Coronavirus (COVID-19) vaccines for developing countries: An equal shot at recovery

 The case for a co-ordinated approach to vaccines

On 26 January 2021, on the occasion of the World Economic Forum in Davos, OECD Secretary-General Angel Gurría described the challenges surrounding global access to vaccines against COVID-19 as the “greatest test for mankind as a whole and for OECD countries in particular”. He highlighted the need for joined up solutions to end the pandemic, including the important role of international development assistance to support developing countries (Gurria, 2021[1]). His statement followed new warnings from the World Health Organization (WHO) on the growing risk that “me first” approaches to securing vaccines will undermine multilateral efforts (Ghebreyesus, 2021[2]).

As the OECD Development Co-operation Report 2020 highlights, the case for a co-ordinated multilateral response to the crisis is well established, and further attention to expanding access to vaccines for developing countries and closing the financing gap is urgently needed (OECD, 2020[3]). Without such action, the pandemic is unlikely to be contained, inequalities within and between countries are set to escalate, and recovery of the global economy will be delayed, exacerbating negative spillovers from the current crisis across the 2030 Agenda for Sustainable Development. Meanwhile, a report from the International Chamber of Commerce estimated that should countries continue to pursue an uncoordinated approach to vaccine distribution, the world risked global GDP losses in 2021 alone of as much as USD 9.2 trillion, with around half of that loss expected to be borne by advanced economies (Çakmaklı et al., 2021[4]).

The COVID-19 pandemic compounds pre-existing challenges and inequalities for developing countries. The OECD Global Outlook on Financing for Sustainable Development 2021 estimates that development flows from all sources may have fallen by as much as USD 700 billion in the past year (OECD, 2020[5]). This is equivalent to more than four times the value of Development Assistance Committee (DAC) official development assistance (ODA). Despite global efforts to suspend debt repayments for the poorest countries, the pandemic has given rise to new levels of unsustainable sovereign debt as exports dwindle, access to finance is constrained and public spending grows. Meanwhile, developing or emerging market economies where tourism is critical are expected to continue to see their circumstances deteriorate in 2021 and will require further international assistance (OECD, 2020[5]).

In the face of this unfolding crisis, many developing countries find themselves lacking the same response tools deployed by OECD governments (such as large monetary and fiscal stimulus packages) to raise debt to gross domestic product (GDP) ratios. On current estimates, developing countries would have required an additional USD 800 billion to USD 1 trillion in emergency stimulus to respond to the crisis at a comparable magnitude of spending. Sub-Saharan Africa as a whole, would need to spend an additional 6% of its GDP to match the scale of OECD countries’ recovery relief packages (OECD, 2020[5]).

As the world’s biggest and wealthiest economies look forward to new vaccines in 2021 and 2022, the question of how to provide equitable access to vaccines globally remains unresolved. By current estimates, the bulk of the adult population in advanced economies will have been vaccinated by mid-2022. For middle-income countries, this timeline may stretch to late 2022 or early 2023, while for poorer countries, mass immunisation will stretch until 2024, if it happens at all (Duke Global Health Institute, 2020[6]; BMJ, 2020[7]; The Economist Intelligence Unit, 2021[8]). Meanwhile, vaccine diplomacy is also expected to play a major role in determining which developing countries will have access to vaccines first, as countries with vaccine supply capacity compete for international influence (Kumar, 2021[9]; Shepherd and Seddon, 2021[10]; Choudhury, 2021[11]).

Collaborative efforts – such as the Access to COVID-19 Tools (ACT) Accelerator and its associated tools have emerged to help bridge current gaps in the world’s ability to respond to the crisis, including through the provision of international development assistance (OECD, 2020[3]; WHO, 2020[12]). These efforts make a powerful economic case for joined up global action on access to vaccines, focused on the links between health security and global economic recovery (WHO, 2020[13]). Within the ACT Accelerator’s vaccines pillar, COVAX (the global initiative to ensure rapid and equitable access to COVID-19 vaccines for all countries, regardless of income level) has arrangements in place to access nearly two billion doses of COVID-19 vaccine candidates, on behalf of 190 participating economies. This includes delivering at least 1.3 billion donor-funded doses of approved vaccines by the end of 2021 to the 92 low- and middle-income countries eligible for the COVAX Advance Market Commitment (COVAX AMC) (Gavi, 2020[14]). Yet these efforts remain seriously underfunded and are competing for limited vaccine supply against bilateral agreements negotiated by developed countries.

