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 Health & Place 83 (2023) 103051

Contents lists available at ScienceDirect

Health and Place

journal homepage: www.elsevier.com/locate/healthplace

Global inequities in access to COVID-19 health products and technologies:

A political economy analysis
Deborah Gleeson a, *, Belinda Townsend b, Brigitte F. Tenni a, c, Tarryn Phillips d
a
School of Psychology and Public Health, La Trobe University, VIC, 3086, Australia
b
Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, 8 Fellows Road Acton, Canberra, ACT, 2000,
Australia
c
Nossal Institute for Global Health, University of Melbourne, 5th Floor, 333 Exhibition Street, Melbourne, Victoria, 3189, Australia
d
Department of Social Inquiry, La Trobe University, VIC, 3086, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: This paper presents a political economy analysis of global inequities in access to COVID-19 vaccines, treatments,
COVID-19 and diagnostic tests. We adapt a conceptual model used for analysing the political economy of global extraction
Inequity and health to examine the politico-economic factors affecting access to COVID-19 health products and tech­
Access to medicines
nologies in four interconnected layers: the social, political, and historical context; politics, institutions, and
Global vaccine equity
policies; pathways to ill-health; and health consequences. Our analysis finds that battles over access to COVID-19
Political economy
Structural violence products occur in a profoundly unequal playing field, and that efforts to improve access that do not shift the
Pharmaceutical industry fundamental power imbalances are bound to fail. Inequitable access has both direct effects on health (pre­
TRIPS waiver ventable illness and death) and indirect effects through exacerbation of poverty and inequality. We highlight how
COVAX the case of COVID-19 products reflects broader patterns of structural violence, in which the political economy is
COVID-19 technology access pool structured to improve and lengthen the lives of those in the Global North while neglecting and shortening the
lives of those in the Global South. We conclude that achieving equitable access to pandemic response products
requires shifting longstanding power imbalances and the institutions and processes that entrench and enable
them.

1. Introduction globally by March 2022 were administered in LICs (Balakrishnan,

COVID-19 vaccines were developed at amazing speed and have been
critical in reducing mortality from the pandemic. In January 2021,
however, the Director-General of the World Health Organization (WHO)
Dr Tedros Ghebreyesus warned that “… the world is on the brink of a
catastrophic moral failure – and the price of this failure will be paid with
lives and livelihoods in the world’s poorest countries” (WHO, 2021a). At
that stage, more than 39 million COVID-19 vaccine doses had been
administered in at least 49 higher-income countries, in comparison with
just 25 doses in a single lowest-income country. These inequities have
persisted throughout the pandemic. By November 2022, almost 13
billion doses of COVD-19 vaccines had been administered around the
world, but less than 25% of people in low-income countries (LICs) had
received a dose (Global Change Data Lab, 2022).
Access to diagnostic tests and treatments for COVID-19 has also been
highly inequitable. Only 0.4 percent of the 3 billion diagnostic tests used
2022). Inequities in access to COVID-19 therapeutics have been even
more marked, with more than 70% of treatment courses reserved by
high income countries (People’s Vaccine Alliance, cited in Iacobucci,
2022) and only eight LICs having received deliveries of oral antiviral
treatments by November 2022 (UNICEF, n.d.).
These inequities reflect failures in the global response to COVID-19.
Early in the pandemic, the Access to COVID-19 Tools Accelerator (ACT-
A) was set up as a global collaboration to “… speed up an end to the
pandemic by supporting the development and equitable distribution of
the tests, treatments and vaccines the world needs to reduce mortality
and severe disease …” (WHO, n.d.-a). The vaccines pillar of ACT-A,
COVAX, began with the modest aim to deliver 2 billion doses by the
end of 2021, enough to vaccinate 20% of the population in every
country (WHO, 2020). But COVAX is widely acknowledged to have
failed (de Bengy Puyvallée and Storeng, 2022). By the end of 2021, more
than 76% of people in high and upper-middle-income countries had

* Corresponding author.
E-mail address: d.gleeson@latrobe.edu.au (D. Gleeson).

https://doi.org/10.1016/j.healthplace.2023.103051
Received 5 April 2023; Received in revised form 30 May 2023; Accepted 31 May 2023
Available online 8 June 2023
1353-8292/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
D. Gleeson et al.
received a vaccine dose, in contrast to only 8.5% of those in low-income
countries (LICs) (de Bengy Puyvallée and Storeng, 2022). Instead of
COVAX, donations became the main mechanism through which
COVID-19 vaccines were provided to LICs. However, by June 2022, less
than 50% of the 2.1 billion vaccine donations pledged by G7 countries to
poorer countries had been delivered (Oxfam International, 2022, June
25).
The other three ACT-A pillars were even less successful. The thera­
peutics pillar received less than 20% of the US$ 9.1 billion sought
(WHO, 2022a). The diagnostics pillar, which planned to provide 500
million diagnostic tests to low and middle-income countries (LMICs) by
mid-2021, had only delivered 97 million by the end of 2021 (WHO,
2022a). The health systems strengthening pillar was widely perceived to
be dysfunctional (WHO, 2022a).
In addition to problems with the global distribution of vaccines, the
development and manufacturing of COVID-19 vaccines and other
products was concentrated in Western countries, with little sharing of
intellectual property (IP) or technology transfer to enable
manufacturing in the Global South. Efforts to encourage voluntary
sharing, such as the COVID-19 Technology Access Pool (C-TAP) set up
by the WHO, failed to correct the imbalance, and negotiations at the
World Trade Organization (WTO) over a temporary waiver of its IP rules
for COVID-19 health products and technologies ultimately failed to
secure a meaningful outcome (Amin and Kesselheim, 2022).
In the wake of these failures, attention has now begun to shift to
planning for future pandemics and the Pandemic Prevention, Pre­
paredness and Response Accord (hereafter, Pandemic Accord) currently
being negotiated at the WHO presents an opportunity to take a different
approach. However, as we will show in this paper, the inequities of the
COVID-19 pandemic are deeply rooted in power asymmetries in the
global political and economic order which have shaped the unfair
development and distribution of COVID-19 health products and tech­
nologies. We illustrate the pathways to ill health extending from these
global dynamics by tracing the politics and policies that have led to a
high burden of disease and avoidable deaths due to inadequate vacci­
nation rates, low testing levels and lack of access to treatments. We
argue that future efforts to equitably share health products must be
Fig. 1. Schematic of the political economy of global extraction and health (Schrecker et al., 2018).
2
Health and Place 83 (2023) 103051
based on structural reforms that tackle these power imbalances,
including through reforming the ways in which pharmaceutical R&D are
funded, preventing exclusive monopolies on health products and tech­
nologies, and empowering LMICs in global governance structures.
The purpose of this paper is to apply a political economy of health
approach to analysing the development of global inequities in access to
COVID-19 health products and technologies, the failures to correct them
and the prospects for change. We adapt a conceptual framework applied
to the political economy of extraction and health, and in doing so pre­
sent a novel framework for examining the causes of global inequities in
the distribution of COVID-19 products and their impacts on health.
2. Materials & methods
In order to systematically interrogate the global political and eco­
nomic dynamics underpinning the inequitable distribution of COVID-19
vaccines, diagnostics and therapeutics, we applied a ‘political economy
of global health’ framework first developed by Birn et al. (2017), and
then adapted by Schrecker et al. (2018) in the context of analysing the
political economy of global resource extraction (i.e. mining) and its
health effects (see Fig. 1). This conceptual framework provides a
structured and theory-informed tool for unpacking the layers of political
economy from global forces to the health consequences for communities
and individuals. To our knowledge, the conceptual framework has not
previously been applied in the context of access to medicines, and its
application for examining the global distribution of COVID-19 medical
products and technologies represents a novel development in applying a
structured political economy approach to this topic.
