A nurse holds a vial of the Pfizer vaccine

COVAX is essential for the lowest-income countries, which lack the purchasing power that comes with economies of scale.Credit: Ismael Rosas/Eyepix Group/Barcroft Media/Getty

In a significant moment for the fight against the coronavirus, international funders came together in early June and pooled funding towards an ambitious undertaking: to buy enough COVID vaccines to immunize the 20% of people most vulnerable to the virus worldwide, such as health-care workers and the elderly. High- and middle-income countries would pay into the fund and receive a share of the vaccines procured, and poorer countries would receive vaccines free of charge. But the project, a pioneering effort called COVAX, is struggling to meet expectations.

High-income countries have been buying up large tranches of the current and future vaccine doses directly from vaccine suppliers. Middle-income countries are also negotiating their own supplies. This has left relatively few vaccines for COVAX, which needs to deliver 2 billion doses by the end of this year to reach its goal. COVAX has confirmed purchases for 1.07 billion doses and options reserved on at least 900 million more, according to researchers.

But, as the director-general of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus, said in an impassioned plea last week, COVAX is competing for these supplies. Some people in the lowest-income countries might need to wait until at least 2022 to get their vaccines.

Last August, Sweden’s prime minister, Stefan Löfven, declared: “This cannot be a race with a few winners.” But nations are not only competing, they are in the most unequal of races. It must now be a priority for governments everywhere to get the COVAX project back on track — both to help the world’s most vulnerable people and as a means to control the pandemic.

Governments no doubt think they are acting in the best interests of their people by negotiating directly with suppliers. But, by competing in this way, they are sowing panic and undermining the principle of mutuality that underpins COVAX, which they initially agreed to back, and which researchers argue could help to bring a faster end to the pandemic.

COVAX was conceived to prevent what happened with vaccines for pandemic influenza A (H1N1) in 2009, when richer countries monopolized vaccine supplies by doing one-on-one deals with suppliers. At the start of the coronavirus pandemic, COVAX’s founders were convinced that a better system could be found to ensure more-equitable access to vaccines, especially for the world’s most vulnerable populations.

At one level, COVAX has had a strong start. It has 190 member countries. It has so far raised just over US$4 billion of its $6.8-billion funding target for 2021. COVAX says it has enough vaccines in the pipeline to achieve its target of providing low-income countries with access to 1.3 billion doses, free of charge, by the end of this year. Nothing like this has been attempted before, says Seth Berkley, the chief executive of Gavi, an organization that funds vaccine provision for low-income countries and which helped to create COVAX, together with the WHO and the Coalition for Epidemic Preparedness Innovations, a consortium of funders, companies, governments and researchers involved in vaccine development.

But one reason why COVAX might not be able to reach the target set out in its timetable is its funding mechanism, called the COVAX Facility. This allows countries to make their own purchases — as many have been doing — at the same time as putting money into COVAX. Pressure groups are also concerned about a lack of transparency on pricing. Nations buying their vaccines through COVAX are placing orders without knowing precisely how much they will need to pay.

At present, says Andrea Taylor, a researcher at Duke University in North Carolina who is studying COVID vaccine manufacturing capacity around the world, it looks likely that in 2021 COVAX will deliver around 570 million doses, which is between one-quarter and one-third of its total target for the year. COVAX disagrees, and says it has many more deals with suppliers in the pipeline.

However, in an effort to help steady the ship, COVAX launched a scheme in mid-December by which countries can donate surplus vaccine doses. COVAX says some of these donations could be imminent, but, with vaccination programmes just starting, it is not clear at what point countries will be willing to let go of excess supplies. The WHO is urging nations to release any surplus stock immediately.

In the middle of a pandemic, perhaps it was too much to expect countries to prioritize a collective scheme over securing their own supplies. Even the European Union’s collective vaccine-procurement scheme is struggling to prevent individual member states from seeking to do separate deals to obtain vaccines.

COVAX has to succeed. It is essential for the lowest-income countries, which lack the purchasing power that comes with economies of scale. A pandemic must be managed at a global scale. Until the virus is controlled everywhere, every nation is at risk of further outbreaks. And until COVAX gets the support it deserves, there is little hope of vaccinating the most vulnerable one-fifth of humanity. Not only would this have an obvious human cost, but, without it, it will take longer for the pandemic to end.