A Proposal to End the COVID-19 Pandemic

Urgent steps are needed to arrest the rising human toll and economic strain from the COVID-19 pandemic that are exacerbating already-diverging recoveries. Pandemic policy is also economic policy as there is no durable end to the economic crisis without an end to the health crisis. Building on existing initiatives, this paper proposes pragmatic actions at the national and multilateral level to expeditiously defeat the pandemic. The proposal targets: (1) vaccinating at least 40 percent of the population in all countries by the end of 2021 and at least 60 percent by the first half of 2022, (2) tracking and insuring against downside risks, and (3) ensuring widespread testing and tracing, maintaining adequate stocks of therapeutics, and enforcing public health measures in places where vaccine coverage is low. The benefits of such measures at about $9 trillion far outweigh the costs which are estimated to be around $50 billion—of which $35 billion should be paid by grants from donors and the residual by national governments potentially with the support of concessional financing from bilateral and multilateral agencies. The grant funding gap identified by the Access to COVID-19 Tools (ACT) Accelerator amounts to about $22 billion, which the G20 recognizes as important to address. This leaves an estimated $13 billion in additional grant contributions needed to finance our proposal. Importantly, the strategy requires global cooperation to secure upfront financing, upfront vaccine donations, and at-risk investment to insure against downside risks for the world.

Abstract

Urgent steps are needed to arrest the rising human toll and economic strain from the COVID-19 pandemic that are exacerbating already-diverging recoveries. Pandemic policy is also economic policy as there is no durable end to the economic crisis without an end to the health crisis. Building on existing initiatives, this paper proposes pragmatic actions at the national and multilateral level to expeditiously defeat the pandemic. The proposal targets: (1) vaccinating at least 40 percent of the population in all countries by the end of 2021 and at least 60 percent by the first half of 2022, (2) tracking and insuring against downside risks, and (3) ensuring widespread testing and tracing, maintaining adequate stocks of therapeutics, and enforcing public health measures in places where vaccine coverage is low. The benefits of such measures at about $9 trillion far outweigh the costs which are estimated to be around $50 billion—of which $35 billion should be paid by grants from donors and the residual by national governments potentially with the support of concessional financing from bilateral and multilateral agencies. The grant funding gap identified by the Access to COVID-19 Tools (ACT) Accelerator amounts to about $22 billion, which the G20 recognizes as important to address. This leaves an estimated $13 billion in additional grant contributions needed to finance our proposal. Importantly, the strategy requires global cooperation to secure upfront financing, upfront vaccine donations, and at-risk investment to insure against downside risks for the world.

The Global Race Against the COVID-19 Virus

It is over a year into the COVID-19 pandemic, and new cases worldwide are higher than in any previous phase of the pandemic. The measured worldwide cumulative death toll exceeds 3 million, and daily death tolls are close to record highs. The actual death toll is estimated to be several times higher. This worsening of the pandemic is being fueled by a potent mix of factors including virus mutations that are more transmittable, highly unequal vaccine coverage across countries, and erosion of public health measures because of complacency and fatigue.

The April 2021 World Economic Outlook (IMF, 2021a) projected a dangerous divergence in prospects across countries with emerging and developing economies (excluding China) expected to have slower recoveries and greater scarring. This was despite the fact that the pandemic had on average hit the advanced economies harder and that several developing countries with weak health systems had been spared the worst of the pandemic. However, the ongoing catastrophic second wave in India, following a terrible wave in Brazil, is a sign the worst may be yet to come in the developing world. While India’s health system held up fairly well in the first wave, this time around its health system is so overwhelmed that many are dying because of a lack of medical supplies like oxygen, hospital beds, and medical care. India is a warning of possible events in other low- and middle-income countries (LMICs) that so far have seemingly escaped the pandemic, including in Africa.

These developments represent not a country or regional problem but a global problem. As public health officials have noted numerous times, “the pandemic is not over anywhere until it is over everywhere.” Further unchecked transmission of the virus can give rise to new variants, some of which may render existing vaccines ineffective, putting the world back to the starting line in the race against the virus. Several organizations and initiatives including the ACT Accelerator, Coalition for Epidemic Preparedness Innovation, Gates Foundation, GAVI, Global Fund, World Bank, World Health Organization, and World Trade Organization have led the effort in the fight against the pandemic. The proposal in this paper seeks to build on and complement these important efforts.

Pandemic policy is economic policy, as there is no durable end to the economic crisis without an end to the health crisis. It is critical for global macro and financial stability, which makes it of fundamental importance to the IMF and other economic institutions. Indeed, IMF economic projections and policy recommendations for the global economy rely crucially on the relative success of the race against the virus. To make this assessment, this paper analyzes multiple dimensions of the fight against the pandemic including projecting global and cross-country vaccination rates under alternative scenarios. The projections point to highly unequal health prospects well into 2022, which poses severe risks for the world. To contain the rising global costs of the COVID-19 pandemic, urgent steps are needed to bring the virus under control in every corner of the world.

This proposal involves pragmatic actions at the national and multilateral levels, as outlined in Table 1, to help expeditiously tackle the global health crisis. The proposal targets (1) vaccinating at least 40 percent of the population in all countries by the end of 2021 and at least 60 percent by the first half of 2022, (2) while tracking and insuring against downside risks, and (3) ensuring widespread testing and tracing, maintaining adequate stocks of therapeutics, and enforcing public health measures in places where vaccine coverage is low. The strategy is one not of commitments but of upfront financing, upfront vaccine donations, and at-risk investment for the world.

Table 1:

Core Elements of the Global COVID-19 Action Plan

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Notes: Darker cells correspond to greater importance of the measure in the given quarter. While our budgeting exercise attributes a zero additional cost for in-kind donations of surplus vaccinations since much of the procurement is sunk cost, there is a strong case to count donations to the COVAX-AMC facility as official development assistance (ODA). The unutilized financing from lending facilities is based on the World Bank and Asian Development Bank pandemic lending facilities. The grant funding gap identified by the Access to COVID-19 Tools (ACT) Accelerator amounts to about $22 billion, which the G20 recognizes as important to address. See Annex VI for details.

