Lessons From Covax

(Photo by iStock/MarsBars)

In May, the COVID-19 national public health emergency officially ended. As the world emerges from this period of death, economic displacement, and social reordering, it will take years to fully understand how the pandemic impacted households, communities, and countries. But the COVID-19 pandemic will not be the last novel infectious disease in our lifetimes, and climate change will be a threat to human and planetary health without equal. Without an equally unprecedented level of coordination and collaboration—requiring rigorously examining the lessons of the pandemic response—all of us will be impacted by these future challenges, particularly people living in global majority (or lower- and middle-income) countries.

In retrospect, we can see with a borderless threat like COVID-19, collaboration was stymied across and within countries: Lacking clearly defined and owned targets, country responses often failed to meaningfully engage civil society. With attention too focused on the architecture of supranational decision-making, processes in service of agile and responsive country-led action were neglected. The pandemic response also suffered from public skepticism of political leaders, while collaboration was too focused on spurring innovation within high-income countries (susceptible to stockpiling supply), and economic nationalism undermined local capacity.

We must do better, or humanity will be vulnerable to future pandemics and other borderless threats. Having helped lead the management office for COVAX Delivery, I present lessons learned from the rollout of COVID-19 vaccines—the largest public health intervention in human history—to better prepare for and mobilize responses to the future.

1. Establish clear, realistic, and dynamic country-level objectives and action plans maintained by national governments.

COVAX set out to vaccinate 70 percent of humanity by mid-2022, with the additional dual goals of establishing equity around vaccine access and increasing the chances of inducing herd immunity to squash future threats from COVID-19. These aggressive targets were not met.

One reason for this failure was a lack of commitment to international cooperation, which is particularly consequential when it comes to borderless emergencies. As vaccines were introduced, global minority countries (or high-income countries) hoarded vaccines for their own populations, allowing variants elsewhere to evade the full protection offered by vaccines. By the time global majority countries were finally able to access vaccines in significant volumes, the goal of herd immunity had already become unattainable. COVID-19 vaccine inequities contributed to an additional 1.3 million lives lost globally and 296 million COVID-19 infections in global majority countries.

Another problem was that the processes established for global majority countries to access vaccines became irrelevant and burdensome amidst the dynamism of COVID-19, with an evolving virus, limited financing, and unstable vaccine supplies. For countries to access subsidized COVID-19 vaccines via COVAX, global majority countries had to develop a National Deployment Vaccination Plan (NDVP). However, though intended to be used as a roadmap for reaching the globally defined targets, NDVPs become obsolete amidst supply constraints in global majority countries, the short shelf lives and unpredictable volumes of vaccines donated by global minority countries, and without additional financial resources to implement vaccine campaigns. Moreover, NDVPs were oriented toward the 70 percent target, but it became clear that more realistic and country-defined targets would mean shifting the focus to covering 90 percent of vulnerable populations (healthcare workers, elderly, and people living with co-morbidities). Countries were forced to pay lip service to the 70 percent target while repositioning their vaccination strategies, making it hard to track progress against NDVPs and to unlock global financing.

As global majority countries struggled with operational challenges, the dynamics around COVID-19 changed. Global majority countries experienced the largest backsliding in essential vaccines in almost three decades, with significant, negative downstream impacts (food insecurity, risks from intimate partner violence, adolescent depression and anxiety, the continued emergence of COVID-19 variants of concern that evade the vaccines full protection, and higher than anticipated seroprevalence caused by natural infection). Despite shifting dynamics, the WHO maintained the 70 percent target, even if the emerging science and country priorities suggested a need for an updated focus.

In short, while COVAX’s advocacy, coordination, guidance, and support accelerated the uptake of COVID-19 vaccines, strategic mistakes and risk aversion from UN agencies and donors alike—as well as inapt technical leadership from the WHO and priorities that reflected global agendas rather than local realities—resulted in higher transaction costs for global majority countries.

Global majority countries should have been in control of their targets and the roadmaps to meet them, including the ability to update both as contexts changed. For example, by early 2022, most global majority countries were seeking to shift toward long-term COVID-19 control and integrated healthcare delivery. COVAX and donors should have followed their lead and supported bottom-up, country-driven leadership in service of a more equitable recovery. This would have meant offering global majority countries access to sufficient vaccines, funding, resources, expertise, guidance, and coordination based on updated, realistic targets, and joint decision-making at the country and global levels. Instead, UN agencies and global minority countries fought over separate and overlapping organizational mandates with little accountability at the country and global level.

If global majority countries had the resources to take ownership over outcomes, they would have been equipped to focus on response, surge capacity, shoring up emergency processes and systems, clear and consistent public communication, overcoming operational and logistical bottlenecks, and harmonizing policies and regulations with their implementation plans. Instead, too much of global majority countries time was spent interfacing with sclerotic UN processes and gatekeeping by donors’ intent on keeping a narrow focus on outdated strategies and realities.

In future pandemics and emergencies requiring global collaboration, countries need to own their strategies, plans, and outcomes, with accurate tracking of interim milestones, accountability, and contingent but stable financing. Global guidance and support should be designed with country implementers in mind. Specifically, guidance should be dynamic by acknowledging exogenous constraints and realistic in weighing country capacity and competing priorities. Resources should support countries on their self-defined journeys while incentivizing action that supports the global collective.

2. Global coordinating mechanisms should be agile, limited, and accountable to countries rather than driven by donors.

Global coordination should maintain a narrow focus on supporting countries to have the financing, resourcing, expertise, and guidance to reach their country-defined targets. However, COVAX’s failure to deliver on its promises led to competition within and across organizations, an overemphasis on process and structures at the global level, and too much energy directed toward deal-making and supplies instead of on health system capacity and delivery.

