The Proposal

On Thursday, December 8, the board of Gavi, the Vaccine Alliance (Gavi) agreed, in principle, to explore integrating future COVID-19 vaccinations into its core programming after 2023 and changing its approach to financing middle-income countries. Stressing that the decision would remain flexible to account for developments in the pandemic next year, the board’s proposal would see COVAX’s vaccine distribution model shift away from an emergency response program to something more routine.

If implemented, the proposal would end full COVAX support for 37 middle-income countries after 2023 that are now among the more than 90 countries fully supported through the COVAX Advanced Market Commitment (AMC). These countries would nonetheless receive a one-time payment to enable them to buy vaccines at a reduced price, with the portion of the vaccine dose cost to be covered dependent on the pandemic’s severity. Beyond 2023, COVID-19 vaccines would still be provided to 54 low-income countries for free, with additional funding for delivery, through Gavi’s core immunization programming. The shift would streamline COVID-19 and routine immunization for these countries, which still have the world’s lowest rates of COVID-19 vaccination.

A final decision on COVAX beyond 2023 will not be made until June 2023, following consultation with the affected middle-income countries. There will be no change to COVAX through 2023; all 92 low- and middle-income countries currently supported through COVAX’s AMC will continue to receive support through next year.

The board also approved the relaunch of its HPV vaccination initiative; an evolution of its immunization programming that would refocus efforts on ending backsliding in routine immunization; a strengthened role for Gavi in pandemic preparedness and response; and support for regional vaccine manufacturing.

The Proposal’s Potential Impacts

Should the proposal go ahead, Gavi would still provide some support to the 37 middle-income countries for COVID-19 vaccination beyond 2023, depending on the state of the pandemic. If COVID-19 hospitalizations and deaths continue to decline and SARS-CoV-2 mutations are less dangerous, COVAX would likely forgo procuring COVID-19 vaccinations for the middle-income countries, and would use a portion of the money saved to offer a one-time “catalytic grant” that would cover 50-60% of the cost for vaccinating vulnerable groups, like health workers and older populations.

Under an alternative scenario with high COVID-19 mortality and new dangerous SARS-CoV-2 variants, the 37 middle-income countries would receive a greater level of support from Gavi. In any scenario where support is decreased, Gavi plans to use part of the savings to create a new pandemic financing pool that could be deployed rapidly to procure vaccines if dangerous SARS-CoV-2 variants emerge. With these changes, Gavi would be in a better position to wield its resources to meet SARS-CoV-2 changes and surges. While Gavi remains committed to leaving no one behind, there is still concern that its proposed shift from an emergency approach could be premature — leaving middle-income countries ill-equipped to bolster and maintain COVID-19 vaccination coverage, or feeding a false perception that the pandemic is over.

For the 54 low-income countries, COVID-19 vaccines would be integrated into countries’ routine vaccination programs that Gavi ordinarily supports. This could have positive impacts: people could get all of their vaccines at once, increasing demand and coverage, and it could streamline COVID-19 vaccine delivery by reducing administrative burdens.

The proposal would also allow Gavi to refocus its finances on routine immunization — which declined during the COVID-19 pandemic — and on HPV vaccination to fight cervical cancer, which took 342,000 lives in 2020, mostly in low-income countries.

Who Will Be Most Affected?

Any changes to the COVAX funding model are likely to be limited, though much will rest in the hands of the individual governments of the 37 middle-income countries that would be required to cover part of the costs of maintaining their vaccination programs come 2024. Impacts are built into the board’s current thinking, where COVAX would cover a portion of the vaccine costs for the middle-income countries. Demand for COVID-19 vaccines has also fallen. Unless demand unexpectedly soars, with partial COVAX funding and access to vaccines at Gavi-negotiated prices, the expenses in 2024 are likely to be limited. With only a one-time catalytic grant, the costs would likely increase in the following years.

The effect, then, will depend on policy and funding choices of those middle-income countries’ governments. If countries limit COVAX vaccine purchases and funding for delivering and administering the vaccines without full funding support, groups with the highest risks of severe disease — the elderly, immunocompromised, and others with underlying conditions — would be most affected, as would those, like health workers, with greatest COVID-19 exposure risk. However, governments could prioritize these populations, as Gavi intends. Prior vaccination would only have limited impact on mitigating risks, as the vaccine’s effectiveness wanes over time.

Impacts could extend beyond the health consequences of reduced COVID-19 vaccination. If governments fail to fund COVID-19 vaccination, and if COVID-19 surges, the resulting increased hospitalization may burden hospitals and affect capacities to care for patients.

This risk is attenuated by one of Gavi’s planning scenarios, as money saved from reduced funding for middle-income countries would be channeled to a Pandemic Vaccination Pool, and even middle-income countries would receive at least an initial higher grant, if COVID-19 took a turn for the worse. The Pandemic Vaccination Pool would also help ensure that low-income countries, least able to cover vaccination costs, will continue to receive free vaccines from COVAX. Meanwhile, if governments do cover their share of COVID-19 vaccination costs, additional risks arise if such funding is diverted from other domestic health programs.

To the extent governments do not maintain robust COVID-19 vaccination efforts, separately or as part of routine vaccination programs, lower COVID-19 vaccination will lead to more infections — meaning more opportunities for SARS-CoV-2 to mutate, potentially leading to new variants that spread globally. However, compared to the overall number of COVAX infections, and in light of existing low demand for vaccines, this impact is limited.

What Can Be Done to Continue Vaccine Distribution for the Affected Countries?

With COVAX covering part of the vaccine costs, and the continuation of Gavi-negotiated reduced pricing, unless demand significantly increases, COVID-19 vaccination distribution could continue through domestic financing. If governments choose to de-prioritize COVID-19 vaccination, despite the continued threat, they may be able to secure funds from international funders, like the World Bank or bilateral agencies.

It is also possible that they could access vaccines at even lower prices than those available through COVAX. Possibilities include the Serum Institute of India — itself a major COVAX supplier — which produces the AstraZenca/Oxford vaccine, and new possibilities, like the low-cost Corbevax vaccine, produced by a team led by Peter Hotez at the Baylor College of Medicine. Through September 2022, 80 million people in India had received Corbevax. The WHO-established mRNA vaccine technology transfer hub in South Africa is likely to have also completed clinical trials of its mRNA COVID-19 vaccine and to begin its distribution in 2024. Further, other mRNA vaccine production sites have been established in Brazil and Argentina.

More significant than COVAX’s likely future are core aspects of the global response to COVID-19. With low demand for vaccines, it is critical to couple vaccine purchases and distribution with vaccine education campaigns to increase uptake — through partnerships with trusted community-based organizations and strengthening vaccine delivery infrastructure. Continued support is needed to bolster vaccine access for marginalized communities. Failing in these areas seems far more likely to contribute to increased death and disease from COVID-19 than any reduction in COVAX support for middle-income countries beyond 2023.