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Bulletin of the World Health Organization logoLink to Bulletin of the World Health Organization
. 2022 Mar 25;100(5):315–328. doi: 10.2471/BLT.21.287516

COVAX and equitable access to COVID-19 vaccines

COVAX et accès équitable aux vaccins contre la COVID-19

COVAX y el acceso equitativo a las vacunas contra la COVID-19

COVAX والحصول العادل على لقاحات كوفيد 19

新冠肺炎疫苗实施计划以及平等获取新冠肺炎疫苗

Механизм COVAX и справедливый доступ к вакцинам против COVID-19

Katelyn J Yoo a,✉, Akriti Mehta b, Joshua Mak b, David Bishai b, Collins Chansa a, Bryan Patenaude b
PMCID: PMC9047429  PMID: 35521037

Abstract

Objective

To evaluate equity in the allocation and distribution of vaccines for coronavirus disease 2019 (COVID-19) to countries and territories participating in the COVID-19 Vaccines Global Access (COVAX) Facility.

Methods

We used publicly available data on the numbers of COVAX vaccine doses allocated and distributed to 88 countries and territories qualifying for COVAX-sponsored vaccine doses and 60 countries self-financing their vaccine doses facilitated by COVAX. We conducted a benefit–incident analysis to examine the allocation and distribution of vaccines based on countries’ gross domestic product (GDP) per capita. We plotted cumulative country-level per capita allocation and distribution of COVID-19 vaccines from COVAX against the ranked per capita GDP of the countries and territories to generate a measure of the equity of COVAX benefits.

Findings

By 23 January 2022 the COVAX Facility had allocated a total of 1 678 517 990 COVID-19 vaccine doses, of which 1 028 291 430 (61%) doses were distributed to 148 countries and territories. Taking account of COVAX subsidies, we found that countries and territories with low per capita GDP benefited more than higher-income countries in the numbers of vaccines. The benefits increased further when the analysis was adjusted by population age group (aged 65 years and older).

Conclusion

The COVAX Facility is helping to balance global inequities in the allocation and distribution of COVID-19 vaccines. However, COVAX alone has not been enough to reverse the inequality of total COVID-19 vaccine distribution. Future studies could examine the equity of all COVID-19 vaccine allocation and distribution beyond the COVAX-facilitated vaccines.

Introduction

Equitable vaccine distribution can be a major factor towards global control of the coronavirus disease 2019 (COVID-19) pandemic.1 The COVID-19 Vaccines Global Access (COVAX) Facility was created to facilitate vaccine distribution, although it is unknown whether investments in the initiative have yielded equitable benefits across countries.2 There have been increasing concerns about vaccine nationalism where wealthy nations acquire a disproportionate share of global COVID-19 vaccines.3 As of 24 January 2022, only 9.7% (about 63 million) of people in low-income countries have received at least one dose of COVID-19 vaccine.4

Established in June 2020, the COVAX Facility is a vaccine acquisition mechanism for countries and territories unable to bargain directly with manufacturers.5 Financing for participants is dependent on need. The 92 countries and territories with a gross national income per capita of less than 4000 United States dollars (US$) qualify for the COVAX advance market commitment and are allocated COVAX-funded vaccines to cover up to 20% of their populations.1 Advance market commitment funding comes from bilateral and multilateral development partners, private industry and individual philanthropists.6,7 Countries and territories who participate in COVAX but do not qualify for advance market commitment have to self-finance their COVID-19 vaccine purchases. However, depending on their financial commitment, these countries are guaranteed COVAX-approved vaccine doses for 10–50% of their populations.8

COVAX-secured dose allocation follows the World Health Organization’s (WHO) allocation framework for fair and equitable access to COVID-19 health products.9 This framework recommends that all countries must receive doses to vaccinate high-risk and vulnerable people before roll-out of the vaccination programmes to the rest of the population. Although this framework seeks to achieve fairness in access to COVID-19 vaccines among countries, some scholars argue that the initial 20% coverage requirement fails to account for vulnerabilities existing in poorer countries and countries with large outbreaks of COVID-19.3,10–14 Nonetheless, adherence to the framework’s recommendation can allow equal distribution of COVAX benefits among countries relative to their population sizes.15

To assess the extent to which COVAX has fulfilled its commitment, we evaluated equity in the allocation and distribution of COVAX-facilitated COVID-19 vaccines to countries and territories by income group and by proportion of older people. The cross-country analysis will add to the evidence on whether collaborative efforts such as the COVAX Facility can contribute to the equitable international allocation and distribution of scarce global public goods (in this case, vaccines) during international health emergencies.

Methods

Data sources

We analysed secondary data on countries’ COVID-19 vaccine purchases, allocation and distribution, including data on the COVAX Facility and donations by bilateral and multilateral agencies, international nongovernmental organizations and private firms. We extracted the data from the United Nations Children’s Fund’s (UNICEF) COVID-19 vaccine dashboard as of 23 January 2022 at 20:00 Eastern Standard Time.16 We used the COVID-19 vaccine dashboard because it is the most comprehensive repository of up-to-date information on the distribution of the COVID-19 vaccines worldwide. Furthermore, UNICEF is leading efforts to procure and supply COVID-19 vaccines on behalf of the COVAX Facility.

To understand the differences between actual and intended distribution of COVAX benefits, we obtained: (i) allocated dose counts from the COVAX deliveries category of the UNICEF dashboard and (ii) distributed dose counts from the doses shipped subset of the COVAX allocation values. Vaccine allocation describes the projected number of COVAX vaccine doses available to the country, based on potential supplies and the allocation framework. The doses distributed describes the quantities of COVID-19 vaccines delivered to countries by COVAX at a given point in time.