Central to a political economy approach is the notion that to un­
derstand inequities in health outcomes, we need to examine how po­
litical, economic and social factors operate and interact at multiple
levels. Birn and Schrecker’s frameworks enable these factors to be
mapped out at multiple levels: from the broad social, political, economic
and historical context at the global level, to the international and na­
tional politics, institutions and policies which structure health and ill
health, to the pathways to ill health at the national and local level (such
as exposures and living conditions), and ultimately to the embodiment
D. Gleeson et al.
of these structural factors in the health consequences for communities
and individuals (Birn et al., 2017; Schrecker et al., 2018).
We adapted these frameworks specifically for examining inequities
in access to COVID-19 health products and technologies, using the four
categories of factors at different levels set out by Schrecker et al. (2018):
⋅ The social, political, economic, and historical context (international)
⋅ Politics, institutions and policies (international and national)
⋅ Pathways to (ill) health (national and local)
⋅ Human health consequences (local and individual).
The first level (the social, political, economic, and historical context)
focuses on the international context and enables a deep examination of
the historical evolution of the global order in which the problem –
resource extraction in the context of the work of Schrecker et al. (2018),
and inequities in access to COVID-19 products in the current study – has
arisen. The second level (politics, institutions, and policies) enables an
examination of the way this global order interacts with contemporary
international and national politics, institutions, and policies. The third
level (pathways to ill health) illuminates the ways in which the global
political economy and the politics, institutions and policies are linked
with health outcomes and their distribution (the fourth and final level).
This multi-layered framework acts as a blueprint for understanding
health inequities as a form of structural violence. A term coined by
Johan Galtung (1969) and developed further by Paul Farmer (2004),
structural violence refers to systematic forms of oppression “built into
structures, institutions, ideologies and histories” (Dilts et al., 2012, p.
91). Violence, here, refers to the more “invisible, indirect and insidious”
Fig. 2. Schematic of the political economy of access to COVID-19 health products and technologies.
3
Health and Place 83 (2023) 103051
forms of harm caused by systemic poverty, power asymmetries and
neglect, which ultimately lead to reduced life chances for many of the
world’s poor (Hamed et al., 2020, p. 1663). Given the colonial and
racialised lines along which this structural violence plays out, this in
turn reveals a form of necropolitics, in which elites of the Global North
tend to hold the power to determine who lives and who dies (Mbembe,
2019; Sumba, 2021). Made explicit through the framework, these un­
derlying theories lay bare how health inequities – whether in relation to
global extraction or COVID-19 health products and technologies – tend
to be well-trodden grooves within the political economy. To identify the
factors impacting access to COVID-19 health products and technologies
at each level, we drew on our extensive knowledge of the literature on
access to medicines from over a decade of research in this field, along
with a comprehensive review of scholarly and grey literature on the
political and economic factors affecting access to medicines in the
context of the COVID-19 pandemic.
3. Results
Fig. 2 presents the framework adapted for the political economy of
access to COVID-19 health products and technologies.
3.1. The social, political, economic, and historical context
The dynamics which have shaped inequitable access to COVID-19
health products and technologies – and which have given rise to the
politics, institutions and policies adopted to procure and distribute these
products during the COVID-19 pandemic – are deeply embedded in
D. Gleeson et al.
various aspects of the social, political, economic, and historical context.
These include capitalism, neoliberalism and globalisation, the estab­
lishment of the global IP regime in the context of trade liberalisation, the
corporate power of the pharmaceutical industry, entrenched power
asymmetries in global health governance, and failures to ensure equi­
table access to pharmaceuticals during previous pandemics. In this
section, we trace the history of these factors and how they created the
conditions in which efforts to equitably distribute COVID-19 vaccines,
treatments and tests were bound to fail.
3.1.1. Capitalism, neoliberalism, and globalisation
Many of the root causes of the failure to achieve an equitable dis­
tribution of COVID-19 medical products and technologies can be traced
to twenty-first century capitalism and neoliberal political regimes.
Neoliberalism, while a term used in many different ways, broadly refers
to the “doctrine of the free market and related political and individual
freedoms” (Ahlberg and Bradby, 2022) or the “extension of competitive
markets into all areas of life, including the economy, politics and soci­
ety” (Springer et al., 2016, p. 2). Sell (2020, p. 150) explains that while
neoliberalism in the 1970s and 1980s was characterised by “deregula­
tion, privatization, and the transformation of social protection regimes –
all underpinned by a faith in free markets”, twenty-first century capi­
talism has shifted towards a focus on the role of intangible assets (such as
IP), financialisation, profits and competitiveness in global markets.
Financialisation, a key feature of 21st century capitalism, refers to the
dominance of financial markets, instruments and institutions over eco­
nomic outcomes and policies. This incentivises the pharmaceutical in­
dustry, for example, to reorder its priorities from creating products that
meet health needs to delivering value to shareholders (Sell, 2020). Such
shifts have been accompanied by globalisation, described by Jenkins
(2004, p. 1) as “a process of greater integration within the world
economy through movements of goods and services, capital, technology
and (to a lesser extent) labour, which lead increasingly to economic
decisions being influenced by global conditions”.
The historical shifts towards 21st century capitalism, neoliberalism
and globalisation help to explain many of the intractable problems
associated with the maldistribution of COVID-19 products explored
further below, including the over-reliance on market solutions, the
monopoly power of the pharmaceutical industry – underpinned by the
recognition of intellectual property rights (IPRs) – and the tolerance for
massive pharmaceutical industry profits from products which are
extremely inequitably distributed.
3.1.2. The establishment of the global intellectual property regime
It was in the context of this broader shift towards neoliberal glob­
alisation in the 1980s and 1990s that the global IP regime originated
(Townsend, 2016). After the Second World War, companies in countries
like the USA, Germany, and the UK, facing intense domestic competi­
tion, sought to expand into new markets where national pharmaceutical
industries were not yet established (Drahos, 2002a). As countries like
India began to develop the technology and capacity to manufacture
generic drugs, the absence of IP protections in many developing coun­
tries began to threaten the market share and profitability of the phar­
maceutical giants, such as Pfizer (Drahos, 2002a). By the 1980s, the US
pharmaceutical and other industries had begun to focus on the General
Agreement on Tariffs and Trade and the subsequent establishment of the
WTO as a forum where they could make gains that were not possible
through unilateral pressure on individual countries (Drahos, 2002a).
Prior to the establishment of the WTO in 1995, few developing
countries provided pharmaceutical patents, which were seen to advan­
tage pharmaceutical companies in developed countries, rather than
benefiting the Global South (Townsend, 2016). Those developing
countries that did introduce IP standards similar to those of developed
countries during the 1900s did so largely as the result of colonialism
(Drahos, 2002b).
The establishment of the Agreement on Trade-Related Aspects of
4
Health and Place 83 (2023) 103051
Intellectual Property Rights (TRIPS) in 1995 was a watershed moment in
the evolution of the global IP regime, resulting in the internationalisa­
tion of enforceable IP standards that had mainly been adopted by
wealthy countries until that time (’t Hoen, 2016). TRIPS mandated
patent terms of at least 20 years for both products and processes, in all
fields of technology, along with a suite of other IPRs.
IP was successfully linked with trade through the intense lobbying of
the pharmaceutical industry along with other IP-intensive industries
such as the software and entertainment industries (Shadlen, 2007).
These industries worked together with developed states, particularly the
United States and European Union, to incorporate IPRs within a wider
package of agreements and trade-offs (Drahos, 2002b, ’t Hoen, 2009).
Drahos (2002a) describes how US pharmaceutical company, Pfizer,
played a key role in the lobbying campaign, selling the importance of
IPRs to the US economy through industry associations, business net­
works and trade advisory committees, and making financial contribu­
tions to think tanks with political influence. Having secured US
government support, US corporations then focused on building an in­
ternational business coalition to pressure other governments to support
their IPR agenda, particularly in Europe and Japan (Drahos, 2002a).
