COVID-19 vaccinations shift to regular immunization as COVAX closes

COVAX, the multilateral mechanism for equitable global access to COVID-19 vaccines launched in 2020, closed on 31 December 2023.

Jointly led by the Coalition for Epidemic Preparedness Innovations (CEPI), Gavi, the Vaccine Alliance (Gavi), UNICEF and the World Health Organization (WHO), COVAX has so far supplied nearly 2 billion COVID-19 vaccine doses and safe injection devices to 146 economies.

Its efforts are estimated to have helped avert the deaths of at least 2.7 million people in the COVAX Advance Market Commitment (AMC) low- and lower middle-income participating economies (lower-income economies) that received free doses through the mechanism, alongside nearly US$ 2 billion in critical support to turn vaccines into vaccinations.

These 92 lower-income economies that were eligible to participate in the programme with support from the financing mechanism known as the Gavi COVAX Advance Market Commitment  (COVAX AMC) will continue to have the option to receive COVID-19 vaccine doses and delivery support through Gavi’s regular programmes.

So far, 58 lower-income economies have requested a total of 83 million doses in 2024, with plans to focus on the continued protection of priority groups, including health care workers, community workers and older adults.

Unprecedented emergency response

Drawing on the lessons of the H1N1 pandemic, when the majority of countries missed out on vaccines, COVAX partners advocated from the earliest stages of the COVID-19 emergency that “no one is safe until everyone is safe” – urging the world to place vaccine equity at the heart of the global response, and calling for every country to have at least enough doses to protect those most at risk.

By the end of 2020, 190 economies of all income levels had signed agreements to participate in COVAX, making it one of the most significant multilateral partnerships of the 21st century. By November 2020, it had raised US$ 2 billion towards vaccine procurement; and in January 2021, 39 days after the first vaccine administration in a high-income country, the first COVAX-supplied doses were administered in a lower-income country.

COVAX was designed as an end-to-end coordination mechanism encompassing R&D and manufacturing, policy guidance, vaccine portfolio development, regulatory systems, supply allocation and country readiness assessments, transport logistics, vaccine storage and administration, and monitoring country coverage and absorption rates.

However, as an emergency solution launched in the midst of the pandemic, COVAX faced many challenges. Without having any cash reserves up front, it was initially limited in its ability to sign early contracts with manufacturers, and while it was able to ship doses to 100 economies in the first six weeks of global roll-out, export bans and other factors meant that large-volume deliveries were only received in the third quarter of 2021.

While COVAX was unable to completely overcome the tragic vaccine inequity that characterized the global response, it made a significant contribution to alleviating the suffering caused by COVID-19 in the Global South.

Today, the initiative has supplied 74% of all COVID-19 vaccine doses supplied to low-income countries (LICs) during the pandemic; and in total, 52 of the 92 AMC-eligible economies relied on COVAX for more than half of their COVID-19 vaccine supply.

Thanks to the tireless efforts of national governments, health and frontline workers, civil society organisations and others, those doses, delivered free of charge and combined with nearly US$2 billion in delivery support, helped to lift primary series coverage among the 92 AMC-eligible economies to 57%, compared to a global average of 67%.

Two-dose coverage of health care workers, those most critical to saving lives and keeping health systems running, stands at 84% in lower-income economies.

COVAX also deployed 2.5 million doses to protect the most vulnerable in humanitarian and conflict settings through a first-of-its kind mechanism called the Humanitarian Buffer, co-designed with international humanitarian organisations, and set up as a last resort to reach those who are not easily reached through government programmes.

Attempting to deliver novel products through non-governmental channels proved to be incredibly difficult, but the effort provided deep insight into the systemic barriers that are exacerbated by a global emergency situation.

Governments, humanitarian institutions, global health organisations and others are now working to apply these lessons towards ongoing programmes, and advocating for how we can better protect the most vulnerable populations in a future pandemic.

Investing in lessons learnt for a future response

COVAX’s successes and challenges in the bid to overcome inequity have underscored the clear need for the world to be better prepared the next time a viral threat with pandemic potential emerges. The plethora of learnings from COVAX’s unique effort must be considered in the development of future global pandemic preparedness and response architecture.

These include strengthening existing capacity by designing, investing in and implementing an end-to-end solution to equitable access ahead of time, one that centres on the needs of the most vulnerable; recognising that vaccine nationalism will persist in future pandemics and putting in place mechanisms to mitigate it – including by diversifying vaccine manufacturing so all regions have access to supply; and accepting the need to take financial risks to avoid potentially deadly delays to the development, procurement and delivery of medical countermeasures.

With collaboration from manufacturers, all of COVAX’s advance purchase supply agreements will have been completed or terminated by the end of 2023, with the exception of one, where a modest volume of supply will continue into the first half of 2024 in support of the new COVID-19 routine immunization programme.

Thanks in large part due to the savings gained through the successful renegotiation of supply contracts, some COVAX AMC funds remain in the contingency mechanism known as the Pandemic Vaccine Pool, and these can now be reinvested into translating the lessons from COVAX Facility into concrete actions.

This includes the establishing of an African Vaccine Manufacturing Accelerator (AVMA), a result of our learnings from the pandemic where Africa was left vulnerable to supply restrictions. Investment in AVMA will make up to US$ 1 billion available to support vaccine manufacturing on the African continent. In addition, a First Response Fund will be established to ensure financing for a vaccine response is immediately available in the event of a future pandemic.

It also includes funding “The Big Catch-up” effort designed to fill the gaps in immunization resulting from the pandemic which are now causing outbreaks of vaccine-preventable diseases around the world and threatening the achievement of Immunization Agenda 2030 goals.

“Millions of people are alive today who would not have been here without COVAX. Those averted deaths mean mothers can continue to nurture their children, and grandparents can enjoy watching future generations flourish,” said Jane Halton, Chair of the Board of CEPI. “Despite being built and funded from scratch amid the deadliest pandemic the world has seen in more than a century, COVAX’s life-saving accomplishments were considerable. It should take its place in history and be proud of what it was able to accomplish but also serve as a reminder to us all that we can and must do better next time.”

“COVID-19 has been the greatest health challenge of our time, and it was met with innovation and partnership on an equally unprecedented scale,” said José Manuel Barroso, Chair of the Board of Gavi, the Vaccine Alliance. “COVAX’s impact has been historic, as are the insights it has generated on how, concretely, the world can do better next time. As we transition COVID-19 into Gavi’s routine programming, we do so with deep gratitude for the passion, dedication and sacrifice of so many around the globe who fought tirelessly for three years to try and create a more equitable world – and with an unwavering commitment to improve by transforming learnings into tangible action.”

“The joint efforts of all partners to ensure an equitable response to the pandemic helped protect the futures of millions of children in vulnerable communities,” said UNICEF Executive Director Catherine Russell. “This huge and historic undertaking is something we can be collectively proud of and build on. UNICEF will continue to deliver vaccines to the world’s youngest to stop the spread of all preventable diseases and build strong health systems for the future.”

“We knew that market forces alone would not deliver equitable access to vaccines and other tools,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “The creation of ACT-A and COVAX gave millions of people around the world access to vaccines, tests, treatments and other tools who would otherwise have missed out. COVAX has taught us valuable lessons that will help us to be better prepared for future epidemics and pandemics.”