Exclusive: Global Vaccine Alliance Denies Reports It Has Decided to End Free COVID Vaccines for 37 Middle Income Nations
A United States delivery of 655,200 COVID-19 vaccine doses through COVAX to Ethiopia on September 23, 2021.

Gavi, the Vaccine Alliance, has pushed back on media reports that its board has decided to end COVID vaccine support for 37 middle-income countries next year – and end altogether the dedicated COVAX vaccine facility, supplying free vaccines to some 92 low- and middle-income countries, in 2024.

A high-ranking official at Gavi told Health Policy Watch that its Board’s approval Thursday in principle of a plan to end the free provision of vaccines to the 37 countries – including Egypt, Indonesia and Argentina – is neither final nor definitive, and would not in any case affect vaccine deliveries in 2023. 

Other officials, meanwhile, said that if funding cuts for middle income countries are made in 2024, the money saved would be shifted to a pandemic pool to confront new, and more dangerous SARS-CoV2 surges or similar future threats. 

Even so, no changes to Gavi’s support of some 92 middle and low income countries for COVID vaccines through the COVAX facility’s Advance Market Commitment (AMC) will be made in 2023, said Dr Derrick Sim.  A final decision on the shape the COVAX facility takes in 2024 will not be voted on until June of 2023, he added, following consultations with countries themselves. 

“We are not changing the approach for 2023, all AMC countries including AMC-supported middle-income countries will be supported to get fully-funded doses and delivery support,” said Sim, who is the Acting Managing Director of the Gavi-led COVAX facility, which has rolled out some 1.8 billion COVID vaccines to 146 low and middle income countries over the past two years.  

“Looking forward to 2024, every scenario we are considering involves some support for middle-income countries, and no decision will be taken until at least next year after countries have been fully consulted – and it will be based on the state of the pandemic at that time,” he added. 

New pandemic pool aims to correct problems in COVID vaccine rollout 

A lack on on-hand funding at the onset of the COVID pandemic hamstrung Gavi’s ability to respond in the early stages of the outbreak.

Under the proposal approved by the board on Thursday, any money saved on procuring vaccines for the 37 middle-income AMC countries would instead go to funding a new pandemic finance pool, which could be rapidly and flexibly deployed to confront surges of new SARS-CoV2 variants, or similar threats, added Olly Cann, Gavi’s director of communications.

“The idea behind it is, can we learn the lessons from 2020?,” said Olly Cann, Gavi’s director of communications.

During the early stages of the COVID vaccine rollout, Gavi and COVAX were heavily criticized for over reliance on just one vaccine supplier, the Serum Institute of India, which then froze its shipments when India faced a major COVID surge. 

The problem, widely acknowledged later, was that Gavi had no cash in hand at that time  to seal deals with some of the other large vaccine manufacturers, like  Pfizer, Moderna and Johnson & Johnson, for advance vaccine purchases. So it was forced to the back of the vaccine procurement line. 

New strategy part of scenario planning 

The new strategy approved by the Gavi Board Thursday is anchored in alternative scenarios for COVID’s evolution, developed by the World Health Organization, which leads the policy side of COVAX. 

WHO has defined three scenarios for the evolution of the SARS-CoV2 virus and pandemic: a worst case surge of new or existing variants; a medium case; and a best case, in which mortality from SARCoV2 continues to decline as virus mutations become less deadly. 

Only in the ‘best-case’ scenario would the COVAX programme of free vaccines and vaccine distribution support to the 37 middle income countries be replaced with a more step-wise approach, officials said. 

Under the new approach, the countries would be able to receive a “catalytic grant” – a one-time payment covering 50-60% of the estimated cost of the jabs needed to immunize health workers, older people and other vulnerable groups. 

In a medium or worst-case scenario, assistance to these middle-income nations would be increased accordingly.

Integration of COVID vaccines into routine countries may be preferred  

COVAX deliveries arrive in Sudan, August 5, 2021.

In best-case scenarios, the COVAX facility might foreseeably dissolve its emergency operations and integrate COVID vaccine distribution – into routine national vaccination programmes, officials also admitted.  

However, regardless of whether COVAX is dissolved entirely, or not, the progressive main-streaming of Covid vaccinations into national vaccine delivery programmes is in line with good practice – and what countries want.  

