Vaccine politics: Law and inequality in the pandemic response to COVID‐19
| Published date | 01 May 2023 |
| Author | Matthew M. Kavanagh,Renu Singh |
| Date | 01 May 2023 |
| DOI | http://doi.org/10.1111/1758-5899.13203 |
Global Policy. 2023;14:229–246.
|
229
wileyonlinelibrary.com/journal/gpol
1 | A POLITICALLY UNSOUND
APPROACH TO EQUITY
Within weeks of the first reported cases of SARS-
CoV- 2, scientists were already working on a vaccine
for the virus that would rapidly trigger the COVID- 19
pandemic. High- profile efforts to ensure equitable
distribution of those vaccines to the world were
announced not long after— with political and global
health leaders setting out plans to ensure equity well
before any effective vaccine was available. Not only
was equity seen to be an important moral objective of
global vaccination efforts, but it was also considered
to be an instrumentally useful goal for mitigating the
negative impacts of the pandemic (von der Leyen &
Ghebreyesus, 2020). Yet while the global scientific
effort to create COVID- 19 vaccines was a remarkable
success, global efforts failed to achieve equitable
distribution.
A year after the first vaccines were registered, 9 bil-
lion doses had been administered, but just 1% of them
were delivered in low- income countries (Our World in
Data, 2022). Seventy- two per cent of the population
in Western Europe had been fully vaccinated, but just
4% in Western Africa had been (Schellekens,2022b).
The highest- profile global vaccine equity effor t, the
COVID- 19 Vaccine Global Access Facility (COVAX),
reached less than half of its goal of distributing 2 bil-
lion doses in 2021 (UNICEF,2022). As the share of
COVID- 19 deaths fell in highly vaccinated countries and
grew where vaccination was rare, insufficient vaccina-
tion led to the rise of viral variants and prolonged the
pandemic, disrupting life and economies in even the
wealthiest countries. While global governance ef forts
may yet achieve wide vaccination coverage, they did
not achieve their stated goal of equitable distribution.
Why did vaccine equity efforts, with the backing of
many of the world's most powerful governments and
RESEARCH ARTICLE
Vaccine politics: Law and inequality in the pandemic
response to COVID- 19
Matthew M.Kavanagh1,2 | RenuSingh2,3
Received: 1 July 20 22
|
Revised: 2 March 2 023
|
Accepted: 3 Marc h 2023
DO I: 10 .1111/17 58- 589 9.13 203
© 2023 Durham Unive rsity and John Wiley & So ns Ltd.
1Department of G lobal Health, School
of Health, Georgetown University,
Washington, District of Columbia, USA
2O'Neill Institute for National & Global
Health Law, Georgetown Law Center,
Washington, District of Columbia, USA
3Department o f Social and Political
Sciences, Bo cconi University, Mila n, Italy
Correspondence
Matthew M. Kavanag h, Department
of Global Healt h, School of Health,
Georgetown University, Washington, DC,
USA.
Email: matthew.kavanagh@georgetown.edu
Abstract
International mechanisms failed to achieve equitable distribution of COVID- 19
vaccines— prolonging and deepening the pandemic. To understand why, we
conduct process tracing of the first year of international policymaking on vac-
cine equity. We find that, in the absence of a single venue for global negotiation,
two competing law and policy paradigms emerged. One focused on demand
and voluntary action by states and firms, while the alternative focused on open-
ing knowledge and expanding production through national and international law.
While these could have been complementary, power inequalities between key
actors kept the second paradigm from gaining traction on the global agenda.
The failure of the prevailing policy paradigm to secure equity is explained, not by
unforeseen technical and financing challenges as some suggest, but by a fun-
damental misalignment with the political environment. While norm entrepreneurs
encouraged sharing, political incentives pushed governments towards securing
and hoarding doses. Firms responded to the latter. Mechanisms like COVAX
proved incapable of countering these predictable international and domestic
political forces. Earlier funding would not likely have changed the behaviour of
states or firms in the absence of legal commitment. Barring significant geopoliti-
cal changes, a shift to include open/supply- focused policies will be necessary to
achieve equity in future pandemics.
