Global justice and the COVID-19 vaccine: Limitations of the public goods framework

ABSTRACT

As vaccines for COVID-19 were first being approved for use, there were widespread calls for it to be assigned a ‘global public good’. However, allocating the COVID-19 vaccine globally poses a novel challenge of redistribution, one that cannot be effectively undertaken using current mechanisms for the dispensation of aid. An examination of the origins and implicit logic of global public goods theory shows that it would not be effective as a framework in this context. I argue that while it is a useful rhetorical tool to underscore the need for global access, it fails to account for concerns arising out of structural inequities between countries in the Global South and North. In addition to being ill-defined, the phrase encodes a neoliberal logic – one that prioritises the protection of private capital over democratic claims of redistribution and social justice. To ensure global access, our attention must be focussed instead on explicitly accounting for inequities, securing access for countries in the Global South and addressing the norm-setting powers of pharmaceutical companies.

KEYWORDS:

• COVID-19
• vaccine
• access
• equity
• global public goods

Introduction

With the number of people affected by COVID-19 escalating around the world, vaccines have emerged as a potential tool for public health programmes. When combined with other interventions such as masks, widespread testing, physical distancing and psycho-social support, mass vaccination programs may help to limit the spread of the virus. Most countries are currently trying to ensure that an effective vaccine can be administered to a large proportion of their population, which some estimate to be 80% (McNeil, 2020), to attain ‘herd immunity’. This would prevent transmission between people and act as a self-reinforcing protective mechanism against the virus. At a global scale, that implies that between 5.5 and 6.2 billion doses of the COVID-19 vaccine will be required to immunise enough people in the short term.

Currently, there are a number of vaccine candidates undergoing human trials and there is no singular definitive ‘COVID-19 vaccine’. It is likely that in the coming years, multiple vaccines will be approved against the SARS-CoV-2 virus. These may vary in efficacy, dose response and supply chain requirements. If hurdles related to uptake and distribution can be overcome, the vaccines may provide protection to vulnerable groups and avert thousands of preventable deaths in the future. For the sake of convenience, I refer to these collectively as ‘the vaccine’.

In multilateral negotiations, these efforts have been accompanied by calls to designate the vaccine a ‘global public good’ (GPG). Lacking a formal legal definition, the phrase signals a commitment to ensure ‘equitable’ access for all countries. More than a 100 sponsoring member states proposed its inclusion in a World Health Assembly resolution on the COVID-19 response. However, this proposal was rejected, and the language diluted in the final resolution to refer to ‘extensive immunization’ as a GPG instead (WHA, 2020).

These developments are reminiscent of past global public health crises, including the AIDS and SARS pandemics. During the H5N1 and H1N1 pandemics in 2004 and 2009, high-income countries bought up the inventories of pharmaceutical companies before these could be accessed by low and middle-income countries (Fidler, 2010). Similarly, even though effective antiretroviral therapies for HIV had been discovered by 1994, pharmaceutical companies claimed for many years that they could not reduce their annual price of $15,000. Millions of people in the Global South died before cheaper generic drugs were made widely available starting in 2001 (t’Hoen et al., 2011).

In this paper, I focus on global access and argue that the GPG framework would be of limited use in diagnosing and addressing the problem of distribution and redistribution of the vaccine. For any allocation framework to be equitable, it would have to explicitly account for the historical inequities between countries in the Global North and South and institutional barriers to accessing the vaccine.

The global public good framework

With its roots in classical neoliberal economics, the framework of ‘global public goods’ has been used to promote the fair distribution of social services like health. It is a formulation of the concept of ‘public goods’ – goods that are ‘non-excludable’ and ‘non-rival’ in nature (Samuelson, 1954). A good has the property of non-rival consumption if its use by one does not diminish its use by others. It is non-excludable if no individual can be excluded from the benefits of the good. Goods that satisfy both these conditions are characterised as ‘pure public goods’, though it is rare for goods to meet both conditions. Some classic examples of pure public goods include national defence, peace and security.

Market failures created by these properties form the rationale for the public provision of these goods (Stiglitz & Rosengard, 2015). Any form of exclusion for a non-rival good introduces inefficiencies associated with underconsumption. There is no incentive for people to voluntarily contribute to the provision of the good, leading to free-riders and an undersupply. The government must therefore step in to correct these market inefficiencies and provide these goods. Applying this canonical definition, a vaccine cannot be considered a public good, since it is obviously both rival and excludable. In their discussion of GPGs, Stein and Sridhar (2017) cite similar health goods such as pills and syringes as private goods.

