Global inequities in access to COVID-19 health products and technologies: A political economy analysis

Abstract

This paper presents a political economy analysis of global inequities in access to COVID-19 vaccines, treatments, and diagnostic tests. We adapt a conceptual model used for analysing the political economy of global extraction and health to examine the politico-economic factors affecting access to COVID-19 health products and technologies in four interconnected layers: the social, political, and historical context; politics, institutions, and policies; pathways to ill-health; and health consequences. Our analysis finds that battles over access to COVID-19 products occur in a profoundly unequal playing field, and that efforts to improve access that do not shift the fundamental power imbalances are bound to fail. Inequitable access has both direct effects on health (preventable illness and death) and indirect effects through exacerbation of poverty and inequality. We highlight how the case of COVID-19 products reflects broader patterns of structural violence, in which the political economy is structured to improve and lengthen the lives of those in the Global North while neglecting and shortening the lives of those in the Global South. We conclude that achieving equitable access to pandemic response products requires shifting longstanding power imbalances and the institutions and processes that entrench and enable them.

1. Introduction

COVID-19 vaccines were developed at amazing speed and have been critical in reducing mortality from the pandemic. In January 2021, however, the Director-General of the World Health Organization (WHO) Dr Tedros Ghebreyesus warned that “… the world is on the brink of a catastrophic moral failure – and the price of this failure will be paid with lives and livelihoods in the world's poorest countries” (WHO, 2021a). At that stage, more than 39 million COVID-19 vaccine doses had been administered in at least 49 higher-income countries, in comparison with just 25 doses in a single lowest-income country. These inequities have persisted throughout the pandemic. By November 2022, almost 13 billion doses of COVD-19 vaccines had been administered around the world, but less than 25% of people in low-income countries (LICs) had received a dose (Global Change Data Lab, 2022).

Access to diagnostic tests and treatments for COVID-19 has also been highly inequitable. Only 0.4 percent of the 3 billion diagnostic tests used globally by March 2022 were administered in LICs (Balakrishnan, 2022). Inequities in access to COVID-19 therapeutics have been even more marked, with more than 70% of treatment courses reserved by high income countries (People's Vaccine Alliance, cited in Iacobucci, 2022) and only eight LICs having received deliveries of oral antiviral treatments by November 2022 (UNICEF, n.d.).

These inequities reflect failures in the global response to COVID-19. Early in the pandemic, the Access to COVID-19 Tools Accelerator (ACT-A) was set up as a global collaboration to “… speed up an end to the pandemic by supporting the development and equitable distribution of the tests, treatments and vaccines the world needs to reduce mortality and severe disease …” (WHO, n.d.-a). The vaccines pillar of ACT-A, COVAX, began with the modest aim to deliver 2 billion doses by the end of 2021, enough to vaccinate 20% of the population in every country (WHO, 2020). But COVAX is widely acknowledged to have failed (de Bengy Puyvallée and Storeng, 2022). By the end of 2021, more than 76% of people in high and upper-middle-income countries had received a vaccine dose, in contrast to only 8.5% of those in low-income countries (LICs) (de Bengy Puyvallée and Storeng, 2022). Instead of COVAX, donations became the main mechanism through which COVID-19 vaccines were provided to LICs. However, by June 2022, less than 50% of the 2.1 billion vaccine donations pledged by G7 countries to poorer countries had been delivered (Oxfam International, 2022, June 25).

The other three ACT-A pillars were even less successful. The therapeutics pillar received less than 20% of the US$ 9.1 billion sought (WHO, 2022a). The diagnostics pillar, which planned to provide 500 million diagnostic tests to low and middle-income countries (LMICs) by mid-2021, had only delivered 97 million by the end of 2021 (WHO, 2022a). The health systems strengthening pillar was widely perceived to be dysfunctional (WHO, 2022a).

In addition to problems with the global distribution of vaccines, the development and manufacturing of COVID-19 vaccines and other products was concentrated in Western countries, with little sharing of intellectual property (IP) or technology transfer to enable manufacturing in the Global South. Efforts to encourage voluntary sharing, such as the COVID-19 Technology Access Pool (C-TAP) set up by the WHO, failed to correct the imbalance, and negotiations at the World Trade Organization (WTO) over a temporary waiver of its IP rules for COVID-19 health products and technologies ultimately failed to secure a meaningful outcome (Amin and Kesselheim, 2022).

In the wake of these failures, attention has now begun to shift to planning for future pandemics and the Pandemic Prevention, Preparedness and Response Accord (hereafter, Pandemic Accord) currently being negotiated at the WHO presents an opportunity to take a different approach. However, as we will show in this paper, the inequities of the COVID-19 pandemic are deeply rooted in power asymmetries in the global political and economic order which have shaped the unfair development and distribution of COVID-19 health products and technologies. We illustrate the pathways to ill health extending from these global dynamics by tracing the politics and policies that have led to a high burden of disease and avoidable deaths due to inadequate vaccination rates, low testing levels and lack of access to treatments. We argue that future efforts to equitably share health products must be based on structural reforms that tackle these power imbalances, including through reforming the ways in which pharmaceutical R&D are funded, preventing exclusive monopolies on health products and technologies, and empowering LMICs in global governance structures.

The purpose of this paper is to apply a political economy of health approach to analysing the development of global inequities in access to COVID-19 health products and technologies, the failures to correct them and the prospects for change. We adapt a conceptual framework applied to the political economy of extraction and health, and in doing so present a novel framework for examining the causes of global inequities in the distribution of COVID-19 products and their impacts on health.

2. Materials & methods

In order to systematically interrogate the global political and economic dynamics underpinning the inequitable distribution of COVID-19 vaccines, diagnostics and therapeutics, we applied a ‘political economy of global health’ framework first developed by Birn et al. (2017), and then adapted by Schrecker et al. (2018) in the context of analysing the political economy of global resource extraction (i.e. mining) and its health effects (see Fig. 1 ). This conceptual framework provides a structured and theory-informed tool for unpacking the layers of political economy from global forces to the health consequences for communities and individuals. To our knowledge, the conceptual framework has not previously been applied in the context of access to medicines, and its application for examining the global distribution of COVID-19 medical products and technologies represents a novel development in applying a structured political economy approach to this topic.

Fig. 1.

Schematic of the political economy of global extraction and health (Schrecker et al., 2018).

Central to a political economy approach is the notion that to understand inequities in health outcomes, we need to examine how political, economic and social factors operate and interact at multiple levels. Birn and Schrecker's frameworks enable these factors to be mapped out at multiple levels: from the broad social, political, economic and historical context at the global level, to the international and national politics, institutions and policies which structure health and ill health, to the pathways to ill health at the national and local level (such as exposures and living conditions), and ultimately to the embodiment of these structural factors in the health consequences for communities and individuals (Birn et al., 2017; Schrecker et al., 2018).

We adapted these frameworks specifically for examining inequities in access to COVID-19 health products and technologies, using the four categories of factors at different levels set out by Schrecker et al. (2018):

• ·The social, political, economic, and historical context (international)
• ·Politics, institutions and policies (international and national)
• ·Pathways to (ill) health (national and local)
• ·Human health consequences (local and individual).

