Reflections on Covid-19 vaccine access in 2021 and recommendations to achieve equity in 2022

Reflections on Covid-19 vaccine access in 2021  and recommendations to achieve equity in 2022

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Executive Summary

As widely acknowledged, the last two years have been unprecedented with the development and roll out of new vaccines.  A year on since the first Covid-19 vaccines were approved for use, half of the world is fully vaccinated and COVAX just passed the one billionth dose delivered mark. At the same time, transmission of SARS-CoV-2 is higher than ever and even with the unprecedented vaccination progress, access to Covid-19 vaccines is still grossly inequitable. Eighty-eight countries have not met the WHO goal of vaccinating at least 40% of their populations by the end of 2021.

In this context we started 2022 by seeing if there are lessons around access to Covid-19 vaccines in 2021 that could be applied to the year ahead so that equity and national and global vaccination goals are achieved.

Drawing from publicly available data and information, we analyzed: vaccination coverage; actual supply of Covid-19 vaccine in 2021 vs. projected supply; demand scenarios including with one or two additional booster doses; supply vs. demand scenarios; the number of doses delivered by vaccine platforms.  We did this analysis through country, regional and global lenses. We also looked more closely at mRNA vaccine including the amount produced and distribution, given the increasing need for variant adapted vaccines. We observed some key issues that we think should influence action early this year.

·        Countries self-prioritize Covid-19 vaccines produced and/or developed within their borders. This is more obvious with government owned vaccine manufacturers. But it is also affected via the banning of exports and commercial terms that require manufacturers to serve national needs over export customers. While nationalization eased in the last months of 2021, it is possible that demand for booster doses will create new pressure. We think further de-prioritization of exports should be anticipated including from India. This will primarily translate to delays in deliveries to low-income and lower-middle income countries. In turn, further delaying achievement of vaccination coverage and exacerbating the inequity.

·        In general, the current private sector vaccine manufacturers have designed their set-up such that around 80% oftheir production serves the more lucrative (primarily high-income and upper-middle income) markets. More specifically, more than 80% percent of mRNA production went to high income and upper-middle income countries in 2021 (these groups of countries are approximately half of the global 7.9 billion people).

·        Most vaccine manufacturers were able to produce the volumes of vaccines that they planned, as publicly announced. In aggregate, manufacturers were within 10-20% of their plans which is a similar level to regular (non-pandemic) production planning. Shortfalls hit the less lucrative markets first.

·        While there has been unprecedented industrial collaboration to increase production capacity of many Covid-19 vaccines, there has not been a production build out of the two mRNA vaccines.

·        The current portfolio of Covid-19 vaccines is not sufficient, let alone optimal. Including because of the location and business set-up around access. National regulators and WHO should continue to use emergency use pathways for candidate Covid-19 vaccines in particular mRNA vaccines and those that will prioritize licensing, production and use in Africa and other underserved regions.

·        The relationship between a country’s access to Covid-19 vaccines and their vaccine development/production capabilities and financial resource is clear. We don’t have a true counterfactual, but if production build out in regions with lower access (Africa, Latin America, the Middle East) began in 2020 or 2021, we think access would look differently today. MOUs have been signed and hubs have been established in Africa and Latin America – the groundwork is laid -- for regional vaccine production. It’s time for a moonshot effort - the public and private sector should rapidly move production – starting with the fill and finish stage – to regions with the least access, notably Africa. This is perhaps the most important of our observations. As the Head of the IMF recently wrote, “Vaccine manufacturing is a sophisticated enterprise that requires specialized equipment, inputs, storage facilities, and skilled labor. But anyone who tells you that this cannot be done in Africa has not been paying attention.”

·        Finally, we do not have insight into the causes of lower or slower absorption rates of vaccines delivered in lower income countries. But as this could quickly emerge as an issue, the main drivers of vaccine hesitancy should be closely monitored, understood, and mitigated. In a discussion on global access – an acute understanding of any vaccine preferences is a key input to an optimal vaccine portfolio.

Also, as there are no signs of vaccine nationalism truly dissipating, we would be remiss to not mention the importance of continuing the pressure for more equitable distribution of vaccine. The case put forth by WHO is technically sound and politically acceptable: the pandemic is being perpetuated by the grossly inequitable access to vaccines. Increasing distribution to low and lower-middle income countries is a matter of national health security and is in all countries’ self-interest.