The arrival of several vaccines against the SARS-CoV-2 virus is a global and scientific feat to be commended. Hopes remain high that eventual population immunity from vaccination, or at least protection of people at risk, will mean that health systems can potentially recover, economies resume activity, and restrictions on mixing be relaxed. However, as international attention focuses on which countries will achieve widespread covid-19 vaccine coverage first, we wish to join a growing chorus of public health and clinical policy observers in highlighting the short-sightedness and moral consequences of not distributing the first vaccines equitably around the world.

Many have pointed to the miscalculations involved in failing to disseminate covid-19 vaccines worldwide.^1,2,3 Uncontrolled international viral circulation risks further mutation of the virus to become more pathogenic. It also increases the chances of immune escape variants that are resistant to existing vaccines and re-importation of infection to high-income countries including from mutated strains of the virus.⁴ Economic analyses suggest up to $9 trillion could be lost in the global economy,  if high-income countries vaccinate their own populations while leaving low and middle income countries’ (LMIC) populations unprotected.⁵ Vaccinating citizens in high-income countries without parallel delivery globally is likely to prolong the pandemic and yield fewer gains: around 50% fewer deaths averted by one analysis.⁸

Above all, we believe that access to covid-19 vaccines is a human right;¹³ it morally reprehensible that health and care workers in one region of the world and citizens most at-risk from complications of covid-19 infection may achieve full protection, while they remain unprotected in another region because of lack of access to vaccine doses. In countries like Nigeria, where the health system has been exhausted, vaccination of frontline health workers has only just started. With adequate financing and a coordinated global response, we believe governments can chart a more positive and equitable path through COVAX, the global mechanism to distribute vaccines to 90% of the global population.

We propose three key actions for governments to take now: vaccine sharing or exchange, monetary commitments to COVAX, and fostering collaboration between vaccine manufacturers. These actions align with the Public Health Emergency of International Concern (PHEIC) status of the pandemic, the guidance from the World Health Organization’s director general, and the 2005 International Health Regulations—an instrument of international law that is legally binding for all 194 WHO member states.

Firstly, vaccine sharing. High-income countries have bought vaccine doses far in excess of what they require to protect priority groups.¹⁰ Canada, for example, obtained up to four times the total number needed to cover its entire population. Whilst pre-purchasing is not bad in itself, high-income governments should use only the doses they need to vaccinate their high risk groups in 2021. Excess doses produced this year should be shared equitably to protect all vulnerable populations internationally on the basis of epidemiologically sound criteria, including population counts, viral circulation, and numbers of workers and citizens in vulnerable groups.² Canada, for example, has already pledged to donate or exchange excess doses;¹² discussions between countries and agencies coordinating COVAX should progress this further and more widely with immediate effect.

Doses in excess of what is needed to cover at-risk groups in countries that have over-ordered should be shared without delay until all vulnerable populations are covered everywhere. Only then should high-income countries start vaccinating low risk populations. 

Secondly, funding to COVAX, the WHO/GAVI platform for global vaccine purchasing and equitable distribution, and WHO’s emergency use listing of vaccines also needs prioritisation. While pledges by high-income countries and private finance institutions seem positive, with funding calls by GAVI all largely met to date, vaccine delivery to LMICs has been undermined by the fact that the first wave of vials have almost entirely gone to rich countries. Governments have shown willingness and the ability to fund their own economies and covid responses to around 11% of GDP, compared with merely 0.004% of GDP to global covid-19 distribution.⁹

Furthermore, covid-19 isn’t the only health crisis affecting the world; distributing vaccines equitably worldwide in a way that buys confidence among communities and health workers is critical to tackling wider health programmes and improving health worker recruitment with technical support where needed. Countries around the world still lack access to personal protective equipment, covid-19 testing technology, and other essential products needed to tackle local epidemics.⁶ Vaccine manufacturers also have their part to play. For a coronavirus vaccine to be distributed through the COVAX facility, it needs to have regulatory approval through the emergency-use listing from WHO. Instead, we have seen pharmaceutical companies prioritise regulatory approval in wealthier countries, where profits can be maximised. So far, only the Pfizer-BioNTech vaccine has received the listing from WHO—a vaccine that was added to the COVAX portfolio as recently as 22 January 2021, with only 40 million doses. The renewed commitment from the USA to WHO and COVAX is a welcome announcement: the G7 and other global forums should clearly prioritise COVAX in upcoming meetings and seize this opportunity to place global health security at the centre of policy and strategy.

Finally, rapid coverage of covid-19 vaccines in at-risk populations worldwide is unlikely to be successful if we rely on current manufacturing capacity. The announcement that Sanofi and Novartis—French and Swiss multinational pharmaceutical companies, respectively—would produce vaccine doses originally developed by Pfizer-BioNtech is the kind of collaborative  approach that is needed from manufacturers and governments. Intellectual property rights are a recognised method that allows pharmaceutical manufacturers to recoup their investment; there are, however, established protocols to sharing technology to allow generic production at lower cost—for example, using the World Trade Organisation’s Trade Related Aspects of Intellectual Property Rights (TRIPS) protocols.¹¹ Manufacturers and governments in LMICs are ready and willing to support the global drive to scale up production of covid-19 vaccines and should be supported and enabled to do so because it is in everyone’s interest and will help shorten the pandemic. They should not be prohibited from doing so because of a desire to maximise profits. Licensing arrangements and technology transfer, such as those between AstraZeneca and the Serum Institute of India and other parties should be encouraged. LMICs should be able to access vaccines at a fair price: the example of South Africa being asked by the Serum Institute to pay almost twice the price paid by the EU for the Astra Zeneca vaccine⁷ is an example of unfair purchasing arrangements created by the current market structures and lack of transparency. Greater transparency called for in the WHO resolution on the transparency of markets for medicines, vaccines, and medical products and reiterated by the European Commission is key to fair distribution of covid-19 vaccine in a way that best supports the goal of ending this pandemic.

The covid-19 pandemic has shown the need for responsive and coordinated global health responses. No country can tackle this challenge alone. Protecting the citizens of some countries and not of others, is not good public health policy as the eventual arrival of new variants in one region puts everyone everywhere at risk. Stopping the spread of the pandemic everywhere is ultimately the only way to guarantee the safety of people globally. We call on governments, international institutions, health worker and patient organisations around the world to renew their partnerships with friends and colleagues around the world, and begin delivering an equitable strategy to covid-19 vaccine delivery without delay.

Lenias Hwenda, founder and chief executive officer, Medicines for Africa

Faisal Shuaib, executive director and chief executive officer, National Primary Health Care Development Agency, Nigeria

Julius Mugwagwa, associate professor in innovation and development, UCL Department of Science, Technology, Engineering, and Public Policy, UK

Skhumbuzo Ngozwana, president and chief executive officer, Kiara Health; board member, Federation of African Pharmaceutical Manufacturers Associations

Feras Hawari, president, Centre for Disease Control, Jordan

Atousa Bonyani, pharmacist and WHO consultant, Iran

Luke N Allen, director, Healthier Systems, UK

Jonny Currie, public health and primary care doctor, Wales

Declaration of interests: We declare that we have read the BMJ policy on declaration of interests and have nothing to declare.

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