The first level (the social, political, economic, and historical context) focuses on the international context and enables a deep examination of the historical evolution of the global order in which the problem – resource extraction in the context of the work of Schrecker et al. (2018), and inequities in access to COVID-19 products in the current study – has arisen. The second level (politics, institutions, and policies) enables an examination of the way this global order interacts with contemporary international and national politics, institutions, and policies. The third level (pathways to ill health) illuminates the ways in which the global political economy and the politics, institutions and policies are linked with health outcomes and their distribution (the fourth and final level).

This multi-layered framework acts as a blueprint for understanding health inequities as a form of structural violence. A term coined by Johan Galtung (1969) and developed further by Paul Farmer (2004), structural violence refers to systematic forms of oppression “built into structures, institutions, ideologies and histories” (Dilts et al., 2012, p. 91). Violence, here, refers to the more “invisible, indirect and insidious” forms of harm caused by systemic poverty, power asymmetries and neglect, which ultimately lead to reduced life chances for many of the world's poor (Hamed et al., 2020, p. 1663). Given the colonial and racialised lines along which this structural violence plays out, this in turn reveals a form of necropolitics, in which elites of the Global North tend to hold the power to determine who lives and who dies (Mbembe, 2019; Sumba, 2021). Made explicit through the framework, these underlying theories lay bare how health inequities – whether in relation to global extraction or COVID-19 health products and technologies – tend to be well-trodden grooves within the political economy. To identify the factors impacting access to COVID-19 health products and technologies at each level, we drew on our extensive knowledge of the literature on access to medicines from over a decade of research in this field, along with a comprehensive review of scholarly and grey literature on the political and economic factors affecting access to medicines in the context of the COVID-19 pandemic.

3. Results

Fig. 2 presents the framework adapted for the political economy of access to COVID-19 health products and technologies.

Fig. 2.

Schematic of the political economy of access to COVID-19 health products and technologies.

3.1. The social, political, economic, and historical context

The dynamics which have shaped inequitable access to COVID-19 health products and technologies – and which have given rise to the politics, institutions and policies adopted to procure and distribute these products during the COVID-19 pandemic – are deeply embedded in various aspects of the social, political, economic, and historical context. These include capitalism, neoliberalism and globalisation, the establishment of the global IP regime in the context of trade liberalisation, the corporate power of the pharmaceutical industry, entrenched power asymmetries in global health governance, and failures to ensure equitable access to pharmaceuticals during previous pandemics. In this section, we trace the history of these factors and how they created the conditions in which efforts to equitably distribute COVID-19 vaccines, treatments and tests were bound to fail.

3.1.1. Capitalism, neoliberalism, and globalisation

Many of the root causes of the failure to achieve an equitable distribution of COVID-19 medical products and technologies can be traced to twenty-first century capitalism and neoliberal political regimes. Neoliberalism, while a term used in many different ways, broadly refers to the “doctrine of the free market and related political and individual freedoms” (Ahlberg and Bradby, 2022) or the “extension of competitive markets into all areas of life, including the economy, politics and society” (Springer et al., 2016, p. 2). Sell (2020, p. 150) explains that while neoliberalism in the 1970s and 1980s was characterised by “deregulation, privatization, and the transformation of social protection regimes – all underpinned by a faith in free markets”, twenty-first century capitalism has shifted towards a focus on the role of intangible assets (such as IP), financialisation, profits and competitiveness in global markets. Financialisation, a key feature of 21st century capitalism, refers to the dominance of financial markets, instruments and institutions over economic outcomes and policies. This incentivises the pharmaceutical industry, for example, to reorder its priorities from creating products that meet health needs to delivering value to shareholders (Sell, 2020). Such shifts have been accompanied by globalisation, described by Jenkins (2004, p. 1) as “a process of greater integration within the world economy through movements of goods and services, capital, technology and (to a lesser extent) labour, which lead increasingly to economic decisions being influenced by global conditions”.

The historical shifts towards 21st century capitalism, neoliberalism and globalisation help to explain many of the intractable problems associated with the maldistribution of COVID-19 products explored further below, including the over-reliance on market solutions, the monopoly power of the pharmaceutical industry – underpinned by the recognition of intellectual property rights (IPRs) – and the tolerance for massive pharmaceutical industry profits from products which are extremely inequitably distributed.

3.1.2. The establishment of the global intellectual property regime

It was in the context of this broader shift towards neoliberal globalisation in the 1980s and 1990s that the global IP regime originated (Townsend, 2016). After the Second World War, companies in countries like the USA, Germany, and the UK, facing intense domestic competition, sought to expand into new markets where national pharmaceutical industries were not yet established (Drahos, 2002a). As countries like India began to develop the technology and capacity to manufacture generic drugs, the absence of IP protections in many developing countries began to threaten the market share and profitability of the pharmaceutical giants, such as Pfizer (Drahos, 2002a). By the 1980s, the US pharmaceutical and other industries had begun to focus on the General Agreement on Tariffs and Trade and the subsequent establishment of the WTO as a forum where they could make gains that were not possible through unilateral pressure on individual countries (Drahos, 2002a).

Prior to the establishment of the WTO in 1995, few developing countries provided pharmaceutical patents, which were seen to advantage pharmaceutical companies in developed countries, rather than benefiting the Global South (Townsend, 2016). Those developing countries that did introduce IP standards similar to those of developed countries during the 1900s did so largely as the result of colonialism (Drahos, 2002b).

The establishment of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) in 1995 was a watershed moment in the evolution of the global IP regime, resulting in the internationalisation of enforceable IP standards that had mainly been adopted by wealthy countries until that time (’t Hoen, 2016). TRIPS mandated patent terms of at least 20 years for both products and processes, in all fields of technology, along with a suite of other IPRs.

IP was successfully linked with trade through the intense lobbying of the pharmaceutical industry along with other IP-intensive industries such as the software and entertainment industries (Shadlen, 2007). These industries worked together with developed states, particularly the United States and European Union, to incorporate IPRs within a wider package of agreements and trade-offs (Drahos, 2002b, ’t Hoen, 2009). Drahos (2002a) describes how US pharmaceutical company, Pfizer, played a key role in the lobbying campaign, selling the importance of IPRs to the US economy through industry associations, business networks and trade advisory committees, and making financial contributions to think tanks with political influence. Having secured US government support, US corporations then focused on building an international business coalition to pressure other governments to support their IPR agenda, particularly in Europe and Japan (Drahos, 2002a).

Developing countries initially opposed the inclusion of patents in the WTO agreements but ultimately agreed to TRIPS, at least partly in the hope that a multilateral agreement would reduce unilateral pressure from the USA and other wealthy countries (’t Hoen, 2009). However, this was not to be – the USA in particular continued to pressure other states to increase IP protection using its Special 301 law, which identifies countries that are perceived to provide inadequate IP protection and market access for US IP owners, and subjects them to trade sanctions (’t Hoen, 2009). Various scholars have also documented the undemocratic process for the negotiations, where ‘Green Room’ consultations were held between key countries to discuss technical details, often excluding developing countries, which also lacked the expertise in their negotiating teams to fully understand the implications of what was being proposed (Drahos, 2002a).

Sell (2007, p. 42) argues that:

Overall, TRIPS reflects and promotes the interests of global corporations that seek to extend their control over their intellectual property. These firms, acting through the United States government (and with the support of Europe and Japan), largely captured the WTO process and succeeded in making public international law to suit their particular needs.

