By Rodrigo Ibarrola.
Citizens continue to show their dissatisfaction with the government’s policies to combat the pandemic. Vaccines arrive in insufficient numbers, those that do arrive are not used as expected because there is no serious effort to get them to the people who need them, while the Government does not make any effort to convince skeptics that vaccines actually work, do not pose major health risks, and can save lives and keep families from economic ruin. In the midst of all this, every now and then, the COVAX mechanism is trotted out as an excuse to avoid responsibility when the pressure rises. The Government has already stated that the main reason for the lack of shots was that “they screwed us with COVAX.” This was echoed by public officials, doctors, and members of Congress, to the point that, finally, the representative of the Pan American Health Organization (PAHO), Luis Roberto Escoto, left the country. Just on June 1, it was published that Senator Blas Llano accused COVAX of being a scam in front of the Inter-Parliamentary Union.
The criticisms against the COVAX mechanism were never seriously questioned. The media even jumped on the bandwagon, giving the feeling that this mechanism had a perverse animosity towards our country. There were no voices to inquire or explain how COVAX works. Here we will try to fill that void.
The COVAX Facility is an international system created to pool resources with the objective of accelerating the development of vaccines and ensuring equitable access between countries, regardless of income level. It was created by the Gavi Alliance, the Coalition for Epidemic Preparedness Innovations (CEPI) and the World Health Organization (WHO). In the structure of COVAX, CEPI focuses on the research and development of potential vaccines, Gavi on vaccine acquisition and distribution, and the WHO on the development of vaccination policies. The goal of this entire system is – and this is important to point out – to diminish the social and economic impact of the pandemic, reduce its mortality, and immunize 20% of the member countries’ population. For this, the plan was to distribute at least 2 billion vaccine doses by the end of 2021.
Several pathways were established to let countries participate in the COVAX program. Interested countries had pay 15% of the value of the requested vaccines in advance, plus another amount as a security deposit, before October 2020. These countries belong to the group labelled “self-financed”. Another way to participate was through the Advance Market Commitment (AMC), a platform created to raise funds to allow low-income countries to receive vaccines through donations. The resources allocated to this group come from donors such as governments of rich countries, corporations, foundations, etc. Paraguay, due to its income level, is not part of this last group, but rather the self-financed set.
the accusations against COVAX are intended to hide the fact that they did not take risks to sign bilateral agreements in time, as well as to undermine diplomatic decisions that make it impossible to accept vaccines produced by China (as do those who lead regional vaccine efforts).
Less well known is the way in which the vaccine distribution program operates, which occurs in two phases. The first —and most fundamental— aims to cover up to 20% of the population of each country, which would be the proportion of the population in priority risk groups. Furthermore, it is the minimum percentage expected for all self-financed participants; for the AMC Group, it is expected to be 28%. The second phase, aimed at the other groups at risk, will only be activated once all countries have received enough vaccines to cover the population targeted in the first phase. In other words, in the case of Paraguay, which paid in advance to cover 30% of the population (4,279,800 doses), would only receive the remaining 10% once the prerequisite has been met.
Graph 1. Vaccine allocation and distribution phases
Source: Concept for the equitable allocation of vaccines through the COVAX program.
Right from the start, the program advocates anticipated that the vaccines would not be immediately available. This was known to the governments involved. When it was announced that the vaccine quantities would be insufficient for Phase 1, they determined that the doses would be assigned in rounds that would cover, if possible, 3% of the population, or as many as possible, depending on availability, as it finally turned out. This percentage was considered sufficient to reach front line medical personnel, who were prioritized. Then they would follow incrementally larger rounds, that is, each round would serve to cover a larger population than the previous one.
Based on signed agreements, the preliminary supply schedule (Graph 2) for our region initially estimated the availability of 20 million vaccines by March 2021, with distribution subject to contracts with pharmaceutical companies, clinical trials, regulatory approval, production and delivery chains, availability of resources, among other factors. However, delays in the production chain reduced the forecast, such that the calendar had to be readjusted twice.
Graph 2. Supply forecast for the Pan American Health Organization (PAHO). In millions of doses
Source: Gavi Alliance COVAX Global Supply Forecast Report. Note: Supply refers to vaccines made available by the manufacturer.
Once the vaccines become available, the allocation proposals for the rounds are prepared by the Joint Allocation Taskforce (JAT) and validated by the Independent Allocation Validation Group (IAVG) which are then approved by the Director-General of WHO and communicated to Gavi.
Vaccine allocations for the first round – delivered between March and May – were discussed and approved by consensus between February 22 and 23, later published and updated in March. Due to AstraZeneca’s problems in its production chain – since most countries were assigned these biologics – it was agreed that each country would be assigned enough vaccines to cover between 2.2% and 2.6% of its population, with the exception of small countries due to the high logistics costs of smaller shipments. The portfolio of vaccines approved and allocated up to that moment included just three: AstraZeneca / Oxford, those produced by SK Bioscience, in South Korea and by the Serum Institute (Covishield), in India, and that of Pfizer / BioNTech, manufactured by Pfizer Europe MA EEIG, in Belgium. Currently, the list also includes the Janssen, Moderna and Sinopharm vaccines.
Thus, as expected, countries smaller than Paraguay received a sufficient number to cover a greater proportion of people than the rest of the countries, given their smaller population, as shown in Figure 3.
Figure 3. First round of allocations to PAHO countries. Proportion of population to be covered.
Source: Own elaboration with data from PAHO. Note: In dark green, small developing countries.
In the relationship between allocation and distribution of vaccines, there is no pattern of preference or particular bias in favor or against any country. Small countries and the others received, on average, 74% and 73%, respectively, of the allocated amounts, with Paraguay located above the average with 100% of allocated vaccines received or in transit (Figure 4).
Figure 4. Vaccine distribution to PAHO countries. Proportion of vaccines delivered and in transit in relation to the first round of assignments
Source: Own elaboration with data from PAHO, updated as of May 30, 2020. Note: In dark green, small developing countries.
From everything discussed so far, it is clear that when the President announced the vaccines would arrive in February, no allocation had yet been approved, nor were there any plans by pharmaceutical companies to make them available; so the announcement was, to say the least, reckless. In addition, given the distribution policy set forth and carried out, there was no reason to expect nor to announce the reception of vaccines in the publicized amounts, much less decry any discrimination, since it was well known that Paraguay would receive no more than 304,800 doses before the end of May. Nor could COVAX have become the main supplier of vaccines in the country, because the objective of the program was never to achieve herd immunity, but limited to an attempt to vaccinate 20% of the population by the end of 2021.
Consequently, the accusations against COVAX are intended to hide the fact that they did not take risks to sign bilateral agreements in time, as well as to undermine diplomatic decisions that make it impossible to accept vaccines produced by China (as do those who lead regional vaccine efforts). These reasons, and not others, surely had a greater weight in our shortage of immunizations. Besmirching the name of an institution that has historically cooperated deeply with the country in disease eradication is just not what is necessary right at this particular moment.
Cover image: ABC Digital.