For example, COVAX’s anchor organizations—Gavi, WHO and UNICEF—fought over turf. These organizations were not only funded by global minority countries and high-net-worth individuals, but they defined their agendas, leading to a variety of problems: Staff were pulled from their day-to-day jobs managing core programs and expected to take on more responsibility; the WHO lost trust and credibility by prioritizing fundraising that targeted its own delivery operations rather than shoring up government capacity and supporting local organizations; and UN organizations prioritized staffing with technical experts rather than people with project management, administrative, and diplomacy skills.

When it was clear that COVAX was failing in its commitments, Ted Chaiban was appointed as the Global Lead Coordinator for the COVID-19 Vaccine Delivery Partnership (CoVDP) in early 2022. Mr. Chaiban re-oriented CoVDP to serve country-defined priorities rather than donor-driven agendas, something he was able to do because he had the necessary political buy-in, technical knowledge, and management experience, as well as the political leverage to harmonize the budgets, team, and plans across donors and implementing partners. This allowed countries to be in the driver’s seat of managing their operational plans and lowered the transaction costs of interfacing with multiple donors and systems. CoVDP also maintained a focus on the areas of comparative advantage for UN agencies, specifically “urgent operational funding, technical assistance and political engagement to rapidly scale up vaccination and monitor progress towards targets.” This required CoVDP and its partners to fit into country-plans, priorities, and data ownership rather than expecting countries to adapt to global agendas and processes.

Mr. Chaiban recently reflected that CoVDP “emphasized the importance of reaching country milestones and focusing on high-priority groups, or specifically, the elderly above 60, health care and other frontline workers and people with comorbidities.” As a result, over the past year, CoVDP helped mobilize and accelerate access to over $143 million to fund vaccination campaigns, supporting COVAX countries to vaccinate 139 million additional people.

3. Global funding should prioritize local capacity to spur innovation.

Rapidly developing and deploying vaccines across the world required innovation, starting with the unproven but promising mRNA platform. Global minority countries therefore underwrote research and development (R&D) costs for pharmaceutical companies with guarantees that these countries would have first dibs on promising vaccine candidates. However, as a result of vaccine hoarding in global minority countries, intellectual property (IP) protections erected by pharmaceuticals, insufficient manufacturing capacity, and supply chain disruptions, vaccine access efforts prioritized the residents of a few global minority countries rather than targeting the most effective ways to prevent variants of concern from emerging. COVID-19 was a lost opportunity to build local capacity and resilience to respond to future pandemics, as well as the most efficient way to move past the current one.

While R&D for COVID-19 vaccines and their production were concentrated within a few global minority countries, global majority countries had more recent experiences confronting health emergencies (for example, HIV/AIDS, malaria, and Ebola), had success immunizing their populations at levels of parity or in excess to global minority countries, and had latent manufacturing capacity. The COVID-19 pandemic and the vaccination effort were lost opportunities to increase the innovative capacity, technological breakthrough potential, and resilience of health systems in global majority countries that could have benefited all of humanity.

Global majority countries can and should be at the forefront of developing and deploying technology and solutions. For COVID-19, the IP used to develop the mRNA vaccines should have been shared widely, with technical support to expand manufacturing to global majority countries. Moving forward, investors and implementors should demand reciprocal relationships across researchers, manufacturers, distributors, country governments, and civil society, particularly for innovations that address global and borderless threats such as pandemics and climate change.

4. Public trust must be earned … but once lost, it’s hard to get it back.

Prior to the emergence of COVID-19, epidemiologists repeatedly warned that the world was ill-prepared to respond to a pandemic. These warnings went largely unanswered, and as the “novel coronavirus” became the COVID-19 pandemic, the tools available were limited, requiring blunt instruments such as lockdowns, which led to severe economic hardship, demoralized health workforces, deferred education, sexual and domestic abuse, depression and anxiety, and decreases in routine immunization, cancer treatment, and maternal health. As the pandemic experience degraded the public’s trust in their political leaders, this lack of trust limited the ability of these leaders to make hard decisions in the future. The public often perceived lockdowns as causing more harm than good, and vaccines as an attempt by elites to enrich themselves.

Because of misinformation and distrust of elites, many people in global majority countries were slow to get immunized against COVID-19, even after COVID-19 vaccines were widely available. By the time vaccines reached global majority countries, misinformation was rampant across social media and the impression among many people in global majority countries was one of frustration. People openly questioned why the singular focus was on COVID-19 vaccines, and whether this focus was coming at the expense of more urgent priorities such as HIV, TB, malaria, and sustaining livelihoods. Public mistrust of governments’ ability to act with their interests in mind existed long before COVID-19, but the pandemic accelerated and hardened this skepticism. Public policies in global majority countries did not address the profound unequal effects of the pandemic, with the greatest impacts concentrated in vulnerable and marginalized communities.

Conclusion

My work at COVAX was aimed at turning vaccine doses into vaccinated, protected communities, focusing on supporting global majority countries to accelerate uptake. The COVID-19 pandemic, and specifically the campaign to immunize the world with COVID-19 vaccines, is the closest analogue we have in recent history to mobilizing as a species to address an existential threat.

Humanity lost our opportunity to contain COVID-19 or reach herd immunity, and we are reaching planetary thresholds where the effects of climate change will be irreversible. But as I’ve learned with my work with COVAX, good intentions are not enough. What’s required is local ownership of the global threat, and global mechanisms that are architected to lower transaction costs, advocate for intra-agency collaboration, invest in local and Indigenous solutions, and support the public’s understanding of the threats and how it will impact them.

Read more stories by Trevor Zimmer.