Can COVAX Finally Deliver on its Delayed Vaccine Promises?
COVAX vaccine deliveries in Africa.

The global vaccine facility, COVAX, is on the cusp of delivering large amounts of vaccines to countries that need them the most – but will poorer countries have the ability to properly absorb these?

And how can COVAX ensure that it has the trust of low and middle-income countries (LMICs) who need the vaccines most, given complaints about its lack of transparency by the African Union’s vaccine envoy?

These are some of the issues flagged in a recent review of the Access to COVID Tools Accelerator,(ACT-A) of which COVAX is the most prominent project, with diagnostics and therapeutics forming the other pillars

The global vaccine alliance, Gavi, which manages COVAX, told Health Policy Watch that the coming months “will represent the busiest period of the largest and most complex roll-out of vaccines in history”. 

COVAX’s latest public supply forecast projects that it will have around 1.4 billion vaccine doses ready for delivery by end of year – 1.2 billion for the world’s poorest 92 countries to enable them to vaccinate 20% of their populations.

More support for countries to absorb vaccines

The review recommends “greater downstream support” to help LMIC to absorb more vaccines, something that Gavi says has been addressing over the past few months.

For instance, there has been a massive roll-out of ultra-cold storage facilities as the mRNA vaccines Pfizer and Moderna vaccines need to be stored at very cold temperatures.

“Over the last few months we’ve seen the largest roll-out of ultra-cold chain in history: hundreds of units to 47 countries in under five months,” a Gavi spokesperson said.

However, Gavi added that “ultimately, however, delivery is the responsibility of participating countries and so it is important that countries are able to access all sources of support for delivery”. 

Gavi and its alliance members, including WHO and UNICEF, have been working with many of these countries for two decades, and work closely with national governments and partners to monitor, identify and help to resolve delivery challenges. 

While Gavi acknowledges that new challenges will emerge once doses start arriving in larger volumes, it is “confident at least that systems are in place to ensure that when there is a risk of wastage, to ensure doses are redeployed rapidly to other countries”.

The cold storage facility at Pfizer’s warehouse in Kalamazoo, Michigan.

COVAX undermined by bilateral deals

When COVAX was set up, it declared its aims to be “speeding up the search for effective vaccines for all countries” and “supporting the building of manufacturing capabilities and buying supply, ahead of time, so that two billion doses can be distributed fairly in the places of greatest need, worldwide, by the end of 2021”. 

COVAX aimed to pool investment in candidate vaccines and, if any were successful, become the procurement facility for the entire world, wealthy and poor countries alike. Wealthy countries would pay for their own doses while the Advance Market Commitment (AMC) would use donor funds to help buy vaccines to cover 20% of people living in the world’s 92 poorest countries.

But COVAX was so underfunded that it couldn’t buy enough vaccines, and its paralysis fuelled bilateral deals between pharmaceutical companies and the high-income countries (HIC) that were also COVAX members.

“The critical lesson to be learned from this experience, and the current inequity in access to vaccines between HICs and LMICs, is the need for dedicated resourcing to be in place – before a pandemic occurs,” the Gavi spokesperson told Health Policy Watch

“It is notable that, building on the initial $4 billion raised via upfront payments and donor pledges in 2020, the COVAX AMC was only fully funded in June 2021 – by which time bilateral deals between governments and manufacturers had locked up most of the doses available in 2021,” said Gavi.

If funding had been available to COVAX earlier, says Gavi, the facility “would have been able to secure earlier supplies of vaccine from the manufacturers who are currently prioritising those bilateral customers”. 

“This, combined with transparency and accountability from manufacturers on which deals are being prioritised and when, could have avoided many of the supply challenges COVAX has faced to date.”

Gavi believes that it was important to include all countries “given the unknowns” about vaccine development at the start, but it is currently finalising new rules of engagement for the wealthy self-financing countries for next year.