Among the 148 countries and territories included on the dashboard, 88 countries qualified for COVAX-sponsored vaccine doses under the advance market commitment mechanism and 60 countries were self-financing their vaccine doses facilitated by COVAX. We grouped the countries into four income groups based on the World Bank country classification:17 25 low-income countries (gross domestic product, GDP, per capita: less than US$ 1026), 55 lower-middle-income countries (GDP per capita: US$ 1026–3995), 43 upper-middle-income countries (GDP per capita: US$ 3996–12 375) and 25 high-income countries (GDP per capita: above US$ 12 375). Only three of the 92 countries and territories with advance market commitment were not included in the UNICEF dashboard: Burundi, Eritrea and Marshall Islands. Most upper-middle-income and high-income countries and territories had bilateral arrangements to obtain vaccines from other sources, which is not accounted for in this analysis. We used GDP per capita in US$ purchasing power parity (PPP) from the World Development Indicator database to rank countries and territories by income level. We used 2019 data which did not include the economic losses due to the COVID-19 pandemic. We obtained population data for 2020 from the United Nations Population Division. The focus of our study was equity across all COVAX participants. Other sources can shed light on vaccine allocations to crisis-affected populations.18 We only analysed cross-country and not intra-country allocation and distribution of COVID-19 vaccines.

Data analysis

In line with COVAX guidelines and WHO’s fair allocation framework, we assumed that COVAX will fully subsidize vaccines for 20% of the population in countries and territories qualifying for advance market commitment.9 COVAX estimates state that the average cost per dose for those participating in COVAX is US$ 7.00 per dose for participants under the advance market commitment mechanism and US$ 10.55 per dose for countries and territories using self-financing.19 These costs include the costs of safety boxes and syringes (devices), UNICEF’s Supply Division procurement fees, freight and transport fees, and all other costs until arrival of the vaccines to the respective countries and territories. The estimate excludes cost categories such as labour and capital costs, cold chain and wastage or buffer stocks.

We used standard benefit–incident analysis methods for doses allocated and doses distributed to evaluate differences between actual and intended distribution of COVAX benefits. We performed the following steps: (i) ranking countries and territories from poorest to richest via per capita GDP adjusted for PPP; (ii) obtaining both COVAX vaccine doses allocated and distributed by country; (iii) estimating total per capita benefits received from COVAX; (iv) estimating self-financed per capita benefits that were facilitated by COVAX; (v) deducting self-financed per capita benefit from total per capita benefits to obtain COVAX-sponsored per capita benefits; and (vi) aggregating COVAX-sponsored per capita benefits. We plotted COVAX-sponsored per capita benefits on Lorenz concentration curves to assesses whether benefits were distributed equitably. A 45° line on the curves represents perfect equality and enabled us to quantify deviation from perfect equality.

We then calculated Wagstaff concentration index (C):20

graphic file with name BLT.21.287516-M1.jpg (1)

where, μ is the average benefit from COVAX, and cov(h,r) is the weighted covariance between per capita COVAX benefit h received by country i and the country’s rank r in the GDP per capita distribution. The number of countries and territories, N, are ranked from 1 to N, that is, from poorest to richest. For computation, a more convenient formula for the concentration index defines it in terms of the covariance between the vaccine doses allocated or distributed and the fractional rank in the GDP per capita.13,14

When data are categorical rather than continuous, calculation of a standard concentration index may be insufficient. We therefore also calculated the Erreygers modified concentration index (MC), which accounts for the chosen transformation:21,22

graphic file with name BLT.21.287516-M2.jpg (2)

where, hmin is the lower limit of hi.

We analysed per capita COVAX benefits measured as country-level per capita COVAX expenditures on vaccines net of domestic expenditures on the vaccines, plotted against the ranked per capita GDP adjusted for PPP. We calculated Wagstaff and Erreygers concentration indices for total benefits, COVAX-sponsored benefits and self-financed per capita COVAX benefits for all countries and territories. We made the calculations for the total population of each country or territory. We also examined the distribution of COVAX benefits based on the proportion of the population aged 65 years and older as a proxy for the relative size of the most vulnerable population in each country or territory.

For both indices, a concentration index of 0 to –1 reflects a pro-poor distribution, and an index of 0 to 1 reflects a pro-rich distribution.23 In a traditional benefit–incidence analysis approach, benefits are measured against individuals or entities ranked by an income metric. The analysis would therefore be based on individual-level data and the terms pro-rich or pro-poor would be used to refer to benefits accruing to different quintiles of the income distribution of countries. In our analysis we use the terms pro-rich to refer to COVAX benefits that were disproportionately accrued by wealthier countries and territories, as ranked by GDP per capita and adjusted for the size of the eligible population (and vice versa for the term pro-poor).

We used Excel (Microsoft Corp., Redmond, United States of America) and Stata version 16 (Stata Corp., College Station, USA) for the analysis.

Results

Vaccines allocated and distributed

At the time of analysis COVAX had allocated a total of 1 678 517 990 COVID-19 vaccine doses among 148 countries and territories, of which 1 028 291 430 (61%) doses had been distributed (Table 1). Fig. 1 demonstrates the disparity between the log of vaccine doses allocated and distributed to these countries and territories, while Fig. 2 and Fig. 3 stratify the doses by country income level as a share of the population. The lowest income group had relatively low total vaccine doses allocated and distributed in both absolute and relative terms to the population (Fig. 2). The lowest income group had one of the greatest gaps between the shares of total vaccine doses allocated and distributed to their populations (Fig. 3). Additional findings from the exploratory data analysis are presented in the authors’ online data repository.24

Table 1. Vaccine doses allocated and distributed to 148 countries and territories participating in the COVAX Facility, 23 January 2022.

