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PLOS BLOGS Speaking of Medicine and Health

In the new year, resolve to learn from the past to advance pandemic response in the future

By guest contributor Jirair Ratevosian, DrPH, MPH

As COVID-19 sweeps across China after an abrupt U-turn on its pandemic control policies, it is a grave reminder that the impact of the ongoing pandemic is far from over. In many parts of the world, COVID-19 cases continue to rise, and a concomitant number of factors threaten access to effective vaccines, diagnostics and therapeutics. As global health leaders and lawmakers debate pandemic preparedness policy in 2023, understanding the factors that influenced the early actions to COVID-19 is critical to closing equity gaps and improving and designing systems for global health and pandemic response for the future.

Despite the rapid advent of science to develop COVID-19 medical countermeasures, gaps in access to vaccines and therapeutics remain between high and low-income countries, nearly three years after the start of the pandemic. Nowhere have the effects of this inequity been more devastating than on the world’s most vulnerable communities. The early missteps of the global COVID-19 response have spurred calls to expand regional manufacturing for health commodities, rethink intellectual property rights, and redraw the architecture of global health governance.

To bolster our collective understanding of the global public health response to COVID-19, I devoted my doctoral research, in 2022, to document factors that influenced the early implementation of COVAX, the vaccine pillar of the ACT-Accelerator, a mechanism charged with developing and delivering diagnostics, treatments, and vaccines to fight COVID-19. COVAX was set up as a platform to support the research, development and manufacturing of COVID-19 vaccine candidates, and negotiate pricing, allocation, procurement and distribution.  To identify factors that influenced the early workings of COVAX, I applied an implementation science framework to analyze barriers and facilitators of vaccine supply and procurement, and COVAX administration in Armenia, South Africa, Chile and Nepal in its first 15 months of operation, from April 2020 to June 2021. Qualitative data were collected through 31 semi-structured interviews with key informants using a purposive sampling strategy of diverse stakeholders to describe implementation experience (full publication forthcoming).

In its first fifteen months from inception, COVAX faced several obstacles, proving challenging for the entity to meet its stated goals. Despite the recognition of Gavi’s strengths and comparative advantage to lead COVAX, disruptions to the global supply chain due to aggressive vaccine nationalism and an export ban imposed by India on Gavi’s largest supplier, the Serum Institute of India, hampered early efforts to ensure equitable access to COVID-19 vaccines.

Informants reflected on other foundational, cultural, and structural barriers that contributed to implementation challenges for COVAX. These included a culture at Gavi that minimized risk and operated without sufficient industry experience and liquid financing to negotiate purchase agreements, as well as a governance model that neglected inclusion of low-income countries, civil society and private sector in its inception and subsequent decision making.

Further, while countries saw COVAX as a viable alternative to vaccine donations from China and Russia and jumpstarted vaccination programs to administer COVID-19 vaccines to populations, it faced several implementation obstacles, proving challenging for the entity to meet country demand and delivery schedules during its first 15 months of operations. These included customs and regulatory policies, poor national planning, and weak national commitments and capacities to deliver widespread vaccination.

The results from this early implementation review add to the emerging literature on factors that impacted COVAX implementation. The qualitative data from country-level stakeholders add new evidence to support previous claims and emerging documentation of COVAX operations. These recommendations add to the dialogue about both the successes of COVAX as well as its challenges, including those recently identified in a September 2022 Lancet Commission paper, and reinforces calls for strengthened international cooperation and dedicated financing to purchase COVID-19 commodities. The findings also provide evidence to support recommendations for national governments, global institutions, and international stakeholders to better prepare for future health threats.

Rapid learning about the political, economic, and other social factors that impacted the implementation process is essential to our ability to accelerate widespread and equitable access to, and delivery of, safe and effective COVID-19 vaccinations in the future. The COVAX mechanism is likely to remain operationally valuable for the conceivable future as countries navigate variants, weigh the multiple options they have for securing vaccines, and as COVID-19 persists, in the post-acute phase, in an increasingly endemic form. Gavi’s most recent Board decision, in December 2022, called for a continuation of efforts while identifying new ways to integrate COVID-19 vaccinations into routine operations. Others have articulated a transition plan for the Act-Accelerator and its various components through 31 March 2023.

To maximize vaccination and address implementation gaps, COVAX and future pandemic response efforts should design inclusive governance structures and robust communication channels to be able to accurately assess country readiness and address local implementation barriers. To increase vaccine supply, the findings from my research support calls for expansion of sustainable regional pharmaceutical production cooperation and capacity, which is critical to ensure equitable access to COVID-19 vaccines and other critical health commodities. In the early days of the pandemic, licensing arrangements by COVID-19 vaccine manufacturers limited the pace of vaccine production and ultimate distribution by COVAX.

​​Others have cited vaccine nationalism during the COVID-19 response and the failure of international cooperation as justification for a new international pandemic instrument to enshrine cooperation among nations and commitments to preparations for future health emergencies and pandemics. Beyond overcoming existing COVID-19 supply and COVAX implementation issues, findings from my research support calls to rethink and retool the purpose and engagement strategies of major global health actors, including international organizations and donors, with the intended purpose strengthening national and regional health security capacities. Further, the data support calls for dismantling power imbalances that too often dominate donor-driven development and aid efforts. Governments and international actors must embrace governance structures that promote regional and country-level health autonomy and security as a means to support international cooperation for global health and the meaningful recognition and participation of civil society.

Since its first delivery in February of 2021, COVAX has continued to evolve and adapt as circumstances have changed. Despite falling short of its initial goal to deliver 2 billion doses by 2021, the entity is on track to nearly meet that goal one year later, delivering 1.8 billion vaccines to 146 countries by November 2022. Understanding the factors that contribute to lingering equity gaps is important to advance global health equity and design equitable pandemic response efforts in the future. The experience of COVAX offers valuable lessons if only we are ready to learn them.

About the author:

Jirair Ratevosian completed a doctoral degree from Johns Hopkins Bloomberg School of Public Health in December 2022. He currently serves as senior advisor in the U.S. Department of State. Twitter @jratevosian

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.

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