The Global Race to Vaccinate

PUBLISHED: MARCH 29, 2021

As of March 15, 2021, there have been over 120 million cases and 2.66 million deaths from COVID-19 around the globe, an increase of 43 percent in cases and 45 percent in deaths, since January 1. A second wave of the pandemic in the fall and winter resulted in a substantial increase in cases, severely straining even the strongest health care systems. Now, some countries are bracing for third and fourth waves. Several mutations of the virus—the three most prominent ones having emerged from the U.K. (B.1.1.7), South Africa (B.1.351), and Brazil (P.1)—have been complicating COVID-19 management just as vaccines are rolling out. According to The Johns Hopkins School of Medicine and the Centers for Disease Control and Prevention, the U.K. variant has been spreading quickly across the U.K., the U.S., and elsewhere, while laboratory studies indicate that the South African and Brazilian variants may be more resistant to vaccines. These mutations and stalled rollout of the vaccine across many parts of the world compound the urgency with which nations must act.

The authorization, approval, and initial distribution of 13 different COVID-19 vaccines, and the development of nearly 100 more that are currently in trials, offer hope for more effective management and an eventual end to the pandemic. As of this writing, there are seven vaccines approved for widespread use, six in early or limited use, and 23 in large-scale efficacy Phase 3 testing. A comparative summary of the leading vaccines currently being distributed globally is below:

All 36 countries in FP Analytics’ COVID-19 Global Response Index have access to doses of vaccines, through either their own governments’ procurement or allocation by supranational organizations such as the African Union or the European Union. However, access and distribution among the Index countries and around the world have been uneven and inequitable, hindered by procurement, supply chain, and geopolitical issues. Despite the initial rollout of vaccines, COVID-19 cases are still increasing rapidly.

Wide Disparity Between Rich and Poor Countries’ Access to Vaccines

The data on vaccine doses purchased clearly illustrates a gulf between rich and poor countries. Many wealthier countries moved early to secure a substantially higher number of doses relative to their population sizes as compared with poorer nations. As of March 15, on average, the wealthiest 25 percent of countries with the highest GDP per capita purchased nearly twice the number of doses needed to fully vaccinate their entire respective populations, while the poorest 25 percent (lowest GDP per capita) of countries have only secured enough doses to cover less than a quarter of their populations. In terms of actual doses, the richest countries have procured 4.1 billion doses (48.7 percent), while the poorest have procured just 1.1 billion doses (13 percent) of the 8.4 billion global total. Canada and the U.K., for example, have procured 4.3 times and 3.6 times, respectively, the number of doses needed to treat their entire populations. A summary of other countries’ procurement is below:

The wealthier countries that have procured disproportionate supplies of vaccines, by and large, also represent those with the highest case rates. The U.S. and the U.K., which have been among the worst performers globally with respect to COVID-19 case and death rates, and lowest performers in the Global Response Index over the last year, are now among the leaders rolling out the vaccine. Still, they trail Israel and the United Arab Emirates, which have been the most effective at vaccine administration by far.

North American manufacturers are the world’s leading vaccine suppliers. Just under half (45.3 percent), or 29 countries out of 68 for which data is available, have a vaccine manufactured by an American or Canadian company as their primary supplier. The next closest, Europe, is the major supplier in almost half as many countries (25 percent, or 16 countries). Among vaccine makers, Pfizer/BioNTech and Oxford-AstraZeneca both lead the way, each being the primary vaccine in 25 percent of all countries, followed closely by China’s vaccines and Russia’s Sputnik V at 17.6 percent and 16.2 percent, respectively. Vaccines’ properties, dosage, pricing, and transportation requirements all influence uptake rates. While highly effective, the Pfizer-BioNTech vaccine’s need for ultra-cold freezers has challenged distribution. Though recent relaxation of that requirement by the Food and Drug Administration could facilitate broader distribution, both Pfizer and Moderna still require cold storage, making the other vaccines—Oxford AstraZeneca, Sinovac, Sputnik V and Johnson & Johnson—much more deployable, particularly in developing country contexts.