“Countries are finding it administratively burdensome to administer COVID vaccines as an entirely separate emergency programme,” one Gavi official said, speaking on condition of anonymity. “They would rather see vaccine distribution integrated into ongoing routine vaccination programmes.”

“COVAX’s planning is driven by countries’ needs and what we are hearing,” Sim added.  “They want to find ways to integrate COVID-19 into existing programmes in a way that benefits both, and reduces the administrative burdens of running a separate emergency programme in a time of other competing priorities, from routine immunization to outbreak response.” 

The Pandemic Vaccine Pool is the long-term strategy 

Under one of the scenarios included in the proposal approved by the Board on Thursday, any savings in supplying free vaccines to the 37 middle-income AMC countries, that would be channelled into Gavi’s new Pandemic Vaccine Pool – so as to have cash in hand for any new SARS-2 surge, or other future pandemic threat. 

The Pandemic Vaccine Pool created by the Gavi Board in April is a critical, new part of Gavi’s long-term pandemic preparedness strategy, Sim said. The aim is to ensure ready funding that would allow the Alliance to be on proactive footing should another deadly variant or virus emerge. 

“The Pandemic Vaccine Pool helps us have funding on hand to act immediately if there is a need, for example, for new vaccines,” he explained. “Gavi put in place this contingency measure based on COVAX learnings from the beginning of the pandemic that the course of the pandemic can change suddenly and delays can occur due to lack of available financing.” 

Middle-income countries normally do not qualify for Gavi support

Arrival of the first COVAX package to Argentina, comprised of Oxford/AstraZeneca vaccines.

Gavi officials also stressed that prior to the COVID pandemic, Gavi’s remit was limited to assisting the world’s 54 lowest-income countries, as defined by World Bank economic data. Middle income countries were eligible only for targeted funding, upon request, and not free vaccines as such. 

But the historic nature of the Covid emergency led to an expansion of eligibility for countries that qualified for free vaccines and support. And thus for COVID vaccine rollout purposes, some 37 middle income countries, as well as India, were included to the Gavi “Advanced Market Commitment (AMC)” scheme – making for 92 countries eligible for free COVID vaccines as well as distribution support.  

“These middle-income countries normally run their own routine vaccination programs, without Gavi support except for one-off targeted interventions,” Sim said. “When COVAX was set up, it exceptionally included a larger group of countries given the unique challenges of equitable access in a supply-constrained pandemic environment.”

In effect, then, any policy change in 2024 would revert Gavi’s scope to what it was pre-pandemic: a system of free vaccines and distribution support for 54 of the world’s lowest-income countries – and targeted support to middle income countries in need, he said. 

Proposal not related to vaccine contracts

Gavi also pushed back on reports by the New York Times that the draft proposal, approved by the Board, is reflective of financial pressures resulting from Gavi being overcommitted to vaccine purchases for which there is now no demand. 

In fact, Gavi’s fixed purchase commitments for 2023 amount to only 150 million vaccine doses, one Gavi official told Health Policy Watch – while the rest are simply “options to buy”.

At the same time the existing list of AMC countries have already expressed interest in twice as many doses – 300 million in total for 2023 – and that is only after a polling of half of the eligible countries.    

 Global demand for vaccines has indeed fallen significantly as the world’s population already builds immunity, the Gavi official added.  For instance, some 52% of people in low income countries have at least had a primary vaccine dose – a far higher proportion than six months or a year ago. And countries have some 400 million doses in stock, as well. 

As a result of declining demand trends, Gavi had earlier renegotiated a number of fixed-order commitments in its portfolio to become options – orders they can fulfill if demand jumps.

But these negotiations had already happened before this week’s board meeting. 

And between a replenishment for the 2021-2025 period that exceeded Gavi’s request for $7.4 billion, reaching $10.5 billion, and the $4.8 billion committed by world leaders at the COVAX AMC summit in April, the alliance’s financials are in order.

“The focus is on increasing coverage rates, protecting high-risk groups including with boosters, and laying the foundation for integration into existing programs,” said Sim.

 “Budget isn’t a problem, and supply isn’t a problem,” Cann said. “The biggest problem is we have no idea what 2024 will look like.”


Image Credits: US State Department, Nana Kofi Acquah, Argentina Health Ministry.

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