Battles over IP protection continued after TRIPS. In the context of lack of access to HIV drugs, developing countries successfully negotiated the Declaration on the TRIPS Agreement and Public Health (Doha Declaration) which affirmed the right of WTO members to take measures to protect public health through the use of ‘TRIPS flexibilities’. These included compulsory licensing (licensing a patented invention without the consent of the patent holder), parallel importation (importing a patented product without the permission of the patent holder) and transition periods for least developed countries (LDCs) (’t Hoen, 2009). A subsequent WTO decision in 2003 on the implementation of the Doha Declaration sought to address the inability of countries lacking domestic pharmaceutical manufacturing capacity to effectively utilise compulsory licensing (Abbott, 2005). While the Doha Declaration was a very significant development that facilitated compulsory licensing, the complex process for exporting to countries without domestic production capacity remained so cumbersome and impractical that it has only been used once (’t Hoen, 2009).

The USA and EU also sought to further expand IPRs and reduce the scope for using TRIPS flexibilities through ‘TRIPS-plus’ rules in bilateral and regional free trade agreements, including provisions requiring, for example, extensions to patent terms, exclusivity for test data submitted to regulators, and restrictions on compulsory licenses (Sell, 2007). The widespread adoption of these rules has resulted in further delays to the market entry of generic drugs, increasing medicine costs for consumers and governments (Tenni et al., 2022).

3.1.3. Corporate power of the pharmaceutical industry

A key aspect of the global historical context for inequitable access to COVID-19 health products and technologies is the corporate power of the pharmaceutical industry. Kapczynski (2022) describes four mutually reinforcing sources of the pharmaceutical industry's power: property power, vertical power over politics, ideational power, and material power. While Kapzynski's analysis focuses on the USA, these forms of power can also be seen on a global scale. The pharmaceutical industry's property power derives from overlapping IPR over patents, regulatory data, and trade secrets, which allow them to keep competitors out of the market and charge high prices for their products (Kapczynski, 2022). Vertical power, Kapczynski (2022, p. 4) argues, involves “forms of power over the political process itself that help industry entrench the status quo”. This vertical power is exerted primarily through intense lobbying (particularly in the USA), underpinned by the huge profits generated from property power, and the enshrinement of these property rights in international law. Ideational power arises from invoking neoliberal narratives about the crucial role of the private sector in pharmaceutical innovation (and scepticism about the role of government) (Kapczynski, 2022) along with the narrative that IP drives innovation and economic growth. The industry also holds material power in the form of technical expertise, experience and control over personnel and facilities, which governments cannot quickly and easily replicate (Kapczynski, 2022). While the industry's power is not absolute, challenges to it tend to have limited success (Kapczynski, 2022).

At the global level, the research-based pharmaceutical industry acts as a transnational industry to consolidate and expand its power and pursue a global agenda around entrenching and expanding its monopoly rights (Gleeson et al., 2017). Financialisation of the industry has been driven by mergers and acquisitions, giving rise to “pharmaceutical behemoths” focused on maximising profits and shareholder value (Keenan et al., 2022, p. 2). Large pharmaceutical companies establish many subsidiary companies incorporated in various countries, with opaque relationships between them, enabling taxable income to be moved to countries with lower tax rates (Gleeson et al., 2017). These subsidiaries tend to become members of industry associations in the countries in which they are incorporated, exerting political influence at the national level which reflects the global agenda of the parent company (and the wider agenda of the research-based pharmaceutical sector) (Gleeson et al., 2017). As we discussed in the previous section, a key part of the industry's global agenda is to drive the expansion of strong monopoly rights through international trade agreements. These power dynamics help to explain how entrenched and diffuse the industry's power is, and how difficult it is for governments and other stakeholders to shift the status quo.

3.1.4. Power asymmetries in global health governance

The global health governance context in which efforts to procure and distribute COVID-19 products for LMICs were generated is also riddled with power asymmetries. These dynamics are not unique to COVID-19. As Otterson et al. (2014) point out, power asymmetries that compromise efforts to address health inequities in all policy areas are entrenched and reinforced by dysfunctions in global governance structures and systems. Krikorian and Torreele (2021) describe the emergence of a donor-driven global health architecture from the early 2000s, with a central role for the private sector and a more marginal role for governments in correcting market failure. Donor funds were used to support vertical disease-focused programs relying on market mechanisms, including public-private partnerships, to secure pharmaceuticals in bulk at reduced prices for the poor (Krikorian and Torreele, 2021). These arrangements left the global world order, prevailing ideologies, and the pharmaceutical industry's business models intact, supporting the status quo (Krikorian and Torreele, 2021).

In this donor-driven architecture, global health has become dominated by actors committed to neoliberal ideologies and private market solutions (Stein, 2021). Large private philanthropic organisations such as the Bill and Melinda Gates Foundation arise from the global concentration of wealth and resources and are invested in maintaining existing power structures (Kim, 2021). The Gates Foundation, while contributing enormously to global health spending and undoubtedly saving lives (McCoy and McGoey, 2011), has played a particularly pivotal role in the financialisation of the global health sector and the creation of new financial markets in global health (Stein, 2021). This is in the context of an increasingly weak and under-resourced WHO (Stein and Sridhar, 2018). The neoliberal framing that infuses global health governance “obfuscates the relations of power that undergird global health inequities” (Kim, 2021), enabling, as McCoy and McGoey (2011, p. 161) argue, “palliative” rather than “long-term structural solutions”.

Crucially, many aspects of global health governance reflect legacies of colonialism. Tropical medicine, the antecedent of modern global health, originated in the late nineteenth century, when colonial powers sought to treat diseases like malaria that afflicted colonised people as part of a wider process of ‘civilising’ them, in the context of protecting their own commercial interests (Fofana, 2021; Kim, 2021). The era of ‘international health’ that followed in the twentieth century was a continuation of this ‘civilising’ mission: philanthropic organisations armed with technological solutions engaged in paternalistic disease eradication programs that paid little regard to the recipients (Fofana, 2021). The ‘global health’ era that followed from the 1990s in response to new disease threats such as HIV, while acknowledging the interconnectedness of the world, remained dominated by institutions and experts from high income countries (HICs) who continue to set the global agenda, in a continuation of colonial practices (Fofana, 2021). These practices perpetuate a view of the recipients of global health support as inferior, support the imposition of donor control, and foster dependency (Kwete et al., 2022).

3.1.5. Failures of previous pandemics

Inequitable access to pharmaceuticals in the context of public health emergencies and pandemics is a longstanding problem. In the 1990s, the emergence of antiretroviral therapies for HIV turned it from a uniformly fatal disease into a treatable chronic illness; however, until political mobilisation enabled widespread generic production in the early 2000s, millions of people in developing countries lacked access to these drugs (’t Hoen, 2009). When an avian influenza (H5N1) outbreak emerged in Asia in 2004, the Indonesian Government refused to share virus samples with the WHO, for fear they would be used to develop commercial vaccines which Indonesia and other developing countries would not be able to access (Fidler, 2010). Developments during the 2009-H1N1 pandemic saw these LMIC concerns come to fruition. HICs made large advance purchase agreements, reserving almost all of the vaccine doses that could be manufactured in the first year (Fidler, 2010). While WHO negotiated with pharmaceutical companies and HICs to secure some donations, pledges were made only after HICs had enough vaccine for their own populations, and even then were pledged without nominating delivery dates (Fidler, 2010). Fortunately, the 2009-H1N1 pandemic did not turn out to be as severe as expected, but the inequities in access to vaccines that occurred in 2009 were not successfully resolved – and set the scene for what was to play out in the COVID-19 pandemic more than a decade later.

