COVAX, vaccine donations and the politics of global vaccine inequity

BACKGROUND: In 2021, donor countries, the pharmaceutical industry, and the COVAX initiative promoted vaccine donation or "dose-sharing" as a main solution to the inequitable global distribution of Covid-19 vaccines. COVAX positioned itself as a global vaccine-sharing hub that promised to share doses "equitably, effectively and transparently," according to rational criteria overseen by independent scientists. This article provides a critical analysis of the principles and practice of "dose-sharing," showing how it reveals the politics at play within COVAX. RESULTS: Donated doses were an important source of COVAX's vaccine supply in 2021, accounting for 60% of the doses the initiative delivered (543 million out of 910 million). However, donations could not compensate fully for COVAX's persistent procurement struggles: it delivered less than half of the two billion doses it originally projected for 2021, a fraction of the 9.25 billion doses that were administered globally in 2021. Donor countries and vaccine manufacturers systematically broke COVAX's principles for maximizing the impact of dose-sharing, delivering doses late, in smaller quantities than promised, and in ad hoc ways that made roll-out in recipient countries difficult. Some donors even earmarked doses for specific recipients, complicating and potentially undermining COVAX's equitable allocation mechanism. CONCLUSIONS: COVAX's pivot from global vaccine procurement mechanism to dose-sharing hub can be seen as a "win-win-win" solution for COVAX itself (who could claim success by having access to more doses), for donor countries (who could rebrand themselves as charitable donors rather than "vaccine hoarders"), and for the pharmaceutical industry (maintaining the status quo on intellectual property rights and protecting their commercial interests). Although dose-sharing helped COVAX's vaccine delivery, its impact was undermined by donors' and industry's pursuit of national security, diplomatic and commercial interests, which COVAX largely accommodated. The lack of transparency and accountability mechanisms within COVAX's overly complex governance structure as a global public-private partnership enabled these practices.