Developing countries initially opposed the inclusion of patents in the
WTO agreements but ultimately agreed to TRIPS, at least partly in the
hope that a multilateral agreement would reduce unilateral pressure
from the USA and other wealthy countries (’t Hoen, 2009). However,
this was not to be – the USA in particular continued to pressure other
states to increase IP protection using its Special 301 law, which iden­
tifies countries that are perceived to provide inadequate IP protection
and market access for US IP owners, and subjects them to trade sanctions
(’t Hoen, 2009). Various scholars have also documented the undemo­
cratic process for the negotiations, where ‘Green Room’ consultations
were held between key countries to discuss technical details, often
excluding developing countries, which also lacked the expertise in their
negotiating teams to fully understand the implications of what was
being proposed (Drahos, 2002a).
Sell (2007, p. 42) argues that:
Overall, TRIPS reflects and promotes the interests of global corpo­
rations that seek to extend their control over their intellectual
property. These firms, acting through the United States government
(and with the support of Europe and Japan), largely captured the
WTO process and succeeded in making public international law to
suit their particular needs.
Battles over IP protection continued after TRIPS. In the context of
lack of access to HIV drugs, developing countries successfully negotiated
the Declaration on the TRIPS Agreement and Public Health (Doha
Declaration) which affirmed the right of WTO members to take measures
to protect public health through the use of ‘TRIPS flexibilities’. These
included compulsory licensing (licensing a patented invention without
the consent of the patent holder), parallel importation (importing a
patented product without the permission of the patent holder) and
transition periods for least developed countries (LDCs) (’t Hoen, 2009).
A subsequent WTO decision in 2003 on the implementation of the Doha
Declaration sought to address the inability of countries lacking domestic
pharmaceutical manufacturing capacity to effectively utilise compul­
sory licensing (Abbott, 2005). While the Doha Declaration was a very
significant development that facilitated compulsory licensing, the
complex process for exporting to countries without domestic production
capacity remained so cumbersome and impractical that it has only been
used once (’t Hoen, 2009).
The USA and EU also sought to further expand IPRs and reduce the
scope for using TRIPS flexibilities through ‘TRIPS-plus’ rules in bilateral
and regional free trade agreements, including provisions requiring, for
example, extensions to patent terms, exclusivity for test data submitted
to regulators, and restrictions on compulsory licenses (Sell, 2007). The
widespread adoption of these rules has resulted in further delays to the
market entry of generic drugs, increasing medicine costs for consumers
D. Gleeson et al.
and governments (Tenni et al., 2022).
3.1.3. Corporate power of the pharmaceutical industry
A key aspect of the global historical context for inequitable access to
COVID-19 health products and technologies is the corporate power of
the pharmaceutical industry. Kapczynski (2022) describes four mutually
reinforcing sources of the pharmaceutical industry’s power: property
power, vertical power over politics, ideational power, and material
power. While Kapzynski’s analysis focuses on the USA, these forms of
power can also be seen on a global scale. The pharmaceutical industry’s
property power derives from overlapping IPR over patents, regulatory
data, and trade secrets, which allow them to keep competitors out of the
market and charge high prices for their products (Kapczynski, 2022).
Vertical power, Kapczynski (2022, p. 4) argues, involves “forms of
power over the political process itself that help industry entrench the
status quo”. This vertical power is exerted primarily through intense
lobbying (particularly in the USA), underpinned by the huge profits
generated from property power, and the enshrinement of these property
rights in international law. Ideational power arises from invoking
neoliberal narratives about the crucial role of the private sector in
pharmaceutical innovation (and scepticism about the role of govern­
ment) (Kapczynski, 2022) along with the narrative that IP drives inno­
vation and economic growth. The industry also holds material power in
the form of technical expertise, experience and control over personnel
and facilities, which governments cannot quickly and easily replicate
(Kapczynski, 2022). While the industry’s power is not absolute, chal­
lenges to it tend to have limited success (Kapczynski, 2022).
At the global level, the research-based pharmaceutical industry acts
as a transnational industry to consolidate and expand its power and
pursue a global agenda around entrenching and expanding its monopoly
rights (Gleeson et al., 2017). Financialisation of the industry has been
driven by mergers and acquisitions, giving rise to “pharmaceutical be­
hemoths” focused on maximising profits and shareholder value (Keenan
et al., 2022, p. 2). Large pharmaceutical companies establish many
subsidiary companies incorporated in various countries, with opaque
relationships between them, enabling taxable income to be moved to
countries with lower tax rates (Gleeson et al., 2017). These subsidiaries
tend to become members of industry associations in the countries in
which they are incorporated, exerting political influence at the national
level which reflects the global agenda of the parent company (and the
wider agenda of the research-based pharmaceutical sector) (Gleeson
et al., 2017). As we discussed in the previous section, a key part of the
industry’s global agenda is to drive the expansion of strong monopoly
rights through international trade agreements. These power dynamics
help to explain how entrenched and diffuse the industry’s power is, and
how difficult it is for governments and other stakeholders to shift the
status quo.
3.1.4. Power asymmetries in global health governance
The global health governance context in which efforts to procure and
distribute COVID-19 products for LMICs were generated is also riddled
with power asymmetries. These dynamics are not unique to COVID-19.
As Otterson et al. (2014) point out, power asymmetries that compromise
efforts to address health inequities in all policy areas are entrenched and
reinforced by dysfunctions in global governance structures and systems.
Krikorian and Torreele (2021) describe the emergence of a donor-driven
global health architecture from the early 2000s, with a central role for
the private sector and a more marginal role for governments in cor­
recting market failure. Donor funds were used to support vertical
disease-focused programs relying on market mechanisms, including
public-private partnerships, to secure pharmaceuticals in bulk at
reduced prices for the poor (Krikorian and Torreele, 2021). These ar­
rangements left the global world order, prevailing ideologies, and the
pharmaceutical industry’s business models intact, supporting the status
quo (Krikorian and Torreele, 2021).
In this donor-driven architecture, global health has become
5
Health and Place 83 (2023) 103051
dominated by actors committed to neoliberal ideologies and private
market solutions (Stein, 2021). Large private philanthropic organisa­
tions such as the Bill and Melinda Gates Foundation arise from the global
concentration of wealth and resources and are invested in maintaining
existing power structures (Kim, 2021). The Gates Foundation, while
contributing enormously to global health spending and undoubtedly
saving lives (McCoy and McGoey, 2011), has played a particularly
pivotal role in the financialisation of the global health sector and the
creation of new financial markets in global health (Stein, 2021). This is
in the context of an increasingly weak and under-resourced WHO (Stein
and Sridhar, 2018). The neoliberal framing that infuses global health
governance “obfuscates the relations of power that undergird global
health inequities” (Kim, 2021), enabling, as McCoy and McGoey (2011,
p. 161) argue, “palliative” rather than “long-term structural solutions”.
Crucially, many aspects of global health governance reflect legacies
of colonialism. Tropical medicine, the antecedent of modern global
health, originated in the late nineteenth century, when colonial powers
sought to treat diseases like malaria that afflicted colonised people as
part of a wider process of ‘civilising’ them, in the context of protecting
their own commercial interests (Fofana, 2021; Kim, 2021). The era of
‘international health’ that followed in the twentieth century was a
continuation of this ‘civilising’ mission: philanthropic organisations
armed with technological solutions engaged in paternalistic disease
eradication programs that paid little regard to the recipients (Fofana,
2021). The ‘global health’ era that followed from the 1990s in response
to new disease threats such as HIV, while acknowledging the intercon­
nectedness of the world, remained dominated by institutions and experts
from high income countries (HICs) who continue to set the global
agenda, in a continuation of colonial practices (Fofana, 2021). These
practices perpetuate a view of the recipients of global health support as
inferior, support the imposition of donor control, and foster dependency
(Kwete et al., 2022).
