FOUR: COVID-19 Vaccine Inequality and Global Development: A Primer


Access to COVID-19 vaccines, key to ending the pandemic and its devastating consequences, is characterized by vast inequalities. High-income countries pre-purchased most of the initial supply of vaccines licensed to big pharmaceutical companies and approved in Europe and the United States, vaccinating their own populations ahead of the global interest in vaccinating healthcare workers and vulnerable people everywhere. The proposed multilateral solution to vaccine supply, the World Health Organization- and GAVI-backed COVAX initiative, has suffered from ‘vaccine nationalism’. While India was projected as the key source of COVAX’s initial supply, its vaccine production has also been redirected to domestic distribution. China and Russia have instead emerged as alternative sources of supply with their domestically developed vaccines. Amid overall scarcity, enormous controversy has emerged over how to scale up vaccine production and increase vaccine accessibility. The chapter reveals layers of vaccine inequalities not just between the Global North and South, but also within the Global South – especially between middle- and low-income countries. The chapter concludes that the challenge of providing COVID-19 vaccines, and the inequalities involved, appears indicative of wider challenges related to 21st-century global development.

COVID-19 vaccine development, manufacture and supply is a triumph yet also an ongoing tragedy for global development. COVID-19 vaccines were brought to use in unprecedentedly quick terms. Billions of doses have been manufactured and administered, helping mitigate the impact of a devastating pandemic. However, despite widespread discursive acknowledgement that ‘it will not be over anywhere until it’s over everywhere’, the availability and accessibility of COVID-19 vaccines has been grossly inequitable – challenging what the world needs economically, ethically and epidemiologically.

A brief assortment of facts provides an initial glimpse into the scale of the inequalities related to COVID-19 vaccines. By the time more than 50 per cent of people in Europe and the United States had been fully vaccinated (11 September 2021), only 3.4 per cent of those in Africa were, with many health workers still not fully unvaccinated (The Guardian, 2021). By 1 January 2022, the number of booster doses administered in high-income countries (300.6 million) was just over quadruple that of first doses in low-income countries (LICs) (74.8 million). Some vaccines have even been sent from places with low-vaccination rates to those with much higher ones – such as 5 million doses from India to the UK in March 2021 – at a time when the UK had administered more than 23 times the number of doses per 100 people than India (OWID, 2021).

This chapter unpacks the nature of, and factors underlying, COVID-19 vaccine inequality as a global development challenge. It argues that high-, and to some extent middle-income, countries have prioritized addressing their own immediate problems – in this case domestic COVID-19 vaccination – but ultimately at the self-defeating expense of addressing global collective challenges and leaving people in LICs behind. In that regard, the case of COVID-19 vaccines may be indicative of wider challenges related to 21st-century global development (Horner, 2020; Oldekop et al, 2020).

Vaccine nationalism and the scramble for COVID-19 vaccines

Once the genetic make-up of COVID-19 was identified from early January 2020, vaccine development began. Although usually taking over ten years (Thanh Le et al, 2020), within the space of a year, the administration of COVID-19 vaccines outside clinical trials had begun. An ideal global distribution of a successful vaccine would prioritize health workers, followed by countries with major outbreaks and then elderly and those particularly at risk (Wouters et al, 2021). However, fears that the distribution of vaccines may not meet that ideal were fuelled both by the case of high-income countries hoarding vaccines for the swine flu (H1N1) pandemic in 2009 (Okonjo-Iweala, 2020) and personal protective equipment (PPE) in the early weeks of the COVID-19 pandemic in 2020 (Dallas et al, 2021).

By the time COVID-19 vaccines began to be widely administered, the initial seeds for inequalities in their distribution were already sown. Key vaccine developers received large amounts of public funding from governments in high-income countries in support of the trial, development and manufacture of their COVID-19 vaccines. In return, those governments booked priority access to those vaccines. However, such governments have been criticized for not acquiring the rights to manufacturing know-how when investing in research and development (R&D) and thus not obtaining greater rights to potentially force the technology to be shared in the interests of vaccinating the world (Love, 2021).