Even if enough vaccine doses are eventually made available through multilateral and other channels, success will be also constrained by challenges in the health systems of many developing countries. These challenges range from a lack of trained medical personnel and inadequate health infrastructure (including adequate vaccine storage facilities) to limited tracking mechanisms. Despite the clear evidence on the importance of a more holistic approach, as of January 2021 the ACT Accelerator’s pillar on strengthening health systems had received less funding than any other area (Usher, 2021[15]).

To ensure vaccines for all, key challenges ahead include:

• Availability: High income countries have purchased a high proportion of available vaccine doses, signing purchasing agreements for quantities of vaccines sufficient to vaccinate their entire populations several times over;

• Cost: While some pharmaceutical companies have set lower vaccine prices for developing countries, or have committed to sell without profit for the duration of the pandemic (Oxford University-AstraZeneca), others have not;

• Barriers to local production: While several developing countries have the capacity to manufacture vaccines, intellectual property (IP) rights and limited technology transfer remain barriers to build local production capacity; and

• Logistics and infrastructure challenges: Beyond access, developing countries have different challenges and capacities. As such, they must have a central role in rolling out and communicating vaccination programmes, including in determining key risk groups and prioritising those most in danger of being left behind.

Beyond learning from evaluations and increased development finance, effective responses to the pandemic will also require policy makers in advanced economies to adopt more coherent approaches on the speed and scale of vaccination efforts. This includes ensuring more effective and efficient multilateral co-operation on access in close co-ordination with developing countries’ strategies, as well as broader efforts to strengthen health systems (see the policy options below).

Overall, in the absence of a comprehensive solution to effective and efficient global immunisation efforts, poor and vulnerable countries are at risk of falling further behind in their development and integration into the global economy, and ongoing health security threats will delay a global recovery (OECD, 2020[5]).

 Challenges for vaccine access and delivery in developing countries

Providing timely and equitable access to vaccines against COVID-19 for all people in developing countries presents enormous challenges, especially when taking into account competing health priorities and broader commitments in line with the 2030 Agenda for Sustainable Development. At the same time, it is clear that failure to meet these challenges will jeopardise global recovery from the COVID-19 pandemic and limit the integration of developing countries into the global economy. There is also evidence that delays in vaccine roll-out will deepen inequalities both within and between countries, with estimates that an additional 150 million people have already been forced into extreme poverty due to COVID-19 (World Bank, 2020[18]). In this context, key challenges faced by developing countries include overcoming barriers to availability, cost, local production, and logistics and infrastructure. In addressing these challenges, much can be learned from past approaches in dealing with health crises, while also taking on board emerging evidence from initial responses to the COVID-19 pandemic.

 1. Availability of vaccines

Despite the many positive steps towards international co-ordination and collaboration in response to the crisis throughout 2020 and 2021, demand for vaccines is expected to far outstrip supply, at least throughout the early months of 2021. Of the 12.5 billion doses that the principal vaccine producers have so far pledged to deliver in 2021, an estimated 6.4 billion have been pre-ordered, most of them by wealthy countries (The Economist Intelligence Unit, 2021[8]). Some advanced economies have faced claims of harmful practices such as “vaccine hoarding,” hedging their bets on potential candidates and reserving vaccine volumes sometimes several times greater than their populations (NYT, 2020[19]). At the same time, at least one advanced economy is reported to have paid far more than other countries to secure doses of the Pfizer vaccine (Rabinovitch, Lubell and Scheer, 2021[20]). In the wake of these developments, civil society has raised concerns1 around the impact of “vaccine nationalism” – where countries prioritise their own citizens and insist on priority access to vaccines through bilateral deals (Oxfam, 2020[21]). Meanwhile, WHO has called on countries with bilateral contracts – and control of supply – to be transparent on these contracts, including on volumes, pricing and delivery dates. This includes calling on these same countries to give greater priority to COVAX’s place in the queue, and to share their own doses with COVAX, especially once they have vaccinated their own health workers and older populations, so that other countries can do the same. At the same time, WHO has called on vaccine producers to provide full data for regulatory review in real time to accelerate approvals and to allow countries with bilateral contracts to share doses with COVAX, while also prioritising filling COVAX orders rather than signing new bilateral deals (Ghebreyesus, 2021[2]).