3.1.5. Failures of previous pandemics
Inequitable access to pharmaceuticals in the context of public health
emergencies and pandemics is a longstanding problem. In the 1990s, the
emergence of antiretroviral therapies for HIV turned it from a uniformly
fatal disease into a treatable chronic illness; however, until political
mobilisation enabled widespread generic production in the early 2000s,
millions of people in developing countries lacked access to these drugs
(’t Hoen, 2009). When an avian influenza (H5N1) outbreak emerged in
Asia in 2004, the Indonesian Government refused to share virus samples
with the WHO, for fear they would be used to develop commercial
vaccines which Indonesia and other developing countries would not be
able to access (Fidler, 2010). Developments during the 2009-H1N1
pandemic saw these LMIC concerns come to fruition. HICs made large
advance purchase agreements, reserving almost all of the vaccine doses
that could be manufactured in the first year (Fidler, 2010). While WHO
negotiated with pharmaceutical companies and HICs to secure some
donations, pledges were made only after HICs had enough vaccine for
their own populations, and even then were pledged without nominating
delivery dates (Fidler, 2010). Fortunately, the 2009-H1N1 pandemic did
not turn out to be as severe as expected, but the inequities in access to
vaccines that occurred in 2009 were not successfully resolved – and set
the scene for what was to play out in the COVID-19 pandemic more than
a decade later.
3.2. Politics, institutions, and policies
We now turn our attention to the politics, institutions, and policies in
place during the COVID-19 pandemic – born out of power asymmetries
in the global order described in the previous section – and how they have
shaped access to COVID-19 medical products and technologies. We
begin by scrutinising the way in which the development of these prod­
ucts and technologies has been underpinned by massive injections of
public funding, generating equally massive profits for private companies
D. Gleeson et al.
with few (or no) strings attached. We then analyse how the governance
and design of ACT-A reproduces existing power asymmetries and colo­
nial practices in global health governance, and the reliance of COVAX on
neoliberal ideologies and market arrangements. We next examine the
vaccine nationalism of HICs, and the vaccine charity and diplomacy
approaches which developed in the absence of equitable sharing, and
which exacerbated and further entrenched power imbalances. Finally,
we unpack the pharmaceutical industry’s stranglehold on the produc­
tion of COVID-19 products and technologies, and the failure of efforts to
correct inequities, including the COVID-19 Technology Access Pool (C-
TAP), the mRNA vaccine technology transfer hub and negotiations to
waive IP rights for COVID-19 products.
3.2.1. Public funding of private monopolies
Enormous amounts of public funding were poured into the research
and development of COVID-19 vaccines. Early in the pandemic, at least
US$5.6 billion was provided by governments in up-front funding to
support vaccine R&D, along with more than US$45 billion committed in
advance to purchase the resulting products (Moon et al., 2021). Wouters
et al. (2021) estimated that US$10 billion was invested in 26 vaccine
candidates that had been approved in at least one country, were in phase
3 clinical trials, or were under contract to CEPI or COVAX.
These injections of funding meant that governments, rather than the
private sector, took on the risks and costs associated with vaccine
development (Moon et al., 2021). But despite this heavy subsidisation,
governments chose not to attach conditions to this funding to require
companies to price their products affordably, or to share their data,
technology, and know-how. The Trump Administration’s initiative for
funding vaccine R&D, Operation Warp Speed, for example, gave close to
US$1 billion to Moderna for the development of its COVID-19 vaccine,
but Moderna – despite relying on previous research undertaken by the
National Institutes of Health – retained ownership of its technology and
know-how and full control over price (Cancryn et al., 2021, May 11).
Moreover, Moderna stipulated that doses purchased by the USA could
not be shared with other countries – a condition that severely con­
strained the US Government’s capacity to donate excess doses later on
(Cancryn et al., 2021, May 11).
When a team of scientists at the University of Oxford developed a
front-runner COVID-19 vaccine, for which they planned to offer non-
exclusive, royalty free licenses to enable the product to be provided
free or at cost during the pandemic, Bill Gates reportedly pushed the
team to sign an exclusive license deal with pharmaceutical giant
AstraZeneca (Baker, 2020, July 15). This was despite an estimated
97–99% of the funding for the research behind the vaccine coming from
public and charitable sources (Cross et al., 2021). Governments
contributed 45.9% (£31.8 million) and charitable trusts 31% (£21.5
million) while only 2.8% (£1.9million) was contributed by industry
sources (Cross et al., 2021). This called into question the prevailing
view, famously espoused by Boris Johnson, that the successful devel­
opment of COVID-19 vaccines was a product of capitalism and greed
(Safi, 2021). While AstraZeneca pledged to sell the vaccine at
not-for-profit prices during the pandemic, it included a clause enabling it
to declare the pandemic over (Scheibner et al., 2022), and began to sign
for-profit contracts in November 2021 for the following year (Espiner,
2021, November 12).
Leading COVID-19 vaccine manufacturers have profited handsomely
from the pandemic, bringing in billions of dollars in revenue and many
hundreds of millions in profit (Hassan et al., 2021). Pfizer, for example,
brought in almost $37 billion in revenue from its COVID-19 vaccine in
2021, and expected vaccine sales of $32 billion and sales of its antiviral
drug Paxlovid of $22 billion in 2022 (Kollewe, 2022, February 9). Its net
profit for 2021 was almost $22 billion, more than double its profit in the
previous year (Kollewe, 2022, February 9).
Prices set by vaccine manufacturers have varied wildly. While
AstraZeneca and Johnson & Johnson pledged to sell their vaccines at
low prices during the pandemic, other companies have charged far
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more, with some prices exceeding the highest prices previously set for
vaccines (Wouters et al., 2021). While price information is generally
kept confidential, various revelations (some accidental) have exposed
large anomalies in pricing between countries. For example, South Africa
paid more than double per dose for the Oxford-AstraZeneca vaccine than
the European Union (Dyer, 2021).
Pfizer, which priced its COVID-19 vaccine at US$30 per dose in the
USA – a price estimated as nearly 30 times the cost of manufacturing –
announced in late 2022 that it would increase the cost per dose to
around $110–130 in 2023 (Cullinan, 2022, October 24).
3.2.2. Top-down governance and design of the Access to COVID-19 Tools
Accelerator (ACT-A)
ACT-A was quickly assembled in April 2020 as a loose collaboration
between established global health actors including private sector
stakeholders, public-private partnerships, and donors, reflecting the
existing global health landscape rather than new governance arrange­
ments (Moon et al., 2022). Initial participants included the Gates
Foundation, CEPI, Gavi, the Vaccine Alliance, The Global Fund to Fight
AIDS, Tuberculosis and Malaria (The Global Fund), Unitaid, Wellcome,
the WHO, the Developing Countries Vaccine Manufacturers Network,
International Federation of Pharmaceutical Manufacturers and Associ­
ations, and the International Generic and Biosimilar Medicines Associ­
ation (Moon et al., 2022). The governance structures of ACT-A were
plagued by a lack of transparency and accountability, with the roles of
various parties, including donors, HICs and industry groups, unclear and
shifting over time (WHO, 2022a; Moon et al., 2022).
From its inception, ACT-A’s reliance on the existing global health
architecture meant it was invested in perpetuating market-based ar­
rangements and adopting a charitable model which distinguished be­
tween donors and recipients (Krikorian and Torreele, 2021). It was
heavily criticised by civil society for its limited focused only on stop-gap
measures during the acute phase of the pandemic and the assumption
that LMICs would be able to obtain COVID-19 products and technologies
through normal market operations after this time (ACT-A Civil Society
and Community Representatives, 2021).