Building on the budgeting of the ACT Accelerator (WHO, 2021b) and prior work on gaps in vaccine coverage in LMICs (Agarwal and Reed, 2021), we estimate the overall cost of this proposal to be around $50 billion.1,2 IMF research (IMF, 2021b) estimates that the cumulative gain to the world from greater success on all aspects of the fight against the virus—including vaccinations, diagnostics, and therapeutics—is around 9 trillion dollars by 2025, with over 40 percent of this gain going to advanced economies as stronger recoveries in the rest of the world raises demand for their goods, and through stronger confidence effects at home as the pandemic ends durably. This translates into a cumulative gain of $1 trillion dollars in additional tax revenue for advanced economies, which means that funding this proposal may possibly be the highest-return public investment ever (IMF 2021c). The window for realizing these gains, however, is closing quickly, and action is needed now.

Given that ending the pandemic in a timely manner is a global public good, of the $50 billion total cost of this proposal, there is a strong case for grant financing of at least $35 billion from public, private, and multilateral donors and the remainder by national governments potentially supported by concessional financing from multilateral agencies. The grant funding gap identified by the ACT Accelerator amounts to about $22 billion, which the G20 and other governments recognize as important to address. In addition, at least $15 billion is available from COVID-19 financing facilities created by multilateral development banks. This leaves an estimated $13 billion in additional grant contributions needed to get to the $50 billion identified by our proposal. This additional amount is mainly for raising the COVAX vaccine coverage to 30 percent, procuring additional COVID-19 tests, and expanding vaccine production capacity to insure against downside risks. We emphasize the need for grant financing since the identified needs are largely on behalf of low- and lower-middle income countries.

The proposal focuses on what is needed to bring the current pandemic under control. This complements the work of the G20 High Level Independent Panel, the G-7 Pandemic Preparedness Partnership group, and the Report of the Independent Panel for Pandemic Preparedness and Response (G20, 2021; G7, 2021; and IPPP, 2021), which primarily focus on addressing future pandemics.

The following sections outline the opportunities and the challenges and discuss possible solutions. We also note that there is considerable uncertainty around the projections given the shifting vaccine and virus landscape, and the lack of sufficient transparency in vaccine contracts.

Accelerating Global Vaccine Coverage

Opportunities

A) Vaccines work: Vaccine discovery has been hugely successful (Agarwal and Gaule, 2021), and so far the evidence from multiple countries like Israel, the UK, and the US provide real-world reinforcement that vaccines are effective and can help bring the virus under control (Burn-Murdoch, 2021; Rossman and others 2021). Further, there is growing evidence that different vaccines in the existing vaccine portfolio retain an effectiveness of 50 percent or greater against most variants of concern or interest—especially in preventing hospitalization and deaths (see Table 2).

Table 2:

Efficacy of COVID-19 Vaccines Against Different Variants

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Source and Notes: Abdool Karim (2021), Abu-Karim (2021), Madhi (2021), and compiled by Eric Topol (2021), based on data available as of early May 2021. A check corresponds to efficacy of at least 50 percent in clinical trials.

B) Vaccine supply in the pipeline for 2021 is sizable: More than 1.1 billion vaccine doses had been administered globally by the end of April 2021. Further, the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA), which represents pharmaceutical companies around the world, projects an accelerating supply of vaccines. IFPMA stated on April 23, 2021, that “current projections to produce close to 10 billion doses by the end of 2021 is thought to be feasible.” (IFPMA, 2021; Airfinity, 2021).

  • ⇒ While these estimates remain subject to significant downside risks due to the fragility of the supply chain, the pace of global vaccination reached 20 million doses per day as of the end of April 2021 (as per data consolidated by Our World in Data). This is equivalent to 0.25 per 100 people in the world. Even at this pace, under the baseline we should expect conservatively at least 6 billion vaccine doses produced and administered worldwide by the end of 2021. For our business-as-usual projections of vaccine coverage by the end of 2021, we take this conservative estimate of 6 billion doses and treat the industry baseline of 10 billion doses as a potential upside scenario (discussed below).

  • ⇒ Accounting for single-dose shots, the 6 billion doses would translate to about 3.5 billion vaccine courses (that is, would vaccinate 3.5 billion people) and will be sufficient to cover about 45 percent of the worlds population by the end of 2021.

C) Vaccinating the high-risk population provides significant benefits: If vaccine prioritization is followed in line with guidance from the WHO to first vaccinate priority populations (WHO 2020a), the 6 billion doses would allow for universal coverage for the worldwide high-risk population (that is, older adults plus those with underlying health conditions that account for about 22 percent of world population) (Clark and others 2020).

  • ⇒ The evidence from countries ahead on the vaccination drive is that vaccinating the high-risk population (for example, those in nursing homes and older individuals) can significantly ease the severity of the pandemic as health systems are not overwhelmed. So even before reaching anywhere close to herd immunity, significant benefits from vaccinations can be realized if coupled with sensible public health measures.

Challenges

A) Vaccine access is highly unequal: The access to vaccines remains deeply unequal across countries with the 1.1 billion doses already administered concentrated in a few countries. As of the end of April 2021, less than 2 percent of Africas population had been vaccinated. By contrast, more than 40 percent of the population in the US and more than 20 percent in Europe had received at least one dose of the vaccine (Figure 1).

  • ⇒ The inequality in vaccine access is expected to persist. Based on the estimate of 6 billion doses under the business-as-usual scenario, our projections show that the inequality in vaccine access is likely to persist until the end of 2021 and beyond—significantly jeopardizing global health prospects (Figure 2). This scenario does not include in-kind vaccine donations from donor countries, as stockpiled vaccines will simply go unused in the near-term in the absence of donations. To evaluate the degree of inequality in vaccine access, it is useful to split the LMICs (excluding China and India) into a group of 91 countries that require explicit global support and the rest. The first group is referred to as AMC91 (given their eligibility to access the grant-financed COVID-19 Vaccines Advance Market Commitment, or COVAX AMC, facility) containing LMICs with a combined population of about 2.5 billion, and the rest contains 35 upper-middle-income countries with a population of about 1.1 billion (see Annexes I and II).