3.2. Politics, institutions, and policies

We now turn our attention to the politics, institutions, and policies in place during the COVID-19 pandemic – born out of power asymmetries in the global order described in the previous section – and how they have shaped access to COVID-19 medical products and technologies. We begin by scrutinising the way in which the development of these products and technologies has been underpinned by massive injections of public funding, generating equally massive profits for private companies with few (or no) strings attached. We then analyse how the governance and design of ACT-A reproduces existing power asymmetries and colonial practices in global health governance, and the reliance of COVAX on neoliberal ideologies and market arrangements. We next examine the vaccine nationalism of HICs, and the vaccine charity and diplomacy approaches which developed in the absence of equitable sharing, and which exacerbated and further entrenched power imbalances. Finally, we unpack the pharmaceutical industry's stranglehold on the production of COVID-19 products and technologies, and the failure of efforts to correct inequities, including the COVID-19 Technology Access Pool (C-TAP), the mRNA vaccine technology transfer hub and negotiations to waive IP rights for COVID-19 products.

3.2.1. Public funding of private monopolies

Enormous amounts of public funding were poured into the research and development of COVID-19 vaccines. Early in the pandemic, at least US$5.6 billion was provided by governments in up-front funding to support vaccine R&D, along with more than US$45 billion committed in advance to purchase the resulting products (Moon et al., 2021). Wouters et al. (2021) estimated that US$10 billion was invested in 26 vaccine candidates that had been approved in at least one country, were in phase 3 clinical trials, or were under contract to CEPI or COVAX.

These injections of funding meant that governments, rather than the private sector, took on the risks and costs associated with vaccine development (Moon et al., 2021). But despite this heavy subsidisation, governments chose not to attach conditions to this funding to require companies to price their products affordably, or to share their data, technology, and know-how. The Trump Administration's initiative for funding vaccine R&D, Operation Warp Speed, for example, gave close to US$1 billion to Moderna for the development of its COVID-19 vaccine, but Moderna – despite relying on previous research undertaken by the National Institutes of Health – retained ownership of its technology and know-how and full control over price (Cancryn et al., 2021, May 11). Moreover, Moderna stipulated that doses purchased by the USA could not be shared with other countries – a condition that severely constrained the US Government's capacity to donate excess doses later on (Cancryn et al., 2021, May 11).

When a team of scientists at the University of Oxford developed a front-runner COVID-19 vaccine, for which they planned to offer non-exclusive, royalty free licenses to enable the product to be provided free or at cost during the pandemic, Bill Gates reportedly pushed the team to sign an exclusive license deal with pharmaceutical giant AstraZeneca (Baker, 2020, July 15). This was despite an estimated 97–99% of the funding for the research behind the vaccine coming from public and charitable sources (Cross et al., 2021). Governments contributed 45.9% (£31.8 million) and charitable trusts 31% (£21.5 million) while only 2.8% (£1.9million) was contributed by industry sources (Cross et al., 2021). This called into question the prevailing view, famously espoused by Boris Johnson, that the successful development of COVID-19 vaccines was a product of capitalism and greed (Safi, 2021). While AstraZeneca pledged to sell the vaccine at not-for-profit prices during the pandemic, it included a clause enabling it to declare the pandemic over (Scheibner et al., 2022), and began to sign for-profit contracts in November 2021 for the following year (Espiner, 2021, November 12).

Leading COVID-19 vaccine manufacturers have profited handsomely from the pandemic, bringing in billions of dollars in revenue and many hundreds of millions in profit (Hassan et al., 2021). Pfizer, for example, brought in almost $37 billion in revenue from its COVID-19 vaccine in 2021, and expected vaccine sales of $32 billion and sales of its antiviral drug Paxlovid of $22 billion in 2022 (Kollewe, 2022, February 9). Its net profit for 2021 was almost $22 billion, more than double its profit in the previous year (Kollewe, 2022, February 9).

Prices set by vaccine manufacturers have varied wildly. While AstraZeneca and Johnson & Johnson pledged to sell their vaccines at low prices during the pandemic, other companies have charged far more, with some prices exceeding the highest prices previously set for vaccines (Wouters et al., 2021). While price information is generally kept confidential, various revelations (some accidental) have exposed large anomalies in pricing between countries. For example, South Africa paid more than double per dose for the Oxford-AstraZeneca vaccine than the European Union (Dyer, 2021).

Pfizer, which priced its COVID-19 vaccine at US$30 per dose in the USA – a price estimated as nearly 30 times the cost of manufacturing – announced in late 2022 that it would increase the cost per dose to around $110–130 in 2023 (Cullinan, 2022, October 24).

3.2.2. Top-down governance and design of the Access to COVID-19 Tools Accelerator (ACT-A)

ACT-A was quickly assembled in April 2020 as a loose collaboration between established global health actors including private sector stakeholders, public-private partnerships, and donors, reflecting the existing global health landscape rather than new governance arrangements (Moon et al., 2022). Initial participants included the Gates Foundation, CEPI, Gavi, the Vaccine Alliance, The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), Unitaid, Wellcome, the WHO, the Developing Countries Vaccine Manufacturers Network, International Federation of Pharmaceutical Manufacturers and Associations, and the International Generic and Biosimilar Medicines Association (Moon et al., 2022). The governance structures of ACT-A were plagued by a lack of transparency and accountability, with the roles of various parties, including donors, HICs and industry groups, unclear and shifting over time (WHO, 2022a; Moon et al., 2022).

From its inception, ACT-A's reliance on the existing global health architecture meant it was invested in perpetuating market-based arrangements and adopting a charitable model which distinguished between donors and recipients (Krikorian and Torreele, 2021). It was heavily criticised by civil society for its limited focused only on stop-gap measures during the acute phase of the pandemic and the assumption that LMICs would be able to obtain COVID-19 products and technologies through normal market operations after this time (ACT-A Civil Society and Community Representatives, 2021).

Both the design and the initial governance structure of ACT-A excluded LMICs (Moon et al., 2022). In contrast, nine HICs were initially included (Moon et al., 2022). Civil society organisations were also largely excluded from the governance structure in ACT-A in 2020, although this had improved by 2021 (WHO, 2022b). An independent external evaluation of ACT-A (WHO, 2022a) found that the top-down governance structure meant the countries ACT-A was primarily intended to benefit were not meaningfully engaged and did not have a sense of ownership of the initiative (WHO, 2022a). The exclusion of LMICs also resulted in an overwhelming focus on the procurement of products, with insufficient attention to delivery and the logistical and health system supports needed by LMICs to roll out vaccines (WHO, 2022a).

3.2.3. COVAX: a private-public partnership based on power asymmetries and private markets

The governance and operating model of COVAX, the vaccines pillar of ACT-A, was equally deeply embedded in existing power asymmetries, neoliberal ideologies, and market arrangements. Its governance was based on global public-private partnerships; a governance mechanism that is afflicted with power asymmetries and where wealthy governments and corporate partners hold the most power (de Bengy Puyvallée and Storeng, 2022).