Both the design and the initial governance structure of ACT-A
excluded LMICs (Moon et al., 2022). In contrast, nine HICs were
initially included (Moon et al., 2022). Civil society organisations were
also largely excluded from the governance structure in ACT-A in 2020,
although this had improved by 2021 (WHO, 2022b). An independent
external evaluation of ACT-A (WHO, 2022a) found that the top-down
governance structure meant the countries ACT-A was primarily inten­
ded to benefit were not meaningfully engaged and did not have a sense
of ownership of the initiative (WHO, 2022a). The exclusion of LMICs
also resulted in an overwhelming focus on the procurement of products,
with insufficient attention to delivery and the logistical and health
system supports needed by LMICs to roll out vaccines (WHO, 2022a).
3.2.3. COVAX: a private-public partnership based on power asymmetries
and private markets
The governance and operating model of COVAX, the vaccines pillar
of ACT-A, was equally deeply embedded in existing power asymmetries,
neoliberal ideologies, and market arrangements. Its governance was
based on global public-private partnerships; a governance mechanism
that is afflicted with power asymmetries and where wealthy govern­
ments and corporate partners hold the most power (de Bengy Puyvallée
and Storeng, 2022).
In many ways, COVAX represented a new type of ‘super public pri­
vate partnership’ (Storeng et al., 2021). Not only does it have the fea­
tures of established PPPs, such as a vertical, single-disease focus and
focus on technological solutions; it also has distinctive features due to its
scale and complexity. These include its attempt to coordinate a frag­
mented global governance field in a complex and convoluted structure –
in which WHO becomes a partner rather than a coordinator – its vast
scale; and its blurring of the boundaries between public and private
D. Gleeson et al.
actors (Storeng et al., 2021).
The operating model of COVAX was based on advanced purchase
agreements with manufacturers. Self-financing countries would pay for
their own vaccines, while the Advanced Market Commitment (AMC)
arm of COVAX would provide donor-funded doses free of charge to 92
mainly LICs.
COVAX not only continued the existing trend of financialisation in
the global health sector, but also expanded the use of financial in­
struments in global health governance (Stein 2021). Initially set up as a
‘global buyers’ and distribution club’, the idea was that countries would
share the financial risks of vaccine production, while equitably distrib­
uting the resulting products. However, early in the process, concessions
were made to HICs to enable them to negotiate bilateral deals directly
with vaccine manufacturers, which undermined the premise on which
COVAX was based and transformed COVAX from a buyer’s club to an
‘insurance policy’ for rich countries whose focus turned to more direct
ways to secure vaccines (Stein, 2021). The separation of COVAX into
two arms, with the AMC funded through donations, also meant
self-financing countries could benefit from the insurance policy COVAX
provided without being obliged to contribute to the AMC. As a result, by
December 2020, “COVAX had changed from a buyer’s club based on
global solidarity and sacrifice to a charity-based aid project” (Stein,
2021, p. 8).
COVAX accommodated the interests of commercial actors, chan­
nelling public funds towards vaccine development and manufacturing
and requiring little of the industry in return (Storeng et al., 2021). As
Eccleston-Turner and Upton (2021, p. 433) argue, “This arrangement is
therefore a win-win for pharmaceutical companies, because the COVAX
pillar bears a significant share of the financial risks associated with
failure, leaving the pharmaceutical companies free to profit on the back
of any success. In essence, this arrangement privatizes profit and so­
cializes risk”. Vaccine manufacturers were able to prioritise selling doses
at high prices to wealthy countries, without having to provide any at
cost to COVAX (de Bengy Puyvallée and Storeng, 2022). No vaccine
manufacturers donated doses to COVAX in 2020-21 (de Bengy Puyvallée
and Storeng, 2022), and vaccine procurement contracts often prohibited
countries from exporting, donating and even re-selling vaccines without
the manufacturer’s permission (Apuzzo and Gebrekidan, 2021, January
28). The COVAX model also “obscures the power the industry holds over
the global allocation of vaccines, placing primary responsibility for
redistribution (or failure to do so) on wealthy country governments.” (de
Bengy Puyvallée and Storeng, 2022).
3.2.4. Vaccine nationalism - hoarding of COVID-19 vaccines by rich
countries
The absence of a global governance framework that effectively
enabled equitable sharing of vaccine doses meant that, faced with
intense political pressure to cater for their own populations, states ten­
ded to adopt a stance of moral nationalism (privileging domestic access)
rather than moral cosmopolitanism (prioritising other countries’ pop­
ulations along with their own) (Scheibner et al., 2022). Predictably, rich
countries quickly began to undermine COVAX by negotiating directly
with pharmaceutical companies to pre-purchase large quantities of
vaccines for their domestic populations even before COVAX had started
to negotiate with industry, essentially starving COVAX of supplies. By
November 2020, more than half of the first 7.5 billion doses had been
pre-purchased by HICs representing less than 14 percent of the world’s
population (So and Woo, 2020). By December 2020, when the first
vaccine doses were being rolled out, Canada had entered pre-purchase
agreements for 9.5 doses per head of population (So and Woo, 2020);
by August 2021 Australia had exceeded this, with more than 10 doses
per person ordered (Gleeson et al, 2022).
In 2022, HICs proceeded to third and fourth doses, placing continued
pressure on supply. By December 2021, the rate of administration of
booster doses in HIC had exceeded the total doses administered in LICs
(Mancini and Stabe, 2021, December 19). Moreover, pleas by the WHO
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to halt the administration of boosters until LIC had completed vacci­
nation of high-risk groups (Cullinan, 2021) were ignored.
The pharmaceutical industry was also complicit. The monopolisation
of vaccines by HICs was facilitated by the vaccine manufacturers, who
ultimately held greater power over the distribution of vaccines and
could have forced HICs to go through COVAX to obtain vaccines rather
than negotiating bilateral agreements (Scholz et al., 2022).
The callousness of HICs in the face of the “fatal implications of global
inequality” – the tacit acceptance of preventable death on a large scale –
has been described by Sumba (2021, p. 48) as “necropolitics at large”,
while these dynamics have also been understood in terms of “vaccine
apartheid” and “structural violence” for privileging the lives of those in
the global North over the global South (Sparke and Levy, 2022; Harman
et al., 2021; Hassan et al., 2021).
3.2.5. Vaccine charity and diplomacy
Unable to purchase vaccines in a market where supply had been
monopolised by rich countries’ bilateral deals, COVAX had to rely on
donations. However, it lacked enforcement mechanisms to require
countries that had purchased more than their fair share of vaccines to
share their excess doses. Donations of doses to COVAX were pledged
early but generally arrived late; with few eventuating before the second
half of 2021 after donor countries had already met their domestic de­
mand and most failing to materialise before the end of 2021 (de Bengy
Puyvallée and Storeng, 2022). Some were earmarked for specific
countries, and many excess doses were donated bilaterally rather than
through COVAX (de Bengy Puyvallée and Storeng, 2022).
Many vaccine donations were too ill-timed or too close to expiry to
be able to be absorbed by recipient countries. In December 2021, the
WHO Director-General noted that more than two thirds of donated doses
had an expiry date of less than 3 months (WHO, 2021b). The ad hoc
timing and lack of predictability made it difficult for developing coun­
tries to prepare, for example by putting cold chain arrangements in
place, and often meant that countries’ preferences for vaccine type were
not able to be accommodated (WHO, 2022a).
Many countries sidestepped COVAX altogether, opting for a ‘vaccine
diplomacy’ approach, making bilateral donations to countries in line
with their national interests, to “reap diplomatic and geopolitical
benefit” (Storeng et al., 2021, p. 9). These dynamics have further
entrenched power asymmetries, disempowering recipient countries and
increasing their dependency on the charity of the rich countries that seek
to wield influence through their donations (Holzer et al., 2022). Sparke
and Levy (2022) argue that both “vaccine charity” (humanitarian do­
nations through COVAX) and “vaccine diplomacy” (bilateral donations
made for strategic and geopolitical motives) have not only failed to
deliver the vaccines needed in LIC in a timely way, they have also
protected the existing global vaccine market from more radical alter­
native approaches to equitable manufacturing and distribution, which
might have achieved “vaccine liberty” for LMICs.
