While still unfolding, the COVID-19 vaccine experience is a story of light in terms of speed and reach. Just over two years after the first cases of SARS-CoV-2 were detected, around 10.5 billion vaccine doses have been administered globally. Unfortunately, it is also a story of shadows. Profound vaccine inequity continues to limit access in low-income countries (LICs) where even today, only 11.4 per cent of people have received at least one shot. With 4.4 billion doses having crossed borders as of December 2021, trade has proven instrumental in the manufacturing and distribution of vaccines across the world. The global trading system, underpinned by World Trade Organization (WTO) rules, has helped keep markets open and supplies moving. Yet greater trade cooperation to tackle geographic concentration, supply chain bottlenecks and regulatory divergences, can strengthen preparedness for future pandemics.
A recent study1 on the historical record in the development and deployment of vaccines finds that the world has never witnessed such a rapid development of a viable vaccine, a massive ramp up of production and a fast and effective rollout of vaccination (figure below). Significant investments and public-private collaboration bolstered the emergence of the COVID-19 supply chain in the middle of the pandemic. While insufficient jabs significantly hampered vaccine access in 2021, supply-side constraints have begun to recede, and 24 billion doses are now forecast to be produced by mid-2022.
Despite the success in scaling up production, inoculation rates across countries at different stages of development are still unbalanced. The share of the population that has received at least one vaccine dose is almost seven times higher in high-income countries (HICs) than in low-income countries (LICs). Africa continues to suffer from low vaccination levels (figure below), and at least 20 countries in the region could miss the World Health Organization (WHO) target of vaccinating 70 per cent of their populations by mid-year. While stockpiling of doses that could be redeployed in regions facing greater need is still a risk, widespread country-specific challenges associated with delivery, demand and vaccine hesitancy, and cost and financing are increasingly hampering the diffusion of shots. Vaccine inequity is a global policy failure with negative consequences for the entire world. A recent paper argues that sharp disparities in vaccine allocation between HICs and LICs lead to sooner and larger outbreaks of new waves; by contrast, equitable vaccine allocation strategies substantially curb the developmebt and spread of new strains of the virus.
Share of people who have received at least one vaccine dose (% of population)
Trade has been a force of good in fighting COVID-19. Following a slow start, exacerbated by certain trade policies, vaccine exports ramped up in the third quarter of 2021 to reach 4.4 billion doses by the end of the year (figure below). Such an outcome would not have been possible without the cross-border movement of dozens of specialized vaccine inputs along tightly knit supply chains. From vaccine core ingredients to vials and rubber stoppers to cold boxes, to consumables (such as specialized plastic bags), specialized machinery (such as bioreactors and cold chain equipment) and other products (such as dry ice), there is a high degree of trade interdependence between the ingredients and goods needed to produce, distribute and administer vaccines. One stark lesson from 2021 is that trade is an indispensable conduit to vaccine access.
Despite its central role in immunizing the world, the 2021 export experience unearthed challenges and shortcomings of vaccine trade. First, vaccine production is highly concentrated, with 87 per cent of the total number of doses exported last year supplied by the European Union, China and the United States. While manufacturing under licensing agreements has played an important role in serving some markets, the main ingredient of vaccines, i.e. the drug substance, is only produced in nine economies (counting the European Union as one) (figure below). Since governments prioritize their own populations, the fallout of geographic concentration is limited vaccine exports in times of crisis, at least until production ramps up. To help manage the risk of vaccine inequity, supporting sustainable manufacturing capacities in all regions, and in Africa in particular, is a key priority. The WHO recently announced that Egypt, Kenya, Nigeria, Senegal, South Africa and Tunisia will receive the technology needed to produce mRNA vaccines on the continent, which will help address ongoing and future health crises.
COVID-19 drug substance capacity production by location
Governments have taken steps to speed up and expand trade in many COVID-19 goods, including by eliminating tariffs, smoothing or digitizing customs procedures and introducing green lanes for medical products and their inputs. But trade restrictions and logistics bottlenecks have exacerbated and magnified the pitfalls of export supply concentration. Vaccine manufacturers reported that export restrictions affected access to vaccine inputs as well as exports of finished vaccines and even the conduct of clinical trials. Some of these restrictions have been lifted, for example in the European Union and in India, easing the flow of vaccine doses and vaccine inputs across countries, but others are still in place.
Vaccine regulatory divergence has proven to be one major hurdle in the fight against COVID-19. While the WHO’s Emergency Use Listing Procedure provided governments with a set of available quality, safety, and efficacy and performance data to facilitate emergency authorization of vaccines, different regulatory frameworks, procedures and timelines added complexity and delayed the delivery of jabs. Manufacturers still face additional in-country requirements, unique labelling and other specifications, duplicate procedures and other regulatory barriers to expanding and optimizing production post-approval. Paperwork often needs to be resubmitted when a new production facility is opened or a production line is modified, which interrupts supply chains and discourages expansion of investments into new locations.
More recently, attention has shifted to country readiness and absorption capacity for vaccines once they are received, with the Africa Centres for Disease Control and Prevention requesting donations to be paused until later in the year. While different measures are necessary to address these challenges, trade can be part of the answer by facilitating access to ancillary vaccine supplies such as syringes, needles, saline, personal protective equipment kits and safe waste-disposal mechanisms, as well as equipment needed to increase cold chain storage capacity. Timely access to such goods can prevent costly delays or potential wastage of doses, particularly given their short shelf life. As vaccination expands in many countries, protection against the risk of illicit vaccine trade is also important.
In the global race to produce vaccinations, policies to support production and equity are needed. The Multilateral Leaders Task Force, integrated by the heads of the WTO, WHO, the World Bank and the International Monetary Fund, has been backing countries across the world in their efforts to vaccinate their populations. But trade policy cooperation is a critical part of the solution to end vaccine inequity and fast-track delivery. Governments are currently discussing their collective response as WTO members to the pandemic, including on the controversial issue of the role of intellectual property rights on vaccines. The global trading system played a key role in helping the world move COVID-19 vaccines from the lab, out the factory gate and into people’s arms at record speed and massive scale. The insights gained from this pandemic must feed into our efforts to enhance international cooperation for better future pandemic preparedness.
This piece is adapted from a WTO Blog published on 23 February 2022.
Disclaimer: The views expressed in this article are those of the authors based on their experience and on prior research and do not necessarily reflect the views of UNIDO (read more).
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