Although the full details of these funding arrangements are mostly not publicly available, some basic facts illustrate the scale of this support. Most prominently, the United States’ Operation Warp Speed, launched on 15 May 2020, took an ‘at-risk’ approach to support the trials and manufacturing of vaccines that had not yet been approved. More than $1 billion was provided to each of Moderna, Pfizer, Johnson & Johnson, Novavax, AstraZeneca and Sanofi/GlaxoSmithKline for their joint candidate (Bown and Bollyky, 2021). Due to the invocation of the Defense Production Act, manufacturers had to prioritize allocating their capacity to filling US government orders. The funding supported not just the vaccine developer (for example, Moderna), but also other firms that would play key roles in the supply chain. In another example, the UK government announced spending of more than £2.9 billion from May to October 2020 for priority access to 267 million doses (Bown and Bollyky, 2021: 37). The European Union (EU) also provided direct financing support, for example to BioNTech and CureVac. Other countries, including Australia, Canada, Japan and South Korea, bought directly from vaccine developers. Over-ordering was widespread and justified on the basis of uncertainty over which vaccines would be successfully developed and the need to spread risk (Wintour, 2021).

Once these vaccines received initial regulatory approvals, they were rolled out in national programmes by countries that had pre-ordered. Vaccination programmes in Europe and the United States began at the end of 2020/beginning of 2021 with the Pfizer/BioNTech and Moderna vaccines – both of which are mRNA vaccines. However, the demand for vaccines in already well-vaccinated countries has not ended with an initial two doses for all adults – the original definition of fully vaccinated for most vaccines, except single-dose regimens – as vaccination programmes have expanded with booster shots and doses for children. Israel was the first country to start booster shots, in July 2021, and was joined in the following two months by many other high-income countries. However, they and others planning booster doses were criticized by the World Health Organization’s (WHO) Director General Tedros Adhanom Ghebreyesus, who called in early August 2021 for a moratorium on such programmes, while the WHO Africa Director said that booster shots ‘make a mockery of African recovery’ (Dahir, 2021). COVID-19 vaccination programmes were also expanded in the second half of 2021 to include children in high(er)-income countries, although such allocation before doses have been administered in low(er)-income countries has been criticized by the WHO’s Director General and Oxford University’s Sarah Gilbert (one of the original developers of the Oxford/AstraZeneca vaccine). Such programmes and the possibility of further boosters undermine any idea that already highly vaccinated countries no longer need more COVID-19 vaccines and may continue to delay availability of doses for other countries.

It was not just high-income countries that developed, manufactured and initially accessed COVID-19 vaccines, however, with China and Russia prominently developing their own candidates with state support. On 31 December 2020, China gave conditional approval for general use of a Sinopharm vaccine, produced by Beijing Bio-Institute of Biological Products Co Ltd, a subsidiary of China National Biotec Group. A second Chinese vaccine, Sinovac’s CoronaVac, was approved for general use on 6 February 2021. Both Sinopharm and Sinovac vaccines are inactivated vaccines (a long-established approach to boosting the body’s immunity by exposing it to killed viral particles). China’s domestic vaccination programmes, using both vaccines, passed the milestones of 1 billion COVID-19 doses administered on 19 June 2021 and 2 billion on 26 August 2021. In Russia, a widespread rollout of its Sputnik V vaccine began in December 2020, and the vaccine was key in Russia reaching 100 million doses administered by 22 October 2021.

A substantial number of COVID-19 vaccines have been exported from China, but largely outside of COVAX and especially to middle-income economies. By 8 October 2021, it was estimated that China had exported 1.1 billion doses (either as bulk substances – the key ingredients for vaccines – or finished doses) to 123 countries (Song, 2021), with Brazil, Pakistan and Iran among the biggest recipients (Mallapaty, 2021). By October 2021, CoronaVac was the most administered COVID-19 vaccine in the world.

