The Role of Global Health Partnerships in Achieving Vaccine Equity: A case study of the COVAX Facility

Background: The COVID-19 pandemic led to the creation of COVAX, a novel structure to support the discovery, development, and distribution of COVID-19 vaccines. It differed in an important aspect from the previous mechanisms, in that it was based on global solidarity. Ideally, one would have expected that the design of this innovative mechanism would draw on the lessons of the previous global health partnerships operating in the vaccine field. Consequently, this thesis asks two questions: (a) what lessons can we learn from previous experiences with vaccine global health partnerships?; (b) to what extent were those lessons learnt, or not learnt, when creating COVAX and what might explain this? Methods: This study uses an explorative single case study design, using qualitative methods, with a constructivist international relations framework by Rushton and Williams (2012). The research questions were answered using a combination of methods. The first involves a scoping review of the existing published literature. The second question is answered by means of an analysis of relevant documents and interviews with key informants involved in the creation and operation of COVAX. The documents reveal, primarily, the extent to which the lessons learnt, as identified in the answer to the first question, were addressed in the process of creating COVAX. The interviews confirm or refute the findings from the documents and seek explanations for why issues were addressed or were not. Data was analysed thematically, using inductive coding. Ethics approval was provided by the Research Ethics Committee at the London School of Hygiene and Tropical Medicine. Findings: COVAX has largely replicated approaches adopted in existing global health partnerships (GHPs). Overall, this has been characterised by an exclusion of civil society organisations (CSOs) and low-middle income countries (LMIC) stakeholders in decision making processes, a subsidy-based approach to tackling innovation. This approach has largely ignored political determinants of vaccine equity, resulting in a mismanagement of political externalities which have led to vaccine nationalism and have benefitted a specific set of stakeholders, namely donors and high-income countries (HICs). COVAX endorses the assumption that market friendly policies can be leveraged to achieve innovation which ultimately address donor concerns of cost effectiveness, however such measures have proven to be ineffective. Summary of recommendations: The recommendations are as follows for GHPs: • Ensure inclusivity in decision making processes: GHPs should champion the inclusion of LMICs and CSOs across all decision-making stages; • Diversify regional manufacturing of vaccines: Expanding regional manufacturing will prevent manufacturing bottlenecks; • Diversify solutions for different economies; • GHPs should influence reform across the vaccine innovation process.