  • ⇒ Under the business-as-usual scenario, the vaccine coverage in AMC91 countries is expected to remain below 30 percent by the end of 2021, whereas coverage in India is expected to reach under 35 percent (Figure 3). Other LMICs and high-income countries are expected to have a coverage of around 50 percent and 70 percent, respectively.

Figure 1:
Figure 1:

Share of population vaccinated as of End-April 2021

(% of total population, at least one dose)

Citation: Staff Discussion Notes 2021, 004; 10.5089/9781513577609.006.A001

Source and Notes: Authors’ calculations. See Annex III. Country borders or names do not necessarily reflect the IMF’s official position.
Figure 2:
Figure 2:

Estimated share of population fully vaccinated as of End-2021 under a Business-as-Usual Scenario

(% of total population)

Citation: Staff Discussion Notes 2021, 004; 10.5089/9781513577609.006.A001

Source and Notes: Authors’ calculations. See Annex III. Country borders or names do not necessarily reflect the IMF’s official position.
Figure 3:
Figure 3:

Vaccination Coverage at End-2021 Under Downside Scenarios

Citation: Staff Discussion Notes 2021, 004; 10.5089/9781513577609.006.A001

Source and Notes: Authors’ calculations. See Annex IV. AMC91 stands for the group of 91 low- and middle-income countries (excl. India) that are eligible to access the COVAXAMCfacility. Other LMIC refers to the group of low- and middle-income countries excluding India, China, and AMC91 countries. HIC refers to high-income countries as per World Bank income classifications. The bars report the fraction of population fully vaccinated within the country group, under different scenarios.

B) Several downside risks exacerbate this inequality: We describe three downside scenarios in which even the conservative estimate of 6 billion doses do not materialize by the end of 2021. Our projections show that in all three scenarios, LMICs are disproportionately impacted, worsening inequality (Figure 3 and Annex IV):

  • Scenario 1: Persistent shortage of raw materials and export restrictions lead to longer delays. Vaccine manufactures are aiming to produce this year around three times the annual global supply of vaccines in a normal year. Such rapid scaling up is posing substantial supply chain challenges with shortages of raw materials shared among multiple vaccine candidates. Already, various manufacturers including the Serum Institute of India (licensed to manufacture Novavax and AstraZeneca) have experienced substantial delays. Some of these delays can be attributed to ongoing export restrictions placed by the US as part of the Defense Production Act to secure its own vaccine supply chain. In addition, India has delayed most of its vaccine exports to prioritize vaccinations at home. Such delays disproportionately impact developing countries—for instance, the Serum Institute is contracted to supply about 85 percent of the supplies to the COVAX AMC facility, and persistent shortage of raw materials and export restrictions can reduce access to vaccines for 4 billion people in 91 developing countries plus India relying on this facility.

  • Scenario 2: Safety concerns in a class of vaccines. Concerns about safety—genuine or otherwise— of the AstraZeneca and Johnson & Johnson (J&J) vaccines have led to temporary halts in various jurisdictions. There is growing evidence that such halts have contributed to vaccine hesitancy. The developing world is heavily relying on adenovirus-based vaccines, with more than 80 percent of currently contracted vaccine courses in the group of AMC91 LMICs and India expected to come from three developers: AstraZeneca, J&J, or Sputnik V. All three share the same platform technology and are thus exposed to similar risks. Thus, safety concerns in this class of vaccines could significantly impact vaccine rollout and exacerbate the cross-country inequality in vaccine access. To demonstrate the distributional impact of such a scenario, Figure 3 depicts a case in which 30 percent of global vaccine supply in 2021 is compromised due to a shock to the adenovirus-based vaccines (reducing the vaccine supply from 3.5 billion courses to 2.5 billion courses). Under this scenario, vaccine coverage for AMC91 countries and India by the end of 2021 will decline by more than half—from about 26 percent and 33 percent to 10 percent and 12 percent, respectively.

  • Scenario 3: Vaccinations of children and booster doses administered in high-income countries due to reduced vaccine efficacy against new escape variants. New mutations can render a class of vaccines less effective as is already the case with the B.1.351 variant (originally found in South Africa), although so far most vaccines remain highly effective in preventing severe illness and death. If existing or new variants of concern were to seriously compromise vaccine efficacy it could impact the global vaccination path in two ways:

    • i) First, it will raise demand for booster shots, which will require existing manufacturing capacity to be repurposed. This will divert capacity away from the unvaccinated world to the already-vaccinated people in high-income countries.

    • ii) Second, we have already seen that some vaccines that are so far available to developing countries—in particular AstraZeneca—have been associated with significant reduction in efficacy against the B.1.351 variant discovered in South Africa (Madhi and others 2021). Thus, the rise of further escape variants is likely to create a two-class system of vaccine portfolios under current capacity constraints—with high-income countries having access to relatively more effective vaccines supplemented by boosters.

    • iii) This scenario additionally assumes rapid vaccination of children in high-income countries in line with current development plans of leading vaccine developers (for example, Pfizer). Under this scenario, about 85 percent of the population in high-income countries will be vaccinated by the end of 2021, in addition to all vaccinated adults in high-income countries receiving a booster shot. This results in a reallocation of about 425 million vaccine courses from AMC91 countries to high-income countries, leading to the vaccine coverage of AMC91 countries and India falling to around 10 percent.

    • iv) Overall, these channels will leave LMICs with fewer and less-effective vaccines. Figure 3 quantifies such a scenario (see Annex IV for details) in which the coverage of AMC 91 countries and India may fall to around 10 percent at the end of 2021.

Proposed Solutions

I. Achieving the Vaccination Targets

To bring the pandemic substantially under control the goal should be to vaccinate at least 40 percent of the population in all countries by the end of 2021 and at least 60 percent by the first half of 2022. The 60 percent vaccination target is also consistent with the African Unions target of vaccinating 60 percent of the continents 1.3 billion people. Reaching this target in developing countries and especially in Africa (where about 40 percent of the population is below age 15), may require near-universal vaccine coverage among adults or lowering the approved minimum age of vaccines (for example, from age 16 to age 12 as is being currently evaluated by regulatory authorities).