Non-Western powers including China and Russia also engaged in
significant vaccine diplomacy, distributing millions of nationally
developed doses to other countries through bilateral sales and dona­
tions, but largely bypassing COVAX (de Bengy Puyvallée and Storeng,
2022). These donations were driven by a somewhat different set of
motivations to those of the West, including economic and reputational
factors in addition to strategic geopolitical considerations (Suzuki and
Yang, 2022). While these doses played a significant role in lifting global
vaccination rates, for politico-economic reasons as well as their limited
effectiveness in comparison with mRNA vaccines developed in the West,
they did not provide an effective solution to global inequities.
3.2.6. The pharmaceutical industry’s stranglehold on production of COVID-
19 products and technologies
Pharmaceutical companies have protected their exclusive rights to
manufacture COVID-19 products and exclude others from the market by
filing large numbers of patents in multiple countries. Gaviria and Kilic
D. Gleeson et al.
traced the complex webs of patents and license agreements on various
aspects of the technology underpinning the mRNA COVID-19 vaccines,
which involves a very large number of entities (Gaviria and Kilic, 2021).
Scheibner et al. (2022) searched patent databases for patents filed in just
two countries for six key COVID-19 vaccines and found over 100 active
and pending patent applications for the USA and more than 40 for
Australia.
Facing criticism over the inequitable distribution of its COVID-19
vaccine in 2020, Moderna made a pledge not to enforce its COVID-19
patents during the pandemic (Moderna, 2020, October 8). However,
by March 2022, Moderna announced that while it would never enforce
its COVID-19 patents in the 92 LMICs included in the COVAX AMC, it
expected its IP to be respected beyond these 92 (Moderna, 2022).
The pharmaceutical industry, with few exceptions, kept a tight grip
on the exclusive rights to manufacture COVID-19 vaccines, engaging in
very little voluntary sharing of IP or know-how to enable more wide­
spread manufacturing. There have been few voluntary licenses negoti­
ated with companies in LMICs, with the notable exception of the Oxford-
AstraZeneca vaccine (Chaudhuri, 2022). AstraZeneca licensed the
Serum Institute of India to provide a billion doses for LMICs, along with
several companies in various other countries. However, these voluntary
licenses come with conditions. For example, the terms of its contract
prevented the Serum Institute of India from supplying upper-middle
income and HICs (Chaudhuri, 2022).
The two companies making mRNA vaccines – Pfizer/BioNTech and
Moderna – have not entered any licensing agreements involving tech­
nology transfer with companies in LMICs. While Pfizer entered an
agreement with the Biovac Institute in South Africa to manufacture the
Pfizer-BioNTech vaccine for African Union countries, Biovac’s role was
limited to the fill and finish stage of manufacturing, with the vaccine
substance provided ready-made from Europe (Pfizer, 2021, July 21).
BioNTech announced in February 2022 that it would establish a
‘modular’ mRNA manufacturing facility to manufacture mRNA vaccines
for African countries, but this involves shipping fully equipped pro­
duction lines along with BioNTech staff to operate them, at least initially
(Davies, 2022).
Companies have been more prepared to engage in voluntary
licensing agreements for the small-molecule antiviral COVID-19 treat­
ments, presumably because these are more likely than vaccines to be
subject to compulsory licensing if the industry does not enter voluntary
arrangements. But these agreements tend to exclude large parts of the
world. Both Merck Sharpe & Dohme and Pfizer have established
agreements with the Medicines Patent Pool for Lagevrio and Paxlovid
respectively, resulting in license agreements for their antiviral treat­
ments with generic manufacturers (Medicines Patent Pool, 2021a,
November 16, Medicines Patent Pool, 2021b, October 27). But the
countries that can benefit from these are limited to mainly low and
lower-middle income countries (106 and 95 respectively), with
upper-middle income countries such as Thailand, China and Mexico
unable to be supplied under these licenses. Pfizer has also agreed to
deals with UNICEF and the Global Fund, for a total of 10 million treat­
ment courses of Paxlovid to be provided at not-for-profit and/or tiered
prices (Pfizer, 2022, September 22). However, this represents a very
small proportion of the treatment courses being manufactured, pro­
jected by Pfizer (2022) to amount to 120 million by the end of 2022.
3.2.7. Failure of efforts to correct inequities
Efforts to encourage the pharmaceutical industry to voluntarily share
its IP and know-how largely failed. Following a request by Costa Rica,
the WHO set up the COVID-19 Technology Access Pool (C-TAP) in May
2020 to provide a platform for such voluntary sharing (WHO, n.d.-b).
However, although 45 countries (mainly LMICs) endorsed this platform,
it remained unused for eighteen months. At the time of writing, the only
licensing agreements included under auspices of C-TAP have been
negotiated with public research agencies, the Spanish National Research
Council (finalised in November 2021) and the United States National
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Institutes of Health (signed in May 2022) (WHO, n.d.-b). No private
sector pharmaceutical companies have contributed to the pool, and
some pharmaceutical industry executives have dismissed and ridiculed
the initiative (Silverman, 2020).
The WHO also established an mRNA vaccine technology transfer hub
in South Africa, which has used information in the public domain to
develop a vaccine similar to the Moderna vaccine (World Health Orga­
nization, n.d.-b). However, despite appeals from WHO, the mRNA vac­
cine manufacturers (Moderna, Pfizer and BioNTech) have all refused to
cooperate and share their technology and know-how with the mRNA
hub (Wise, 2022). BioNTech hired a consultancy firm that reportedly
sought to undermine the hub, lobbying for its termination (Davies,
2022). Moderna has filed patents in South Africa and has been granted at
least three, according to Médecins Sans Frontières (2022), and is suing
Pfizer and BioNTech for patent infringement, claiming that it copied
mRNA technology that Moderna developed before the pandemic (Reed,
2022, 26 August). Moderna also announced that it would set up an
mRNA manufacturing facility in Kenya, possibly an effort to undermine
the mRNA hub. At this stage, it is not clear what the mRNA hub’s
prospects are for successfully navigating what could be a minefield of
continuing obstruction and potential litigation over IP rights.
In October 2020, India and South Africa put a proposal to the WTO to
temporarily relax IP rules in the TRIPS Agreement for COVID-19 medical
products during the pandemic (WTO, 2020). The proposed TRIPS waiver
would have enabled companies around the world to freely produce
COVID-19 products and technologies including vaccines, treatments,
tests, and equipment (e.g., face masks and ventilators) without fear of
litigation over possible infringements of IPR. The TRIPS waiver proposal
eventually gained the support of more than 100 of the WTO’s 164
member countries and was sponsored by more than 60, but faced strong
opposition from wealthy countries, including the EU, the UK,
Switzerland, Canada, Japan, and Australia (Wijesinghe et al., 2022).
Ultimately, the TRIPS waiver negotiations failed to secure a mean­
ingful outcome. The USA, which had originally opposed the waiver,
announced its support for a waiver limited to vaccines in May 2021
(Office Of The United States Trade Representative, 2021), a move which
dramatically improved the prospect of agreement on a waiver. However,
the EU (particularly Germany), the UK and Switzerland – where many
companies making COVID-19 products are headquartered – remained
staunch opponents (Third World Network, 2021). The research-based
pharmaceutical industry was vocal in its opposition, claiming that a
waiver would decimate further innovation on COVID-19 vaccines
(Wijesinghe et al., 2022).