Lack of LMIC representation

A COVAX vaccine delivery of vaccines is offloaded in Abuja in March

The ACT-A review notes “a lack of inclusion and meaningful engagement of LMICs, regional bodies, civil society organisations (CSO), and community representatives” in the ACT-A.

Some LMICs have felt left in the lurch as COVAX has failed to deliver vaccines while those countries that broke ranks and did private deals with pharmaceutical companies 

In July, Strive Masiyiwa, African Union Envoy on Vaccines and head of the African Vaccines Acquisition Task Team, accused COVAX of not being upfront about its vaccine supply problem early enough, resulting in false complacency amongst members who thought their vaccine supply was secure.

Other civil society members have said that COVAX was based on a Western charity model.

Dr Bruce Aylward, the World Health Organization’s (WHO) lead on COVAX, said the concern that the ACT-A Council was not balanced across low, middle and high-income countries “is going to have to be addressed and rebalanced”.

“We need to go back and look at every single one of the engagement mechanisms that already exists…  if it’s not working, we need to fix it,” Aylward told a WHO media briefing last week.

The Global Fund to Fight AIDS, TB and Malaria, which manages the diagnostics pillar of the ACT-A, said that the limitations identified by the review would be addressed by a “revised strategy and budget which is being prepared by the ACT-A partners for publication by the end of October”, a Global Fund spokesperson told Health Policy Watch.

However, Gavi says that lower-income countries are on the Gavi Board and committee structures as well as in the COVAX AMC Engagement Group and the WHO also gives member states regular briefings on COVAX. 

“All of these groups are actively involved in the governance and decision making for COVAX design, strategy and policy,” says Gavi, adding that “each country involved in COVAX has a dedicated team focused on providing tailored information and support, both at the Gavi Secretariat or COVAX Office level as well as via UNICEF and WHO country offices”. 

“These teams liaise directly with country-appointed focal points, usually at ministries of health, and communicate on a daily basis to receive participants’ feedback on various COVAX processes,” said Gavi.

Diagnostics and therapeutics

The review complemented ACT-A’s COVID-19 Response Mechanism (C19RM), which is based on the Global Fund’s well-established health procurement and distribution system, which was already operating in 100 countries. 

To address its three priority diseases – HIV, TB and malaria – the Global Fund had developed, an online marketplace for medicines and health commodities that enables  countries to get cheaper prices through pooled procurement.

“When the COVID-19 crisis hit, we opened to all countries and organisations so they can access pooled procurement volumes of quality-assured health products, including COVID-19 products,” said the Global Fund spokesperson.

Over 38 million diagnostic tests have already been procured for 90 countries through the Global Fund’s Pooled Procurement Mechanism and Countries could also buy oxygen and PPE on

While many countries are not doing nearly enough COVID-19 testing, the Global Fund identifies those with the lowest number of tests (less than seven tests per 1000 population per week for 24 months) and offers support to procure rapid tests or laboratory strengthening support.

The review noted that the ACT-A therapeutics pillar “does not yet have a clearly articulated procurement structure to supply countries or to negotiate contracts”.

Tanzanian and US officials celebrate the arrival of the first COVID-19 vaccine donations in the country.

Funding the gap

The review notes that there is a funding gap of $16.6 billion and warns that some of the country pledges to COVAX have not yet been turned into contributions agreements. 

It also recommends that ACT-A should ensure “regular access to up-to-date consolidated financial data to enhance trust and accountability between donors and agencies”. 

WHO’s Aylward puts the shortfall over the next year to be closer to $20 billion “to get equitable rollout” of vaccines, diagnostics and therapeutics to defeat COVID-19. 

“If we go forward next year with the same gaps we had last year, the pandemic will be prolonged,” said Aylward, adding that WHO Director-General Dr Tedros Adhanom Ghebreysus was lobbying G20 finance and health ministers to close the financing gap.


Image Credits: UNICEF, Pfizer, NPHCDA.

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