Ending the covid-19 pandemic requires widespread, global vaccination, but vaccine costs and logistics present serious obstacles. Over 12 billion doses of covid-19 vaccines have been procured, and high income countries have already begun giving them. This has led to growing concern that barring a major increase in high income country support for multilateral initiatives, low and middle income countries will be increasingly dependent on potentially less efficacious vaccines from other sources, particularly China. It is now predicted that high income countries will have full coverage by the end of 2021, while low income countries might not achieve full coverage until 2023, if at all. 

Tiered pricing based on the income levels of recipient countries can also affect the delivery dates and number of doses available, and the few pricing negotiation details that have been made public indicate serious discrepancies. Notably, richer countries that supported the development of the vaccines will pay less for them. For example, the EU will pay a fraction of the cost of the Pfizer/BioNTech vaccine, which it invested in early on, compared to the Philippines ($14.76 vs $25 per dose respectively). 

The costs of deploying the vaccines represents a further challenge, especially for poorer countries that already face budget constraints and may have to retool their existing health infrastructure to implement large scale vaccination campaigns. Global funding mechanisms have been developed to allow low and middle income countries to gain more equitable access to vaccines, in particular the COVAX Facility, a partnership among GAVI, the World Health Organization, and the Coalition for Epidemic Preparedness Innovations (CEPI). Currently, COVAX is the third largest player in the vaccine market in terms of both potential and confirmed dose purchases. COVAX, which has received a fresh infusion of money from the Biden Administration and has announced the arrival of its first shipment in Ghana, aims to distribute over 330 million doses of the vaccine in the first half of this year, but this will still not be enough to ensure that all participating low income countries have sufficient doses to achieve community protection. Moreover, wealthier nations have also requested allocations of COVAX vaccines, and Canada has already received initial doses.

The Chinese government is providing loans to countries in Africa, Latin America, and the Caribbean to purchase Chinese vaccines, which is not only more affordable but also easier to deploy. However, borrowing to finance health expenditure for vaccines raises critical, ethical issues. Such financing mechanisms can further compromise the long term sustainability of these countries’ health systems if borrowing countries remain indebted to China.

The Russian government is also leveraging its Sputnik V vaccine for political advantage, beginning with a deal with the Palestinian Authority.

What we have right now is a vaccine struggle that pits nation against nation and also affects impoverished inner cities and remote areas that may be neglected or deprioritized within high income nations. This is a moral dilemma with health consequences, as preferential distribution can only increase existing health inequities and could escalate the emergence and spread of new variants.

Failure to address these issues may jeopardize the overall effectiveness of vaccination campaigns and the prospects of ending the pandemic. In line with a recent announcement by the World Health Organization and United Nations, we urge global collaboration to ensure vaccine equity and the rapid deployment of vaccines to all corners of the world. 

Moving forward, a multilateral approach in the international system is key. Above and beyond the pledges made at the recent G7 meeting, global funding for COVAX must increase further and high income countries must avoid requesting vaccine allocations from COVAX.

We should and must use this crisis as an opportunity to address the larger issue of the structure of the global health system and begin to shape a more rational and equitable vaccine financing strategy for the future. Borrowing to finance health expenditures is nothing new for low and middle income countries, but increased, unexpected borrowing coupled with the emergence of China (and, to a lesser extent, Russia) as a leading steward for vaccine acquisition is problematic. This is particularly true in the case of China, whose vaccine is reported to be less efficacious than the vaccines currently on the market. There is also a concern that China may use countries’ indebtedness and reliance to garner support for its own interests. 

In short, in respect to protecting the world against covid-19 and averting ongoing economic disruption, the greatest part of our task remains undone. We are still very much in the grip of the pandemic and have not yet devoted the funding and political will to ensure no one is left behind. Unless we can ensure worldwide vaccination coverage, the pandemic will continue, posing a threat both to lower and higher income countries, guaranteeing health, social, political, and economic consequences that will ultimately cost more to recover from than vaccinating populations now.

Jeffrey V Lazarus, Barcelona Institute for Global Health (ISGlobal), Spain

Danielle Guy, Barcelona Institute for Global Health (ISGlobal), Spain

Kenneth Rabin, City University of New York (CUNY) Graduate School of Public Health and Health Policy, USA

Kathleen E Upton, Barcelona Institute for Global Health (ISGlobal), Spain

Scott C Ratzan, City University of New York (CUNY) Graduate School of Public Health and Health Policy, USA

Heidi J Larson, London School of Hygiene & Tropical Medicine, United Kingdom

Lawrence O Gostin, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, USA

Ayman El-Mohandes, City University of New York (CUNY) Graduate School of Public Health and Health Policy, USA

Competing interests: none declared