Lessons learned from the end of COVAX: major achievements and key success factors to prepare for the next pandemic

At the beginning of the pandemic, GAVI, The Vaccine Alliance, the United Nations Children’s Fund (UNICEF), and the Coalition for Epidemic Preparedness Innovations (CEPI) set up the COVID-19 Vaccines Global Access Facility, COVAX, to help quickly distribute developed COVID-19 vaccines to low-and middle income (LMIC) countries. The original goal was to provide enough vaccines to each country to cover 20% of the population or approximately 2 billion doses, to cover healthcare workers and high-risk groups. At the beginning of December 2022, GAVI announced they would be ending COVAX in 2024. Since the decision is not final it’s a good time for Alcimed to take stock and ask whether COVAX has met its goals, what impact it had on pandemic outcomes this far, and what we can learn from the COVAX experiment for future pandemics to be more prepared. Our team answers all these questions in this article.

The end of COVAX

According to GAVI, COVAX has enough capacity to run through 2024, at which point the 37 developing or middle-income countries currently involved in the COVAX scheme will no longer be able to access vaccines, while the 54 low-income countries which qualify for GAVI vaccine support will still have access to COVID-19 vaccines through 2025, with the currently allocated funding.

After that, GAVI will transition COVID-19 vaccines to be included in their routine vaccination programs in preparation for the transition to endemic potentially seasonal COVID-19 infections. At that point, COVID-19 vaccinations would be restricted to booster vaccines for the high-risk groups. Discussions prior to the final decision are ongoing as GAVI completes in-country discussions. Should a COVID-19 variant arise that drives the need for wider booster efforts, COVAX will still have a place in that emergency response.

What was accomplished by COVAX?

Since its inception, COVAX has delivered 1.84 billion vaccine doses to 146 countries. Only 500 million of those doses were delivered by November 2021 , when most developed Western countries had already vaccinated 70% of their population and were considering distributing booster shots. The major criticism of COVAX is that most of the doses that arrived, arrived late enough to not have a large impact on the pandemic in developing countries. The most critical shortcomings of COVAX, identified by public health officials, is basing COVAX on market dynamics, i.e., allowing those who were willing to pay more for vaccines to jump to the front of the line. The second major hit came with the Serum Institute of India being prohibited from delivering its contracted doses to COVAX during the deadly Delta wave in India. Rather than meet their commitment, political leaders in India opted to shift vaccines to their national vaccination campaign. These delays and unpredictable stock shortages made running vaccination programs in COVAX countries very challenging. This only encouraged COVAX countries that could afford to do so to negotiate for vaccine doses on their own rather than rely on COVAX.

This does not mean that the COVAX initiative was a waste of time. Like many 1st implementations of an innovative concept, COVAX has driven important conversations, set aspirational goals for equitable vaccine access, and highlighted some important key success factors for a future iteration of COVAX for a future pandemic.

What are the key success factors for COVAX 2.0?

Improving COVAX by considering vaccine nationalism

Understanding how vaccine nationalism works provides insights into how to improve COVAX.

As with any innovation, you must consider the way people work. In this case, even though vaccine nationalism, the tendency for countries to see to their own vaccine needs first, was driving both major shortcomings of COVAX. Attempting to overcome vaccine nationalism directly is unlikely to result in a better outcome for COVAX during the next pandemic. However, understanding how vaccine nationalism works provides insights into how to improve COVAX. For example, the countries that fared best for vaccination supply during the pandemic were those countries in which the vaccines were manufactured or countries in their geographic vicinity.

Develop LMICs’ vaccine manufacturing capabilities

Regional manufacturing hubs would likely be a large improvement over the current COVAX setup.

Therefore, a key success factor for COVAX 2.0 would be to make low and middle-income countries (LMICs) less dependent on vaccines purchased from major pharmaceutical companies manufactured in wealthy nations and more self-reliant or at the very least regionally reliant.

This would require LMICs to focus on developing their own vaccine manufacturing capabilities. Not every country needs to develop the capacity to manufacture its own vaccines. Regional manufacturing hubs would likely be a large improvement over the current COVAX setup.

These efforts are already underway. In 2021, the WHO invested in an mRNA vaccine technology hub in South Africa and GAVI recently announced “a plan to support the development of a regionally diversified vaccine manufacturing ecosystem ”. Such a vaccine ecosystem would focus on 3 main pillars:

• Support from GAVI for strategic antigen selection by manufacturers/countries
• Vaccine market shaping
• Demand creation through regional manufacturing

Read also : Pandemic Preparedness: how to prepare for the next pandemics?

An initiative supported by the African Union, Africa CDC, G7, and others may also institute financial support for regional manufacturing through Advance Market Commitment (AMC) for African vaccine manufacturing. With these discussions and initiatives ongoing, the future of COVAX 2.0 already looks bright indeed. Pharma and biotech companies need not get left out of these discussions, but should start considering how this push for regional manufacturing could impact them and their current vaccine distribution structures. Alcimed follows closely the fast evolutions in this field and is ready to support you on these subjects! Don’t hesitate to contact our team!