Winding down COVAX – lessons learnt from delivering 2 billion COVID-19 vaccinations to lower-income countries

Even before the first COVID-19 vaccine was approved, it was clear that ensuring equitable access to it was going to be a huge challenge.

In the absence of a global agreement to make sure pandemic vaccines were accessible to all, there was concern that doses would be monopolized by higher-income countries.

To prevent this from happening, COVAX was established, a partnership between the Coalition for Epidemic Preparedness Innovation (CEPI), vaccine alliance Gavi, UNICEF and the World Health Organization (WHO).

Now, nearly three years and 2 billion vaccines later, COVAX is being wound down. So, what did it achieve? And what have we learnt for a future pandemic?

During the H1N1/swine flu pandemic, many countries missed out on vaccines. Drawing on these lessons, COVAX was set up on the principle that ‘no one is safe until everyone is safe’.

COVAX was launched in April 2020, and by the end of that year, 190 countries of all income levels had agreed to participate in COVAX, making it one of the most significant multilateral partnerships of the 21st century, WHO says.

The first deliveries of vaccines were made in January 2021 and by the end of 2022, it had delivered 1.9 billion vaccines to people in 146 countries – approximately 90% of which went to lower-income countries. This represents the fastest and most complex vaccination deployment programme ever. The roll-out averted around 2.7 million deaths, modelling by Imperial College London suggests.

COVAX’s first priority was to help rapidly protect high-priority groups – those most likely to come into contact with the virus and those most vulnerable to severe illness or death.

Countries who could not afford the vaccine would be provided it free of charge, funded by donor governments. A funding mechanism known as the Gavi COVAX Advance Market Commitment (AMC) was made available to 92 countries.

The first vaccines were rolled out to people in lower-income countries around a month later than high-income countries first made them available. Shortly after this, COVAX had delivered doses to 100 countries.

However, a succession of delays, caused by factors including a lack of up-front cash reserves, vaccine hoarding and export bans, slowed the pace of the roll-out in COVAX’s early phases.

By April 2023, almost three-quarters of all doses supplied to lower-income countries came via the COVAX partnership. Around three-quarters of deaths were averted in low-income countries, modelling suggests.

For the poorest nations, who have limited alternatives to secure vaccines, COVAX provided a vital safety net. For many African countries, which typically have poor vaccine manufacturing capabilities, COVAX was the largest source of vaccines. It provided nearly 550 million doses free of charge, as well as supported countries with technical assistance, cold chain equipment, training and awareness campaigns.

Although COVAX closed at the end of 2023, low- and lower-middle-income economies will continue to receive COVID-19 vaccines and delivery support from Gavi, the Vaccine Alliance in 2024 and 2025. So far, 83 million doses have been requested for 2024 from 58 economies.

Through a first-of-its-kind mechanism called the Humanitarian Buffer, COVAX also deployed 2.5 million doses to protect vulnerable populations affected by humanitarian crises and conflict. These people are typically hard to reach through government programmes, and the Buffer came across a number of issues in delivering a novel product through non-governmental channels.

Any delays to providing vaccines during a pandemic will cost lives and cause economic damage, Gavi says in a preliminary report into COVAX’s impact in lower-income countries. “The best possible global pandemic response is an equitable one, global future mechanisms should be designed particularly with these countries in mind,” it says.

Anticipating and overcoming potential barriers to equity is a key part of being better prepared for the next pandemic. The World Economic Forum’s Global Health and Healthcare Strategic Outlook lays out a vision for a more equitable healthcare system which is better able to cope with future pandemics and the demands being placed on it.

There are many lessons that can be learnt from COVAX, particularly in regards to strengthening capacity by designing and investing in end-to-end systems which protect the needs of the vulnerable ahead of time.

It is also important to recognize that vaccine nationalism and hoarding will persist, so steps must be taken to mitigate this. This includes diversifying manufacturing so that regions are not left exposed.

Financial risks also need to be taken to avoid delays to procuring and delivery of treatments and countermeasures.

Some COVAX AMC funds remain as the programme is wound down, in large part due to renegotiation of supply contracts. These funds will be reinvested to help make progress on some of the lessons learnt.

This includes setting up an African Vaccine Manufacturing Accelerator to help make the region less vulnerable to supply restrictions. $1 billion will be made available to support manufacturing on the continent and a First Response Fund will ensure that financing for a vaccine response is immediately available for the next pandemic.

Funds will also be used to support efforts to catch up on all vaccination programmes for other diseases which were affected by the pandemic. These gaps are now causing outbreaks of illness which can be prevented by vaccines.