Other countries also participated in the manufacture and distribution of COVID-19 vaccines but through technology transfer under license. India’s COVID-19 vaccination drive has primarily been driven by a vaccine branded as Covishield, manufactured by the Serum Institute of India (SII) – the world’s largest vaccine manufacturer by volume – under license from AstraZeneca. The modified adenovirus vaccine was originally developed at Oxford University. SII did not receive financial support from the Indian government until 2021 (along with Bharat Biotech), although at-risk funding of $300 million from the Bill & Melinda Gates Foundation via GAVI, the Vaccine Alliance, to support supply to COVAX was announced in August and September 2020. Covishield received government approval for emergency use on 3 January, paving the way for the commencement of India’s COVID-19 vaccination programme on 16 January 2021. A domestically developed and manufactured vaccine, Bharat Biotech’s Covaxin, also received emergency use approval at the same time and inclusion in the country’s vaccination programme. While other technology transfer agreements have been made (for example, Hyderabad-based Biological E with Johnson & Johnson) and other Indian companies have attempted developing their own vaccines, SII has played the primary role in India’s domestic vaccination programme – producing 88 per cent of the first 1 billion doses administered domestically, a milestone reached on 21 October 2021. However, despite India receiving global praise for the export – especially to neighbouring countries – of more than 60 million vaccines before the end of March 2021, its exports were suspended until October 2021.

South America has also made significant progress on COVID-19 vaccination (Harrison et al, 2022). Indeed, by late August 2021, it had a higher share of vaccinated people than other continents – a position it still held through to April 2022 (the last data update before print) (see Figure 4.1). This was helped mostly by the import of vaccines from China, as well as some local production of vaccines. For example, Brazil has local production of vaccines under license from Oxford/AstraZeneca and Sinovac, while Latin American production also involves a Mexico–Argentina collaboration to co-produce the Oxford/AstraZeneca vaccine and Cuba’s domestically developed vaccine.

Figure 4.1:
Figure 4.1:

Share of people vaccinated against COVID-19, 18 April 2022

Note: Alternative definitions of a full vaccination, for example having been infected with SARS-CoV-2 and having one dose of a two-dose protocol, are ignored to maximize comparability between countries.Source: Our World in Data (2022)

LICs, and especially Africa, have been left behind on COVID-19 vaccination. This inequality is not just vis-à-vis high-income economies or what are typically classified as countries in the ‘Global North’, but also vis-à-vis upper middle-income countries, and to a lesser extent vis-à-vis lower-middle-income countries – see Figure 4.2.

Figure 4.2:
Figure 4.2:

COVID-19 vaccine doses administered per 100 people, by income group

Notes: All doses, including boosters, are counted individually. Country income groups are based on the World Bank Classification.Source: Our World in Data (2022)

COVAX and the struggle for vaccine equity

COVAX (the COVID-19 Vaccine Global Access Facility), the vaccines component of the Access to COVID-19 Tools (ACT), was launched in April 2020 with the aim of promoting equitable access to COVID-19 vaccines. COVAX was created by GAVI (The Global Alliance for Vaccines and Immunization), the WHO and Coalition for Epidemic Preparedness Innovations through push financing (supporting pharmaceutical companies’ R&D directly) and also employs advanced market commitments as a pull mechanism through procurement upon licensure. Its initial aim was to distribute 2 billion doses by the end of 2021 (Berkley et al, 2020), sufficient to cover 20 per cent of people in participating countries (that is, enough for high-risk people and healthcare workers). It aimed that all countries would buy-in – some self-financing and others as donor-funded (Shadlen, 2020).

The first COVAX vaccines were delivered relatively early in the overall context of global COVID-19 vaccination, with a batch of AstraZeneca vaccines arriving in Ghana on 24 February 2021. That vaccine received emergency use authorization approval from the WHO on 15 February 2021 – a necessary standard for COVAX procurement. Seth Berkley, CEO of GAVI, noted that the time gap between the administration of first doses of COVID-19 vaccines anywhere and their distribution in ‘many countries in the developing world … is extraordinary compared to the historical timeline’ (Berkley, 2021).

However, COVAX’s push for equitable access has been undermined especially by countries prioritizing national procurement of vaccines and therefore reducing availability for COVAX given the limited overall supply. High-, and then middle-income, countries pursued bilateral procurement deals, seeking to have many more doses than the coverage of 20 per cent of their populations they could aim for with COVAX (Shadlen, 2020). The WHO’s Director General has consistently pleaded for more doses to be given to COVAX. In April 2021, for example, he suggested that while leaders of the world’s biggest economies had provided some financial support for COVAX, they had also undermined it by hoarding supplies (Ghebreyesus, 2021b).

