All hopes are pinned on the development of a COVID-19 vaccine. But there are going to be huge political challenges to overcome if and when an effective vaccine does become available
As COVID-19 has revealed, even some of the wealthiest countries in the world were totally unprepared to deal with a pandemic. One prominent issue has been national shortages of vital medical products and technologies, coupled in many countries with a lack of domestic production capacity. Dependent on global supply chains at a time of unprecedented demand, governments have tried to persuade (or even require) domestic manufacturers to increase production or to begin manufacturing everything from medical ventilators right down to disposable gloves and gowns, with mixed results. At the same time, many producing countries have imposed export restrictions to prevent domestically-manufactured products being sold abroad.
Politically, the disputes we have seen so far over international supplies of medical products are as nothing compared to what we are likely to witness if and when a COVID-19 vaccine becomes available. Currently, all hopes are pinned on a vaccine to allow countries to return to something like ‘normal’ (or whatever the post-pandemic ‘normal’ will be). In this post, we sketch out some of the problems with existing vaccine markets, and the specific political economy challenges that are likely to emerge around production and distribution of a COVID-19 vaccine.
Vaccine development has long been characterised by profound market failure (or, more accurately, the failures that happen when markets behave as we would expect). Amongst other things, reliance on the market has resulted in vaccine development for emerging and re-emerging infectious diseases (ERIDs) not being prioritised.
One reason is the high costs involved in the development of new vaccines, with estimates of the cost of a single vaccine being up to $1.1 billion once the costs of unsuccessful R&D efforts is factored in. Pharmaceutical companies can generate a much greater return on investments by focussing on other markets.
A second problem is perhaps even more acute: the problem of ‘missing markets’. Most ERIDS primarily afflict lower income countries, whose governments and populations are simply too poor to provide the ‘effective demand’ that would make it economically rational for pharmaceutical companies to focus on diseases such as Lassa fever, Nipah virus, Chikungunya or – until recently – Ebola virus. COVID-19 is relatively unusual for an ERID in having had a major impact on rich countries too. But even so, there will be enormous political pressure for a vaccine to be patent free, and some countries may impose compulsory licensing. Significant profits are certainly not guaranteed.
Third, vaccine production (even more so than other pharma markets) is dominated by an oligopoly of four firms: GSK, Sanofi, Merck and Pfizer. These firms sit atop a pyramid of smaller public and private research enterprises, including universities and small biotech firms. Although there has been a gradual growth of smaller producers around the world, these four are the only forms with the real capacity to bring new vaccines to market and produce them at huge scale. This commercial dominance has had significant downstream effects on who is researching what, and where.
Finally, for new diseases like COVID-19, we cannot by definition have a vaccine ready in advance. The race to rapidly create one requires the rapid and open sharing of information and data, the command of platform technologies and production facilities, and the type of coordination that market competition between firms does not engender.
In response to these problems –spurred on by the West African Ebola crisis of 2014-16 – over 20 Product Development Partnerships have been launched, attempting to correct the failures that result from relying on market forces. Most prominent among these is the Coalition for Epidemic Preparedness Innovations (CEPI), which functions as both a financing platform, providing an upfront ‘push’ mechanism for R&D funding, and a coordinating mechanism. But 3 years into its first 5-year plan, CEPI has not yet delivered a vaccine for any of its priority diseases, and has encountered criticism for its failure to guarantee Intellectual Property-free vaccine products when it does succeed.
Crises can create opportunities for change. No doubt because it has had such a major impact on the world’s largest economies, as of 8 April 2020 there were 115 COVID-19 vaccine candidates and 78 active R&D projects. The pace has been extraordinary, indicating what can be achieved when collaboration is open and data and R&D is not commodified or secretive. CEPI and WHO have been instrumental in coordinating financing, collaboration and data sharing. There is still a long way to go before a vaccine becomes available – and some are warning against the assumption that it will even be possible to make one. But an effective vaccine that can be made widely available would transform attempts to end the pandemic. It is currently our best hope.
But although the COVID-19 crisis seems to have allowed for the transcendence of some of the longer-standing structural problems around vaccine development, if/when a vaccine does exist some major challenges are almost certain to arise:
1) Manufacturing capacity: There have been warnings for many years of under investment in vaccine manufacturing facilities and the dangers of concentrating production in only a few countries. The type of vaccine that will be needed for COVID-19 will have a major impact on where and how quickly it can be made. But it is clear that most countries will be reliant on the few that have manufacturing capacity. How will this affect:
2) Access and equity: Which countries will get the vaccine first? Will producing countries try to limit exports to preserve supplies for themselves? Will it be an open market, favouring rich and powerful countries? Or will there be some more equitable system developed for global distribution?
3) Intellectual property: Who will win the race to get a vaccine into production, and what will this mean for Intellectual Property over it? Will the vaccine be priced at a level that is affordable for all countries? Will we see countries use the emergency to compulsorily licence the vaccine – and how will the politics of this play out? Or, more optimistically, is this a chance to prompt a transformation in which essential medicines come to recognised as global public goods?
4) Knock-on consequences: Given the manufacturing capacity limitations, mass production of a COVID vaccine is likely to mean switching capacity away from existing essential vaccines. What will be the health impacts of this, and how can they be mitigated?
It remains to be seen what consequences COVID-19 will have for the global economic system, but it should at minimum prompt a rethinking of how we produce and deliver vaccines. Quite apart from the scientific complexity, the fact that commercial incentives and the market system cannot be relied on to deliver vaccines in ways that promote global access and equity points to the need for fundamental change. And whilst vaccines markets are an extreme example, COVID-19 has revealed the same to be true around a whole range of other essential technologies.