Country or territory, by log(y) COVAX doses allocated Income groupa Advanced market commitment status Total population 2020 GDP per capita  PPP,  current international $ No. of COVAX doses allocated No. of COVAX doses distributed Per capita no. of doses allocated Per capita no. of doses distributed Log(y) COVAX doses allocated Log(x) COVAX doses distributed
Nauru High income Self-financing 10 834 14 099 7 200 7 200 0.66 0.66 3.86 3.86
Micronesia (Federated States of) Lower-middle income Sponsored 115 021 3 552 7 200 NA 0.06 NA 3.86 NA
Bermuda High income Self-financing 63 903 85 264 9 600 9 600 0.15 0.15 3.98 3.98
Tuvalu Upper-middle income Sponsored 11 792 4 456 16 800 9 600 1.42 0.81 4.23 3.98
Saint Kitts and Nevis High income Self-financing 53 192 27 345 21 600 21 600 0.41 0.41 4.33 4.33
Andorra High income Self-financing 77 265 49 900 28 740 28 740 0.37 0.37 4.46 4.46
Kuwait High income Self-financing 4 270 563 51 962 35 100 35 100 0.01 0.01 4.55 4.55
Antigua and Barbuda High income Self-financing 97 928 22 460 60 000 60 000 0.61 0.61 4.78 4.78
Tonga Upper-middle income Sponsored 105 697 6 648 81 800 91 800 0.77 0.87 4.91 4.96
Montenegro Upper-middle income Self-financing 621 718 23 344 84 000 48 000 0.14 0.08 4.92 4.68
New Zealand High income Self-financing 5 084 300 45 073 100 620 100 620 0.02 0.02 5.00 5.00
Brunei Darussalam High income Self-financing 437 483 64 724 100 800 100 800 0.23 0.23 5.00 5.00
Dominica Upper-middle income Sponsored 71 991 12 409 101 920 91 980 1.42 1.28 5.01 4.96
Bahrain High income Self-financing 1 701 583 46 966 107 820 107 820 0.06 0.06 5.03 5.03
Barbados High income Self-financing 287 371 16 300 114 840 114 840 0.40 0.40 5.06 5.06
Saint Vincent and the Grenadines Upper-middle income Sponsored 110 947 13 013 115 800 115 800 1.04 1.04 5.06 5.06
Kiribati Lower-middle income Sponsored 119 446 2 366 118 400 104 000 0.99 0.87 5.07 5.02
Qatar High income Self-financing 2 881 060 93 852 122 400 122 400 0.04 0.04 5.09 5.09
Grenada Upper-middle income Sponsored 112 519 17 771 124 710 114 630 1.11 1.02 5.10 5.06
Uruguay High income Self-financing 3 473 727 24 007 148 800 148 800 0.04 0.04 5.17 5.17
Seychelles High income Self-financing 98 462 28 685 154 440 74 880 1.57 0.76 5.19 4.87
Bahamas High income Self-financing 393 248 38 669 158 130 158 130 0.40 0.40 5.20 5.20
Belize Lower-middle income Self-financing 397 621 7 559 159 300 159 300 0.40 0.40 5.20 5.20
Suriname Upper-middle income Self-financing 586 634 19 842 165 600 144 000 0.28 0.25 5.22 5.16
Vanuatu Lower-middle income Sponsored 307 150 3 250 178 800 95 950 0.58 0.31 5.25 4.98
Trinidad and Tobago High income Self-financing 1 399 491 26 920 184 800 184 800 0.13 0.13 5.27 5.27
United Arab Emirates High income Self-financing 9 890 400 69 958 198 900 NA 0.02 NA 5.30 NA
Saint Lucia Upper-middle income Sponsored 183 629 16 102 202 470 197 430 1.10 1.08 5.31 5.30
Georgia Upper-middle income Self-financing 3 714 000 15 623 224 820 160 020 0.06 0.04 5.35 5.20
Sao Tome and Principe Lower-middle income Sponsored 219 161 4 175 237 120 129 120 1.08 0.59 5.37 5.11
Samoa Lower-middle income Sponsored 198 410 6 778 245 000 215 200 1.23 1.08 5.39 5.33
Comoros Lower-middle income Sponsored 869 595 3 189 250 380 12 000 0.29 0.01 5.40 4.08
Guyana Upper-middle income Sponsored 786 559 13 635 339 540 291 540 0.43 0.37 5.53 5.46
Cabo Verde Lower-middle income Sponsored 555 988 7 475 361 840 361 220 0.65 0.65 5.56 5.56
Djibouti Lower-middle income Sponsored 988 002 5 769 386 250 254 850 0.39 0.26 5.59 5.41
Albania Upper-middle income Self-financing 2 837 743 14 231 418 200 331 800 0.15 0.12 5.62 5.52
Solomon Islands Lower-middle income Sponsored 686 878 2 774 432 620 209 420 0.63 0.30 5.64 5.32
Eswatini Lower-middle income Sponsored 1 160 164 8 986 441 420 441 420 0.38 0.38 5.64 5.64
Dominican Republic Upper-middle income Self-financing 10 847 904 19 192 463 200 463 200 0.04 0.04 5.67 5.67
Gambia Low income Sponsored 2 416 664 2 317 477 420 376 800 0.20 0.16 5.68 5.58
Jordan Upper-middle income Self-financing 10 203 140 10 497 477 750 477 750 0.05 0.05 5.68 5.68
Bhutan Lower-middle income Sponsored 771 612 12 333 505 850 505 850 0.66 0.66 5.70 5.70
Fiji Upper-middle income Sponsored 896 444 14 263 500 800 501 280 0.56 0.56 5.70 5.70
Australia High income Self-financing 25 687 041 52 203 513 630 513 630 0.02 0.02 5.71 5.71
United Kingdom High income Self-financing 67 215 293 48 514 539 370 539 370 0.01 0.01 5.73 5.73
North Macedonia Upper-middle income Self-financing 2 083 380 17 583 552 420 201 420 0.27 0.10 5.74 5.30
Oman High income Self-financing 5 106 622 28 449 577 680 520 260 0.11 0.10 5.76 5.72
Maldives Upper-middle income Sponsored 540 542 20 357 581 770 371 170 1.08 0.69 5.76 5.57
Timor-Leste Lower-middle income Sponsored 1 318 442 3 703 587 640 393 420 0.45 0.30 5.77 5.59
Armenia Upper-middle income Self-financing 2 963 234 14 231 640 800 360 000 0.22 0.12 5.81 5.56
