To the Editor—Although the rapid development of several vaccines against COVID-19 is an unparalleled scientific accomplishment, one made possible through the collaboration of researchers, industry and funding bodies, the absence of a system that secures equitable access to vaccines has uncovered deep fissures in the global governance systems for health, as noted in a recent Nature Medicine Editorial1.

For example, advance purchase agreements for vaccines against COVID-19 have favored affluent countries, allowing them to secure 150–500% of their predicted needs2, while many citizens of low-and middle-income countries (LMICs) will remain unvaccinated until 2024.

Additionally, the power of patent-holders and pharmaceutical companies to place conditions on the use of vaccines prices out access for LMICs, and bilateral purchasing deals are rarely disclosed.

By affording priority on the basis of economic or political power, today’s discourse clearly deviates from previous ethical and public-health principles of maximizing lives or life-years saved, and the sentiment that “people’s entitlement to lifesaving resources should not depend on nationality”3.

The COVID-19 pandemic has tested wealthy nations’ commitments to Agenda 2030 (ref. 4) and to ‘leaving no one behind’ at the same time that it has revealed democratic deficits, institutional rigidity, weak accountability systems, and inadequate policy space that protects health-governance systems from economic goals5.

Thus, the as-yet-limited support for the vaccine-sharing and allocation principles of the COVAX initiative6 may be a sign not only of a moral catastrophe, to quote the director-general of the World Health Organization (WHO), but also of inadequate global accountability mechanisms that exposes the consequences of commercial determinants of health.

The ongoing battle for scarce vaccines against COVID-19 also highlights the lack of legally binding mechanisms that hold market actors accountable for failing to act for the public good, and the absence of global mechanisms for coordinating the pooling and sharing of resources.

In a recent example, high-income countries blocked an effort to enable timely, affordable access to products for the ‘prevention, containment or treatment’ of COVID-19, when India and South Africa proposed that the World Trade Organization temporarily suspend Trade Related Aspects of Intellectual Property Rights rules7.

Already in 2019, a Lancet Commission recommended increased utilization of legal mechanisms to advance global health through justice systems8 and to harness the power of law to promote global health and sustainable development, calling upon governments, the WHO and United Nations organizations to make necessary legal reforms to translate vision into action.

The current crisis is a salient opportunity for strengthening the global response to upcoming pandemics. With the belief that vaccines against COVID-19 are a global common good and that allocation should be based on need, we make the following recommendations.

First, a global legal framework is needed to regulate the commercial determinants of health and to secure universal fair access to essential technologies and vaccine production. This may be financed through existing alliances (such as COVAX, or Gavi, the Vaccine Alliance) or by new G7 or G20 standing funds for vaccine development and allocation9. In times of emergency, the World Trade Organization should also grant temporary waivers for Trade Related Aspects of Intellectual Property Rights rules for governments to produce their own vaccines or, if necessary, to exercise compulsory licensing powers for a third party to produce a patented technology. Ideally, perceived legal risk could facilitate the negotiation of purchase transparency, voluntary licensing arrangements and patent sharing while committing the industry to global justice.

Second, to strengthen crisis preparedness4 and make the response less blunt and more evidence-based, coordinated and effective, the existing gaps in infrastructure, technology and information must be reduced. The WHO warns that lockdown-induced disruption (e.g., of childhood immunization and essential care) could cause greater death and suffering than COVID-19 itself10. As LMICs embark on an unprecedented vaccination scale-up, substantial investment is needed to prevent redistribution of scarce health personnel that further undermines routine immunization. Future plans must have a clear health-systems dimension and must include social mobilization and strategies for fighting vaccine misinformation7.

Third, as shown by COVID-19, updated global governance mechanisms are needed that better reflect the contemporary geopolitical order and truly encourage international collaboration across sectors, through political and legal solutions rooted in commitments to justice and shared global responsibility5,8. We call for a 21st-century Bretton Woods–type conference, similar to that of 1944, when states met to improve global economic interaction, secure peace and provide assistance to countries devastated by World War II, which resulted in new global governance structures such as the International Monetary Fund and the World Bank.

Using the dynamics of one acute crisis to build resilience against the next could also serve a greater good in line with the growing notion of the United Nations Security Council that health, poverty mitigation, security and peace are interlinked.