The EU issued a counterproposal that sought to merely clarify and
make minor adjustments to the existing compulsory licensing provisions
in the TRIPS Agreement (Yu, 2022). However, the compulsory licensing
provisions in TRIPS have limitations that make them difficult to use,
particularly for vaccines. A separate compulsory license would need to
be issued in each country for each patent, and the complex patent
landscape for vaccines, where multiple patents can be held by multiple
entities on various aspects of the underlying technologies, components,
and processes, makes it difficult to even discover all the relevant patent
claims. Much of the knowledge and technology essential to making
vaccines is not included in patent applications and is instead covered by
trade secrets protection – but compulsory licensing covers only patents
and not trade secrets (Amin and Kesselheim, 2022). It is also so proce­
durally difficult for countries without manufacturing capacity to import
pharmaceuticals under the TRIPS compulsory licensing provisions that
they do not represent a feasible solution for health emergencies (Wije­
singhe et al., 2022). Due to these and other barriers, to date, there has
not yet been any successful use of compulsory licensing to manufacture
COVID-19 vaccines.
It was not until June 2022, 20 months after India and South Africa
first tabled their proposal, that agreement on a Ministerial Decision on
the TRIPS Agreement (WTO, 2022) was finally reached. More than five
million people died because of the pandemic during those 20 months
D. Gleeson et al.
(Yu, 2022). But the Ministerial Decision was only a shadow of the
original TRIPS waiver proposal (Amin and Kesselheim, 2022). In
contrast to the comprehensive original proposal, it was limited to one
type of COVID-19 product (vaccines), at least in the first instance, and
one type of IPR (patents). While the original proposal aimed to waive 40
articles of the TRIPS Agreement, the final outcome waived only one
paragraph of one article (TRIPS Article 31(f)), making it easier for
vaccines made using its provisions to be exported from the country of
manufacture to a second developing country. Perversely, developing
countries with vaccine manufacturing capacity were encouraged to
make binding commitments to opt out of utilising the Decision (WTO,
2022; Footnote 1).
The Ministerial Decision included a clause committing WTO mem­
bers to decide on its expansion to cover the production and supply of
COVID-19 diagnostics and therapeutics within 6 months (WTO, 2022).
However, this deadline passed with no agreement, and at the time of
writing, it appears unlikely that members will ever agree to include
diagnostics and therapeutics within its scope.
3.3. Pathways to ill health and human health consequences
We now trace the pathways to ill health and the human health
consequences of inequitable access to COVID-19 vaccines, treatments,
and tests, drawing on published evidence to date. Since the pathways are
relatively straightforward, we discuss these two levels of the framework
together (following Schrecker et al., 2018), in relation to direct health
effects (mortality and morbidity arising directly from COVID-19 infec­
tion) and indirect health effects (excess mortality, exacerbation of global
inequality and poverty, exacerbation of other health inequalities, and
perpetuation of the pandemic).
3.3.1. Direct health effects
The most obvious immediate health consequence of the inequitable
distribution of COVID-19 health products and technologies is a high
burden of disease and avoidable deaths due to inadequate vaccination
rates, low testing levels and lack of access to treatments. Vaccination
protects individuals against severe illness and death and also helps to
slow transmission of COVID-19. Access to diagnostic tests is necessary
not just for surveillance and guiding policy, but also for preventing
asymptomatic and pre-symptomatic transmission, and identifying those
high-risk individuals who have contracted the disease and need treat­
ment (Batista et al., 2022).
It is important to note that LMICs suffered disproportionately from
the pandemic even before COVID-19 vaccines were available in any
country. A systematic review and meta-analysis of COVID-19 serology
studies found that the infection fatality rate was at least twice as high for
LMICs as for HICs in the first year of the pandemic (Levin et al., 2022).
Moreover, eight of the twelve nations with the highest number of deaths
from COVID-19 are developing countries (Levin et al., 2022). Mortality
data for LMICs is also likely to underestimate the impact of COVID-19
due to reporting limitations (Levin et al., 2022).
Reflecting the necropolitics outlined above, there was a stark impact
of vaccine inequity on COVID-19 mortality and morbidity. Retrospective
mathematical modelling quantifying the impact of the first year of
COVID-19 vaccination estimated that vaccinations prevented 19.8
million excess deaths from COVID-19 from December 2020 to December
2021, however the deaths per capita averted were highest in HICs due to
their earlier and faster vaccine rollouts (Watson et al., 2022). While
vaccination saved an estimated 7.4 million lives in LICs over this period,
if COVAX had met its target of vaccinating 20% of each country by the
end of 2021, an additional 156,900 deaths would have been avoided in
the COVAX AMC countries (Watson et al., 2022). If the WHO’s goal of
40% vaccine coverage had been reached, almost 600,000 more lives
would have been saved in the 96 countries that did not reach this target
(Watson et al., 2022). Another modelling study by Savinkina et al.
(2022) found that vaccinating the whole population in low and
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Health and Place 83 (2023) 103051
lower-middle income countries with three doses of an mRNA vaccine
would avert approximately 1.5 million deaths at a cost of $US61 billion.
Moore et al. (2022) used 2021 data from 152 countries to quantify the
effects of different vaccine sharing strategies, finding that a more equi­
table distribution of vaccines would result in substantial decreased
mortality in LICs without producing correspondingly large increases in
HICs, as long as vulnerable groups are vaccinated. Additionally, more
equitably sharing vaccines would reduce the total number of infections,
reducing the opportunities for more severe variants to emerge. The
authors estimated that the equitable vaccine distribution scenario would
have averted at least 1.3 million deaths attributable to COVID-19 by the
end of 2021.
While it is difficult to estimate the impact of COVID-19 on life ex­
pectancy in LMICs at this stage due to limited data, emerging evidence
from India and Latin America suggests that the impact is likely to be
larger than for HICs (Schöley et al., 2022). It is also too early to measure
the burden of post COVID-19 condition (also known as ‘long COVID’) in
LMICs. Post COVID-19 condition is defined by the WHO as “… the illness
that occurs in people who have a history of probable or confirmed
SARS-CoV-2 infection; usually within three months from the onset of
COVID-19, with symptoms and effects that last for at least two months”,
where “… symptoms and effects of post COVID-19 condition cannot be
explained by an alternative diagnosis” (WHO, 2021c). However, a (not
yet peer-reviewed) systematic review of the incidence and prevalence of
long COVID estimates that globally, 144.7 million people experienced
long COVID three months after infection in 2020 and 2021, and 15.1%
of these cases had not recovered by 12 months post-infection (Wulf
Hanson et al., 2022). The risk of long COVID is likely to be higher in
unvaccinated people (Notarte et al., 2022), which suggests that the
burden of long COVID resulting from the lag in vaccinating people in
LMICs may be significant.
3.3.2. Indirect health effects
Excess mortality rates (the difference in the number of deaths from
the number expected based on data from previous years) measure both
deaths that are directly attributable to COVID-19 and those indirectly
associated with the pandemic, due to its broader impact on health sys­
tems and other aspects of society (WHO, 2022b). Excess mortality rates
show even greater differences between HICs and LMICs than deaths
directly attributable to COVID-19 (Gill and Schellekens, 2021). Globally,
excess mortality due to COVID-19 has been estimated at 14.9 million in
the two years from 1 January 2020 (WHO, 2022b). Eighty-one percent
of these excess deaths are concentrated in middle-income countries
(53% in lower-middle income countries and 28% in upper-middle in­
come countries respectively), with 4% of excess deaths occurring in
LICs. HICs accounted for only 15% of excess deaths during 2020–2021
(WHO, 2022b).
COVID-19 has also seen a diversion of resources from other health
programs and the suspension of effective health programs due to lock­
downs and other COVID measures. This will likely cause an increase in
morbidity and mortality from other causes in years to come. For
example, the number of people receiving tuberculosis (TB) treatment
globally in 2020 dropped by more than one million, setting progress
against TB back by a decade or more. WHO estimates 500,000 more
deaths from TB in 2020 than would otherwise be expected (Roberts,
2021). WHO and UNICEF have reported the largest decline in childhood
vaccinations in 30 years (WHO, 2022c) and reduced funding for
maternal child health services and family planning has disrupted supply
and demand of maternal child health interventions and decreased con­
traceptive access and use (Rodo et al., 2022; Catterson, 2021). While
these impacts are not directly attributable to inequitable access to
products to address the pandemic, delays in COVID-19 vaccination in
LMICs may have exacerbated the effects of the pandemic on other health
programs.