Mauritius Upper-middle income Self-financing 1 265 740 23 837 666 870 488 070 0.53 0.39 5.82 5.69
Gabon Upper-middle income Self-financing 2 225 728 15 582 688 830 472 200 0.31 0.21 5.84 5.67
Guinea-Bissau Low income Sponsored 1 967 998 2 021 763 200 360 000 0.39 0.18 5.88 5.56
Serbia Upper-middle income Self-financing 6 908 224 18 930 797 280 730 080 0.12 0.11 5.90 5.86
Bosnia and Herzegovina Upper-middle income Self-financing 3 280 815 15 847 835 740 332 640 0.25 0.10 5.92 5.52
Lesotho Lower-middle income Sponsored 2 142 252 2 693 917 490 653 670 0.43 0.31 5.96 5.82
Singapore High income Self-financing 5 685 807 102 573 938 400 938 400 0.17 0.17 5.97 5.97
Canada High income Self-financing 38 005 238 50 661 972 000 972 000 0.03 0.03 5.99 5.99
Taiwan, China High income Self-financing 23 871 085 24 502 1 020 000 1 020 000 0.04 0.04 6.01 6.01
Republic of Moldova Upper-middle income Sponsored 2 617 820 13 573 1 032 810 830 790 0.39 0.32 6.01 5.92
Namibia Upper-middle income Self-financing 2 540 916 10 262 1 055 980 332 640 0.42 0.13 6.02 5.52
Papua New Guinea Lower-middle income Sponsored 8 947 027 4 534 1 099 200 883 200 0.12 0.10 6.04 5.95
Haiti Lower-middle income Sponsored 11 402 533 3 028 1 124 700 805 480 0.10 0.07 6.05 5.91
Botswana Upper-middle income Self-financing 2 351 625 18 529 1 153 260 1 038 240 0.49 0.44 6.06 6.02
South Sudan Low income Sponsored 11 193 729 1 235 1 225 270 1 002 070 0.11 0.09 6.09 6.00
Mongolia Lower-middle income Sponsored 3 278 292 12 838 1 327 260 1 327 260 0.40 0.40 6.12 6.12
Kosovob Upper-middle income Sponsored 1 775 378 11 972 1 325 190 739 620 0.75 0.42 6.12 5.87
Cameroon Lower-middle income Sponsored 26 545 864 3 796 1 521 850 1 380 750 0.06 0.05 6.18 6.14
Kyrgyzstan Lower-middle income Sponsored 6 591 600 5 481 1 528 800 1 428 000 0.23 0.22 6.18 6.15
Liberia Low income Sponsored 5 057 677 1 488 1 691 430 1 246 980 0.33 0.25 6.23 6.10
Jamaica Upper-middle income Self-financing 2 961 161 10 190 1 752 870 1 103 520 0.59 0.37 6.24 6.04
Saudi Arabia High income Self-financing 34 813 867 48 948 1 772 430 1 772 430 0.05 0.05 6.25 6.25
Malaysia Upper-middle income Self-financing 32 365 998 29 564 1 840 800 1 387 200 0.06 0.04 6.27 6.14
Azerbaijan Upper-middle income Self-financing 10 110 116 15 050 2 022 390 2 022 390 0.20 0.20 6.31 6.31
West Bank and Gaza Strip Lower-middle income Sponsored 4 803 269 6 510 2 097 560 1 362 620 0.44 0.28 6.32 6.13
Panama Upper-middle income Self-financing 4 314 768 32 761 2 074 350 484 320 0.48 0.11 6.32 5.69
Congo Lower-middle income Sponsored 5 518 092 4 005 2 124 850 1 882 710 0.39 0.34 6.33 6.27
Sierra Leone Low income Sponsored 7 976 985 1 793 2 258 910 1 510 110 0.28 0.19 6.35 6.18
Chile High income Self-financing 19 116 209 25 975 2 307 800 2 307 800 0.12 0.12 6.36 6.36
Costa Rica Upper-middle income Self-financing 5 094 114 21 792 2 359 860 648 150 0.46 0.13 6.37 5.81
Central African Republic Low income Sponsored 4 829 764 985 2 393 000 1 294 310 0.50 0.27 6.38 6.11
Paraguay Upper-middle income Self-financing 7 132 530 13 149 2 435 550 1 970 340 0.34 0.28 6.39 6.29
Republic of Korea High income Self-financing 51 780 579 42 728 2 516 580 2 516 580 0.05 0.05 6.40 6.40
Yemen Low income Sponsored 29 825 968 3 689 2 497 100 2 177 600 0.08 0.07 6.40 6.34
Lebanon Upper-middle income Self-financing 6 825 442 15 167 2 495 700 1 626 390 0.37 0.24 6.40 6.21
Benin Lower-middle income Sponsored 12 123 198 3 426 3 291 540 2 867 940 0.27 0.24 6.52 6.46
Mauritania Lower-middle income Sponsored 4 649 660 5 417 3 471 150 504 000 0.75 0.11 6.54 5.70
Mali Low income Sponsored 20 250 834 2 420 3 587 850 2 605 600 0.18 0.13 6.55 6.42
Madagascar Low income Sponsored 27 691 019 1 687 3 607 790 3 144 260 0.13 0.11 6.56 6.50
El Salvador Lower-middle income Sponsored 6 486 201 9 168 3 606 050 3 606 050 0.56 0.56 6.56 6.56
Libya Upper-middle income Self-financing 6 871 287 15 816 3 614 840 2 162 070 0.53 0.31 6.56 6.33
Chad Low income Sponsored 16 425 859 1 646 3 864 710 1 294 310 0.24 0.08 6.59 6.11
Cambodia Lower-middle income Sponsored 16 718 971 4 574 3 925 260 3 925 260 0.23 0.23 6.59 6.59
Zimbabwe Lower-middle income Sponsored 14 862 927 3 156 4 366 200 3 990 000 0.29 0.27 6.64 6.60
Togo Low income Sponsored 8 278 737 2 212 4 444 580 3 685 670 0.54 0.45 6.65 6.57
Malawi Low income Sponsored 19 129 955 1 579 5 014 350 2 813 850 0.26 0.15 6.70 6.45
Honduras Lower-middle income Sponsored 9 904 608 5 979 4 959 720 4 714 920 0.50 0.48 6.70 6.67
Niger Low income Sponsored 24 206 636 1 276 5 154 810 3 842 970 0.21 0.16 6.71 6.58
Sri Lanka Lower-middle income Sponsored 21 919 000 13 623 5 128 120 5 128 120 0.23 0.23 6.71 6.71
Guinea Low income Sponsored 13 132 792 2 676 5 270 480 4 793 310 0.40 0.36 6.72 6.68
Tunisia Lower-middle income Sponsored 11 818 618 11 210 5 426 350 4 519 020 0.46 0.38 6.73 6.66
