With the fate and nature of the pandemic accord currently being negotiated by World Health Organization (WHO) member states still uncertain, global health experts are calling for “realistic” backup plans to protect the world against the next pandemic.

“We need an ambitious but implementable pandemic accord – that is the Holy Grail,” Javier Guzman, Director of Global Health at the Center for Development (CDG) told a CDG panel on Thursday convened to discuss the lessons of the pandemic, particularly in relation to the global COVID-19 vaccine access platform, COVAX.

“Now, will it materialize? Will it be enforceable? Would it be ambitious enough? Will it be ratified? I’m not very optimistic, based on what I’ve seen,” said Guzman. “So if that doesn’t happen – or if that happens, but it’s not enforceable, or it’s not what we all need as the globe – then we need to move to the second best option, which is realistic options.”

Guzman said that two such options include building regional vaccine manufacturing capacity and ensuring vulnerable countries have quick access to financing. He cited the regional level, particularly in Africa, as the place to seek solutions to the problems of equitable access to vaccines, which were predominantly felt at a regional rather than global level.

Regional manufacturing efforts are underway

Support for African manufacturing is already progressing. Next month, Gavi, the global vaccine alliance, the African Union (AU) and the African Centre for Disease Control and Prevention (Africa CDC) are convening a regional vaccine manufacturing forum to bolster the least-resourced continent.

The aim of the forum is for African leaders, African manufacturers and Gavi to “strategize around sustainable manufacturing”, said Gavi’s Aurélia Nguyen. Gavi and the AU have already signed a memorandum of understanding in this regard.

“Investing in our routine systems is the backbone of investment in pandemic preparedness and response if we’re able to make more systemic changes,” added Nguyen, COVAX’s former CEO and Gavi’s Chief Program Strategy Officer.

Akhona Tshangela, programme coordinator for the Partnerships for African Vaccine Manufacturing (PAVM) at the Africa CDC, said that the continent “is working towards building a vaccine manufacturing capacity that promotes tech transfer and strengthens the regional framework”.

The PAVM has been formed to address the limited production of vaccines, diagnostics and therapeutics on the continent, said Tshangela, adding that the AU’s memorandum of understanding with Gavi will “help support our manufacturers on the continent to gain entry into the markets”.

“In addition to vaccine manufacturing, we’re also focusing on ensuring that we develop regional regulatory harmonisation frameworks so that whatever products come out of the African continent are seen as good quality and safe for use not just globally,” Tshangela added.

While there is a lot of appetite and political will for diversified vaccine manufacturing, and the benefits for the resilience of the global vaccine supply chain are clear, the costs must also be placed squarely on the negotiating table, said Guzman. 

“Clearly, we need to understand that there is a trade-off,” he said. “If you want to have diversified vaccine manufacturing, you sacrifice some economies of scale, you sacrifice price, affordability.”

Access to financing

Nguyen highlighted five key lessons from COVAX for future pandemics: having financing from day zero; clear communication with stakeholders, particularly about risk; equitable access, particularly for the most vulnerable; legal and regulatory challenges to access, and trade-related barriers in a pandemic setting. 

Whether the world has learnt Nguyen’s first lesson of the COVID-19 pandemic – that financing must be available from day zero – remains uncertain.

Financing for pandemic preparedness

A pandemic fund to bolster global investment in prevention, preparedness and response ahead of the next pandemic was launched at a G20 meeting last year, but the fund has mobilized far less than the estimated minimum of $10 billion a year needed to equip countries to combat future pandemics.

“How we can maximise the investments by the pandemic fund to support pandemic preparedness? And now what is the conversation about surge financing?” asked Guzman. 

“We’ve got new heads of the World Bank and the Inter-American Development Bank – but how can we, either regionally or globally, agree on a framework to provide swift access to funds in response to a pandemic? That could be relaxed rules on country borrowing or it could be automatic access for pre-qualified countries,” he said. 

Saul Walker, Director of Public Partnerships at the Coalition for Epidemic Preparedness Innovations (CEPI), also spoke about the need for quick access to finances in the face of a pandemic.

Although CEPI made some “initial investments” in mRNA vaccine research and development (R&D) in February 2020, it was simply unable to compete with the vast R&D funding coming in from high-income countries and other funders in later rounds. 

If CEPI had been able to compete with this funding, it might have enabled more equitable access to the mRNA vaccines that were later developed.

Matt Cooper, an independent consultant for Itad who took part in an independent evaluation of COVAX completed in May, argued that the global pandemic preparedness and response strategy must find a way to “facilitate, incentivize, perhaps even compel, vaccine manufacturers to engage in tech transfer agreements such that vaccine suppliers can be scaled up as rapidly as possible”.

“Countries are serving their own populations first and companies are pursuing their commercial interests,” warned Cooper. “Let’s be under no illusion that those behaviours will be replicated in the future.”

Ducks in a row

Responding to COVID-19 was like “flying a plane while we were building the plane, and then trying to work out where to land it,” said Walker.

CEPI was only three years old when the pandemic started and had to work out a multitude of things on the fly. This was also true for the many organisations, countries and structures working together as the pandemic unfolded. 

Stakeholders in the pandemic response had to hash out  “roles and responsibilities, handoffs, how information flows up and down a value chain, how much delegation boards are given to be able to move fast, what the risk tolerances of different organisations are,” said Walker.

“And actually as you move along, roles and responsibilities change,” he said.

For Nguyen: “At the end of the day, it really is the strength of the health system that determines the strength of the pandemic response.”

And for Guzman, the current period of preparation must not be wasted as the next pandemic looms: “It’s about timing. It’s about having everything ready to go.”

Image Credits: WHO, UNICEF/Kokoroko.