In many ways, COVAX represented a new type of ‘super public private partnership’ (Storeng et al., 2021). Not only does it have the features of established PPPs, such as a vertical, single-disease focus and focus on technological solutions; it also has distinctive features due to its scale and complexity. These include its attempt to coordinate a fragmented global governance field in a complex and convoluted structure – in which WHO becomes a partner rather than a coordinator – its vast scale; and its blurring of the boundaries between public and private actors (Storeng et al., 2021).

The operating model of COVAX was based on advanced purchase agreements with manufacturers. Self-financing countries would pay for their own vaccines, while the Advanced Market Commitment (AMC) arm of COVAX would provide donor-funded doses free of charge to 92 mainly LICs.

COVAX not only continued the existing trend of financialisation in the global health sector, but also expanded the use of financial instruments in global health governance (Stein 2021). Initially set up as a ‘global buyers’ and distribution club’, the idea was that countries would share the financial risks of vaccine production, while equitably distributing the resulting products. However, early in the process, concessions were made to HICs to enable them to negotiate bilateral deals directly with vaccine manufacturers, which undermined the premise on which COVAX was based and transformed COVAX from a buyer's club to an ‘insurance policy’ for rich countries whose focus turned to more direct ways to secure vaccines (Stein, 2021). The separation of COVAX into two arms, with the AMC funded through donations, also meant self-financing countries could benefit from the insurance policy COVAX provided without being obliged to contribute to the AMC. As a result, by December 2020, “COVAX had changed from a buyer's club based on global solidarity and sacrifice to a charity-based aid project” (Stein, 2021, p. 8).

COVAX accommodated the interests of commercial actors, channelling public funds towards vaccine development and manufacturing and requiring little of the industry in return (Storeng et al., 2021). As Eccleston-Turner and Upton (2021, p. 433) argue, “This arrangement is therefore a win-win for pharmaceutical companies, because the COVAX pillar bears a significant share of the financial risks associated with failure, leaving the pharmaceutical companies free to profit on the back of any success. In essence, this arrangement privatizes profit and socializes risk”. Vaccine manufacturers were able to prioritise selling doses at high prices to wealthy countries, without having to provide any at cost to COVAX (de Bengy Puyvallée and Storeng, 2022). No vaccine manufacturers donated doses to COVAX in 2020-21 (de Bengy Puyvallée and Storeng, 2022), and vaccine procurement contracts often prohibited countries from exporting, donating and even re-selling vaccines without the manufacturer's permission (Apuzzo and Gebrekidan, 2021, January 28). The COVAX model also “obscures the power the industry holds over the global allocation of vaccines, placing primary responsibility for redistribution (or failure to do so) on wealthy country governments.” (de Bengy Puyvallée and Storeng, 2022).

3.2.4. Vaccine nationalism - hoarding of COVID-19 vaccines by rich countries

The absence of a global governance framework that effectively enabled equitable sharing of vaccine doses meant that, faced with intense political pressure to cater for their own populations, states tended to adopt a stance of moral nationalism (privileging domestic access) rather than moral cosmopolitanism (prioritising other countries' populations along with their own) (Scheibner et al., 2022). Predictably, rich countries quickly began to undermine COVAX by negotiating directly with pharmaceutical companies to pre-purchase large quantities of vaccines for their domestic populations even before COVAX had started to negotiate with industry, essentially starving COVAX of supplies. By November 2020, more than half of the first 7.5 billion doses had been pre-purchased by HICs representing less than 14 percent of the world's population (So and Woo, 2020). By December 2020, when the first vaccine doses were being rolled out, Canada had entered pre-purchase agreements for 9.5 doses per head of population (So and Woo, 2020); by August 2021 Australia had exceeded this, with more than 10 doses per person ordered (Gleeson et al, 2022).

In 2022, HICs proceeded to third and fourth doses, placing continued pressure on supply. By December 2021, the rate of administration of booster doses in HIC had exceeded the total doses administered in LICs (Mancini and Stabe, 2021, December 19). Moreover, pleas by the WHO to halt the administration of boosters until LIC had completed vaccination of high-risk groups (Cullinan, 2021) were ignored.

The pharmaceutical industry was also complicit. The monopolisation of vaccines by HICs was facilitated by the vaccine manufacturers, who ultimately held greater power over the distribution of vaccines and could have forced HICs to go through COVAX to obtain vaccines rather than negotiating bilateral agreements (Scholz et al., 2022).

The callousness of HICs in the face of the “fatal implications of global inequality” – the tacit acceptance of preventable death on a large scale – has been described by Sumba (2021, p. 48) as “necropolitics at large”, while these dynamics have also been understood in terms of “vaccine apartheid” and “structural violence” for privileging the lives of those in the global North over the global South (Sparke and Levy, 2022; Harman et al., 2021; Hassan et al., 2021).

3.2.5. Vaccine charity and diplomacy

Unable to purchase vaccines in a market where supply had been monopolised by rich countries’ bilateral deals, COVAX had to rely on donations. However, it lacked enforcement mechanisms to require countries that had purchased more than their fair share of vaccines to share their excess doses. Donations of doses to COVAX were pledged early but generally arrived late; with few eventuating before the second half of 2021 after donor countries had already met their domestic demand and most failing to materialise before the end of 2021 (de Bengy Puyvallée and Storeng, 2022). Some were earmarked for specific countries, and many excess doses were donated bilaterally rather than through COVAX (de Bengy Puyvallée and Storeng, 2022).

Many vaccine donations were too ill-timed or too close to expiry to be able to be absorbed by recipient countries. In December 2021, the WHO Director-General noted that more than two thirds of donated doses had an expiry date of less than 3 months (WHO, 2021b). The ad hoc timing and lack of predictability made it difficult for developing countries to prepare, for example by putting cold chain arrangements in place, and often meant that countries’ preferences for vaccine type were not able to be accommodated (WHO, 2022a).

Many countries sidestepped COVAX altogether, opting for a ‘vaccine diplomacy’ approach, making bilateral donations to countries in line with their national interests, to “reap diplomatic and geopolitical benefit” (Storeng et al., 2021, p. 9). These dynamics have further entrenched power asymmetries, disempowering recipient countries and increasing their dependency on the charity of the rich countries that seek to wield influence through their donations (Holzer et al., 2022). Sparke and Levy (2022) argue that both “vaccine charity” (humanitarian donations through COVAX) and “vaccine diplomacy” (bilateral donations made for strategic and geopolitical motives) have not only failed to deliver the vaccines needed in LIC in a timely way, they have also protected the existing global vaccine market from more radical alternative approaches to equitable manufacturing and distribution, which might have achieved “vaccine liberty” for LMICs.

Non-Western powers including China and Russia also engaged in significant vaccine diplomacy, distributing millions of nationally developed doses to other countries through bilateral sales and donations, but largely bypassing COVAX (de Bengy Puyvallée and Storeng, 2022). These donations were driven by a somewhat different set of motivations to those of the West, including economic and reputational factors in addition to strategic geopolitical considerations (Suzuki and Yang, 2022). While these doses played a significant role in lifting global vaccination rates, for politico-economic reasons as well as their limited effectiveness in comparison with mRNA vaccines developed in the West, they did not provide an effective solution to global inequities.