Disproportionate Procurement and Manufacturing Bottlenecks Exacerbating Access Gap

While this handful of countries are showing leadership administering vaccines, many of the wealthier countries that locked up supply through advanced purchase commitments are struggling to administer them. European nations, in particular, continue to struggle in their efforts to ramp up vaccinations, as approval delays and incoherent distribution plans have been hampering vaccine rollout. Recent concerns over AstraZeneca and risks of blot clots have further complicated rollout as Germany, France, Spain, and Italy have joined other European countries to temporary halt distribution of that vaccine. Meanwhile, manufacturing shortfalls and rising COVID-19 case levels are increasing calls for, and tensions over, vaccine export restrictions, which the EU is in the process of imposing.

Early efforts by wealthier nations to lock in vaccine deals and the subsequent difficulty in distributing vaccines have created global distribution bottlenecks, exacerbating the vaccine access gap between wealthier and poor nations. Economic impacts from the pandemic have further strained developing countries’ governments’ ability to procure costly vaccines. Fewer than half of the African countries in the Global Response Index, for example, has secured vaccine supplies. Even suppliers that regularly provide vaccines and drugs to the developing world, notably the Serum Institute in India, will face serious challenges. As the largest vaccine manufacturer globally, Serum will be critical to the provision of COVID-19 vaccines to the developing world. It is planning to provide one billion doses to poorer nations, in partnership with AstraZeneca. However, the Institute has stated that half its production will be for India, where the coronavirus caseload trails only that of Brazil and the United States globally, significantly limiting availability for other developing countries. According to the People’s Vaccine Alliance, which includes Amnesty International, Frontline AIDS, Global Justice Now, and Oxfam, up to 90 percent of the population in 67 developing countries might not get any vaccines in 2021. In that time, COVID-19 is projected to continue mutating, producing new variants that might not be treatable by existing vaccines.

Countries where a larger share of the population is rural face exceptional challenges to secure and distribute vaccines. Already facing limited healthcare infrastructure, even in rich countries like the U.S., there is a disparity in vaccines procured; the most rural countries have purchased only enough vaccines to fully treat 25 percent of their populations, compared to almost 90 percent of the populations of the least rural countries.

To date, countries (notably Kenya, Ghana, Ethiopia, and Senegal) have relied on very aggressive policy, including stay-at-home orders, early school shutdowns, and restriction of public gatherings, to limit COVID-19’s impact, but it is unclear how long they can maintain it without increased international assistance, most notably for vaccines. Failure to address these inequities will be costly—for everyone. A RAND study puts the economic damage of unequal COVID-19 vaccine allocation at $1.2 trillion per year, with losses coming heavily from contact-intensive sectors, like tourism, travel, and transportation, compared to equitable global vaccine distribution. Conversely, according to the Eurasia Group, equitable distribution could generate an estimated $153 billion in economic benefits by the end of this year, which could triple to over $460 billion by 2025 when accounting for just 10 major economies. The transnational reality of the virus and stark costs of vaccine nationalism make greater multilateral collaboration on global vaccine deployment an imperative as gaps in distribution will allow for further spread and increase the risk of additional mutations.

International Vaccine and COVID-19-Related Aid Needed

Barring any significant change, these countries will have to rely on international financial institutions and other partners to fill gaps to keep the pandemic from worsening. Significant funding commitments will be required. A full treatment of the Pfizer or Moderna vaccine costs $40 or more, which becomes very expensive for poorer nations that need to purchase hundreds of millions of doses. In addition, indirect costs to store, transport, and administer the vaccine are substantial. As such, delivery will require refrigerated vehicles, temperature-monitoring devices, and adequate roads to transport vaccines to rural locations. Glass vials, syringes, and needles are other critical supplies for vaccines that can be costly for developing nations to acquire.

Pharmaceutical companies, among other entities, have stated that they would make low-cost doses available for poorer countries, but with high-income countries already having purchased 4.6 billion doses (out of approximately 8.5 billion purchased globally), and only a few direct deals between vaccine manufacturers and low-income countries for a limited supply of doses, the latter will have to rely entirely on the approximately 13 percent of supplies purchased through global vaccine initiatives such as the World Health Organization’s (WHO) COVAX—a collaboration among governments and manufacturers that seeks to provide equitable access to COVID-19 vaccines. Even if these are all provided at discount prices, they only amount to 1.1 billion doses, enough for just the combined populations of Indonesia, Pakistan, and Brazil, for example. While the COVAX initiative is seeking to provide equitable access to both rich and poor countries, it faces serious funding concerns: at the end of last year, COVAX estimated that it needed to raise another $6.8 billion for 2021, $6 billion of which could facilitate supply and delivery to developing countries. Additional support is being mobilized; in February, the G-7 countries committed $4.7 billion to the ACT (Access to COVID-19 Tools) Accelerator, the project that oversees COVAX. The ACT Accelerator funds development and equitable rollout of tests, treatments, and vaccines. The recent pledge brings total commitments to $10.3 billion, but the Accelerator still faces a $23 billion shortfall for 2021.

