The race for the Covid-19 vaccine is going strong – Can access be more equitable?
Several candidate Covid-19 vaccines have been developed, tested and approved for use in record time. And even with a few candidates dropping out, the vaccine development pipeline is overwhelmingly healthy. Now the focus is manufacturing and access.
In May 2020 we wrote a piece on what an equitable allocation of vaccines  could look like for the world. We used a global health equity goal of reducing deaths and therefore estimated what prioritizing three higher-risk priority groups would look like: health and front-line workers, people over the age of 65, and people with co-morbidities. The percentage of populations that these three groups make up of a country varies widely from country-to-country. High-income and upper middle-income countries have a larger labor force, aging populations, and higher rates of Covid-19 co-morbidities.What our calculation did not include was a vulnerability factor. That being, the vulnerability of living in a country with a weaker health systems and limited capacity to provide critical care such as medical oxygen or ventilation.
COVAX, in which more than 180 countries are participating, is using the recommendation from WHO to use a straight-line percentage that takes into account broad ranges of the percentage of people in each of the high-risk groups at 3% for a first priority and 17% as a next priority. COVAX recommends that only once all countries have 20% should a country receive more.
Calls for equitable allocation of Covid-19 vaccine are increasing as countries start vaccinating their populations, and the vaccine is highly anticipated to accelerate the end of the pandemic. But tensions on access are high, including given hiccups in the limited manufacturing capacity, as currently seen in the EU and Canada not being able to access their expected doses . There is a risk  that instead of the vaccine being seen as a global public good, vaccine nationalism will grow even stronger.
Therefore, we offer two practical ideas to help achieve equity.
First, set an early equity milestone
We recommend setting a date by which low- and middle- income countries, which have a higher vulnerability factor, should have access to vaccine to immunise at least 3% of their population. We think end March is an ambitious milestone but worth aiming for. The number of doses needed for all low- and middle- income countries is 400million. If India and China are excluded, on the basis that most of their needs are being met via national production, the number of doses needed for this group of countries is 232 million, presuming a 2-dose course.. COVAX has secured 145 million doses for delivery to countries through March . We estimate that the Africa Union contracts provide their countries with perhaps 10 to 20 million doses during the first quarter. Plus, some countries have bilateral agreements with. Based on these estimates, and excluding India and China, perhaps an additional 50-60 million doses would be needed for low- and middle- income countries by end March.
As of last week, the end of January, the U.S. vaccinated 1% of their population with 2-doses. If they achieve their goal of 100 million doses administered in 100 days, they would have vaccinated 15% of their population by 1 May.
For the most part, the contracts already in place with manufacturers are determining who gets doses when. Additionally, decisions made by manufacturers of prioritizing certain countries over others is also starting to influence who gets doses when, again referencing the current news from the EU and Canada.
Pfizer has contracts to supply 1.9 billion doses to 24 countries plus the EU and COVAX. Moderna has contracts to supply 895 million doses to 9 countries and the EU. AstraZenica has contracts to provide 2.9 billion doses to 27 countries and the AU, EU, COVAX and Latin America.There are contracts for 5.7 billion doses of vaccines the have been approved by at least one stringent regulatory authority .
The U.S. and EU have the largest number of doses on contract with 3.16 billion and 2.53 billion respectively. The majority of those volumes are for vaccine that have not yet been approved. COVAX has 2.18 billion doses on contract.
So, it seems there is sufficient vaccine ...
Second, track progress with buy-in from industry and countries
Without compromising countries reaching their higher risk populations, countries could agree that at a minimum vaccine for 3% of every countries’ population would be received by end March.
Countries know how much vaccine they are receiving but do not have visibility on what other countries are receiving. Manufacturers know what quantities are being shipped to where but only have visibility on their production. No one has a future facing full picture. An entity needs to bring the data together.
An informal solidarity pact, with data sharing, could allow WHO, the global health agency, to receive plans from manufactures, countries, the EU, AU and COVAX (to which WHO is a core partner) such that they could track equity progress on a weekly basis for the next two months, use the data to influence allocations and garner political will for specific decisions that will prioritize the 3%.
In anticipation of additional vaccines being approved for use and manufacturing production rapidly scaling up, it is likely that after this positive disruption to kickstart early equity, all countries would have doses to protect at least 20% of their population by the 3Q. Achieving early equity requires organization, transparency and data - all within the realm of what is possible.