Nicaragua Lower-middle income Sponsored 6 624 554 5 682 5 874 930 4 163 730 0.89 0.63 6.77 6.62
Ecuador Upper-middle income Self-financing 17 643 060 11 851 6 083 250 3 389 910 0.34 0.19 6.78 6.53
Somalia Low income Sponsored 15 893 219 903 6 434 930 5 096 900 0.40 0.32 6.81 6.71
Lao People's Democratic Republic Lower-middle income Sponsored 7 275 556 8 220 6 557 880 5 088 150 0.90 0.70 6.82 6.71
Mexico Upper-middle income Self-financing 128 932 753 20 448 6 563 940 6 563 940 0.05 0.05 6.82 6.82
Argentina Upper-middle income Self-financing 45 376 763 22 997 6 603 280 5 969 200 0.15 0.13 6.82 6.78
Senegal Lower-middle income Sponsored 16 743 930 3 504 6 973 520 3 770 990 0.42 0.23 6.84 6.58
Zambia Lower-middle income Sponsored 18 383 956 3 617 6 977 140 4 508 320 0.38 0.25 6.84 6.65
Guatemala Upper-middle income Self-financing 16 858 333 9 019 7 237 620 4 282 120 0.43 0.25 6.86 6.63
Burkina Faso Low income Sponsored 20 903 278 2 270 7 524 720 3 776 390 0.36 0.18 6.88 6.58
United Republic of Tanzania Lower-middle income Sponsored 59 734 213 2 773 7 522 380 7 522 380 0.13 0.13 6.88 6.88
Democratic People's Republic of Korea Low income Sponsored 25 778 815 1 700 8 115 600 NA 0.31 NA 6.91 NA
Ukraine Lower-middle income Sponsored 44 134 693 13 350 8 414 990 8 414 990 0.19 0.19 6.93 6.93
Peru Upper-middle income Self-financing 32 971 846 13 397 8 461 740 4 449 810 0.26 0.13 6.93 6.65
Democratic Republic of the Congo Low income Sponsored 89 561 404 1 144 8 901 400 5 149 740 0.10 0.06 6.95 6.71
Bolivia (Plurinational state of) Lower-middle income Sponsored 11 673 029 9 093 9 087 240 6 735 140 0.78 0.58 6.96 6.83
South Africa Upper-middle income Self-financing 59 308 690 13 010 9 269 910 9 269 910 0.16 0.16 6.97 6.97
Sudan Low income Sponsored 43 849 269 4 363 9 604 730 6 354 290 0.22 0.14 6.98 6.80
Tajikistan Lower-middle income Sponsored 9 537 642 3 733 9 614 360 8 069 720 1.01 0.85 6.98 6.91
Afghanistan Low income Sponsored 38 928 341 2 152 10 670 450 7 044 050 0.27 0.18 7.03 6.85
Iraq Upper-middle income Self-financing 40 222 503 11 012 11 898 780 8 598 750 0.30 0.21 7.08 6.93
Myanmar Lower-middle income Sponsored 54 409 794 5 297 12 252 600 NA 0.23 NA 7.09 NA
Brazil Upper-middle income Self-financing 212 559 409 15 388 13 881 600 13 881 600 0.07 0.07 7.14 7.14
Iran (Islamic Republic of)   Lower-middle income Self-financing 83 992 953 12 913 14 423 650 13 115 310 0.17 0.16 7.16 7.12
Morocco Lower-middle income Sponsored 36 910 558 7 856 14 722 825 4 190 190 0.40 0.11 7.17 6.62
Rwanda Low income Sponsored 12 952 209 2 322 15 340 910 14 232 060 1.18 1.10 7.19 7.15
Syrian Arab Republic Low income Sponsored 17 500 657 4 685 15 587 640 4 892 840 0.89 0.28 7.19 6.69
Côte D’Ivoire Lower-middle income Sponsored 26 378 275 5 433 16 581 140 12 618 920 0.63 0.48 7.22 7.10
Ghana Lower-middle income Sponsored 31 072 945 5 625 18 478 400 16 616 490 0.59 0.53 7.27 7.22
Venezuela (Bolivarian Republic of) Upper-middle income Self-financing 28 435 943 17 528 18 584 400 12 076 800 0.65 0.42 7.27 7.08
Uzbekistan Lower-middle income Sponsored 34 232 050 7 311 21 041 690 9 855 590 0.61 0.29 7.32 6.99
Algeria Lower-middle income Sponsored 43 851 043 11 997 21 834 400 15 926 400 0.50 0.36 7.34 7.20
Mozambique Low income Sponsored 31 255 435 1 336 24 603 390 19 172 820 0.79 0.61 7.39 7.28
Kenya Lower-middle income Sponsored 53 771 300 4 513 26 746 470 19 401 270 0.50 0.36 7.43 7.29
Colombia Upper-middle income Self-financing 50 882 884 15 621 26 916 150 11 860 350 0.53 0.23 7.43 7.07
Nepal Lower-middle income Sponsored 29 136 808 4 120 30 406 390 22 926 920 1.04 0.79 7.48 7.36
Angola Lower-middle income Sponsored 32 866 268 6 952 32 323 830 21 564 180 0.98 0.66 7.51 7.33
Uganda Low income Sponsored 45 741 000 2 280 36 895 510 30 922 740 0.81 0.68 7.57 7.49
Ethiopia Low income Sponsored 114 963 583 2 315 40 813 010 22 461 170 0.36 0.20 7.61 7.35
Viet Nam Lower-middle income Sponsored 97 338 583 8 381 68 341 910 49 606 820 0.70 0.51 7.83 7.70
Philippines Lower-middle income Sponsored 109 581 085 9 292 69 869 275 65 724 200 0.64 0.60 7.84 7.82
Egypt Lower-middle income Sponsored 102 334 403 12 261 78 265 520 56 058 610 0.76 0.55 7.89 7.75
Nigeria Lower-middle income Sponsored 206 139 587 5 353 99 119 100 60 070 980 0.48 0.29 8.00 7.78
India Lower-middle income Sponsored 1 380 004 385 6 998 140 000 000 10 000 000 0.10 0.01 8.15 7.00
Pakistan Lower-middle income Sponsored 220 892 331 4 889 146 158 660 77 157 720 0.66 0.35 8.16 7.89
Indonesia Lower-middle income Sponsored 273 523 621 12 312 178 461 900 87 951 970 0.65 0.32 8.25 7.94
Bangladesh Lower-middle income Sponsored 164 689 383 4 955 192 439 610 133 062 580 1.17 0.81 8.28 8.12
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COVAX: COVID-19 Vaccines Global Access Facility; COVID-19: coronavirus disease 2019; GDP: gross domestic product; NA: data not available; PPP: purchasing power parity.