Data aggregated by Duke University (2021[22]), as well as a new initiative by UNICEF (n.d.[23]), highlight the disparities in vaccine doses secured by advanced, middle-income and low-income countries, as shown below in Figure 1.2 However, it should be noted that estimations on vaccine availability may change quickly throughout 2021 as additional vaccines come on to the market. At the same time, the People’s Republic of China (“China”), India and the Russian Federation (“Russia”) are stepping up new “vaccine diplomacy” engagement with developing countries (Kumar, 2021[9]; Choudhury, 2021[11]; Shepherd and Seddon, 2021[10]).

 

Figure 1. Vaccines secured by countries as a percentage of the total population by January 2021

Note: Authors’ illustration based on Duke University (2021[22]) Launch and Scale Speedometer at: https://launchandscalefaster.org/COVID-19 (last accessed 28 February 2020) and has not yet been compared with recently released UNICEF data on this topic for comparison.

 2. Overcoming cost barriers

Multilateral, regional and bilateral efforts to increase access to vaccines and treatments in developing countries are increasing. Nevertheless, the cost of vaccines remains prohibitive for many developing countries. The Access to COVID-19 Tools (ACT) Accelerator is the most prominent example of a collaborative co‑ordination effort bringing together state and non-state actors to develop and deliver vaccines, diagnostics, and therapeutics (Figure 2). Yet even this high profile initiative lacks financing at a critical time, with an additional USD 23.9 billion required in 2021 if tools are to be deployed across the world as they become available (WHO, 2020[24]). A decision by the World Bank’s Board of Executive Directors in October 2020 to provide USD 12 billion for developing countries to finance the purchase and distribution of COVID-19 vaccines, tests, and treatments for their citizens may go some way towards meeting the financing shortfall facing developing countries (World Bank, 2020[25]). But further efforts are urgently needed to close the remaining funding gap for the ACT initiative and to ensure further support for strengthening national health systems in developing countries.

 

Figure 2. The ACT Accelerator and its vaccine pillar

Source: Authors’ own compilation based on the following sources: Requested amount taken form initial ACT Accelerator investment case publishing in September 2020 (WHO, 2020[26]) at: https://www.who.int/publications/i/item/an-economic-investment-case-financing-requirements; Total funding gap and funding gaps for each pillar provided by WHO directly to OECD; and funding gap breakdown for vaccine pillar taken from WHO (2021[27]) funding tracker at: https://www.who.int/publications/m/item/access-to-covid-19-tools-tracker and analysis in Health Systems Neglected by COVID-19 Donors in the Lancet on 9 January 2021 (Usher, 2021[15]) at: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2821%2900029-5.pdf.

* Funding estimates for the ACT Accelerator are evolving quickly. In particular, an additional amount (currently estimated at USD 9.7 billion) has not yet been added to the ACT Accelerator request and is based on internal cost estimates by the Global Fund, World Bank and WHO for strengthening health systems in LICs and LMICs to cope with the pandemic.

** Funding gap as at 1 February 2021 pending the finalisation of a USD 4 billion commitment to the vaccines pillar from the government of the United States of America.

The ACT Accelerator is organised into four work pillars: diagnostics, treatment, vaccines and health systems strengthening (the Connector). Each pillar is vital to the overall effort and involves innovation and collaboration. In addition to the Connector, cutting across all of the work, and fundamental to the goals of the ACT Accelerator, is the Access and Allocation workstream that is led by WHO and is developing the principles, framework and mechanisms needed to ensure the fair and equitable allocation of these tools (WHO, 2020[12]). The economic investment case for this mechanism, launched by WHO and partners in April 2020 (WHO, 2020[26]), notes that required funding commitments would considerably shorten the duration of the crisis while costing less than 1 % of combined G20 government domestic stimulus packages (WHO, 2020[13]).