As the pandemic has reversed decades of progress in international development, targeted foreign aid represents another vital means of support. Foreign, and particularly bilateral, aid details are limited, but data gathered by Cooper-Smith indicates that COVID-19-specific foreign aid, particularly from the United States government, is flowing to countries with the highest case rates.

Geopolitical Competition and the Benefits of Vaccine Diplomacy

The excessive procurement and vaccine nationalism characterizing many wealthier countries has developing and developed countries alike clamoring for supply. Eager to respond and expand their influence abroad, China and Russia have been moving quickly to fill the gap. In addition to early uptake of Chinese vaccines in the Middle East, and Russia’s Sputnik V penetrating Eastern Europe, both countries’ vaccines are making inroads across the developing world. According to data from Duke University, as of March 12, 2021, China’s vaccines have been procured by 25 countries, enough to treat 360 million people. A tally by the Associated Press in early March indicated that China has struck deals with over 45 countries around the world, though it is unclear if these deals have been finalized; nonetheless, the country has been ramping up the diplomacy and committing over 300,000 doses to U.N. peacekeepers, with priority to those in Africa.

When examining the average GDP per capita of countries that had purchased a majority of Chinese, Russian, or North American vaccines, there was a stark difference; For the lowest quartile of GDP per capital, Russia and China actually sold vaccines to more countries than North America. Countries buying pluralities of Chinese or Russian vaccines have GPDs per capita of $17,700 and $18,200, respectively, as compared with those procuring North American vaccines whose GDPs per capita average $30,900. The sales demonstrate China and Russia’s efforts to strengthen ties among least developed countries – such as Pakistan, Zimbabwe, Uzbekistan and Kazakhstan - with whom they already tend to be politically aligned, while expanding soft power elsewhere.

However, while China and Russia are expanding commitments, they are facing production hurdles and must ramp up production capacity in order to inoculate their own populations and actually fulfill the deals brokered around the world.

Geopolitical competition is spurring production. With rivals facing production barriers, India—a major hub for vaccine manufacturing—has been leveraging its production capacity and reinforcing itself as a key supplier of vaccines for Asia and the developing world. While allocating the majority of production to its domestic population, India has already been supplying millions of doses across the region, pre-empting distribution of Chinese vaccines and strengthening its own diplomatic ties across Asia and around the world. India’s critical role in regional (and global) vaccine distribution and diplomacy was amplified in early March at the Quadrilateral Security Dialogue, when the Quad announced their joint commitment to provide one billion doses of vaccine to Southeast Asia, leveraging India production capacity, U.S. biotechnology, Japanese funding and Australia’s logistics. Such efforts will be key to countering China’s influence in the region, but competition among the rivals will also help accelerate access for the billions of people around the world still need of vaccines.

Looking Ahead

The proliferation of COVID-19 variants and threats of backsliding make collaborative action and more equitable distribution of vaccine imperative. Failure to accelerate vaccination globally risks lives as well as the global recovery from the pandemic, for which all countries will bear the costs. Wealthier countries, many of which have secured doses in excess of domestic need, could donate or loan doses—actions recently taken by the U.S.—and/or democratize production, as a range of leading public health experts have called for. Given pharmaceutical companies’ vaccine-production shortfalls and that the vaccines were largely produced using public money, the U.S. and EU could support technology transfer as well as the development and retrofitting of manufacturing capacity across Africa, Asia, and Latin America—as has been done by Russia, they argue. Cooperative international agreements, such as that of the Quad, which leverage countries’ relative expertise and competitive advantages, will be crucial to accelerating the response and ultimately to arresting COVID-19, and they will lay a foundation for stronger and more effective global health networks moving forward.