COVAX was particularly hit by a shortfall on the projected delivery from SII, which was initially expected to be its biggest supplier. Under license from AstraZeneca, the Indian vaccine manufacturer was projected to supply over 1 billion doses of COVAX’s initial (January 2021) forecast of 2.3 billion doses by the end of 2021. However, this target was not met as India’s production capacity was directed towards supplying its domestic vaccination programme from late March 2021 as India’s second wave of COVID-19 materialized. Exports from SII to COVAX did not resume until 26 November 2021. Heavily linked to this shortfall from India, it took until 15 January 2022 for COVAX to reach 1 billion doses shipped (UNICEF, 2022).

COVAX’s struggles are also because of regulatory and availability issues with other COVID-19 vaccines. Novavax’s vaccine was expected to play a key role in COVAX’s 2021 supply but did not receive its first approval from a major regulator – the European Medicines Agency – until late December 2021. COVAX did not initially invest much in the Pfizer or Moderna mRNA vaccines (a relatively recent type of vaccine that instructs cells in the body to make a protein to trigger an immune response), with the suitability of these vaccines for LICs questioned due to extremely low storage requirements (The Economist, 2021). Delays in regulatory approval meant that COVAX procurement from Sinopharm (approved by WHO, 7 May 2021, first COVAX delivery 11 August 2021) and Sinovac (approved by WHO, 2 June 2021, first COVAX doses delivered 31 August 2021) had been limited in 2021, while Russia’s Sputnik V had still not been approved by the WHO by April 2022.

The vaccines that have been central to immunization programmes in high-income countries have not been made widely available in LICs. An analysis of the first nine months of 2021 shows that Pfizer/BioNTech and Moderna only sold 1 per cent and 3 per cent of their supply to COVAX, while Johnson & Johnson sold 25 per cent and AstraZeneca 19 per cent. Remarkably, of the first 2 billion COVID-19 Pfizer vaccines shipped, only 15.4 million went to LICs (Amnesty International, 2021).

Donations of doses – either direct or via COVAX – have been slow and insufficient to address the extent of vaccine inequality. Following a trickle of smaller donation pledges through the first half of 2021, at the G7 Summit in June 2021, the United States pledged an additional 500 million doses (beyond the 87.5 million earlier) and the UK 100 million – both for low- and middle-income countries (LMICs) by 2022 (Padma, 2021). On 22 July 2021, the European Commission announced that ‘Team Europe’ (the EU and all 27 member states) would share 200 million COVID-19 vaccines, mostly through COVAX, with LMICs by the end of 2021. Despite the rhetoric of the importance of vaccinating the world, substantial issues have arisen with donations. Sharing doses sooner is more impactful than later, but often there have been substantial delays between promises made to share vaccines and their actual delivery (for example, Newey et al, 2021, 9 July; see also Our World in Data, 2021). Indeed, AVAT (Africa Vaccine Acquisitions Trust), Africa CDC (Africa Centres for Diseases Control and Prevention) and COVAX issued a statement (29 November 2021) saying that ‘the majority of the donations to-date have been ad hoc, provided with little notice and short shelf lives. This has made it extremely challenging for countries to plan vaccination campaigns and increase absorptive capacity … Countries need predictable and reliable supply’ (Africa CDC, 2021; also see COVAX, 2021).

An ongoing challenge for, and portal on, global development

Global COVID-19 vaccine inequality is an enormous challenge. To date, the pursuit of perceived national self-interest by high-, and to some extent middle-, income countries has overridden what the world needs in terms of managing and ending the pandemic and minimizing the economic impact. While such countries have prioritized access to vaccines for more vulnerable populations domestically, they have not acted to protect the most vulnerable in a global context. The major multilateral initiative to promote vaccine equity, COVAX, has received some funding but has struggled to access doses – being directly undermined by bilateral deals and pre-booking of doses. As a result, LICs and some lower-middle-income countries continue to be left behind in terms of COVID-19 vaccine access. The continuation of vaccination programmes in already relatively highly vaccinated countries – to include children and booster doses – serves to reinforce these inequalities.