Prior work and evidence from the immunization campaign in Israel shows that, as long as vaccines provide protection, this immunization threshold could be sufficient to end the acute phase of the pandemic and enable substantial normalization in social and economic activity (Rossman and others 2021). The required immunization threshold for infections is sensitive to the particular vaccine being administered. However, real-world data demonstrate substantial gains in reducing severe disease, hospitalization, and death at 60 percent coverage in all cases, thus enabling a return to substantial normalcy.

Table 1 outlines the key elements of the proposal and financing required to help achieve this proposal for the AMC countries, with budgeting details for each item provided in Annex VI. Most high-income countries and upper-middle-income countries are already on track to attain the goal. The required actions are the following:

A) Provide additional upfront financing for COVAX. Additional up-front cash contributions (not commitments) of at least $4 billion are needed for the COVAX AMC facility, which is a global initiative aimed at equitable access to COVID-19 vaccines. This will close the current financing deficit and enable COVAX to increase its vaccine coverage goals for 91 LMICs (“AMC91”) from 20 percent to 30 percent.

  • ⇒ With immediate up-front cash contributions, COVAX can finalize orders that are currently under active negotiation. This in turn will help activate the unutilized vaccine capacity. As per industry estimates, only a subset of the 2021 vaccine production capacity has been pre-purchased, suggesting that there may be room to bring marginal supplies online before end-2021 beyond the 6 billion doses assumed in our business-as-usual scenario.

  • ⇒ Estimates suggest that current vaccine pre-purchases (either bilaterally, or through COVAX and the African Union) already provide a coverage of about 40–50 percent in most LMICs (Agarwal and Reed, 2021). Thus, allowing the COVAX AMC to increase its coverage will help ensure that vaccine coverage reaches 60 percent in most of the LMICs eligible to access its AMC facility by the first half of 2022.

  • ⇒ Further, funding will be needed to assist LMICs in financing the costs of delivering the COVID-19 vaccines, including to cover costs for technical assistance, outreach and fixed site delivery costs, and upfront costs such as cold chain installation and training.

B) Countries with insufficient coverage should immediately place purchase orders for vaccines. Countries or regions that are relying on domestic vaccine manufacturing capacity or on executing option contracts in the future should consider immediately placing orders to achieve sufficient vaccine coverage.

  • ⇒ For India, current bilateral purchases plus coverage from COVAX will cover about 25 percent of its population by the first half of 2022. To get to 60 percent coverage, India will need to immediately place sufficient vaccine orders of about 1 billion doses through contracts that incentivize investment in additional capacity and augmentation of the supply chain. In this context, the authorities recently announced financing of about $600 million to the Serum Institute of India and Bharat Biotech to boost production capacity in the near term is a welcome step. Authorities estimate that 2 billion doses will be available by the end of 2021. Efforts should be made to ensure that the projected production capacity will materialize without delay, including through securing the supply chain for raw materials—supported by international efforts to eliminate export restrictions on all critical inputs.

  • ⇒ The African Union has entered a deal with J&J for 220 million single-shot doses with an option to order an additional 180 million doses. Most of this supply is expected to be produced by Aspen Pharma in South Africa. This deal alone provides a vaccine coverage of 18–32 percent to African Union member countries. Efforts should be made to secure additional doses as needed (either through the existing J&J option or other vaccine producers). Further, given the reliance on the South Africa manufacturing facility, proactively monitoring and mitigating supply chain risks in the plant will be important.

(C) Ensure free cross-border flow of raw materials and finished vaccines. An urgent focus should be to eliminate constraints on cross-border exports of critical raw materials and finished vaccines. Free cross-border flow of vaccine inputs and supplies is essential for the world to achieve its vaccination targets without delay. Governments are taking steps to relax such constraints on raw materials (for example, the recent pledge by the US to facilitate greater access of critical raw material to Indian manufacturers after severe shortages emerged). However, there is scope for greater multilateral action on this front, as significant constraints still remain. Greater access to critical raw materials— combined with a commitment by Indian authorities to maintain no restrictions on exports once near-term shortages ease—will also enable the Serum Institute of India (currently the chief supplier to COVAX) to meet its export commitments, which is important for the path to global vaccination.

D) Donate surplus vaccines. Countries ahead on vaccinations already have surpluses or will soon have surpluses even if they prioritize their own populations. They should share these vaccines equitably and based on standard public health principles and not for political or commercial reasons. Donating to COVAX is the best way to accomplish this (IPPP 2021). In addition, because COVAX has a “No Fault Compensation Program,” donating countries are exempt from liability concerns. There is a need for greater urgency in donating surplus vaccines, which will not only help reduce vaccine inequity but also help mitigate the acute near-term shortages in vaccine supply. Securing an international agreement, perhaps led by the UN and its agencies, to share surplus vaccines with COVAX, would help raise the “diplomatic cost” of using vaccine surpluses for national purposes.

  • ⇒ The number of vaccines pre-purchased by high-income countries far exceeds the number of people in these countries. For instance, the United States will have at least 350 million pre-purchased courses available in excess of 75 percent of its population before 2022, and that number rises to about 1 billion courses when considering a select set of eight high-income countries/regions (Figure 6). Further, the scenario analysis depicted in Figure 5 demonstrates even 50 percent of the 1 billion surplus vaccines were available and donated (that is, 500 million courses) would result in close to 40 percent vaccine coverage in all countries by the end of 2021.

  • US case study: Based on data of existing and projected vaccine supplies, the US has an estimated 80 million surplus vaccine doses available to donate as of April 2021, and this stockpile of surplus vaccines will grow to about 350 million doses by August 2021 (Table 3 and Annex V). These numbers correspond to finished products in vials, suggesting that the US has an opportunity to make a significant contribution to the world by rapidly making the surplus vaccines available to COVAX in the form of donations.