However, this traditional understanding of public goods has been critiqued by some as being overly narrow and has evolved over the years (Kaul, 2006; Kaul & Mendoza, 2003; Touffut, 2006). Many goods are provided by governments even though they only partially exhibit properties of non-rivalrousness or non-excludability. In fact, for many such goods, the cost of exclusion is very low and the marginal cost (cost of an additional person being served) is high. For instance, patients can be charged for health services, and it would cost a doctor twice as much to see two patients when compared to one.

As a result, Stiglitz and Rosengard categorise health and education services as private goods. Definitions of public goods must therefore account for these complexities by referencing both the consumers and providers. Love (2020) also argues that a close reading of Samuelson suggests that he did not intend for public goods to be ‘purely’ non-rival and non-excludable. These private goods only partly meet the public goods criteria and require human intervention to be made public ‘by design’ (Kaul et al., 2003). In this reformulation of the public goods theory, a ‘pure private good’ being purchased by an individual would leave other people unaffected. However, there are externalities (or by-products) associated with the use of some private goods.

Going forward, this paper relies on this understanding of public goods, which recommends the public (i.e. government) provision of certain goods due to the larger benefits to society associated with their use. Educating women has a positive effect on levels of domestic violence and child survival. Similarly, even though there is technically a private market for traffic lights, the shared meaning and behavioural expectations associated with their existence create a net social benefit.

An individual receiving treatment for a communicable disease causes the community to become healthier by reducing the overall risk of contracting that disease. Moon et al. (2017) posit that the security afforded to the global community from a stockpile of drugs and vaccines may be considered a GPG. It is these externalities that may be considered ‘impure public goods’ and should be provided by the government. In fact, Cornes and Sandler (1996) argue that pure public goods may be considered special cases of externalities.

Definitional ambiguity

The alternative formulation of public goods as positive externalities of private goods that are made public by design has been criticised by some for definitional ambiguity (Coussy, 2005) and for being overinclusive. Carbone (2007) argues that it ignores any meaningful restrictions and leads to a ‘catch all to which people can attach anything they want’. As a result, ‘Health’ (Chen et al., 1999; Stein & Sridhar, 2017), global epidemiological surveillance (Zacher, 1999), safety and cost effectiveness of pharmaceuticals (Faunce, 2006) have all been described as GPGs.

In the absence of clear normative guidelines, which of these are prioritised at the national and global level will be inherently subjective and a result of political processes. Worse, donors and funders (Sridhar, 2012) or Northern bilateral and international agencies (Carbone, 2007; Moore, 2004) may determine which GPGs are to be prioritised. This not only implies that there may uncertainty about the nature of the vaccine, but also that reliance on this framework invites competition for limited resources with many other private goods.

A global dimension to public goods

With the advent of globalisation and increased interdependence between countries, the benefits of impure public goods may spill over beyond the national level. A country introducing policies to reduce carbon emissions would prevent global warming and benefit the global environment. An effective disease surveillance system increases global health security by reducing the chances of a pandemic that could move across borders. However, individuals or even countries acting privately would result in an undersupply of these public goods (Stiglitz & Rosengard, 2015).

There is therefore a need for collective action that introduces cooperation among nation states. This is typically achieved through international agreements and treaties that are designed to maximise the global good. Limits may be placed on nuclear proliferation (to improve global security) or the use of greenhouse gases (to preserve the global ozone layer) against the threat of trade sanctions.

Kaul et al. (1999) note that identifying criteria for GPGs can ‘provide clues to who might be free riding on whom and need incentives to cooperate’. It is clear that the entity shouldering the responsibility of action in this framework is the nation state. This says nothing about the obligations of other entities that have control over access to the vaccine, such as the World Trade Organisation (WTO) or pharmaceutical companies. The financial and administrative burden of ensuring access to the public good lies with governments, and the benefits of such provision may accrue globally. Despite what the phrase may suggest, it does not necessitate that all countries should have equitable access to the vaccine on reasonable terms.