The extent of COVID-19 vaccine inequality is not just a “catastrophic moral failure”, as termed by the WHO Director General, but is disastrous economically as well as epidemiologically. Various studies have pointed to ongoing economic costs for all countries due to the ongoing pandemic. An International Monetary Fund (IMF) study in May 2021 estimated that immediate investment of $50 billion in COVID-19 vaccination would yield $9 trillion (or a return on investment of 267 per cent per year over four years) in growth by 2025. The IMF’s Managing Director, Kristalina Georgieva, touted COVID-19 vaccination as ‘the highest return on public investment in modern history’ (Kristof, 2021). The heads of the IMF, World Bank, WHO and World Trade Organization (WTO) warned in July 2021 that inequity in COVID-19 vaccine distribution would hold back global economic recovery (Wintour, 2021). Epidemiologically, WHO has stated that ‘vaccine inequality is the world’s biggest obstacle to ending this pandemic and recovering from COVID-19’ (WHO, 2021a). Having substantial unvaccinated populations increases the possibility of new, vaccine-resistant mutations emerging (Ghebreyesus, 2021a). In light of the identification of the Omicron variant in November 2021, South African President Cyril Ramaphosa simply warned: “[V]accine inequality cannot be allowed to continue … Until everyone is vaccinated, we should expect that more variants will emerge” (Ramaphosa, 2021).

COVID-19 vaccine inequality can be addressed by expanding the pie of available vaccines and/or by a better distribution of that pie. The production of COVID-19 vaccines has been scaled up enormously by the original developers of those vaccines and the licensing of their technology to manufacturing partners. The People’s Vaccine campaign, WHO, Unitaid and the South Centre, among others, have advocated expanding the pie of vaccines and other COVID-19-related products through a TRIPS (Trade-Related Aspects of Intellectual Property Rights) waiver, originally proposed by India and South Africa to the WTO in October 2020. While the example of how patent-free antiretrovirals transformed treatment for people living with HIV-AIDS is frequently pointed to, it is unclear what – if any – effect waiving patents would have on the supply of vaccines (for example, Hotez et al, 2021). Vaccines do not have a codified recipe that others can replicate (Gates, 2021), and the cooperation of the originator is required for scaling up – otherwise trials would have to start from the beginning (Science and Technology Committee, 2021). Jamie Love, director of Knowledge Ecology International and prominent campaigner on patents, has thus said that “know-how is the bigger problem than patent rights in the shorter run” (Lerner, 2020). However, mechanisms to force companies to do this are limited, especially as a clause on sharing know-how was not required by many governments when providing initial funding. As the COVID-19 pandemic continues and volumes of vaccines have increased, the weight of the access problem has shifted even more clearly in terms of maldistribution being the key problem. A much better allocation of the growing pie of COVID-19 vaccines would be the fastest way to increase the number of vaccines available to LICs. This requires increased doses (and prompt delivery) for COVAX and donation pledges being delivered promptly, as the WHO (2021b) has repeatedly asked for, and Médecins Sans Frontières (MSF, 2021) has also argued for.

Ultimately, the case, and difficulties of, COVID-19 vaccines may point to wider struggles in addressing global development problems. We live in a world that faces several interconnected development problems that cut across both the Global North and Global South, rather than just being located within the latter. Examples include, notably, climate change, but also addressing global inequality and combatting tax avoidance, which simply cannot be done on a national basis alone. As well as interconnected issues, there are also shared issues such as relative poverty, social protection, decent work, effective states and so on. Although such challenges may relate to all countries, they are extremely uneven in their impacts. Moreover, as with COVID-19 vaccines, the solutions are also likely to cut across Global North and South relations with multidirectional learning and collaboration in the global collective interest required. Lessons must be learnt from the failures currently experienced from COVID-19 vaccination to not just better address the ongoing pandemic, or future crises, but for a wider range of global development issues. Coordination is needed for both COVID-19 vaccination and climate change (Pai and Olatunbosun-Alakija, 2021). A danger is that higher-income countries prioritize their own populations at the expense of the most vulnerable globally and everyone’s interests. The current case has demonstrated how the pursuit of perceived self-interest is not just bad for the world as a whole but also for the original architects of that self-interest.


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    Figure 4.1:

    Share of people vaccinated against COVID-19, 18 April 2022

  • View in gallery
    Figure 4.2:

    COVID-19 vaccine doses administered per 100 people, by income group

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