  • Cross-country prioritization: While the allocation rules between countries are subject to various ethical and health considerations, efforts should be made to prioritize donations to places where it would save the most lives (Emanuel and others 2020). The impact of COVID-19 varies tremendously across geographies, and accounting for that in the allocation of surplus vaccines is likely to save lives. While the initial phase of COVAX allocation has proceeded according to proportional allocation, the COVAX allocation mechanism (WHO 2020c) allows for special consideration for countries that face major outbreaks or national disasters. Increasing and utilizing this special consideration buffer could be a way to achieve better prioritization. An additional step that can facilitate prioritization is a system of vaccine exchange, which could help get doses to places where they are most needed—if intertemporal trade is allowed. Such a mechanism, called the COVAX Exchange, has been under development, and efforts should be made to immediately make the exchange operational.

Figure 4:
Figure 4:

Achieving the Vaccination Targets Scenario

Citation: Staff Discussion Notes 2021, 004; 10.5089/9781513577609.006.A001

Source and Notes: Authors’ calculations. See Annex IV. AMC91 stands for the group of 91 low- and middle-income countries (excl. India) that are eligible to access the COVAXAMCfacility. Other LMIC refers to the group of low- and middle-income countries excluding India, China, and AMC91 countries. HIC refers to high-income countries as per World Bank income classifications. The bars report the fraction of population fully vaccinated within the country group, under different scenarios.
Figure 5:
Figure 5:

End-2021 Vaccine Coverage under Different Upside Scenarios

Citation: Staff Discussion Notes 2021, 004; 10.5089/9781513577609.006.A001

Source and Notes: Authors’ calculations. See Annex IV. The bars report the fraction of population fully vaccinated within the country, group, under different scenarios.
Figure 6:
Figure 6:

Pre-Purchased Vaccines Courses vs. Surplus Available for Donation

Citation: Staff Discussion Notes 2021, 004; 10.5089/9781513577609.006.A001

Source and Notes: Duke Global Health Innovation Center (2021); Authors’ calculations.
Table 3:

U.S. Vaccine Landscape and Estimated Surplus Doses for Donation

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Sources and Notes: CDC, Authors’ calculation, various company and media reports. See Annex III for details.

Figure 4 depicts the “Achieving the Vaccination Targets” scenario, which is based on an immediate implementation of measures (A)-(D) discussed above. Under this scenario, a combination of utilizing the surplus inventory in high-income countries and activating the production capacity through immediate pre-purchases by COVAX and India, could increase the global vaccine supply from 3.5 billion vaccine courses by the end of 2021 (as in the business-as-usual scenario) to about 4.25 billion vaccine courses—and also reduce inequity in vaccine access. This would facilitate vaccine coverage of more than 40 percent in all countries worldwide by the end of 2021. This is equivalent to about 7.5 billion vaccine doses and may still be conservative, given the capacity for 2021 estimated by industry experts. Further, under this scenario there would be an estimated 5.5 billion vaccine courses or more by April 2022, which will facilitate a minimum vaccine coverage of 60 percent in all countries (in line with the 60 percent target in the first half of 2022).

Even if the vaccination targets are secured by such measures, additional measures, described next, will be needed to insure against the downside risks described previously.

II. Insure against downside risks for vaccinations

E) Make at-risk investments to ensure sufficient production. Given the significant downside risks, what is needed is upfront investment to ensure coverage including in downside scenarios and also to potentially address future needs for LMICs (for example, vaccination of children, booster doses). In this context, private incentives to invest in capacity and scale up production in a timely manner may be weak, especially if they are likely to face limits on pricing during the pandemic (Ahuja and others 2021; Castillo and others 2021). Thus, there is scope for greater government support to create at-risk capacity as was done by the US as part of its Operation Warp Speed.

  • Immediately enter contracts to secure an additional 1 billion doses by first half of 2022 to handle downside risks or longer-term needs of LMICs. Increasing vaccine production capacity by 1 billion doses in 2022 will require additional financing of about $8 billion. This is needed to address the type of downside risks discussed in Scenario 1 and Scenario 3. Noting the recently concluded deal between Moderna and COVAX, and previous supplies by Pfizer/BioNTech to COVAX, after careful evaluations, a subset of this capacity could possibly be directed toward mRNA vaccine candidates given their expanding production capacity and potential efficacy against new variants. It will be important to ensure equitable and public health driven access to this additional vaccine capacity, and thus COVAX could be a natural candidate to execute the at-risk investments. A major current bottleneck in vaccine production is raw material shortages, and this at-risk investment to increase capacity by 1 billion doses by early 2022 should include provisions that ensure capacity is increased for all parts of the supply chain. See Annex VII for further discussion on how one could design the at-risk investment.

  • Additional efforts and financing to encourage voluntary licensing and cross-border transfer of technology: There is scope to increase manufacturing capacity through voluntary licensing, and encouraging expansion of regional production capacity. In the near term, focus should be on encouraging more voluntary licensing (for example, AstraZeneca licensing deals in India, China, Brazil) and on encouraging cross-company and cross-border partnerships to increase their manufacturing capacity (such as the U.S. governments move to get J&J and Merck to collaborate on manufacturing capacity, or the Quad vaccine initiative to increase production capacity in India). Efforts to expand manufacturing capacity should be coordinated across countries (for example, through WHO, WTO, and COVAX) to avoid crowding out vaccine supplies that are needed in the immediate short term (WHO 2021c, IPPP 2021). The recently announced COVAX manufacturing taskforce can serve a key role from this perspective. These efforts are important for vaccine equity as crowding out of vaccine supplies has tended to be at the expense of poor nations. These efforts can proceed in parallel to the ongoing WTO negotiations on the sharing of intellectual property for COVID-19 vaccines.

  • Enhance quality control: Thus far, quality control problems have created a number of delays in production for multiple vaccines. Improvements in quality control needs to go hand in hand with capacity expansion and supply chain investments to make sure that vaccine production is reliable, and to mitigate the risk of further delays.

  • Increase yield of existing capacity: Efforts should be made to increase efficiency and yields of existing vaccine production (for example, ongoing work by Pfizer and others to increase the yield of their production process), which when possible should be allocated to increased near-term supplies for LMICs.

F) Scale up genomic surveillance and systemic supply chain surveillance. To ensure vaccines remain up to the task there is a need to prevent downside scenarios impacting the global vaccine portfolio or the vaccine supply chain.

