What are the key features of an equitable global vaccine strategy for the next pandemic? A qualitative study of pandemic control experts.

The COVID-19 pandemic exposed significant weaknesses in global health multilateralism, particularly in its failure to achieve fair and equitable global distribution of COVID-19 vaccines. Soon after vaccines were available, huge inequities in vaccination rates between populations in the global north and the global south became apparent. This study explores why multilateralism fell so short during the pandemic and identifies the steps that must be taken now to ensure global vaccine equity in the next pandemic.We conducted in-depth interviews with 20 expert key informants (KIs) worldwide from May 2023 to January 2024, comprising 16 individual interviews and two group interviews (each group interview had two KIs). The experts included representatives of academia, multilateral health and development agencies, civil society organizations, non-governmental organizations, think tanks, and the pharmaceutical industry. We used a qualitative study design to explore the perspectives, experiences, and insights of global health experts. We used purposive sampling to select participants based on their experience and knowledge of pandemic vaccines and pandemic preparedness. We continued conducting interviews until we had reached theoretical saturation.Five key themes emerged on why multilateralism fell short when it came to global COVID-19 vaccine distribution. Prioritization of national interests-so-called "vaccine nationalism"-was a barrier to sharing doses. COVAX, the global vaccine sharing mechanism, lacked incentives for high-income and upper-middle-income nations to participate or compulsory mechanisms to make them do so, undercutting its ability to serve as an equitable distribution platform. COVAX also left out important constituents from the decision-making process. Rich countries benefitted from having stronger market power in the global economy due to their established, long-term relationships with the pharmaceutical companies. Inadequate vaccine supply fed into inequitable distribution. Five key themes emerged on ways to avert global vaccine inequity in the next pandemic. Promoting regional self-sufficiency in research and development and vaccine manufacturing is crucial. Building manufacturing capacity cannot be deferred until the next pandemic-it must begin now. International collective action will still be important, especially technology transfer agreements between large companies in the global north and partners in the global south as well as south-south partnerships. Public funding for pandemic vaccine development should include conditionalities that support global access. Finally, new kinds of intellectual property agreements are essential in preparing for the next pandemic.Vaccine nationalism-combined with vaccine supply constraints, the dominance of manufacturing by countries in the global north, and the greater purchasing power of wealthy nations-created a "perfect storm" for rich nations to buy up the supply and to leave COVAX and many low- and middle-income countries at the back of the queue. To prevent such inequity in the next pandemic, regions should build capacity not just in manufacturing vaccines but also in regulatory approval and the financing and procurement of vaccines at scale. Such capacity needs to be built now-it cannot be deferred until the next crisis.This study was funded by a research grant to Duke University from the Carnegie Corporation of New York (https://www.carnegie.org/grants/grants-database/?q=duke&per_page=25#!/grants/grants-database/grant/937399121.0/).

Duke Scholars

Author David McAdams Fuqua School of Business

Author Gavin Mark Yamey Duke Global Health Institute