Explainer: Equitable Access to a COVID-19 Vaccine for the World’s Displaced Populations

In times of global crisis, refugees, internally displaced people (IDPs), and other forced migrants are likely to be forgotten or the last to receive services even though they are often among the populations at greatest risk. The COVID-19 pandemic has only underscored this dismal reality. Although the impacts of the coronavirus have varied among forcibly displaced populations, crowded living conditions, inadequate sanitation facilities, and uncertain livelihood opportunities for refugees and IDPs in and outside of camps create special vulnerabilities. This underscores the importance of accessibility to a COVID-19 vaccine or vaccines once they are developed.

But the risk of vaccine nationalism looms very large, threatening access for populations in the global south, host to tens of millions of forcibly displaced people. Moreover, greater access to vaccines for citizens in the global south hardly guarantees access for populations of refugees and internally displaced people. 

The Current Race Among Nations to Develop and Distribute a COVID-19 Vaccine

There are many and varied efforts among wealthy countries to develop a vaccine for their own populations. In the United States, Operation Warp Speed (OWS) “aims to deliver 300 million doses of a safe, effective vaccine for COVID-19 by January 2021.” OWS and other national efforts depend on distribution guarantee arrangements with manufacturers. The United States and the United Kingdom have made deals with the company AstraZeneca to receive doses based on their financial support for the development effort. The Russian government has also engaged AstraZeneca Plc in a vaccine manufacturing arrangement at R-Pharm, a large pharmaceutical company in Russia. Other governments with means to do have acted in similar ways.

The Multilateral Effort, and the COVAX Facility

It is hardly surprising that governments with means to do so are seeking to develop vaccines for their own populations. But concerns about equity and justice, not to mention the importance of averting catastrophe in lower-middle and low-income countries that could also impact wealthier ones, demand an international effort to ensure broad access to a vaccine or vaccines when they are developed.

In April, the World Health Organization (WHO) and others launched Access to COVID-19 Tools (ACT) Accelerator program, a collaboration among global health actors, the private sector, and governments to help ensure equitable access to new COVID technologies.

While the ACT Accelerator is divided into four pillars—diagnostics, treatment, vaccines, and strengthening health systems—the vaccine pillar, COVAX (COVID-19 Vaccine Global Access), and its COVAX Facility, has probably received greatest attention, as it focuses on ramping up vaccine development and manufacturing and on ensuring equitable access to a vaccine internationally. The COVAX Facility focuses on the equitable distribution and access of a COVID-19 vaccine. Under the lead of the Gavi Vaccine Alliance and with the participation of both high, lower-middle, and low-income countries—and financial support from the wealthy countries—the Facility is to invest in promising vaccine candidates, pooling the purchasing power of participating wealthy countries, and securing access to vaccines, which will then be distributed to populations in all participating countries. As of late September, 64 higher-income countries had made commitments, with others reportedly on the way, joining 92 lower-middle and low-income countries in the Facility.

Countries that participate are to be guaranteed a certain number of doses when a vaccine or vaccines become available. In addition to helping to secure vaccines for lower-income countries, the pooled nature of the Facility is designed to ensure that governments that pursue vaccine investments that do not come to fruition will nonetheless have access to effective vaccines.

Once a vaccine is available, it is to be proportionally distributed to participating countries based on their population size. Healthcare workers will be prioritized initially, and then it is to expand to 20 percent of the populations of participating countries by the end of 2021. Afterwards, more created doses would be distributed based on “country need, vulnerability, and COVID-19 threat.” The COVAX Facility will also keep a reserve of doses for emergency and humanitarian purposes. 

Progress to Date

There is some hope that COVAX will be successful, given that a majority of the countries of the world are members. Moreover, in June, the pharmaceutical company AstraZeneca committed to providing 300 million doses to COVAX, and additional and substantial commitments from other partners have been made more recently. It is also worth noting that, at this writing, the World Bank President David Malpass is seeking approval of a $12 billion financing plan to assist low-income countries in procuring vaccines. The financing plan would complement the Gavi COVAX Facility effort, strengthening the ability of participating countries to finance their own purchase of vaccines. 

At the same time, there are several formidable challenges confronting this initiative which merit the engagement of advocates committed to equitable distribution of a vaccine or vaccines.

The United States and China as Non-Participants, and Vaccine Nationalism: In fact, several countries are not, or not yet, participating in this critical international program, including the United States, China, and Russia. To be sure, wealthy governments that participate in the COVAX Facility will also pursue separate arrangements designed to provide prompt access for their own citizens. But this should not deter engagement and support—from the United States and China in particular—for the COVAX initiative. The United States decision not to participate in the COVAX Facility reflected the Trump administration’s hostility toward the World Health Organization. Both China and the United States should strongly endorse and join the Facility.

Funding: On September 30, the United Nations welcomed significant new pledges to the COVAX Advanced Market Commitment (AMC), the financing instrument behind the COVID Facility, representing substantial progress toward a seed funding goal of $2 billion. But the overall ACT Accelerator Initiative requires tens of billions of dollars, which have yet to be pledged. Most urgently, the initiative will need $15 billion to support research and development, manufacturing, procurement, and delivery systems by the end of 2020. It is disappointing that the U.S. Congress has not acted more assertively to fund this need. In particular, Congress should ensure COVID legislation includes monies for procurement and distribution of vaccines to lower-middle and low-income countries.

Ensuring that access to low income countries also means access for refugees and the displaced: Finally, while the COVAX Facility is designed to address distributional equity internationally, it is not focused on distributional equity that will address the needs of the refugees, who are non-citizens, as well as internally displaced people in lower-middle and low-income countries. As mentioned above, and as also noted by Gavi, a small buffer stock of vaccines will be kept aside, “for example, to vaccinate refugees who may not otherwise have access.” But Gavi will be stretched to its limits, and the UN High Commissioner for Refugees, the UN Office for the Coordination of Humanitarian Affairs, and the World Food Program, in cooperation with donors, should work with Gavi and others to develop concrete action plans to address the needs of refugees and others who are forcibly displaced.

To be sure, there has been progress toward equitable access to a COVID-19 vaccine, but the U.S. Congress, donor governments, multilateral institutions, and the private sector must do much more to translate this aspiration into reality.