A new global assessment of purchasing agreements for COVID-19 vaccines reveals that high-income countries, as well as a few middle-income countries have already purchased nearly 3.8 billion doses, with options for another five billion. The analysis, released by the Duke Global Health Innovation Center, shows that many of these countries will be able to vaccinate their entire populationsÂand some many times overÂbefore billions of people are vaccinated in low-income countries.

While other assessments have warned of potential inequalities in vaccine access, this new analysis is the first to quantify the amount of vaccine doses that are being claimed by country-level agreements and how this could delay access to COVID-19 protection across large regionsÂincluding sub-Saharan AfricaÂuntil almost the middle of the decade.

ÂAn ambitious effort to create a global system of vaccine equity is being undermined as a handful of countriesÂincluding those who made a commitment to equalityÂsecure as many doses as they possibly can, said Elina Urli Hodges, MSPH, who leads the CenterÂs Launch and Scale Speedometer, an initiative that identifies impediments to delivering health innovations to low-income countries. ÂCountries are hedging bets by making direct deals while also participating in multilateral platforms, which drives inequality and threatens to prolong a global pandemic.Â

The Launch and Scale analysis revealed that while it will likely take three to four years to manufacture enough vaccines to cover the worldÂs population, nearly four billion doses of COVID-19 vaccine candidates are already part of bilateral advance purchasing deals involving mainly high-income countries, vaccine developers and global vaccine manufacturers. Another five billion doses are the subject of negotiations among these same parties that have yet to be finalized. Meanwhile, the study found that only enough doses to cover 250 million people have been confirmed as purchased thus far by COVAX, a global effort involving both wealthy and poor countries that has promised equal access to COVID-19 vaccines globally, regardless of income levels.

In fact, the data reveal that several COVAX signatories, including the United Kingdom (UK), the European Union (EU) and Canada, are effectively undermining the pact by negotiating Âside deals for large vaccine shipments that will Âresult in a smaller piece of the pie available for equitable global allocation.  Yet the analysis shows that not a single low-income country has made a direct agreement to purchase vaccines, suggesting that low-income countries will be limited to the COVAX pact to secure vaccines. 

  Finite global manufacturing capacity

ÂThere are negotiations underway in which vaccine-rich countries would allocate doses purchased through advance market commitments to the COVAX effort after they have vaccinated a certain portion of their populations, said Andrea Taylor, MSW, who led the analysis for the Launch and Scale initiative. ÂBut thereÂs no requirement, and arguably little incentive to do so.Â

Taylor and her colleagues conducted their assessment by reviewing available evidence from public sources through October 8, 2020, combined with interviews with global and regional vaccine experts, as well as Ministry of Health officials in select countries. The analysis looked at advance market commitments (AMCs) for COVID-19 vaccines in order to better understand their overall volume and ultimate destination.

The insights that emerged show that COVAX members Canada and the UK have already pre-purchased more than enough vaccines to cover their entire populations. The EU has secured the rights to 400 million doses for member countries, with future agreements under discussion, potentially raising that number to almost two billion. The United States (US), which is not part of COVAX, already has agreements to purchase enough doses to cover 230% of its population and could eventually control 1.8 billion dosesÂabout a quarter of the worldÂs near-term supply. None of the vaccine candidates yet have regulatory approval, however, so countries are hedging bets by purchasing multiple candidates and some portion of these doses may never materialize. The UK, for example, has made AMCs with five different vaccine candidates, using four different vaccine technologies.

Among middle-income countries, the Launch and Scale data show that Brazil and IndiaÂeach of which have large vaccine manufacturing infrastructureÂalready have secured the rights to enough vaccines to cover about half of their populations and are negotiating additional deals. It also shows that some countries, such as Peru, are using their status as the site of COVID-19 vaccine trials to secure AMCs for vaccinesÂthough Peru is also participating in COVAX to help cover its needs.

According to the analysis, the root problem is that finite global manufacturing capacity is colliding with wealth disparities and self-interest to create a zero-sum game where low-income countries simply canÂt compete.

ÂHigh-income countries are making deals with major vaccine developers who are in turn reserving the lionÂs share of the worldÂs manufacturing capacity to meet those commitments, Taylor said. ÂWeÂre rapidly reaching the point where soon, even countries that have the finances to shop for vaccines will find there is no manufacturing capacity available to fill their needs. Even with new investments to build or retrofit additional facilities, there is a limit to how much global vaccine manufacturing capacity can expand in the next few years.Â

For example, the study reveals that a pair of vaccine candidatesÂone from the Oxford University/Astra-Zeneca (AZ) vaccine partnership and another from the American vaccine developer NovavaxÂare the subject of agreements with global manufacturers to produce 3.73 billion doses. And about 3 billion of those doses would come from the Serum Vaccine Institute of India. Meanwhile, both vaccine candidates are the subject of large pre-purchasing commitments from high- or middle-income countries. The Oxford/AZ vaccine candidate leads the pack for AMCs at more than two billion doses, though that includes between 300 and 500 million doses for COVAX. In response to this climate, COVAX has moved quickly to reserve manufacturing capacity in Spain and Korea for more than a billion doses of one or more vaccines that have yet to be selected.