In the absence of any larger oversight, Gavi designed COVAX with a small group of like-minded advisors, primarily global north philanthropists, academics, and consultants. Notably absent were the critical perspectives of regional bodies such as the Africa Centers for Disease Control and Prevention and any meaningful representation from low- and middle-income countries.
That there was minimal opportunity for the governments that would be the most reliant on COVAX for vaccines to help shape and inform its structure not only took ownership away from these countries but also undermined COVAX’s ability to succeed.
With only like-minded thinkers in the room, Gavi stuck with what they knew and structured COVAX to operate in the current paradigm of market dynamics, an ill-suited approach for a global pandemic that requires sharing the fruits of medical innovation equitably across the world. The COVID-19 pandemic saw the entire world needing vaccines at the same time. So in addition to the challenge of ensuring equitable distribution of doses, the problem that COVAX needed to tackle was “over-demand."
The way to meet this demand is by expanding vaccine manufacturing through measures such as vaccine technology transfers and intellectual property waivers, yet COVAX failed to address the issue of over-demand. This was a challenge that Gavi—a public-private partnership (PPP)—has faced before: what happens inevitably in such arrangements is that pharmaceutical private-sector actors have the upper hand, and public-sector partners are unwilling to challenge their power and push for conditions that might ensure broader access.
The exclusivity that characterized COVAX’s design process is also reflected in its decision-making and governance processes. The insular nature of Gavi and its resistance to taking advice from outsiders has led to questionable policy decisions that further undermined COVAX.
Most notably was its initial decision to rely on the Serum Institute of India as the primary vaccine supplier for lower-income countries. This was a decision that returned to haunt Gavi. In March 2021, just as COVAX was getting off the ground, India halted all vaccine exports to address their own overwhelming outbreak of COVID-19. Deliveries ceased, leaving COVAX and the many countries relying on them, empty-handed.
In developing COVAX, Gavi also failed to take into account obvious political realities. The “market shaping” premise of COVAX—that by aggregating global demand for future COVID-19 vaccines, they would be the most attractive customer for industry—was dependent on high-income countries participating as self-financing partners. This would provide the funding needed for COVAX to make advance purchase agreements with manufacturers and mitigate vaccine hoarding by high-income countries.
But that’s not how it played out. By August 2020, wealthy countries had already pre-ordered more than two billion doses of future COVID-19 vaccines in bilateral deals and had little incentive to purchase through COVAX. Right off the bat, COVAX found itself competing to purchase vaccines against the very countries they were courting, and without the funds needed to interest pharmaceutical corporations. In competing against the wealthiest countries, COVAX lost. It was naïve at best and irresponsible at worst for Gavi to tether COVAX’s success to the supposition that rich countries would not put the needs of their populations above all others.
