It’s time to change the conversation

Arabella Moore

A call to the global health community to challenge the long-standing dialogue on equitable access to medicines and vaccines

The race for an effective COVID-19 vaccine continues to dominate the news. The pharmaceutical industry is cantering through the research and development process and countries are lining up their plans for procuring and prioritising access to ensure an adequate supply for their populations. But in a world that is far from achieving its 2030 goal of Universal Health Coverage (UHC), and a global health conversation that is currently dominated by the coronavirus pandemic, what is being done to ensure equitable access to medicines, vaccines and technologies to fight the disease? And, perhaps more importantly, what needs to be done to tackle the unfinished business of achieving full coverage of all life-saving healthcare?

This week, global leaders will gather for the high-level political forum (HLPF) on sustainable development – the annual meeting that is at the core of the United Nations platform for review of the 2030 Agenda for Sustainable Development and progress towards its 17 Sustainable Development Goals (SDGs). This year, participants will debate SDG progress in light of the COVID-19 pandemic and reflect on how the international community can respond to the pandemic and achieve the SDGs.

The timing of the HLPF presents an opportunity to start a new conversation about access and UHC. With all eyes on coronavirus, and in a world that, is acutely aware of its interconnectedness and its interdependence when it comes to national safety and security, this is a critical time to correct the systems that drive inequitable access to all life-saving healthcare – including vaccinations, treatments and technologies.


Applying the lens of a pandemic vaccine

The development of a safe and effective vaccine is seen as the only way the world can finally defeat the COVID-19 virus. Over 200 vaccine candidates are reported to be under development, at varying stages of investigation, and the pharmaceutical industry is collaborating with governments and partners around the world to secure the vast investment needed to accelerate this highly complex and costly process.

Increasingly though, if any of these vaccine candidates are proven to be effective, the conversation will shift from R&D to access. The ‘race’ will quickly shift from the successful vaccine development to the global collaboration required to ensure access, especially for those most vulnerable.  And to be successful regarding universal access, COVID-19 global immunisation strategies will have to confront entrenched views among government, industry and the broader global health community regarding vaccine access as a whole.

Inequalities in vaccine coverage, particularly essential childhood vaccines, remain unsolved. Immunisation is a key component of primary health care. Despite tremendous progress, far too many people around the world – including 360 million children under five each year – have insufficient access, and forecasts of the impact of the global pandemic on countries with already challenged health systems are severe.  Progress on immunisation coverage is stalling, or in some countries reversing, and the World Health Organization (WHO) and UNICEF have already reported COVID-19-related disruptions to routine vaccination programmes in as many as 100 countries.

Pneumonia – the leading infectious cause of child mortality globally – is of particular concern. The Every Breath Counts Coalition (EBC) is working with global and national organisations to support countries with very low coverage of pneumonia-fighting vaccines and high numbers of child pneumonia deaths, as these countries are now struggling with “double-burdens” of pneumonia – from COVID-19 and other causes. EBC is calling for urgent action from governments and global health agencies to fully protect all children, especially PCV which only 47% of children currently receive, and support vaccine manufacturers to ensure the continued supply of affordable, quality vaccines for low and middle-income countries (LMICs).

Leith Greenslade, Coordinator of EBC, comments, “COVID-19 has demonstrated how vulnerable every nation is to a pandemic of respiratory infection and underscored the absolutely critical role of new vaccines in ending the outbreak and continued routine vaccination to ensure we don’t get spikes in child deaths from other vaccine-preventable causes like pneumonia.”

Prior to COVID-19, global vaccination coverage had not achieved the goal of universal access and now the international community, the healthcare industry, and national governments will have to work even harder to ensure that all children receive the vaccines recommended by WHO by 2030.


The race to universal access

Coalitions and mechanisms are under rapid development to foster innovation and access to a potential COVID-19 vaccine for LMICs. The Coalition for Epidemic Preparedness Innovations (CEPI), a global partnership established in 2017 to accelerate the development of vaccines against emerging infectious diseases and enable equitable access, is securing financial support from governments, the private sector and philanthropic foundations and has already raised $US1.4 billion towards the $US2 billion it needs to meet its pandemic vaccine response.