230
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KAVAN AGH and SINGH
philanthropies, and with a clear head start before vac-
cines were even developed, fail to achieve vaccine
equity? To answer this puzzle, we trace policy devel-
opment and political processes through the first year of
global vaccine distribution. At the heart of this failure,
we argue, lies a policy paradigm poorly matched to the
global political environment and a global health policy
agenda that excluded key measures more aligned with
political realities.
Some have suggested the model behind the dom-
inant approach to global vaccine equity was sound
and should be replicated in the future. The primary
challenges, they argue, are lack of a permanent, rapid
funding mechanism (Berkley,2022; Open Consultants,
2022) and ‘entirely unexpected’ behaviours by states
and companies (Mancini,2022). We do not find support
for this. Failure to achieve vaccine equity is explained,
not by unforeseen technical challenges in a largely ef-
fective approach, but by the fundamental misalignment
between the dominant policy paradigm pur sued for vac-
cine equity and the international and domestic politics
of 2020– 2021. Several approaches might theoretically
have achieved equity, and a wide literature has debated
the value of specific policies (de Bengy Puyvallée &
Storeng,2022; Geiger & McMahon,2021; Thambisetty
et al.,2021). But, success depended on deployment in
an actual crisis and political realit y. Our primary con-
tribution here is a social science and political analysis
that explores the context and the development of policy
paradigms within it. We find that, ultimately, the dom-
inant approach required actions from powerful states
that were clearly politically untenable, making its failure
predictable. As the world considers future pandemic
preparedness efforts in a global political context that
has not shifted radically, it is important to understand
why so we can design approaches capable of add ress-
ing political barriers.
1.1 | Our analysis centres on
three ndings
First, we describe the emergence of two policy para-
digms for achieving vaccine equity. A demand- focused/
voluntary action paradigm accepted ar tificial scarcity
and depended on voluntary action by states and vac-
cine manufacturers to distribute vaccines equitably
through market mechanisms like pooling purchases.
The alternative supply- focused/openness paradigm,
supported largely by low- and middle- income (LMIC)
governments and civil society organisations, proposed
greater use of legal authority and sharing of vaccine
knowledge and open production to counter vaccine
nationalism.
Second, we show that, while these policy appro aches
could have been complementary (e.g. pooling procure-
ment while compelling the sharing of technology), in
the absence of a single venue for policymaking and n e-
gotiation, the interests of powerful global health actors
put them in competition. These interests ultimately kept
the supply/openness paradigm from gaining political
traction on the global health policy agenda.
Third, we conduct a political analysis of the two-
level game (Putnam, 1988 ) at play in the politics of
COVID- 19 vaccines. Domestic political forces in most
states pushed prioritising vaccines for their whole pop-
ulations as quickly as possible. Despite public pledges
to equity and shared access, states early on signalled
their unwillingness to delegate authority (Bradley &
Kel ley, 2008) necessary to do so and no legal mea-
sures bound either states or companies to allocate
limited doses ethically. Reliant on weak international
norms incapable of countering intractable domestic po-
litical pressures towards vaccine nationalism, the pol-
icy tools deployed under the voluntary approach were
simply not set up to successfully achieve equity. The
viable alternative, in which global health governance
focused on sharing of vaccine technolog y so that coun-
tries and regions could produce vaccines for their own
populations, did not require countering broad state
Policy Implications
• States currently negotiating new pandemic
agreements and financing mechanisms
should avoid replicating a policy approach to
equity that proved incapable of overcoming
political challenges. Solutions focused on fi-
nancing alone will not address the core prob-
lems encountered by international vaccine
allocation efforts.
• An international agreement that commits
states to share technology and support dis-
tributed manufacturing, rather than a focus
on sharing doses, could address the pre-
dictable domestic and international political
forces during a pandemic that undermine eq -
uitable access among countries.
• States should agree on an authoritative venue
for negotiating equitable distribution policies
that include representation of all states (per-
haps under the World Health Assembly or
UNGA's authority) to counter power dynam-
ics within global health that undermined ef-
fective policymaking.
• Glo bal health institutions designing pandemic
response policies should conduct rigorous
political analysis to understand and ar ticulate
real- world feasibility of polices that must be
implemented in a non- ideal context.
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