3.2.6. The pharmaceutical industry's stranglehold on production of COVID-19 products and technologies

Pharmaceutical companies have protected their exclusive rights to manufacture COVID-19 products and exclude others from the market by filing large numbers of patents in multiple countries. Gaviria and Kilic traced the complex webs of patents and license agreements on various aspects of the technology underpinning the mRNA COVID-19 vaccines, which involves a very large number of entities (Gaviria and Kilic, 2021). Scheibner et al. (2022) searched patent databases for patents filed in just two countries for six key COVID-19 vaccines and found over 100 active and pending patent applications for the USA and more than 40 for Australia.

Facing criticism over the inequitable distribution of its COVID-19 vaccine in 2020, Moderna made a pledge not to enforce its COVID-19 patents during the pandemic (Moderna, 2020, October 8). However, by March 2022, Moderna announced that while it would never enforce its COVID-19 patents in the 92 LMICs included in the COVAX AMC, it expected its IP to be respected beyond these 92 (Moderna, 2022).

The pharmaceutical industry, with few exceptions, kept a tight grip on the exclusive rights to manufacture COVID-19 vaccines, engaging in very little voluntary sharing of IP or know-how to enable more widespread manufacturing. There have been few voluntary licenses negotiated with companies in LMICs, with the notable exception of the Oxford-AstraZeneca vaccine (Chaudhuri, 2022). AstraZeneca licensed the Serum Institute of India to provide a billion doses for LMICs, along with several companies in various other countries. However, these voluntary licenses come with conditions. For example, the terms of its contract prevented the Serum Institute of India from supplying upper-middle income and HICs (Chaudhuri, 2022).

The two companies making mRNA vaccines – Pfizer/BioNTech and Moderna – have not entered any licensing agreements involving technology transfer with companies in LMICs. While Pfizer entered an agreement with the Biovac Institute in South Africa to manufacture the Pfizer-BioNTech vaccine for African Union countries, Biovac's role was limited to the fill and finish stage of manufacturing, with the vaccine substance provided ready-made from Europe (Pfizer, 2021, July 21). BioNTech announced in February 2022 that it would establish a ‘modular’ mRNA manufacturing facility to manufacture mRNA vaccines for African countries, but this involves shipping fully equipped production lines along with BioNTech staff to operate them, at least initially (Davies, 2022).

Companies have been more prepared to engage in voluntary licensing agreements for the small-molecule antiviral COVID-19 treatments, presumably because these are more likely than vaccines to be subject to compulsory licensing if the industry does not enter voluntary arrangements. But these agreements tend to exclude large parts of the world. Both Merck Sharpe & Dohme and Pfizer have established agreements with the Medicines Patent Pool for Lagevrio and Paxlovid respectively, resulting in license agreements for their antiviral treatments with generic manufacturers (Medicines Patent Pool, 2021a, November 16, Medicines Patent Pool, 2021b, October 27). But the countries that can benefit from these are limited to mainly low and lower-middle income countries (106 and 95 respectively), with upper-middle income countries such as Thailand, China and Mexico unable to be supplied under these licenses. Pfizer has also agreed to deals with UNICEF and the Global Fund, for a total of 10 million treatment courses of Paxlovid to be provided at not-for-profit and/or tiered prices (Pfizer, 2022, September 22). However, this represents a very small proportion of the treatment courses being manufactured, projected by Pfizer (2022) to amount to 120 million by the end of 2022.

3.2.7. Failure of efforts to correct inequities

Efforts to encourage the pharmaceutical industry to voluntarily share its IP and know-how largely failed. Following a request by Costa Rica, the WHO set up the COVID-19 Technology Access Pool (C-TAP) in May 2020 to provide a platform for such voluntary sharing (WHO, n.d.-b). However, although 45 countries (mainly LMICs) endorsed this platform, it remained unused for eighteen months. At the time of writing, the only licensing agreements included under auspices of C-TAP have been negotiated with public research agencies, the Spanish National Research Council (finalised in November 2021) and the United States National Institutes of Health (signed in May 2022) (WHO, n.d.-b). No private sector pharmaceutical companies have contributed to the pool, and some pharmaceutical industry executives have dismissed and ridiculed the initiative (Silverman, 2020).

The WHO also established an mRNA vaccine technology transfer hub in South Africa, which has used information in the public domain to develop a vaccine similar to the Moderna vaccine (World Health Organization, n.d.-b). However, despite appeals from WHO, the mRNA vaccine manufacturers (Moderna, Pfizer and BioNTech) have all refused to cooperate and share their technology and know-how with the mRNA hub (Wise, 2022). BioNTech hired a consultancy firm that reportedly sought to undermine the hub, lobbying for its termination (Davies, 2022). Moderna has filed patents in South Africa and has been granted at least three, according to Médecins Sans Frontières (2022), and is suing Pfizer and BioNTech for patent infringement, claiming that it copied mRNA technology that Moderna developed before the pandemic (Reed, 2022, 26 August). Moderna also announced that it would set up an mRNA manufacturing facility in Kenya, possibly an effort to undermine the mRNA hub. At this stage, it is not clear what the mRNA hub's prospects are for successfully navigating what could be a minefield of continuing obstruction and potential litigation over IP rights.

In October 2020, India and South Africa put a proposal to the WTO to temporarily relax IP rules in the TRIPS Agreement for COVID-19 medical products during the pandemic (WTO, 2020). The proposed TRIPS waiver would have enabled companies around the world to freely produce COVID-19 products and technologies including vaccines, treatments, tests, and equipment (e.g., face masks and ventilators) without fear of litigation over possible infringements of IPR. The TRIPS waiver proposal eventually gained the support of more than 100 of the WTO's 164 member countries and was sponsored by more than 60, but faced strong opposition from wealthy countries, including the EU, the UK, Switzerland, Canada, Japan, and Australia (Wijesinghe et al., 2022).

Ultimately, the TRIPS waiver negotiations failed to secure a meaningful outcome. The USA, which had originally opposed the waiver, announced its support for a waiver limited to vaccines in May 2021 (Office Of The United States Trade Representative, 2021), a move which dramatically improved the prospect of agreement on a waiver. However, the EU (particularly Germany), the UK and Switzerland – where many companies making COVID-19 products are headquartered – remained staunch opponents (Third World Network, 2021). The research-based pharmaceutical industry was vocal in its opposition, claiming that a waiver would decimate further innovation on COVID-19 vaccines (Wijesinghe et al., 2022).

The EU issued a counterproposal that sought to merely clarify and make minor adjustments to the existing compulsory licensing provisions in the TRIPS Agreement (Yu, 2022). However, the compulsory licensing provisions in TRIPS have limitations that make them difficult to use, particularly for vaccines. A separate compulsory license would need to be issued in each country for each patent, and the complex patent landscape for vaccines, where multiple patents can be held by multiple entities on various aspects of the underlying technologies, components, and processes, makes it difficult to even discover all the relevant patent claims. Much of the knowledge and technology essential to making vaccines is not included in patent applications and is instead covered by trade secrets protection – but compulsory licensing covers only patents and not trade secrets (Amin and Kesselheim, 2022). It is also so procedurally difficult for countries without manufacturing capacity to import pharmaceuticals under the TRIPS compulsory licensing provisions that they do not represent a feasible solution for health emergencies (Wijesinghe et al., 2022). Due to these and other barriers, to date, there has not yet been any successful use of compulsory licensing to manufacture COVID-19 vaccines.