Within the ACT vaccines pillar, a total of USD 16 billion is required for 2020-21, with an outstanding funding gap of USD 7.8 billion to address.3

• R&D for funding of vaccines through the Coalition for Epidemic Preparedness Innovations (CEPI). Of the requested funding of USD 2.4 billion in 2020-21, a gap of 1.3 billion remains.

• Joint procurement of vaccines through Gavi COVAX, which includes indirect financing of R&D costs and building of manufacturing capacity through joint purchase commitments on behalf of participating countries for vaccines under development. This mechanism has two tiers: one for self-funding countries, and a second for a donor-funded Advance Market Commitment to support procurement for 92 low- and middle-income countries and ensure equal access at same time as wealthier countries. For the COVAX AMC, an additional USD 5 billion is required for 2021.

• Delivery preparedness: For country readiness and delivery, including guidance, tools, co‑ordination, technical expertise and support, an estimated USD 492 million was required in 2020, with an additional USD 1 billion needed for roll out in 2021.

Furthermore, the cross-cutting Health Systems Connector pillar aims to strengthen, on a country-by-country basis, human resources, infrastructure, and data management. This pillar is still under development but work is expected to go beyond vaccination to include prerequisites for vaccination campaigns such as cold chains (WHO, 2020[28]). While the challenges are huge in some countries, the funding requirements of USD 9 billion for the Connector represent a small portion of the estimated USD 38 billion required for the ACT Accelerator to the end of 2021.4 In addition, despite the central importance of health system capacity to deliver vaccines, the Connector remains one of the most underfunded elements in the entire mechanism, with a funding gap of USD 7.9 billion. As Figure 2 indicates, further funding of USD 9.7 billion may also be required to help low- and middle‑income countries to cope with the pandemic throughout 2021 through further efforts to strengthen their health systems.5 In 2021, the OECD will undertake further analysis on access and delivery of vaccines against COVID-19, including the implications for fragile states.

In addition to global initiatives, a number of regional initiatives have emerged, such as the COVID-19 African Vaccine Acquisition Task Team (AVATT) to support the roll out of the African Union’s Africa Vaccine Strategy (African Union, 2020[29]) and the Asia-Pacific Vaccine Access Facility (Asian Development Bank, 2020[30]). At the bilateral level, vaccine manufacturers in China and Russia are making agreements with low- and middle-income countries to supply COVID-19 vaccines (So and Woo, 2020[31]). Meanwhile, Australia and New Zealand have committed to purchase vaccines for their Pacific island neighbours (Ministry of Health, New Zealand[32]). A number of other advanced economies (including Australia and Canada) have committed to share unused or excess doses from their national stock with developing countries, although how this arrangement would work, or when it could be put in place, remains unclear. To help guide these initiatives and other emerging access deals, Gavi has released Principles for Dose Sharing in December 2020 (Gavi, 2020[16]; 2020[33]).

 The importance of evaluating vaccine initiatives

A wealth of evidence is available to guide development co-operation providers in achieving equitable access: including ways of effectively supporting sustainable long-term health systems strengthening, supporting uptake of vaccines, and innovative financing mechanisms. Analysis of past experiences – notably with pneumococcal vaccines (BCG, 2015[41]), swine flu and Ebola – can assist decision makers in advancing the understanding of common barriers to equitable vaccine access. With participation from the evaluation departments of the Asian Development Bank, the Global Affairs Canada, the Norwegian Agency for Development Co-operation (Norad), the United Kingdom, the Global Vaccine Initiative (GAVI) and WHO, the COVID-19 Global Evaluation Coalition is currently compiling key evidence and lessons to help decision makers and operational staff. A first brief provides evidence-based recommendations for issues to consider when communicating with the public about vaccines (Glenton and Lewin, 2020[42]). A second brief looks at the effectiveness and impacts of using digital communications tools to promote vaccine uptake (Lewin and Glenton, 2020[43]).