  • ⇒ To mitigate the risk of delays in vaccine production or the impact of new variants, greater global surveillance of SARS-CoV-2 variants and supply chain risks are needed with concrete contingency plans in place to handle the downside scenarios. The contingency plans should be regularly updated, and stress tested with the use of scenario planning—with the participation of multilateral agencies, vaccine developers, and key national governments. The plans should develop guidelines on how manufacturing capacity can be repurposed under different scenarios such as Scenario 2 above (including to handle lineages that evade immunity for certain class of vaccines), while preserving equitable access to vaccines.

  • ⇒ On the supply chain risks, an initial step could involve developing a global database of critical raw materials and manufacturing capacity and utilization, perhaps coordinated by the WTO or World Bank. Further, establishing a centrally coordinated COVID-19 database, including on vaccine contracts and various aspects of diseases surveillance (cases, deaths, testing, etc.) will be important to bring about greater transparency (He and others 2021, Morgan and others 2021; see Annex VIII). In this regard, the World Bank initiative to establish a data base about vaccine orders is highly welcome.

Overall, there is a need for transparent, coordinated, open-access data on multiple aspects to enhance pandemic surveillance. Annex VIII presents a non-exhaustive indicative list of data gaps that need to be addressed to enhance pandemic surveillance. There is also a need to adopt vaccine strategies that will minimize health risks before adequate vaccine supply arrives (without severe lockdowns), especially in LMICs. These strategies are discussed below.

III. Managing the interim period when vaccine supply is limited

G) Invest in infrastructure to prioritize vaccination of high-risk population and address vaccine hesitancy. In countries where vaccine supplies are scarce the high-risk population should be prioritized in vaccination drives as recommended by the WHO (2020a). Real-world evidence from the prioritized vaccine rollout in the U.K. demonstrates that rates of COVID-19 cases, hospital admissions, and deaths have fallen faster among the elderly and other highly vaccinated groups. Further, in the UK, which implemented a strict prioritization of vaccine access by age, the likelihood of getting COVID-19 fell rapidly in each age group as they became eligible to get vaccinated (Burn-Murdoch 2021). Similarly, in the U.S., which prioritized vaccination among the vulnerable groups and older individuals, there was a rapid decline in cases among those in nursing homes starting in January 2021, while COVID-19 cases surged in the overall population (Conley and others 2021). Given the high risk of death among the vulnerable populations, a strict, well-managed, and effective vaccine prioritization can save lives even when vaccine access is scarce.

  • Given the younger demographics in LMICs, the share of vulnerable population is typically in the range of 20–25 percent of the population. Further, only 7 percent of vaccine coverage of the full population will be needed to cover individuals over the age of 65 in LMICs. Recognizing limited state capacity to implement adequate vaccine prioritization, countries at nascent stages of vaccination should invest in the vaccine delivery infrastructure, prioritizing getting shot-in-arms of at-risk groups ahead of time. This requires investing in storage and transportation logistics to reach the vulnerable (WHO 2021a); public health messaging to address vaccine hesitancy; fighting disinformation on social media (Gounder 2021). Countries like Bhutan, which vaccinated most of its adult population within a week, demonstrate that with strategic planning and management a rapid vaccination campaign is possible in LMICs.

  • Evaluate a broad range of vaccines for fast track emergency use authorization. The group of countries that are included in the Stringent Regulatory Authority (SRA) list recognized by the WHO to guide medical procurement decisions globally is comprised of 34 high-income western countries plus Japan. Since most of these countries are thus far not planning to use vaccines developed by the rest of the world (for example, Chinese, Indian, or Russian vaccines), the SRAs have been relatively slow in evaluating non-Western vaccines. This may inadvertently delay adoption of these non-western vaccines by countries around the world—since multilateral financing for vaccine procurement and also regulatory approvals in LMICs are often linked to the regulatory approvals granted by the select group of SRAs. To ensure a broad portfolio of vaccines are available to each country, and to handle possible downside risks due to new variants, regulatory authorities should expedite evaluation of a greater number of vaccine candidates.

  • Ensure vaccine uptake also by making it available free of cost to people. Vaccine hesitancy is a growing concern. Vaccine uptake appears to slow considerably as early as 40–60 percent of population coverage. Overcoming vaccine hesitancy will be important to secure a durable exit from the crisis. From this perspective, the benefits of uptake are so large for countries that a zero price should be implemented for all people to maximize uptake and avoid within-country inequality in vaccine access and uptake. Existing multilateral pandemic facilities should be fully utilized to ensure financing is not an obstacle for these important steps.

H) Urgently evaluate and, where approved, implement dose stretching strategies to expand capacity, and support investment in products that ease vaccine delivery. With a growing global death burden, there is an urgent need for regulatory authorities to evaluate and implement dose stretching strategies where vaccine supply is low as advocated by Tabarrok (2021) and others and implemented in the U.K. and most recently in India. The feasibility of dose stretching will depend on the vaccine portfolio available to a given country, as preliminary real-world evidence suggests that some vaccines (for example, mRNA vaccines or AstraZeneca) may work better with such strategies than others.

  • First Doses First: The first option to consider is the “first doses first” approach that prioritizes first doses by delaying the second shot to 12 weeks or more. In the context of countries facing significant shortage of vaccine supplies, it would be useful to evaluate longer delays for the second shot (say 24 weeks) for the subset of highly effective vaccines, as this could substantially increase vaccination coverage in the immediate future when supply constraints are most binding. For instance, in clinical studies, Novavax, has an efficacy of about 83 percent as early as 14 days after the first shot, and Moderna and Pfizer/BioNTech have comparable efficacy after two weeks of the first shot. AstraZeneca also appears to offer protection of 70 percent or more after the first dose, and the UK government policy of stretching the interval between the two shots of the AstraZeneca vaccine appears to have worked (Iacobucci 2021). As vaccinations rates rise in high-income countries (such as Israel, U.K., and Qatar) more can be learned about the effectiveness of such strategies from real-world data.

  • Fractional Dosing: The second option to consider is the “fractional dosing” approach under which half-doses are administered (or a full dose followed by a half-dose). This strategy has been used effectively in previous epidemics when vaccine supplies were scarce (Guerin and others 2008). The relative benefit of these first two approaches in terms of relaxing the supply constraint will depend on where the bottlenecks in the supply chain currently exist (for example, glass vials vs. raw materials).