It was not until June 2022, 20 months after India and South Africa first tabled their proposal, that agreement on a Ministerial Decision on the TRIPS Agreement (WTO, 2022) was finally reached. More than five million people died because of the pandemic during those 20 months (Yu, 2022). But the Ministerial Decision was only a shadow of the original TRIPS waiver proposal (Amin and Kesselheim, 2022). In contrast to the comprehensive original proposal, it was limited to one type of COVID-19 product (vaccines), at least in the first instance, and one type of IPR (patents). While the original proposal aimed to waive 40 articles of the TRIPS Agreement, the final outcome waived only one paragraph of one article (TRIPS Article 31(f)), making it easier for vaccines made using its provisions to be exported from the country of manufacture to a second developing country. Perversely, developing countries with vaccine manufacturing capacity were encouraged to make binding commitments to opt out of utilising the Decision (WTO, 2022; Footnote 1).

The Ministerial Decision included a clause committing WTO members to decide on its expansion to cover the production and supply of COVID-19 diagnostics and therapeutics within 6 months (WTO, 2022). However, this deadline passed with no agreement, and at the time of writing, it appears unlikely that members will ever agree to include diagnostics and therapeutics within its scope.

3.3. Pathways to ill health and human health consequences

We now trace the pathways to ill health and the human health consequences of inequitable access to COVID-19 vaccines, treatments, and tests, drawing on published evidence to date. Since the pathways are relatively straightforward, we discuss these two levels of the framework together (following Schrecker et al., 2018), in relation to direct health effects (mortality and morbidity arising directly from COVID-19 infection) and indirect health effects (excess mortality, exacerbation of global inequality and poverty, exacerbation of other health inequalities, and perpetuation of the pandemic).

3.3.1. Direct health effects

The most obvious immediate health consequence of the inequitable distribution of COVID-19 health products and technologies is a high burden of disease and avoidable deaths due to inadequate vaccination rates, low testing levels and lack of access to treatments. Vaccination protects individuals against severe illness and death and also helps to slow transmission of COVID-19. Access to diagnostic tests is necessary not just for surveillance and guiding policy, but also for preventing asymptomatic and pre-symptomatic transmission, and identifying those high-risk individuals who have contracted the disease and need treatment (Batista et al., 2022).

It is important to note that LMICs suffered disproportionately from the pandemic even before COVID-19 vaccines were available in any country. A systematic review and meta-analysis of COVID-19 serology studies found that the infection fatality rate was at least twice as high for LMICs as for HICs in the first year of the pandemic (Levin et al., 2022). Moreover, eight of the twelve nations with the highest number of deaths from COVID-19 are developing countries (Levin et al., 2022). Mortality data for LMICs is also likely to underestimate the impact of COVID-19 due to reporting limitations (Levin et al., 2022).

Reflecting the necropolitics outlined above, there was a stark impact of vaccine inequity on COVID-19 mortality and morbidity. Retrospective mathematical modelling quantifying the impact of the first year of COVID-19 vaccination estimated that vaccinations prevented 19.8 million excess deaths from COVID-19 from December 2020 to December 2021, however the deaths per capita averted were highest in HICs due to their earlier and faster vaccine rollouts (Watson et al., 2022). While vaccination saved an estimated 7.4 million lives in LICs over this period, if COVAX had met its target of vaccinating 20% of each country by the end of 2021, an additional 156,900 deaths would have been avoided in the COVAX AMC countries (Watson et al., 2022). If the WHO's goal of 40% vaccine coverage had been reached, almost 600,000 more lives would have been saved in the 96 countries that did not reach this target (Watson et al., 2022). Another modelling study by Savinkina et al. (2022) found that vaccinating the whole population in low and lower-middle income countries with three doses of an mRNA vaccine would avert approximately 1.5 million deaths at a cost of $US61 billion. Moore et al. (2022) used 2021 data from 152 countries to quantify the effects of different vaccine sharing strategies, finding that a more equitable distribution of vaccines would result in substantial decreased mortality in LICs without producing correspondingly large increases in HICs, as long as vulnerable groups are vaccinated. Additionally, more equitably sharing vaccines would reduce the total number of infections, reducing the opportunities for more severe variants to emerge. The authors estimated that the equitable vaccine distribution scenario would have averted at least 1.3 million deaths attributable to COVID-19 by the end of 2021.

While it is difficult to estimate the impact of COVID-19 on life expectancy in LMICs at this stage due to limited data, emerging evidence from India and Latin America suggests that the impact is likely to be larger than for HICs (Schöley et al., 2022). It is also too early to measure the burden of post COVID-19 condition (also known as ‘long COVID’) in LMICs. Post COVID-19 condition is defined by the WHO as “… the illness that occurs in people who have a history of probable or confirmed SARS-CoV-2 infection; usually within three months from the onset of COVID-19, with symptoms and effects that last for at least two months”, where “… symptoms and effects of post COVID-19 condition cannot be explained by an alternative diagnosis” (WHO, 2021c). However, a (not yet peer-reviewed) systematic review of the incidence and prevalence of long COVID estimates that globally, 144.7 million people experienced long COVID three months after infection in 2020 and 2021, and 15.1% of these cases had not recovered by 12 months post-infection (Wulf Hanson et al., 2022). The risk of long COVID is likely to be higher in unvaccinated people (Notarte et al., 2022), which suggests that the burden of long COVID resulting from the lag in vaccinating people in LMICs may be significant.

3.3.2. Indirect health effects

Excess mortality rates (the difference in the number of deaths from the number expected based on data from previous years) measure both deaths that are directly attributable to COVID-19 and those indirectly associated with the pandemic, due to its broader impact on health systems and other aspects of society (WHO, 2022b). Excess mortality rates show even greater differences between HICs and LMICs than deaths directly attributable to COVID-19 (Gill and Schellekens, 2021). Globally, excess mortality due to COVID-19 has been estimated at 14.9 million in the two years from 1 January 2020 (WHO, 2022b). Eighty-one percent of these excess deaths are concentrated in middle-income countries (53% in lower-middle income countries and 28% in upper-middle income countries respectively), with 4% of excess deaths occurring in LICs. HICs accounted for only 15% of excess deaths during 2020–2021 (WHO, 2022b).

COVID-19 has also seen a diversion of resources from other health programs and the suspension of effective health programs due to lockdowns and other COVID measures. This will likely cause an increase in morbidity and mortality from other causes in years to come. For example, the number of people receiving tuberculosis (TB) treatment globally in 2020 dropped by more than one million, setting progress against TB back by a decade or more. WHO estimates 500,000 more deaths from TB in 2020 than would otherwise be expected (Roberts, 2021). WHO and UNICEF have reported the largest decline in childhood vaccinations in 30 years (WHO, 2022c) and reduced funding for maternal child health services and family planning has disrupted supply and demand of maternal child health interventions and decreased contraceptive access and use (Rodo et al., 2022; Catterson, 2021). While these impacts are not directly attributable to inequitable access to products to address the pandemic, delays in COVID-19 vaccination in LMICs may have exacerbated the effects of the pandemic on other health programs.