Current mechanisms for allocation

Development assistance for health (DAH) is expected to play a major role in funding GPGs and in this case the vaccine. Ordinarily, international institutions make decisions about allocating these funds using tools such as cost effectiveness analysis and health technology assessment. However, the structure of these institutions, and the tools of analysis they rely on, would be inappropriate for the allocation of the vaccine. They have not been set-up for a situation where a good has to be distributed globally (not just in a few low-income ‘recipient’ countries) and current tools rarely take into account concerns about distributional equity.

Originating in funding sources such as national treasuries, private philanthropic sources and debt repayments, DAH flows from channels of assistance (bilateral and multilateral assistance agencies and non-governmental organisations) to implementing institutions (such as national ministries of health and private sector contractors). In 2019, the amount of total DAH was estimated at $40.6 billion, an amount that has remained roughly stagnant since 2011 (IHME, 2020). Many low and lower-middle income countries depend on this assistance to fund targeted disease programs and to support their health systems.

In April 2020, several multilateral and private organisations also came together to form the Access to COVID-19 Tools Accelerator (ACT-Accelerator), a framework for collaboration to support the development and equitable distribution of the treatments, vaccines and diagnostics the world needs to end the pandemic. It’s vaccine pillar, called COVAX, is led by the Coalition for Epidemic Preparedness Innovations (CEPI), GAVI and the World Health Organisation (WHO, 2020a).

COVAX will support research, development and manufacturing of vaccine candidates and negotiate their price. GAVI, tasked with implementing the vaccine pillar of the ACT accelerator, is a public-private partnership for delivering vaccines equitably in low-income countries. It works ‘to encourage manufacturers to lower vaccine prices for the poorest countries in return for long-term, high-volume, and predictable demand from those countries’ (GAVI, 2020).

Limitations

Tools for distribution

When making decisions about allocating funds within a country, organisations may choose from among many tools and methodologies for priority-setting. These tools will likely be adopted when distributing the vaccine as well. The most commonly used tool for priority-setting is cost-effectiveness analysis (Norheim et al., 2019). Other tools like health technology assessment may incorporate additional criteria such as economic impact on household expenditure and social impact. However, these tools are primarily used for decision-making within countries, and not between countries. For instance, they could help determine if aid should be targeted at developing new treatments for a potential pandemic or at strengthening the disease surveillance systems of developing countries.

They rarely include formal considerations of distributional impact and equity. The outcome of interest is mostly improvements in health indicators (Brock, 2003) and non-health/indirect effects are not considered. As the preceding discussion on public goods shows, the rationale for funding these goods is the indirect effects (or externalities) and not direct health outcomes associated with their use. Since the externalities in a GPG accrue beyond national boundaries, metrics for measuring the effects of vaccination internationally would have to be devised. It would therefore be inappropriate to apply these models in their current form to inform the allocation of vaccines.

The mechanisms for distributing development aid have been the subject of criticism in the past. In response, the Equitable Access Initiative was convened by nine international agencies in 2015 to understand the consequences of using gross national income as a criterion for allocating funds and to explore alternatives (Srinivasan, 2016). One of the primary concerns was that this indicator failed to account for inequities within countries, excluding a large proportion of the world’s poor who live in middle-income countries. They therefore sought to include indicators such as disease burden, national capacity to intervene and government health budgets to classify country needs.

In 2005, countries also assembled to endorse the Paris Declaration, a set of principles to make aid ‘more effective’ (OECD, 2005). These principles include ownership (developing countries set their own strategies, improve their institutions and tackle corruption), donor alignment with national strategies and use of local systems, harmonisation of actions by donor countries and agencies, a focus on producing and measuring results and mutual accountability through regular reviews. The literature on distributive justice has emphasised the need to ‘make fair choices’ (Ottersen & Norheim, 2014), ‘accountability for reasonableness’ (Daniels, 2000, 2007) and ethics (Roberts & Reich, 2002). However, it says nothing about the equitable and accessible distribution of these goods within or between nation states.

Institutional mechanisms

In 2019, GAVI channelled $1.8 billion in DAH primarily to child health (94.4% of its funding) and non-communicable disease programs (IHME, 2020). A smaller proportion of these funds is also spent on health systems strengthening, cold-chain equipment optimisation programs and targeted country assistance. Its primary function is to draw from a fixed pool of donor money, negotiate with pharmaceutical companies for doses of vaccines required to vaccinate mostly children in sub-Saharan Africa and South Asia and organise the delivery of these vaccines.