Plans to evaluate the use of ODA to support equitable access to COVID-19 vaccines for low- and middle-income countries are currently being developed by the participants of the COVID-19 Global Evaluation Coalition. This collaborative evaluation work, supported by the OECD, will complement accountability and governance mechanisms in place among the key international organisations, including Gavi and the WHO.10 Criteria to be considered, based on the OECD-DAC evaluation criteria, are outlined in Box 1.

 Development finance: current status

Development finance for health is increasing. Between 2000 and 2019 (latest data), ODA targeting health for developing co-operation increased from USD 3 billion to USD 27 billion (Figure 3). This growth was accompanied by a rapid rise in the number of active development partners working in the health sector, with the number of entities reporting health-related disbursements to the OECD’s Creditor Reporting System (CRS) expanding from 27 in 2000 to 86 in 2018, although part of this increase was also due to an increased level of reporting from foundations, multilateral organisations and other providers. In terms of contributions channelled, a small number of development partners dominate the landscape. Among the key players are DAC members such as the United States and the United Kingdom, but also private philanthropic foundations – notably the Bill and Melinda Gates Foundation (BMGF) – as well as a number of global programmes designed to target specific health issues and diseases. Overall, development assistance to health represented 12% of total health spending in lower middle-income countries, and 29% for low-income countries in 2019 (latest data). Data on allocations for 2020 are not yet available, although initial evidence indicates that an increase in spending for this sector can be expected.

 

Figure 3. Development finance trends in health financing

2000-19, disbursements to health, USD billion in constant 2018

Source: OECD Creditor Reporting System (OECD[44]) at: https://stats.oecd.org/Index.aspx?DataSetCode=crs1#, disbursements to health, USD billion constant 2018 (bars) and share of total (line).

This rise in health-related support has largely been driven by increasing contributions to vertical health funds and specific diseases. Between 2016 and 2018, DAC members contributed an annual average of USD 129.5 million in health development finance to vertical funds – in particular to Gavi, the Vaccines Alliance, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and UNAIDS. On average, since 1996, ODA commitments to health systems (regardless of aid modality) have constituted 14% of total ODA commitments to health for DAC members. In recent years, international focus and funding commitments shifted to infectious diseases, such as Ebola, whereas funding for health systems declined to 11% over the period 2013-18 (OECD, 2020[40]). Given the need to improve the functioning of health systems in many developing countries, development co-operation providers (including vertical funds) are increasingly making efforts to ensure that even disease-specific interventions and programmes raise capacity of health systems (Kim, Kessler and Poensgen, forthcoming[45]). In this vein, efforts are needed to organise the roll-out of immunisation campaigns in a way that maximises spill-over effects on health systems overall.

A stronger focus on strengthening national systems in procurement and public financial management can enable more effective COVID-19 vaccine delivery while using and supporting these systems to provide the multi-sectoral response necessary to combat the crisis (e.g. training workers, ensuring logistics, attention to social determinants of health) (OECD, 2020[40]). For this reason, the DAC 2020 High Level Meeting statement prioritises both investment in health systems and social safety nets, which are central to every country’s strategy to combat the medical, social and economic impacts of the COVID-19 crisis (OECD DAC, 2020[46]).

The 2014-15 Ebola epidemic sparked a new political level interest in health crisis response and preparedness, bringing these issues to the G20 Leaders’ Summit for the first time in 2014. In 2016, the World Bank established the Pandemic Emergency Finance Facility and the World Health Organisation published its Blueprint list of diseases and pathogens to be prioritised for research and development in public health emergency contexts. Later that year leaders agreed at the World Economic Forum in Davos, Switzerland to explore new ways to drive product innovation for high-priority epidemic threats, leading to the establishment of the Coalition for Epidemic Preparedness Innovations (CEPI), which finances research projects to develop vaccines against emerging infectious diseases.