The COVID-19 pandemic has had devastating economic consequences for LMICs and has exacerbated global inequality and poverty. Inequality and poverty are both key drivers of inequitable health outcomes (Commission On Social Determinants Of Health, 2008). A World Bank study (Mahler et al., 2022) found that the first year of the pandemic, 2020, saw the largest increase in global inequality and poverty in a single year since 1990, reversing three years of progress. The increases in inequality and poverty were driven by increases in inequality between countries and bigger reductions in average incomes in poorer countries, rather than in changes within countries (Mahler et al., 2022). These changes – which occurred before vaccines were widely available in any country – were postulated to result from illness and death as a result of the virus, the partial shutdowns of economies and flow on effects to employment and income generation, less resources available to mitigate the economic effects of the pandemic in poorer countries, and lower economic growth due to lower demand for export goods (Mahler et al., 2022).

A later World Bank report published in September 2021 found that while globally, progress in reducing extreme poverty had been wound back by 3–4 years during 2020-21, LIC lost 8–9 years of progress (Hill et al., 2021). Due to the pandemic, an additional 97 million people were estimated to be living on less than $US1.90 per day in 2021 (Hill et al., 2021). The incomes of the poorest 40% of the global population fell twice as much as for the richest 20% (World Bank Group, 2022).

The COVID-19 pandemic also exacerbated inequality within countries. For example, in the first few months of the pandemic, a study of 17 LMICs in Latin America and the Caribbean found that households with lower income levels were more likely to experience job losses and business closures (Bottan et al., 2020). Impacts have been more severe on vulnerable groups such as women, low-skilled workers and workers in the informal sector, indigenous peoples and asylum seekers (Burki, 2020; Hill et al., 2021; Nanda, 2020).

While it is difficult, if not impossible, to disentangle the effects of inequitable access to COVID-19 medical products and technologies from other factors contributing to increasing poverty and inequality, it is clear that poorer countries have borne the brunt of the economic impacts and have been slower to recover than wealthier countries. As Hill et al. (2021) argue, an adequate supply of COVID-19 vaccines (along with other medical tools) is critical to accelerate economic recovery in LMICs and to avoid further exacerbation of global economic inequality.

COVID-19 has also exacerbated other health inequalities and social determinants of health. As Bambra et al. (2020, p. 965) point out: “The COVID-19 pandemic is occurring against a backdrop of social and economic inequalities in existing non-communicable diseases (NCDs) as well as inequalities in the social determinants of health”, a situation which they term a “syndemic”, where COVID-19 interacts with and exacerbates NCDs and social disadvantage.

Finally, inequitable access to COVID-19 vaccines and other tools to manage the pandemic is likely to perpetuate the pandemic due to the continued emergence of new variants in areas of uncontrolled transmission. A modelling study by Ye et al. (2022) demonstrated that greater inequity in vaccine allocation drives earlier and larger outbreaks, whereas more equitable sharing suppresses the emergence of new variants.

4. Conclusion

The analysis we have presented above illustrates how the inequities in access to COVID-19 health products and technologies, and the failure to date of various attempts to correct these inequities, are deeply embedded within and born of a historical legacy of capitalism, neoliberal globalisation and structural violence. It is within this context that wealthy nations and the powerful pharmaceutical industry have created a global IP regime which enables the industry to maintain monopoly power even in the face of vast inequities in access to its products. Given these aspects of the global social, political, economic and historical context that permeated the response to COVID-19, it is unsurprising that billions of dollars in public funding was used to support private monopolies on COVID-19 products while the pharmaceutical industry was permitted to maintain exclusive rights, that ACT-A and COVAX failed to equitably distribute products in a timely way, that wealthy countries engaged in hoarding and drip-feeding excess vaccines to the poor through charitable donations, and that efforts to correct the inequities, such as the C-TAP and the TRIPS waiver proposal, received insufficient support.

Several scholars have written about access to COVID-19 vaccines using political economy perspectives, for example, Ahlberg and Bradby (2022) and Sparke and Levy (2022). However, this paper makes a novel contribution by adapting a structured approach to examine the factors at different levels that shape health outcomes. It is telling that a framework related to global extraction can map so easily onto the health impacts of inequitable access to COVID-19 products and technologies. The comparison emphasises that the necropolitics of the political economy play out in predictable ways, tending to improve and lengthen the lives of higher-income communities while reinforcing and tacitly accepting the untimely deaths of the poor. Moreover, the stark realities of this violence are rendered invisible because it occurs in insidious, indirect, and everyday ways: couched in the banal lexicon of “business”, “diplomacy”, and “charity”. Solutions, therefore, need to tackle these systemic problems, rather than applying a bandaid to the specific issues that arise.

What then, are the prospects for change? To enable equitable access to health products and technologies in future public health emergencies, it will be necessary to disrupt the current neoliberal paradigm and power asymmetries, through reforming the ways in which pharmaceutical R&D are funded, preventing exclusive monopolies on health products and technologies, righting the power imbalances between public and private actors and between rich and poor countries — and the ways these are reflected and reproduced in global governance structures. As Krikorian and Torreele (2021) argue cogently in the title of their paper, “We cannot win the access to medicines struggle using the same thinking that causes the chronic access crisis”. These are large and long-term projects, but our analysis points to the need for fundamental reforms to the global order rather than building on the status quo or tinkering at the margins.

The most promising current global initiative to create the conditions for equitable access to health products and technologies for future pandemics is represented by the negotiations for a WHO Pandemic Accord. While the exact legal basis for the Pandemic Accord has not yet been determined, the International Negotiating Body established to negotiate it has agreed that “the instrument should be legally binding and contain both legally binding as well as non-legally binding elements” (WHO, 2023, p. 1).

A ‘zero draft’ of the Pandemic Accord released in February 2023 as the starting point for negotiations (WHO, 2023) revealed promising proposals for provisions that, if couched in enforceable language, could go a long way towards promoting equitable access to products in future pandemics. It includes, among others, measures to increase transparency in the funding of pharmaceutical R&D and to encourage conditions to be placed on R&D funding to drive equitable access, along with rules requiring companies to disclose terms and prices of public procurement contracts. It also emphasises the importance of strengthening local production in LMICs through technology transfer, committing the parties to providing mechanisms and incentives for the transfer of technology to developing countries, along with “measures to support time-bound waivers of intellectual property rights” (Art. 7 para 4(a))) during pandemics. The draft also suggests that 20% of pandemic-related products should be provided to WHO to enable equitable distribution (Art. 10, para 3 (h)). However, many of the specific commitments are couched in non-binding language.

The same forces that have prevented equitable access to COVID-19 health products and technologies threaten to derail or dilute these promising proposals, with the pharmaceutical industry already claiming the Pandemic Accord draft risks undermine its efforts to rapidly develop pandemic products (Cueni, 2023, February 14), and civil society participation limited to date (Hodgson et al., 2022). For the Pandemic Accord to drive equitable access to pandemic response products in future, it will be critical for LMICs and civil society to be empowered to participate meaningfully, with a corresponding reduction in the power wielded by rich countries, donors, and industry stakeholders.

Declaration of competing interest

None.