a Income groups are World Bank classifications.17

b All references to Kosovo should be understood to be in the context of the United Nations Security Council resolution 1244 (1999).

Note: Countries are ordered from the lowest to highest log(y) COVAX doses allocated (Fig. 1).

Fig. 1.

Log of vaccine doses allocated and distributed to 148 countries and territories participating in the COVAX Facility, by income levels, 23 January 2022

COVAX: COVID-19 Vaccines Global Access Facility; COVID-19: coronavirus disease 2019.

Note: Countries on the diagonal line have distributed all the vaccine doses allocated; those above the diagonal line still have unmet need.

Fig. 1

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Fig. 2.

Total vaccine doses allocated and distributed to 148 countries and territories participating in the COVAX Facility, by income levels, 23 January 2022

COVAX: COVID-19 Vaccines Global Access Facility; COVID-19: coronavirus disease 2019.

Note: The average doses for each income group are not weighted for population sizes.

Fig. 2

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Fig. 3.

Total vaccine doses allocated and distributed to 148 countries and territories participating in the COVAX Facility, as a share of total population stratified by income levels, 23 January 2022

COVAX: COVID-19 Vaccines Global Access Facility; COVID-19: coronavirus disease 2019.

Note: The average doses for each income group are not weighted for population sizes.

Fig. 3

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Benefit–incident analysis

Whole populations

The concentration curve for total per capita COVAX benefits shows a pro-poor distribution, which lies mostly along the line of equality (Fig. 4). However, for the poorest 45% of countries and territories, a slight pro-rich trend is demonstrated. The concentration curve for the self-financed countries shows a disproportionate COVAX benefit to countries with higher per capita GDP but becoming slightly pro-poor for the wealthiest 15% of countries and territories. On the other hand, the concentration curve for the COVAX-sponsored per capita benefits consistently demonstrates pro-poor trends with about 50% of the poorest nations receiving about 80% of the benefits.

Fig. 4.

Concentration curves for per capita benefits accruing to 148 countries and territories participating in the COVAX Facility, 23 January 2022

COVAX: COVID-19 Vaccines Global Access Facility; COVID-19: coronavirus disease 2019.

Note: The black line depicts the line of perfect equality, whereby the poorest 10% countries (based on gross domestic product per capita adjusted for purchasing power parity) would receive 10% of the per capita COVAX benefits, poorest 20% countries would receive 20% of the benefits, and so on.