  • Single dose for previously infected: A third option worth considering is a “single dose for previously infected.” A recent study found that the first dose of some vaccines combined with prior infections is as or more effective than two doses for those with no prior infections (Anichini and others 2021). Furthermore, the second dose may not be beneficial or be associated with side effects for those with prior infections. Thus, for countries with high seroprevalence due to prior infections, population level screening for antibodies can significantly reduce vaccine needs under this approach.

  • Other strategies to facilitate faster vaccine delivery: Other strategies/products that need urgent attention include the development of nasal or oral vaccine products to overcome needle hesitancy (which is a non-negligible concern in LMICs), and development of mRNA vaccine doses that have better cold-chain characteristics making them more suitable for LMICs.

  • ⇒ While each of these approaches have some downsides, the current shortages in vaccine supply place a high urgency on evaluating the public health benefits of implementing them. Figure 5 shows how these strategies can significantly improve vaccine coverage and reduce vaccine inequality by the end of 2021. The figure demonstrates that dose stretching strategies could lead to an increase in the global supply of vaccines by 50 percent in 2021 relative to the business-as-usual scenario. Under such a scenario all countries in the world could reach the 60 percent vaccine coverage target by the end of 2021.

  • Provide public support for urgently evaluating these strategies through clinical trials when necessary. Learning about the effectiveness of such strategies is a global public good, with potentially huge social returns. The private sector may have weak incentives to prioritize such trials or products. Thus, there is an urgent need for public support to scale up such clinical trials and development plans with the aim of expanding existing vaccine capacity, increasing speed of vaccine delivery, and to prepare for downside risks.

  • ⇒ Finally, there is also an urgent need for public support for clinical trials and lab studies that evaluate the efficacy of existing vaccines against new variants, and to support parallel progress on updating the vaccines (e.g., by developing multivalent shots) to prepare for mutation scenarios with vaccine escape.

Diagnostics, Therapeutics, and Public Health Measures

Vaccinations need to be supported with essential complementary measures to minimize the loss of lives and morbidity from this pandemic. Many countries will have to maintain public health measures, build up supplies of therapeutics, and continue scaling up their diagnostic/testing and contact tracing efforts. Such measures can help prevent the emergence of new virus strains and ensure that vaccines are up to the task. A globally coordinated procurement for medical supplies as envisioned by the ACT Accelerator will prevent countries crowding out one another. These nonvaccine measures present both opportunities and challenges.

Opportunities

A) Social distancing and public health measures work: Maintaining physical distance, wearing masks, ensuring proper ventilation of indoor spaces, avoiding crowds, and proper hygiene can significantly reduce risk of infections. Such measures can be particularly effective in areas with poor ventilation. (WHO 2021b).

B) Treatments can reduce mortality risk: Improved treatment regimens have reduced probability of death among those infected. Researchers have identified various treatments—including dexamethasone—that bring about a reduction in mortality rates among COVID-19 patients (Wiersinga and others 2020).

C) Testing and contact tracing works: Scaling up testing—including in settings such as universities and schools—and isolating those who test positive can help contain the spread of the virus (Fetzer and Graeber 2020).

Challenges

A) Difficulty and reluctance in maintaining social distancing and public health measures. In developing countries enforcing social distancing comes at considerable cost to livelihoods and poses practical challenges in areas with dense populations. Further, countries who experienced milder first waves may have become complacent with respect to public health measures. Fatigue may also be setting in among those residing in countries with long-standing measures. Vaccine optimism may also be leading to complacency.

B) Testing remains low in LMICs. Testing capacity in many LMICs remain low, especially in rural areas, limiting the benefit of testing and tracing efforts in these countries. While daily testing rates are above 3 per 1000 in most high-income countries, most LMICs are testing far below 1 per 1000 daily.

Proposed Solutions

A) Invest in testing and tracing efforts., Testing measures are a relatively low-cost and effective option to contain the spread of the virus and can enable resumption of activity in select areas of the economy (Reed and others 2021; Cherif and Hasanov, 2020). With expanded access to Rapid Antigen Tests, which are relatively cheap, big advance purchases might make it possible to lower the cost to about $2–3 per test and get billions of these produced. Several countries, including the U.K., are already pursuing this strategy, with the government sending people a free box of tests. Where feasible, rapid tests can be used at workplaces, hot spots, concerts, etc. Further, if people are encouraged to enter their data, they can even be used for tracking the virus. To support effective public health strategies to reduce COVID-19 prevalence and to enable treatment of those infected with the disease, LMICs will need to be supported in rapidly scaling up their testing capabilities, utilizing a range of different diagnostic tools (for example, AgRDTs, PCR auto/manual, genomic sequencing, self-tests) for a variety of purposes such as case management, test-trace-isolate, border control, health-worker protection, disease surveillance, and more. This will likely require WHOs accelerated approval of a broader set of tests satisfying stringent performance criteria, greater access to manufacturer volumes (for example, automated PCR tests), significant procurement funding, more frequently update guidance from WHO reflecting the evolving range of use cases, plus increased on the ground technical assistance to ensure effective implementation. Testing will remain critical as vaccines are deployed, not least to track the impact of vaccine rollout on transmission, but also to detect potential incidence of variants evading vaccine protection.

B) Expand global capacity and procurement of medical supplies and treatments. Capacity should be increased especially at the global level with the aim of ensuring sufficient and rapid access to any country in need. This should be conducted in line with the current procurement and distribution schemes envisioned in the ACT Accelerator strategy. Further, there is a need to accelerate uptake of therapeutics such as dexamethasone and oxygen in LMICs, including by stronger country engagement, technical assistance, and procurement support (ACT Accelerator, WHO 2021b). Further there may be a case for scaling up investment in personal protective equipment (PPE) for healthcare workers in LMICs (Risko and others 2020; WHO 2021b).

