing countries, funded through Official Development Assistance (ODA). Even if this means that in the first phase there is only enough for each country to vaccinate 20% of its population, it will enable them to protect high-risk individuals, such as health workers or vulnerable populations. This will mean that health systems can continue to function, saving many more lives.
The Gavi Covax AMC will form the first building block of the COVAX Facility, which is part of the vaccine pillar of the Access to COVID-19 Tools Accelerator, launched to expedite the development of diagnostics, therapeutics and vaccines for COVID-19. Funding for the Gavi Covax AMC will come through ODA from OECD countries for lower middle-income (LMICs) and low-income countries (LICs), while funding paid into the COVAX Facility from participating high-income countries (HICs) and upper middle-income countries (UMICs) will go into a separate mechanism.
"On 4 June at the Global Vaccine Summit, more than US$ 500 million was pledged towards the AMC."
AMCs are not a new idea. Gavi has already used an AMC very successfully to address market failures that were preventing children in developing countries from getting access to pneumococcal conjugate vaccines (PCV), which prevents the biggest killer of under-fives, pneumonia. Over the last decade, Gavi’s PCV AMC has prevented 700,000 deaths in 60 developing countries. More recently Gavi used a similar mechanism to bring forward an Ebola vaccine that was stuck in development. Building on these successful models the Gavi Covax AMC is seeking seed funding of US$ 2 billion to enable millions of healthcare workers to be protected, and create a flexible vaccine buffer to be deployed where it is needed the most.
On 4 June at the Global Vaccine Summit, more than US$ 500 million was pledged towards the AMC. Additional funding could include concessional finance allocations from Multilateral Development Banks as well as through other innovative funding mechanisms, such as Gavi’s International Finance Facility for Immunisation (IFFIm). The latter is already being used to front load funding for immunisation by issuing Vaccine Bonds on long-term donor commitments. It has also been used to fund COVID-19 vaccine development through CEPI. Given the urgent need for an ability to make commitments to manufacturers, IFFIm is a particularly attractive instrument.
"These represent hugely positive first steps."
Also at the Summit a manufacturer, AstraZeneca, announced that it would be committing 300 million doses of its COVID-19 vaccine, which it is developing with the University of Oxford, towards the COVAX Facility. These doses will be made available on a not-for-profit basis if and when it receives World Health Organization (WHO) prequalification.
These represent hugely positive first steps. But the COVAX Facility and Gavi Covax AMC will need more. More participants, more funding, more vaccines and more doses. Because ultimately that’s what it will take to pull off the single largest vaccine deployment in history and end this crisis. Of course, it is all contingent on first successfully developing one or more COVID-19 vaccines. But if we do, then the COVAX Facility and Gavi Covax AMC are our best insurance policies to ensure that everyone wins, and no one misses out.