The organization that has led the global effort to bring COVID vaccines to poor and middle-income countries will decide this week whether to shut down that project, ending a historic attempt to achieve global health equity with a tacit acknowledgment that the effort fell far short of its goal.
The deliberations reflect the reality that demand for COVID vaccines is waning quickly throughout the world and is near nonexistent in countries that have some of the lowest rates of coverage.
The program, known as COVAX, has delivered more than 1 billion COVID vaccines to developing countries, in hugely challenging circumstances. But it was hobbled by fierce vaccine nationalism in wealthy nations and a series of missteps and misfortunes that undermined demand for the shots.
The proposal to end COVAX will be voted on by the board of directors of Gavi, a nonprofit founded in 2000, that manages strategic stockpiles of emergency vaccines and supplies routine childhood shots to developing countries.
The proposal would “sunset” COVAX sometime in 2023. For 54 poor countries that traditionally receive Gavi support to deliver routine childhood immunizations, COVID shots would still be available for free. However, they would be rolled into Gavi’s standard immunization program, mostly as booster shots for the elderly and others in high-risk groups.
Thirty-seven other countries — middle-income nations including Bolivia, Indonesia, and Egypt — would receive a one-time cash infusion to “catalyze” the setting up of their own independent COVID vaccination programs.
The proposal, which was obtained by The New York Times, comes from Gavi’s planning committee, whose recommendations are usually adopted largely as presented.
The fate and performance of the global COVID vaccination program has become a heated issue among Gavi’s donors and the COVAX partners before the board meeting in Geneva — a gathering that is normally an unremarkable affair. Few of the players in the decision process were willing to speak about it on the record.
Dr. Seth Berkley, the chief executive of Gavi, said the group’s work on COVID vaccination would not be diminished if the plan were adopted.
“The plan in 2023 is to continue to work on getting primary coverage up as high as countries want it but also to really focus in on helping countries get those high-risk populations covered,” Berkley said. “The current proposal is that we integrate the COVAX work into the core work of Gavi — not closing it down but integrating it. Because the belief is that, by the end of 2023, it shouldn’t be seen as an emergency program anymore.”
There is an average of 52 percent coverage of primary vaccination in Gavi-supported countries, but in some countries, the figure is still below 20 percent.
The World Health Organization continues to endorse a target goal of 70 percent COVID vaccination coverage. The WHO, a COVAX partner, declined to comment on the proposal being considered by the Gavi board.
Kate Elder, the senior vaccines policy adviser for Doctors Without Borders’ Access Campaign, said Gavi is moving too quickly to abandon COVAX when countries have been led to expect that support would be there for years to come.
“They don’t have enough analysis for this kind of huge policy decision,” she said. “But this move is driven by donors. When I speak to donors, they say, ‘We don’t want any more fundraising for COVID-19 vaccines.’”
The low demand for the vaccines means COVAX has had to cancel and renegotiate purchase agreements — while high-income nations, with limited interest from their own populations, continue to funnel excess supply into the organization.
Recipient countries are refusing and returning vaccine shipments, saying they have more urgent health priorities. One issue before the Gavi board this week is an effort to redouble efforts on catch-up campaigns for routine vaccinations, rates of which have declined sharply through the COVID pandemic.
“Most African countries would much rather see increased investment in malaria vaccines,” said a board member not authorized to speak on the record about Gavi activities.
While COVID infections are rising in much of sub-Saharan Africa, the least-vaccinated region of the world, few countries there are reporting any increase in hospitalization or death rates, one factor in the declining interest in vaccination. The low rates of serious illness and death reflect the fact that the region has a young and thus less vulnerable population, that fewer people have easy access to hospital care, and that causes of death are rarely determined or registered. All those factors may contribute to a perception that COVID is not an urgent problem.
COVAX was badly hampered from the outset. High-income nations rushed to lock up the supply of vaccines when they were still scarce, and donations were fitful.
COVAX had intended to rely on a supply of AstraZeneca’s vaccine made by the Serum Institute of India in order to start deliveries in mid-2021, but the Indian government blocked the export of 400 million doses in the face of a crushing Delta variant wave.
When COVAX finally had vaccines to distribute, it became apparent that plans to use the routine immunization systems to deliver them were inadequate, said a Gavi board member closely involved in the rollout who was not authorized to speak publicly about the organization’s performance. The COVID shots, intended for adults and requiring multiple doses and extreme refrigeration, presented new challenges that weak health systems were ill-equipped to manage.
Frustrated by the erratic supply, some public health agencies did little to create demand for the vaccines, while a cresting tide of misinformation discouraged people from seeking them out. By the time supply was adequate, Omicron, which caused less severe illness, was the dominant variant. Motivation, especially for people who would need to travel long distances or invest their own scarce resources to get a shot, had fallen away.