Fig. 4

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The average total per capita COVAX benefit was US$ 3.37 while the average COVAX-sponsored and self-financed per capita benefits were US$ 1.40 and US$ 1.98, respectively. The Wagstaff concentration indices for total per capita benefits and COVAX-sponsored per capita benefits were −0.034 and −0.657, respectively, indicating that the poorest 50% nations were allocated about 3% and 49% more total and COVAX-sponsored doses, respectively, compared with the wealthiest 50% nations, after adjusting for need (Table 2). In contrast, the index for self-financed per capita benefits (0.214) shows a disproportionate COVAX benefit to the least poor countries, indicating that about 16% of allocated doses would have to be transferred from the richest 50% countries to the poorest 50% countries to achieve need-based equity. The trend for Erreygers concentration indices was similar at −0.022 for total, −0.657 for COVAX-sponsored and 0.089 for self-financed COVAX-facilitated per capita benefits from doses allocated.

Table 2. Concentration indices showing per capita benefits accruing to 148 countries and territories participating in the COVAX Facility, 23 January 2022.
Variable Whole population
 Population aged 65 years and older
Wagstaff concentration index Relative dose benefit, %a Erreygers concentration index Relative dose benefit, %b Wagstaff concentration index Relative dose benefit, %a Erreygers concentration index Relative dose benefit, %b
Vaccine doses allocated
Total benefits −0.034 3 −0.022 2 −0.258 19 −0.176 13
Benefits to COVAX-sponsored countries −0.657 49 −0.657 49 −0.577 43 −0.438 33
Benefits to self-financed COVAX-facilitated countries 0.214 16 0.089 7 0.057 4 0.031 2
Vaccine doses distributed
Total benefits −0.014 1 −0.012 1 −0.248 19 −0.159 12
Benefits to COVAX-sponsored countries −0.518 39 −0.507 38 −0.514 39 −0.338 25
Benefits to self-financed COVAX-facilitated countries 0.298 22 0.164 12 0.120 9 0.054 4
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COVAX: COVID-19 Vaccines Global Access Facility; COVID-19: coronavirus disease 2019.

a Relative dose benefits calculated from Wagstaff concentration index.

b Relative dose benefits calculated from Erreygers concentration index.

Note: We analysed data for a total of 148 countries and territories: 88 countries qualifying for COVAX-sponsored vaccine doses under the advance market commitment mechanism and 60 countries self-financing their vaccine doses facilitated by COVAX. We calculated both Wagstaff and Erreygers concentration indices as the Erreygers index accounts for when data are categorical rather than continuous.22 An index of 0 to –1 means that the benefits from COVID-19 vaccines supplied by the COVAX Facility are higher for countries and territories with low incomes based on GDP per capita adjusted for PPP (pro-poor). When the concentration index is positive, it signifies a relatively pro-rich distribution of benefits, while when the concentration index is negative, it implies a relatively pro-poor distribution. Relative dose benefit is computed from the formula (CI*75) to interpret the concentration index. This is the amount that would need to be linearly transferred from the top (bottom) 50% to the bottom (top) 50% of countries based on GDP per capita PPP to obtain perfect equality in benefits. For a concentration index which is positive, the relative dose benefit is the percentage of excess doses allocated or distributed to the richest 50% countries relative to the poorest 50% countries. For a concentration index that is negative, the relative dose benefit is the percentage of excess doses allocated or distributed to the poorest 50% countries relative to the richest 50% countries.

The concentration curves for per capita benefits from COVAX doses distributed mirror the trends seen in the curves for doses allocated (Fig. 4). The concentration curve for total per capita benefits lies along the line of equality and crosses it at the 49% mark, showing a disproportionate COVAX benefit to the poorest nations. A list of countries lying above and below the line of equality is shown in the author’s data repository.24 Self-financed per capita benefits were in favour of richer nations, although the curve crosses the line of equality at the 90% mark to become pro-poor. In contrast, the COVAX-sponsored per capita curve showed that benefits were consistently pro-poor, with about 50% of the poorest nations receiving about 75% of the benefits.

The average per capita benefits were US$ 2.46 for total, US$ 1.16 for COVAX-sponsored and US$ 1.29 for self-financed benefits. The Wagstaff concentration indices for total and COVAX-sponsored per capita benefits were pro-poor at −0.014 and –0.518, respectively (Table 2). Meanwhile, the index for self-financed per capita COVAX benefits at 0.298 favoured wealthier nations, indicating the need for a transfer of 22% of doses from the wealthiest 50% of the countries to the poorest 50% of the countries to achieve need-based equity. For reference, an index of –0.518 implies that the poorest 50% countries were receiving 39% more COVAX-sponsored doses than the richest 50% countries after adjusting for need, indicating that the financial benefits of COVAX are accruing to settings with lower ability to self-finance. Erreygers concentration indices for total (−0.012), COVAX-sponsored (−0.507) and self-financed COVAX-facilitated (0.164) per capita benefits showed similar findings to the Wagstaff concentration indices.

Benefits from allocated doses were more pro-poor compared with distributed doses. Additionally, the analysis demonstrates that self-financed expenditure both for doses allocated and doses distributed disproportionately benefited the richest nations in the absence of COVAX’s subsidies. When we took account of COVAX subsidies, we found that total and COVAX-sponsored per capita benefits were pro-poor for both allocated and distributed doses.