The COVID-19 pandemic has had devastating economic conse­
quences for LMICs and has exacerbated global inequality and poverty.
D. Gleeson et al.
Inequality and poverty are both key drivers of inequitable health out­
comes (Commission On Social Determinants Of Health, 2008). A World
Bank study (Mahler et al., 2022) found that the first year of the
pandemic, 2020, saw the largest increase in global inequality and
poverty in a single year since 1990, reversing three years of progress.
The increases in inequality and poverty were driven by increases in
inequality between countries and bigger reductions in average incomes
in poorer countries, rather than in changes within countries (Mahler
et al., 2022). These changes – which occurred before vaccines were
widely available in any country – were postulated to result from illness
and death as a result of the virus, the partial shutdowns of economies
and flow on effects to employment and income generation, less re­
sources available to mitigate the economic effects of the pandemic in
poorer countries, and lower economic growth due to lower demand for
export goods (Mahler et al., 2022).
A later World Bank report published in September 2021 found that
while globally, progress in reducing extreme poverty had been wound
back by 3–4 years during 2020-21, LIC lost 8–9 years of progress (Hill
et al., 2021). Due to the pandemic, an additional 97 million people were
estimated to be living on less than $US1.90 per day in 2021 (Hill et al.,
2021). The incomes of the poorest 40% of the global population fell
twice as much as for the richest 20% (World Bank Group, 2022).
The COVID-19 pandemic also exacerbated inequality within coun­
tries. For example, in the first few months of the pandemic, a study of 17
LMICs in Latin America and the Caribbean found that households with
lower income levels were more likely to experience job losses and
business closures (Bottan et al., 2020). Impacts have been more severe
on vulnerable groups such as women, low-skilled workers and workers
in the informal sector, indigenous peoples and asylum seekers (Burki,
2020; Hill et al., 2021; Nanda, 2020).
While it is difficult, if not impossible, to disentangle the effects of
inequitable access to COVID-19 medical products and technologies from
other factors contributing to increasing poverty and inequality, it is clear
that poorer countries have borne the brunt of the economic impacts and
have been slower to recover than wealthier countries. As Hill et al.
(2021) argue, an adequate supply of COVID-19 vaccines (along with
other medical tools) is critical to accelerate economic recovery in LMICs
and to avoid further exacerbation of global economic inequality.
COVID-19 has also exacerbated other health inequalities and social
determinants of health. As Bambra et al. (2020, p. 965) point out: “The
COVID-19 pandemic is occurring against a backdrop of social and eco­
nomic inequalities in existing non-communicable diseases (NCDs) as
well as inequalities in the social determinants of health”, a situation
which they term a “syndemic”, where COVID-19 interacts with and
exacerbates NCDs and social disadvantage.
Finally, inequitable access to COVID-19 vaccines and other tools to
manage the pandemic is likely to perpetuate the pandemic due to the
continued emergence of new variants in areas of uncontrolled trans­
mission. A modelling study by Ye et al. (2022) demonstrated that greater
inequity in vaccine allocation drives earlier and larger outbreaks,
whereas more equitable sharing suppresses the emergence of new
variants.
4. Conclusion
The analysis we have presented above illustrates how the inequities
in access to COVID-19 health products and technologies, and the failure
to date of various attempts to correct these inequities, are deeply
embedded within and born of a historical legacy of capitalism, neolib­
eral globalisation and structural violence. It is within this context that
wealthy nations and the powerful pharmaceutical industry have created
a global IP regime which enables the industry to maintain monopoly
power even in the face of vast inequities in access to its products. Given
these aspects of the global social, political, economic and historical
context that permeated the response to COVID-19, it is unsurprising that
billions of dollars in public funding was used to support private
10
Health and Place 83 (2023) 103051
monopolies on COVID-19 products while the pharmaceutical industry
was permitted to maintain exclusive rights, that ACT-A and COVAX
failed to equitably distribute products in a timely way, that wealthy
countries engaged in hoarding and drip-feeding excess vaccines to the
poor through charitable donations, and that efforts to correct the in­
equities, such as the C-TAP and the TRIPS waiver proposal, received
insufficient support.
Several scholars have written about access to COVID-19 vaccines
using political economy perspectives, for example, Ahlberg and Bradby
(2022) and Sparke and Levy (2022). However, this paper makes a novel
contribution by adapting a structured approach to examine the factors at
different levels that shape health outcomes. It is telling that a framework
related to global extraction can map so easily onto the health impacts of
inequitable access to COVID-19 products and technologies. The com­
parison emphasises that the necropolitics of the political economy play
out in predictable ways, tending to improve and lengthen the lives of
higher-income communities while reinforcing and tacitly accepting the
untimely deaths of the poor. Moreover, the stark realities of this violence
are rendered invisible because it occurs in insidious, indirect, and
everyday ways: couched in the banal lexicon of “business”, “diplomacy”,
and “charity”. Solutions, therefore, need to tackle these systemic prob­
lems, rather than applying a bandaid to the specific issues that arise.
What then, are the prospects for change? To enable equitable access
to health products and technologies in future public health emergencies,
it will be necessary to disrupt the current neoliberal paradigm and power
asymmetries, through reforming the ways in which pharmaceutical R&D
are funded, preventing exclusive monopolies on health products and
technologies, righting the power imbalances between public and private
actors and between rich and poor countries — and the ways these are
reflected and reproduced in global governance structures. As Krikorian
and Torreele (2021) argue cogently in the title of their paper, “We
cannot win the access to medicines struggle using the same thinking that
causes the chronic access crisis”. These are large and long-term projects,
but our analysis points to the need for fundamental reforms to the global
order rather than building on the status quo or tinkering at the margins.
The most promising current global initiative to create the conditions
for equitable access to health products and technologies for future
pandemics is represented by the negotiations for a WHO Pandemic
Accord. While the exact legal basis for the Pandemic Accord has not yet
been determined, the International Negotiating Body established to
negotiate it has agreed that “the instrument should be legally binding
and contain both legally binding as well as non-legally binding ele­
ments” (WHO, 2023, p. 1).
A ‘zero draft’ of the Pandemic Accord released in February 2023 as
the starting point for negotiations (WHO, 2023) revealed promising
proposals for provisions that, if couched in enforceable language, could
go a long way towards promoting equitable access to products in future
pandemics. It includes, among others, measures to increase trans­
parency in the funding of pharmaceutical R&D and to encourage con­
ditions to be placed on R&D funding to drive equitable access, along
with rules requiring companies to disclose terms and prices of public
procurement contracts. It also emphasises the importance of strength­
ening local production in LMICs through technology transfer, commit­
ting the parties to providing mechanisms and incentives for the transfer
of technology to developing countries, along with “measures to support
time-bound waivers of intellectual property rights” (Art. 7 para 4(a)))
during pandemics. The draft also suggests that 20% of pandemic-related
products should be provided to WHO to enable equitable distribution
(Art. 10, para 3 (h)). However, many of the specific commitments are
couched in non-binding language.
The same forces that have prevented equitable access to COVID-19
health products and technologies threaten to derail or dilute these
promising proposals, with the pharmaceutical industry already claiming
the Pandemic Accord draft risks undermine its efforts to rapidly develop
pandemic products (Cueni, 2023, February 14), and civil society
participation limited to date (Hodgson et al., 2022). For the Pandemic
D. Gleeson et al.
Accord to drive equitable access to pandemic response products in
future, it will be critical for LMICs and civil society to be empowered to
participate meaningfully, with a corresponding reduction in the power
wielded by rich countries, donors, and industry stakeholders.
Declaration of competing interest
None.
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