Despite the significant scale up in funding and collaboration on health financing at the time of the Ebola crisis, the COVID-19 pandemic highlighted the overall vulnerability of existing preparedness and response mechanisms and the need for a broader global response to health crises. To this end, G20 Leaders offered full support to the ACT Accelerator initiative in their declaration of 22 November 2020 (G20, 2020[34]), including for the role of “extensive immunisation” and committed to addressing remaining global financing needs, albeit without an agreed timeline.

Beyond the financing challenges outlined above, the ACT Accelerator’s vaccines pillar aims to promote equitable access and fair allocation globally, with an initial focus on high risk and vulnerable people in all countries. Principles for vaccine distribution within countries have been proposed (e.g. prioritisation of health workforce and older people) and will need fine-tuning based on individual country contexts. However, it is important to note that, while being a step in the direction of more equitable vaccine allocation, COVAX falls short of being a mechanism to distribute vaccines equitably among people on a global scale. Self-funding countries will receive volumes sufficient for between 10-50% of their populations in proportion to their financial contributions, while the 92 low- and middle-income countries are promised volume for up to 20% of their populations, subject to funding availability (Gavi, n.d.[47]).

Discussions are ongoing within the OECD DAC over the issue of ODA eligibility of contributions towards pandemic preparedness and response. In particular whether contributions directly benefit developing countries as development co-operation. For example, the OECD Secretariat has advised that research for vaccines/tests/treatments for COVID-19 cannot be seen today as complying with the ODA criterion of having the economic development and welfare of developing countries as its main objective (OECD, 2020[48]). For this reason, a case-by-case approach is needed to identify the ODA-eligibility of such activities.11 Contributions to the Gavi COVAX AMC are fully ODA-eligible as they are used to support procurement and delivery of vaccines for ODA eligible countries. Nevertheless, at the time of writing, the ODA-eligibility of some activities related to ACT Accelerator tools (i.e. the ODA share of CEPI’s COVID-19 activities, funded by earmarked contributions to CEPI) are still under discussion. Another emerging issue is whether excess vaccines from pre‑purchased bilateral deals can be donated to developing countries as aid “in kind”. While ODA eligibility will largely depend on whether the surplus vaccines are fit for the specific context of developing countries, it will also be important to ensure that any ODA provided in this form is additional and does not lead to crowding out of other development assistance flows, particularly for countries that have a fixed ODA/GNI target. The extent to which bilateral deals can be considered to have undermined the objectives of multilateral mechanisms like the ACT Accelerator for equitable access to vaccines remains an issue of contention.

According to an article published in the Lancet on 9 January 2021 (Usher, 2021[15]), of the total USD 5.8 billion contributed by donors to the ACT-Accelerator, some USD 3.9 billion had gone to vaccine procurement and distribution in low-income and middle-income countries, while just 6% has been reserved for strengthening health care systems. Canada, European Union, Gates Foundation, Germany, Norway, Saudi Arabia and the United Kingdom are the leading providers of development finance for the ACT Accelerator. However, to date, only Germany has provided funding support for health systems strengthening within this initiative, prompting calls for a re-balancing of political attention towards stronger health systems rather than vaccine doses alone (Usher, 2021[15]).

In parallel to the ACT Accelerator, other solutions, such as vaccine and product development partnerships, have emerged to develop vaccines, drugs and diagnostics for neglected and poverty-related diseases and make them available at affordable costs. For example, Gavi’s International Finance Facility for Immunisation (IFFIm) is a model that might be adapted to the case of COVID-19: i.e. Gavi would issue a bond backed by donors, which allows the organisation to obtain immediate funding to develop logistics chains in the hardest-hit countries, purchase and distribute a vaccine or a cure. Donor countries thus spread the cost over a longer period of about 20 years (Gavi[49]).