WHO, CEPI and Gavi, the Vaccine Alliance, have launched the Access to COVID-19 Tools (ACT) Accelerator to promote the development, production and equitable distribution of vaccines, diagnostics and therapeutics for COVID-19. Within this, Gavi is responsible for coordinating the COVID-19 Global Access Facility (Covax Facility) whose purpose is to guarantee access to substantial volumes of vaccines for all countries. The pharmaceutical industry has proclaimed its commitment to the initiative and the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) has joined as a Founding Partner and publicly stated the industry’s commitment to accelerate vaccine development, production and equitable global access, “to ensure that no one is left behind”.

The Gavi Covax Facility is inspired by a similar mechanism that has increased LMIC access to the PCV and Ebola vaccines, called an advanced market commitment (AMC). However, while the AMC model has addressed inherent market challenges for vaccine manufacturers and expanded immunisation coverage in poor countries, there are valuable lessons to be learnt and applied for any future COVID-19 application.  The pneumococcal AMC, launched by Gavi in 2009, has contributed to expanded coverage of PCV, vaccinating an estimated 225 million children across 60 low and lower-middle income countries against the leading cause of bacterial pneumonia in children. However, in 2020, more than half of the world’s children don’t get this vaccine, there are 54 countries that have yet to introduce it and 12 countries where coverage is below 60%. This leaves 340 million children under five dangerously exposed to pneumonia.

Beyond specific mechanisms such as the COVAX-Facility, the non-profit sector has put into motion steps to challenge the industry to broaden its position on Intellectual Property, licensing and pricing in this COVID context. More than 140 world leaders and experts signed an open letter calling on all governments to unite behind a people’s vaccine against COVID-19, demanding mandatory worldwide pooling of patents and sharing of all COVID-19-related knowledge, data and technologies, and a guarantee that COVID-19 vaccines, treatments and tests are provided free of charge to everyone, everywhere.

In response, the industry has continued to defend the critical role that innovation plays, exemplified during the pandemic response, and the subsequent importance of incentivisation if it is to continue to make high-risk investments in medicines and vaccine development. In a recent press briefing with CEOs from four of the biggest pharmaceutical companies, executives were reported to have questioned the concept of intellectual property (IP) pools. Dr Albert Bourla, CEO of Pfizer was quoted as stating, “I think it is nonsense and at this point of time it’s also dangerous…The risks we are taking [represent] billions of dollars and the chances of developing something are still not very good. So to say keep in mind that if you discover [a vaccine or drug], we are going to take your IP, I think it’s dangerous”. Pascal Soriot, CEO of AstraZeneca, added: “I think IP is a fundamental part of our industry and if you don’t protect IP, then essentially there is no incentive for anybody to innovate.” And Emma Walmsley, CEO of GSK, commented that “there isn’t enormous evidence to show that IP is a barrier to access.

Even in these unprecedented times of the COVID-19 pandemic, the longstanding debate on access is underway – and the firm-held areas of contention between the pharmaceutical industry and the global health sector are bubbling once more to the surface.


What are we calling for?

Concerns with global vaccine coverage and other SDG shortfalls should come to the fore this week at the HLPF, providing the impetus for a new conversation around UHC and access to healthcare. Calling on all those responsible for improvements in global health to move beyond their standard argumentation and be prepared to innovate to achieve expansion of UHC should be at the heart of the HLPF deliberations.

Alongside a new normal of collaboration and acceleration for a pandemic vaccine, there is also the potential for – and perhaps an ethical obligation to take – an unprecedented approach to tackling inequitable access to all medicines and vaccines. Moving beyond known mechanisms such as the AMC, which history has proven is not without limitations, revisiting long-held positions on cost transparency, IP and technology transfer agreements, and applying the same level of innovation and collaboration seen during the current state of emergency, are critical. Governments and donors have a responsibility to think beyond their own agendas and challenge their own resource priorities if the nightmare of the coronavirus pandemic can be turned into used to build back better systems that enable universal access to all life-saving healthcare.

Ultimately, if we are to apply today’s rhetoric that the world needs to adapt to a ‘new normal’, we need to change the conversation. This can be a pivotal moment for the future of healthcare accessibility. Now is the time to challenge embedded structural and system inequalities in access to healthcare and work together as partners to take the steps necessary to reach those continually left behind.