C) Maintain social distancing and public health measures. In line with guidance from public health experts, it is important to make public health measures (such as masking) a policy priority until the acute phase of the pandemic ends. In many countries this will require stepped up communication from top officials on the importance of these measures, increasing resources to fight misinformation on social media, and making use of effective public health communication measures (Abaluck and others 2021). Moreover, conducting regional surveillance of COVID-19 cases both within-country and cross-country based on risk projections can help (Malani and others 2021). Knowing where the virus will strike next can help save lives—by guiding behavior change, local public health measures, and allocation of scarce resources.

D) Maintain and strengthen the social safety net for the vulnerable. It is essential to maintain social protection measures—including in-kind and cash transfers to protect vulnerable households and support for viable firms—until the virus is brought under control. Adequate and broad-based coverage will enable national authorities to maintain the necessary public health measures while mitigating the social and economic burden of such measures. A complete discussion of these issues, policy priorities, and associated fiscal costs is found in the IMF’s World Economic Outlook, Fiscal Monitor, and Global Financial Stability Report (IMF, 2020a-c, 2021a-d) and not included here.

Financing

The total cost of the different measures in this proposal to add up to about $50 billion. (Annex VI provides details on the budgeting.) There is a strong case for grant financing of at least $35 billion— given that ending the pandemic in a timely manner is a global public good, and also to ensure that the AMC91 countries (which are mainly low- and lower-middle-income countries) are able to undertake the needed measures without being saddled with large debt burdens. Given the enormous social and economic cost of the pandemic, these grants are likely the highest social-return investments available today and can be made by advanced economies, multilateral agencies, or philanthropic individuals or institutions. From this perspective, there is scope for donor countries to increase the grant element of their international aid budget.

The grant funding gap identified by the ACT-Accelerator amounts to about $22 billion, which the G20 and other governments recognize as important to address. In addition, at least $15 billion is available from COVID-19 financing facilities created by multilateral development banks (World Bank and Asian Development Bank). This leaves an estimated $13 billion in additional grant contributions needed to get to the $50 billion identified by our proposal. This additional amount is mainly for raising the COVAX vaccine coverage to 30 percent, procuring additional COVID-19 tests, and expanding vaccine production capacity to insure against downside risks. Most importantly, all pledges need to be delivered on immediately.

With respect to the COVID-19 pandemic facilities from multilateral development banks, the World Bank has set aside $12 billion to help developing countries purchase and distribute vaccines, tests, and treatments (of which about $2 billion has been utilized as of end-April 2021), and the Asian Development Bank has made $9 billion in financing available for vaccine procurement and delivery in developing Asia. There is scope to scale up utilization of such facilities. Annex I provides additional details of the pandemic financing facilities.

The IMF can also play its role to help countries meet their financing needs—supporting countries’ own efforts to create fiscal space and potentially acting as a third-resort line of finance. In this regard, the IMF could explore options, consistent with its lending mandate, to use our existing toolkit and adapt as needed to support the surge for pandemic financing. For existing IMF-supported programs, based on each country’s circumstance, there may be scope to flexibly approach the financing needed to support pandemic purchases.

Further, the IMF’s Executive Board is considering a Special Drawing Right (SDR) allocation of $650 billion, which, once approved, would add substantial financial resources to all countries in these difficult times. Beyond that, the IMF is also exploring options to channel SDRs from countries with strong external positions to support global public policy goals.

Caveats and Uncertainties

The analysis presented here is subject to several caveats, including due to incomplete information available in the public domain. First, regarding vaccine deals between countries/regions and vaccine developers, there are many contracts that remain unavailable in the public domain. Further, there are many contract negotiations that remain ongoing or contain option arrangements, hindering an adequate accounting of vaccine coverage. From this perspective, the coverage of vaccine contracts between countries and vaccine developers in China and Russia are relatively more likely to be undercounted.

Second, vaccine pricing estimates included here are based on existing assumptions and actual contractual prices reported by COVAX, African Union, and others based on the existing vaccine portfolios. However, the vaccine landscape remains subject to uncertainty, including due to potential issues with safety and/or efficacy, and the future portfolio of vaccines may shift relative to current projections. This is partially addressed by using a reference price of $12 per course (compared to the base price of $10.4 used by COVAX in its internal projections).

Third, similar uncertainty exists around other cost estimates such as costs for vaccine delivery and for the procurement costs and needs for diagnostics, therapeutics, and PPE. Some of these estimates included here are based on the work of various agencies and initiatives, which have carefully documented these uncertainties in their documents.

Fourth, although this proposal addresses a broad range of risks and uncertainties, the global COVID-19 landscape is particularly challenging given the possibility of several unknown unknowns relating to the biology of the virus, the psychology of the people, and the complexity of supply chains.

These caveats also highlight the need for greater data disclosure by country authorities and private sector participants, which will enhance global surveillance of risks and improve the effectiveness of policy actions. We hope future work can build on our analysis as more data becomes available and there is lesser uncertainty about various elements of the exercise.

Conclusion

As described at the start, ending the pandemic is a solvable problem. Thanks to the ingenuity of the scientific community we have multiple successful vaccines, and in countries that are ahead in vaccinations life appears to be returning to normal. This is however a precarious normal. No country can return to normalcy until all countries can defeat the pandemic.

The record-high number of global COVID-19 cases in recent days makes this abundantly clear. Countries that had reopened substantially have gone back into lockdown to fight the new variants of concern. International travel remains highly restricted, and international shipping disruptions are creating shortages of goods and increasing production costs. The social and economic costs of the pandemic continue to rise and already diverging recoveries between rich and poor nations looks to worsen.

The world does not have to live through the pain of another surge of COVID-19 cases. If there is strong global action, which requires very little in terms of financing relative to the outsized benefits, much can be accomplished in the next twelve months to durably exit this health crisis.

A Proposal to End the COVID-19 Pandemic
Author: Ruchir Agarwal and Ms. Gita Gopinath
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    Share of population vaccinated as of End-April 2021

    (% of total population, at least one dose)

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    Estimated share of population fully vaccinated as of End-2021 under a Business-as-Usual Scenario

    (% of total population)

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    Vaccination Coverage at End-2021 Under Downside Scenarios

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    Achieving the Vaccination Targets Scenario

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    End-2021 Vaccine Coverage under Different Upside Scenarios

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    Pre-Purchased Vaccines Courses vs. Surplus Available for Donation