Vulnerable populations

The concentration curves and indices for COVAX-sponsored benefits adjusted for the size of the population aged 65 years and older are presented in Fig. 4 and Table 2. Similar to the whole population analysis, the concentration curves and indices for total and COVAX-sponsored per capita benefits were pro-poor, while the curves and indices for the self-financed COVAX-facilitated per capita benefits were in favour of wealthier nations, for both doses allocated and doses distributed. While the curves for whole population COVAX-sponsored benefits mirrored those after adjusting for the relative size of the older populations, the curves for total benefits adjusted for older populations were more pro-poor than the whole population benefits for both doses allocated and doses distributed. Compared with the whole population curves, the curve for self-financed benefits adjusted for older population size lay much closer to the line of equality for doses allocated, while the doses distributed still disproportionately benefited the wealthier nations, although less so. Overall, after accounting for the size of the population aged 65 years and older, there was an even greater pro-poor distribution of benefits compared with the overall population for both doses allocated and distributed. Additionally, the concentration indices for overall and adjusted for older populations showed that COVAX benefits were more pro-poor for allocated doses as compared with distributed doses.

Discussion

We found that for both allocated and distributed COVID-19 vaccine doses, the total per capita benefits from the COVAX initiative disproportionately benefited countries and territories with lower per capita GDP. This difference applied when analysing the overall population and after accounting for the relative size of vulnerable older populations within each country. The total per capita benefits after adjusting for the size of older populations within each country demonstrated even higher benefits towards countries and territories with lower GDP per capita. These results were similar for COVAX-sponsored per capita benefits for both allocated and distributed COVID-19 vaccine doses.

The results also revealed that the benefits to poorer countries were greater for doses allocated than for doses distributed. This disparity can be explained by differences in the vaccine distribution systems across countries and territories. The differences include availability of cold-chain equipment, warehousing or storage capacities and human resources. Due to variations in supply-chain readiness, COVAX-eligible countries and territories may not receive their allocation from the COVAX Facility until minimum conditions are met. As such, WHO and UNICEF have developed a guidance note on COVID-19 vaccine supply and logistics management to help countries to prepare.25

We found variations in the benefits accrued across country income levels. Although total and COVAX-sponsored per capita benefits favoured poorer countries and territories, the benefits varied across country income levels, especially after adjusting for need using the size of the vulnerable older populations. In general, both total and COVAX-facilitated per capita benefits among self-financing countries disproportionately favoured countries with higher GDP per capita. This difference may be because nations with more resources can procure extra doses of COVID-19 vaccines in addition to the vaccines from the COVAX subsidy. These results also explain why the self-financed COVAX-facilitated per capita benefits accrued to nations with higher GDP per capita. However, the total benefits per capita favoured poorer countries when we took account of COVAX subsidies in the analysis.

Despite substantial investments in vaccine delivery systems during the Global Vaccine Action Plan’s decade of vaccines (2010–2019), vaccine distribution systems of the poorest countries lag behind those of middle- and high-income countries.26,27 The performance gap may be partially due to previous vaccine investments focusing on reaching children, whereas addressing COVID-19 requires health systems to expand to reach the adult population. The ability to adapt to emerging challenges is a long-standing health-system goal that may have eluded past investments in vaccination systems in the poorest countries. Those countries who are facing discrepancies between the doses allocated and distributed may also face issues with allocating and distributing vaccines to the most vulnerable. Future progress on equity in the face of the current COVID-19 crisis will therefore require attention on the core capabilities of the health systems of the lowest income countries.

COVAX alone will not be sufficient to tackle future global inequity of vaccine access unless considerable reforms to the global system of vaccine governance are made. Although COVAX was able to allocate its COVID-19 vaccine doses among countries in an equitable manner, these efforts have not been enough to reverse the inequitable allocation and timely delivery of total COVID-19 vaccine. Inequities also still persist due to countries’ hoarding vaccine supplies for their own populations.28 The disparity in the total share of people vaccinated against COVID-19 between low-income and high-income countries remains large: more than 80% of the population in high-income nations compared with less than 10% of the population in low-income countries as of early 2022.29 This inequity in vaccine access exacerbates already overburdened health systems and economies and costs millions of lives globally, especially within lower-income countries. Without collective action from the international community and governments, paired with improvements in global vaccine equity mechanisms, the challenges will persist.

There were some limitations to the study. First, we used PPP-adjusted GDP per capita to rank countries along a continuum. This country-level average does not reflect cross-country and in-country variations in living standards that may exist. Second, the analysis focused on the benefits received by countries and territories from COVAX in terms of the numbers of vaccine doses allocated and distributed. We were unable to determine how COVAX vaccine doses were allocated and distributed within the countries after the delivery by COVAX. Key issues such as human resources for health availability, geospatial access issues, internal stocking and cold-chain maintenance issues, and vaccine hesitancy may affect the ability of the countries and territories to eventually vaccinate their populations. As such, there may be significant variation in full vaccination coverage within and among the countries and territories. Another limitation is that we only examined doses from COVAX, omitting doses from other bilateral deals or non-COVAX sources. COVAX vaccines represent approximately 20% of all doses in circulation.30 Furthermore, our study was unable to assess the full effectiveness of COVAX, as we focused only on the allocation mechanism and not the procurement component. Lastly, the benefit–incident analysis assumes that expenditure on COVAX is an appropriate proxy for benefit. In reality, benefits are context-specific and require country-level epidemiological parameters to standardize the relative benefits of the additional doses across settings.

In conclusion, global risk-sharing for pooled procurement can foster the equitable distribution of COVID-19 vaccines and help to balance global inequities in the allocation and delivery of COVID-19 vaccines. Without COVAX subsidies and the COVAX Facility as a whole, poorer countries and territories may struggle to access COVID-19 vaccines. Therefore, expanding COVAX subsidies beyond 20% of the population for the poorer countries may be important to further enhance equity in the allocation and delivery of COVID-19 vaccines. Future studies could examine the equity of vaccine distribution within countries and include vaccines beyond the COVAX-facilitated vaccines.

Competing interests:

None declared.

References

Articles from Bulletin of the World Health Organization are provided here courtesy of World Health Organization

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