CAPE TOWN – As the health sector celebrates World Immunisation Week, one of the most pressing related problems is Africa’s almost total dependence on imported vaccines –  something that predates, but was highlighted by, the COVID-19 pandemic.  

But addressing this dependence will mean dismantling the ‘charity’ model that has underpinned many of Africa’s immunisation programmes over the past two decades at least – since the creation of Gavi, the Vaccine Alliance.

The terrible price of Africa’s vaccine dependence was brutally highlighted a year ago at the height of the Delta period of the COVID-19 pandemic. India banned the export of vaccines produced by its generic companies. Western countries bought up the limited international global supply of vaccines. And there were no vaccines left for Africa, which had been relying on COVAX for supplies.

It was a bitter replay of the HIV pandemic when antiretroviral drugs were not affordable or available on this continent. 

Key African leaders resolved that there was only one feasible way forward to break this dependence: to build continental vaccine production capacity.

John Nkengasong, director of the Africa Centre for Disease Control, then-Africa Union chairperson and South African President Cyril Ramaphosa, and Strive Masiyiwa, appointed as the African Union Special Envoy on COVID-19, have led the quest to change the balance of manufacturing power and prowess.

Under pressure to address this inequity, wealthy nations, the global health sector, and the pharmaceutical industry have responded with an array of African-based endeavours.

The most committed initiative to addressing structural inequity is the mRNA vaccine production hub in South Africa initiated by the World Health Organization, which produced a copy of the Moderna-based COVID-19 mRNA vaccine in a few months flat, and is now preparing the product for trials.

Another promising initiative includes generic producer Aspen, which was recently licensed to package, distribute and sell the Johnson & Johnson COVID-19 vaccine under its own name in Africa. 

There also are fill-and-finish operations in South Africa, Egypt, Senegal, Morocco, and Algeria for a range of vaccines from Pfizer’s mRNA COVID vaccine to the Russian Sputnik.

The donor as ‘competitor’

But the elephant in the room is how these newer – and initially more expensive – innovations will be able to ‘compete’ with donated or subsidised vaccines from Gavi-UNICEF and more recently the COVAX platform, in the case of  COVID-19 vaccines, without derailing entire countries’ immunisation programmes

UNICEF’s Supply Division based in Copenhagen is the world’s biggest buyer and supplier of vaccines for developing countries and it procures the majority of Gavi-funded vaccines.

Back in February, Patrick Tippoo took this elephant by the trunk in a webinar organised by the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA).

Tippoo has over 30 years’ experience in the vaccine manufacturing arena, and is a founding member of the African Vaccine Manufacturing Initiative (AVMI).  He also is an executive at Biovac, the South African company playing a key role in the mRNA vaccine hub alongside Afrigen.

“Critically important is the whole issue of sustainability of that which is being built and is being invested in going forward,” said Tippoo. “Without a significant change in the market dynamics on the African continent there’s very little likelihood of successful sustainability of all our efforts behind this initiative.”

Tippoo explained that about 40 of Africa’s 54 countries are “wholly or partly dependent on partially or wholly subsidised vaccines from Gavi through UNICEF. Much of the vaccine supply into Africa comes in a subsidised form, partially or completely by GAVI through UNICEF.” 

And that market is not just COVID-19 vaccines but billions of dollars of vaccines for childhood diseases ranging from measles and mumps to polio.

Traditionally, Gavi and UNICEF have focused on buying the cheapest medicines rather than addressing supply chain diversity or equity, insiders have told Health Policy Watch.

More recently, however, Gavi has given the Developing Countries Vaccine Manufacturing Network (DCVMN), an alliance of 44 companies from 16 developing countries, a seat on its board. It also says that “by 2017, nearly two-thirds of our vaccine suppliers were based in Africa, Asia or Latin America”, although this statement obscures the fact that precious few African companies are part of the mix.

The procurement patterns of the big donor-driven agencies have also tended to foster market dominance by a few, larger firms – whether based in India, China or western nations – at the expense of smaller, start-up (and often African) manufacturers whose products also are inevitably going to be more expensive, at least in the early years.    

“We know that Gavi drives prices down to make vaccines more affordable so more vaccines can be purchased and therefore distributed,” Tippoo added. 

“So some say that the vaccine market in Africa is actually in Copenhagen [the headquarters of UNICEF’s Global supply and Logistics Hub]. This is a structural thing that will have to be addressed because, in order to stimulate and incentivize technology transfers, investment in skills, development, regulatory capacity building and all these things that we repeat ad nauseum, there needs to be an assurance that there’s going to be a market [for African vaccines] when all of this is built.”

Gloomy forecast for African vaccine manufacturing 

Hardly two months later, Tippoo’s gloomy forecast of the market dynamics has already proven accurate: Aspen has not received a single order for its J&J COVID-19 vaccine from African countries that are getting free or heavily subsidised vaccines either directly from rich countries or indirectly through COVAX-backed procurement orders.

This was disclosed two weeks ago by Africa CDC’s John Nkengasong recently, who appealed to Gavi and COVAX to “rally around” Aspen to protect vaccine production on the continent.

It was “shortsighted” of African countries to rely on vaccine donations at the expense of the continent’s vaccine manufacturing capacity, Nkengasong told an Africa CDC media briefing:

“There is a global consensus that, in order to ensure global health security, there must be regional vaccine manufacturing capacity,” he said.

“Here we are with a company that is producing an amazing vaccine that the continent is using, that is running a risk of shutting down that production. We cannot and must not allow that to happen.

“If we only rely on donor vaccines and do not invest in and promote our own facilities on the continent that is a recipe for going backwards the next time we are hit with another pandemic.”

Gavi ‘in discussion’ about Aspen

A GAVI spokesperson told Health Policy Watch on Monday that “COVAX is committed to diversifying global supply, including through the development of regional manufacturing sites, especially in Africa. 

“In the case of Aspen, the current overall demand situation means we are currently not in a position to buy large quantities of vaccines. However, we are in discussion to see if a collaboration would be feasible as part of expanding regional supply.” 

Nkengasong confirmed that there were discussions with Gavi, which manages COVAX, about supporting Aspen’s COVID-19 vaccine production line, which the company has warned it will have to close soon if it doesn’t get orders.

But the immediate outlook is not rosy now that there is a glut of COVID-19 vaccines.  And competition between the big global pharmaceutical players for the African vaccine market is becoming more intense as the continent is the last major source of unvaccinated people on the planet. 

More equity also equals more global health security 

In all the many discussions about a pandemic instrument to address future pandemics, all WHO member states have committed themselves to the principle of equity. But the diversification of vaccine procurement is not just about equity. It will also ensure more robust and flexible supply chains during a pandemic, which will strengthen global health security. 

“We need diversification in terms of geographic locations, where these capacities might be located across the continent, diversification in terms of product mix, what different entities are going to focus on in terms of vaccine development and vaccine manufacturing pipeline, but also diversification in terms of technologies,” Tippoo said. 

“This is not only about Africa for Africa. This is about Africa gearing up to take a significant position and place around the global table. Africa can contribute to a diversified global supply chain when it comes to vaccines.”

Image Credits: UNICEF South Africa/2013/Hearfield.