Table 2.

Approaches for vaccine distribution and pharmaceutical companies' obligations

	Description	Principles emphasised	Evaluation	Companies' obligations
Tiered pricing	Pharmaceutical companies distribute vaccines on the basis of tiered pricing, charging more to wealthy nations and less or even nothing for low-income countries	Sustainability	Insufficient vaccines are produced overall or distributed to poor countries; absence of transparency and effective accountability mechanisms	Tiered pricing among bilateral contractors; publicly disclose details of bilateral contracts
Global public goods	Pharmaceutical companies voluntarily waive their patent rights and engage in technology transfer; vaccines are made available to all	Optimising vaccine production; fair distribution	Might not be sustainable if pharmaceutical companies are insufficiently compensated for knowledge transfer; might target the wrong bottleneck because production know-how and capacity seem to be rate limiting rather than patents; because vaccines are not true public goods and require scarce raw materials, this approach needs complementary approaches to optimise production and achieve fair distribution	Non-enforcement of patent rights; transfer of knowledge and expertise
Partly bilateral	Pharmaceutical companies distribute vaccines through both bilateral contracts and to an international facility (eg, COVAX)	Optimising vaccine production; fair distribution; sustainability	For fair distribution, a principled mechanism to determine how many vaccines are reserved for bilateral agreements and how many for COVAX, a schedule for fulfilling bilateral deals, and an ethical pricing policy are needed	Allocate vaccines between bilateral contracts and the international facilities, such as COVAX, concurrently and in proportion to COVID-19 need; sell to international facilities, such as COVAX, at marginal cost for participating countries; publicly disclose details of bilateral contracts, agreements with international facilities, such as COVAX, and the schedule for fulfilling both agreements
Fully multilateral	Pharmaceutical companies distribute all vaccines through an international facility, such as COVAX	Fair distribution; accountability	Requires levels of international coordination and trust that do not exist; positioning the international facility as the sole distributor exposes it to greater political pressures from wealthy countries; having a single purchaser can conflict with optimising production	Refrain from making bilateral deals; publicly disclose details of the agreement with the international facility

COVAX=COVID-19 Vaccines Global Access.