Social services


World Bank support for Covid-19 vaccination fails to ensure equitable access

23 March 2021

The World Bank announced in October 2020 that it would make $12 billion available to assist “developing countries to finance the purchase and distribution of COVID-19 vaccines, tests, and treatments for their citizens.” The package is part of its $160 billion pandemic support running to June 2021, which goes beyond healthcare, as outlined in the World Bank’s June 2020 Covid-19 Crisis Response Approach Paper. A World Bank factsheet noted that the first vaccine programmes were approved in January and included Lebanon, Cabo Verde, Mongolia, and Tajikistan.

While the World Bank’s quick Covid-19 response and $12 billion vaccine assistance programme have been welcomed, there are concerns its impact will be significantly compromised if key shortcomings of its wider Covid-19 response are not addressed. In December 2020, Oxfam analysed 71 project documents linked to the World Bank’s COVID-19 Strategic Preparedness and Response Program, which has a wider remit than the vaccine initiative and aims to assist countries “to prevent, detect and respond to the threat posed by COVID-19 and strengthen national systems for public health preparedness.” The analysis identified the lack of attention to free healthcare access as a “fatal flaw”, noting that “just 8 of the 71 World Bank COVID-19 health projects include any plans to remove financial barriers to accessing health services…[and] none of the 8 specify that fee waivers will cover all health services as the WHO recommends.” The report underscored that despite a pre-existing global shortage of 17.4 million health workers, “two-thirds of country projects do not include any plans to increase the number of health workers, and that the 25 projects which do, have substantial shortcomings.” Oxfam called on the Bank to remove user fees in projects, redress gaps in support for health workers and cancel debt repayments on its loans.

Adding to those concerns, Allana Kembabazi of the Uganda-based Initiative for Social and Economic Rights stressed that, “countries like Uganda that already borrowed to mitigate the pandemic can’t afford more loans. The World Bank in true solidarity should only provide grants to support COVID vaccination and strengthen public health systems, which are the first point of call for the poor.”

Just 8 of the 71 World Bank COVID-19 health projects include any plans to remove financial barriers to accessing health services…[and] none of the 8 specify that fee waivers will cover all health services as the WHO recommendsOxfam International

World Bank support part of wider global shortcomings

The World Bank’s efforts complement the COVID-19 Vaccine Global Access (COVAX) initiative, which is one of the three pillars of the Access to COVID-19 Tools (ACT) Accelerator, launched in April 2020 by the World Health Organization (WHO), the European Commission and France in response to the Covid-19 pandemic. COVAX, which is coordinated by the WHO, the Coalition for Epidemic Preparedness Innovations (CEPI) and Global Alliance for Vaccines and Immunization (GAVI), acts as a vaccine purchasing mechanism and negotiates deals with vaccine manufacturers. The mechanism pools countries’ resources and is financed by donations from richer nations without a requirement of contributions from the world’s poorest. Concerns were outlined in a May 2020 brief by the East Central and Southern Africa Health Community (ECSAHC) and the Regional Network for Equity in East and Southern Africa (EQUINET) about the initiative, including its time-bound nature and the potential subordination of the WHO’s role by philanthropies more aligned with the interests of the pharmaceutical industry. The scheme aims to have 2 billion vaccine doses available by the end of 2021, which falls far short of achieving the 70 per cent global immunisation rate deemed necessary by the WHO. According to the BBC, COVAX has raised $6 billion to date and requires at least an additional $2 billion to meet its 2021 target.

As the world surpassed 2.5 million deaths attributed to the pandemic, UNAIDS Executive Director Winnie Byanyima was blunt in her assessment of the situation in a January article for UK newspaper The Guardian,  stressing that, “Nine out of 10 people living in the poorest countries are poised to miss out on a vaccine this year,” and that, “the vaccine science, knowhow and technology, paid for in large part by more than $100bn of taxpayers’ money, can no longer be treated as the private property of pharmaceutical corporations.” A December 2020 article by online news outlet The Intercept noted that pharmaceutical company Pfizer is expected to earn $19 billion in revenue from the vaccine in 2021 with a profit margin estimated at between 60 and 80 per cent. A February EQUINET brief pointed out that meeting Africa’s vaccination target is estimated to cost “between US$8 billion and US$16 billion, with an additional 20-30% required for delivery and administration.”

As early as May 2020, more than 140 world leaders and experts signed an open letter calling for a people’s vaccine and demanding, “the rapid establishment of an equitable global manufacturing and distribution plan for all vaccines, treatments and tests that is fully funded by rich nations and which guarantees transparent ‘at true cost prices’.” The call for equitable distribution and sharing of technical knowhow has a long history, with the 1974 UN General Assembly Declaration on the Establishment of a New Economic Order premised on the understanding that, “the benefits of technological progress are not shared equitably by all members of the international community.” It called for developed countries to “promote the transfer of technology and the creation of indigenous technology for the benefit of the developing countries.”

The Bank’s support fails to address structural barriers to equitable access

Beyond the critiques specific to implementation of the the World Bank’s Covid-19 response, at a fundamental level, it fails to address long-standing structural obstacles to equitable access to vaccines: the lack of indigenous production and distribution capacity, linked to decades of deindustrialisation and the barriers posed by intellectual property rights protection. As Director of the Africa Centres for Disease Control and Prevention, John Nkengasong, highlighted in a January interview with news outlet The Africa Report, Africa “still depends on importing more than 99% of its vaccines and therapies.” Policies promulgated by the Bank and Fund, as demonstrated by Cambridge University economist Ha-Joon Chang, have constrained the use by countries in the Global South of the very policies used by industrialised states to develop their capacity to achieve a high degree of concentration in the development and production of pharmaceuticals, including vaccines (see Observer Winter 2017-2018, Observer Spring 2016). The World Bank’s support for this unequal capacity of vaccine production and distribution is evident from its silence on the demand by 100 countries for a waiver of some aspects of the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement, to increase access to vaccines, drugs, and medical technologies needed to prevent, contain, or treat COVID-19, which was once again defeated on 11 March. The World Bank seems happy to ignore the lessons of the HIV and AIDS epidemic, where the manufacture of generic antiviral drugs in developing countries was pivotal in enabling a dramatic decrease in price and increase in access. As explained by Benjamin Hunter and Susan Murray in their June 2019 article in academic journal Development and Change, the World Bank, rather than contributing to robust public health systems and expansion of local production and distribution capacity, has been a strong promoter of the financialisation of healthcare (see Observer Winter 2020; Observer Spring 2017; Update 66). The Bank’s failed Pandemic Emergency Financing Facility (PEF) bond is a clear case in point (see Observer Autumn 2020).

While Reuters news agency reported in January that World Bank President David Malpass stated that Bank officials are “working with countries to address…rules that leave vaccine makers open for lawsuits or judgments”, the Bank’s lack of support for enhanced distributed local production, the TRIPS waiver and lack of action on vaccine pricing are deeply problematic. The Bank’s support fails to address the costs and other structural barriers associated with the vaccination efforts and may in fact exacerbate the debt load of some countries.

In the absence of concerted multilateral action, strongly supported by the World Bank and IMF, developing countries will be left with no choice but to respond to the Covid-19 crisis by borrowing to fund vaccine purchases and cutting essential services or support for vulnerable communities, while pharmaceutical companies continue to reap the rewards.