In order to strengthen resilience and improve preparedness for future shocks like COVID-19, any of the solutions envisaged will require new levels of international co-ordination, as well as new sources of financing and financial instruments. A recent WHO and OECD analysis identified an overall financing gap of USD 95 billion over five years in middle-income and low-income economies for common public goods functions contributing to pandemic preparedness (OECD, 2020[39]). While much of this financing is expected to come from increased domestic resource mobilisation, especially in middle-income countries, WHO has estimated that it would also require an almost 50% increase in ODA for developing countries’ health sectors to help meet this shortfall, particularly for the poorest countries (amounting to an additional USD 12 billion annually on top of the USD 26 billion currently allocated). Writing in the OECD Development Co-operation Report 2020, Professor Inge Kaul suggests that rather than stretching ODA budgets further to fund global public goods like health security, an overhaul of development co-operation finance is needed to give these public goods their own budget line and enable more transparent provision of financing (OECD, 2020[3]). This call is highlighted as part of a broader discussion on the way forward in the Development Co-operation Report 2020, pointing to the need to clarify the role and contribution of public finance to global public goods and to study innovative structures like the ACT-A as a model for tackling other global issues.

Finally, it will be critical to ensure financing is not diverted to COVID-19 related areas at the expense of other areas of the health system, or other sectors, and that any additional financing should be equitably distributed across all areas of the Sustainable Development Goals. This is especially important given that the pandemic is estimated to have set back progress towards many of the goals by up to two decades.12 Overall, the additional billions in development finance to address the COVID-19 crisis must be considered in the broader context of the estimated USD 7 trillion cost to the global economy through lost GDP growth by the end of 2021 due to COVID-19 (OECD, 2020[5]). Moreover, as new research shows (WHO, 2020[50]), if the financing shortfall for low- and middle-income countries to access vaccines, treatments and diagnostics is not met, this will result in a protracted pandemic and severe economic consequences – not just for poorer countries but also for the wider global economy.13

 Preparing for the future: potential scenarios for vaccine access and roll-out

In planning for the future, development co-operation specialists and other policy makers will need to consider various plausible scenarios14 on vaccine roll-out and access based on science and reflecting emerging social, economic and geopolitical signals. Key questions to consider will include:

• Vaccine effectiveness and evolving research: how many times will we need to redevelop or modify the vaccines, and at what cost? While vaccine immunologic targets remained relatively stable during 2020, several variants were identified in December 2020. There are concerns that such mutations may impact the efficacy of existing vaccines.15 Research has already been driven by the need to overcome certain logistical or infrastructural issues for vaccine roll-out – for example, to reduce required vaccine storage temperatures in countries where cold chains are less reliable. Future research may also evolve to take into account inter-generational or ethnic differences in immune responses to different vaccines (e.g. a vaccine has not yet been approved for use on children). In addition, prioritisation of research into vaccines for adult populations may have ramifications for developing countries where children and youth make up around half of the overall population.

• Longevity of immunity: will maintaining herd immunity against COVID-19 require recurrent vaccine administration? The duration of immunity conferred by the various vaccines remains unclear. Initially, it was thought that the immune response in infected individuals was dependent on the severity of the disease and might not be durable. More recent analysis indicates immunity post-infection might in fact last for several years (like MERS or SARS), if not for a lifetime. However, this will depend on the evolution of the virus and further mutations.

• Social acceptability and trust in vaccinations: Demand and uptake depend on transparency, trust, and understanding the benefits of vaccines. Meaningful community engagement, particularly with marginalised groups, those with low levels of trust in government services and/or disproportionately impacted by the pandemic are crucial to successful and equitable uptake of vaccines.

• Towards a global solution or not?: Even if the world agrees on an equitable way to distribute vaccines, they may take years to reach many developing countries and excluded populations and we do not know how many people will agree to be vaccinated. Harvard Professor Kenneth Rogoff is amongst those encouraging policy makers to consider the increasingly likely possibility that the coronavirus could prove more stubborn than expected (Rogoff, 2020[51]), or that first-generation vaccines might only be effective for a short period.

Policy makers need to examine all plausible scenarios available and, while awaiting safe vaccines, significant advances can be made to improve testing, tracing protocols, and treatment in developing countries to assist in adaptation to less optimistic scenarios. At the same time, investments in data management, policy research and evaluation can inform strategic decision making on national and global responses to the pandemic – for example, on how to maximise efficient use of funds and improve the relevance of planning.