There is a key distinction between the current model of multilateral organisations like GAVI and the task before them in providing access to the vaccine. The monetary and physical resources for DAH are mostly sourced from actors in the Global North and directed to countries in the South. GAVI’s highest funder is the Gates Foundation, followed by the United States, the United Kingdom and Norway. Most of the funds granted by them are then spent in sub-Saharan Africa (52.6% in 2017) and South Asia (25.5% in 2017).

A major obstacle to the global provision of a public good, as has been alluded to by some as a ‘foundational challenge’ (Nordhaus, 2010) is the lack of a governmental or organisational mechanism to make binding collective decisions. We lack an effective mechanism to make decisions about the redistribution of resources if countries choose not to cooperate. Unlike national governments that have the authority to regulate actions within their territory, there is no comparable international mechanism through which disinterested majorities or supermajorities can coerce free-riding countries into the provision of GPGs. This means that even though countries in the Global North would benefit from the health security provided by maximised vaccination levels in the Global South, they cannot be forced to join the COVAX facility or contribute to it financially.

Scholars have considered some reasons why countries may cooperate voluntarily to create GPGs. Sen (1999) in his exposition of global justice proposes ‘plural affiliation’ as a potential justification. This is the recognition that ‘we all have multiple identities, and that each of these identities can yield concerns and demands that can significantly supplement, or seriously compete with, other concerns and demands arising from other identities’. It allows us to take into account the demands related to our multiple identities. In addition to our identity as a ‘human being’, we may have additional concerns as part of ‘humanity’ that exceeds those arising out of our membership of a ‘nation’.

Shortcomings of the global public goods framework

The novel issue of redistribution

The World Health Organization has proposed a ‘Fair Allocation Mechanism for COVID-19 Vaccines through the COVAX facility’ to ensure access and fair allocation among all countries (WHO, 2020b). Countries that join the COVAX facility will be eligible to obtain vaccines through the COVAX Advance Market Commitment (AMC). Using funding from official development assistance, foundations, private donors and concessional funds from multilateral development banks, GAVI will purchase doses of the vaccine for global distribution. Low- and middle-income countries are likely to be categorised as ‘COVAX AMC Eligible Economies’ (CAEE) and the remaining countries must self-finance their participation in the facility. It aims to deliver at least two billion doses of the vaccine by the end of 2021 (WHO, 2021).

Under this framework, the vaccine will initially be provided to target groups to maximise the impact of a limited supply. This may potentially include frontline workers in healthcare and social care settings, people over the age of 65, and people with underlying health conditions which put them at a higher risk of mortality from COVID-19. It is estimated an amount of vaccines equivalent to 20% of the population would be sufficient to cover these groups in each country. Vaccines will be allocated in two phases: in phase 1 proportionally to all participating countries and then in phase 2 taking into consideration a country’s risk profile.

The first tranche, however, only guarantees that 3% of the population is covered. Draft documents on the design of the COVAX facility show that preferential access will be given to self-financing countries who can claim vaccines for 20% of their population (Lynch, 2020). CAEE countries, however, will be subject to the rules of the allocation framework and provided with vaccines sufficient for their vulnerable populations and target groups.

Ensuring the equitable distribution of the vaccine presents a novel challenge- one that current institutional mechanisms were not designed to address. As these institutions have been set up, they do not envisage a scenario where a resource would have to be collected into a common pool and allocated not just from North to South but globally. Instead of effectively distributing funds for development assistance, these bodies must address how the vaccine would be redistributed fairly to countries in the Global South. The only other instance of allocating resources globally involved marine natural resources in the oceans under the United Nations Convention on the Law of the Sea of 1982 (Fidler, 2010).

In addition to removing legal and technical barriers for countries to develop and procure their own vaccines, current efforts to allocate the vaccine may also need to be restructured to reflect these concerns. This necessitates an acknowledgement of the power imbalance between the Global North and South, and explicitly accounting for it in any plans for vaccine access.

Inequities between the Global North and South

To ensure that their citizens have access to the vaccine as soon as it is approved and manufactured, countries have started placing orders with these pharmaceutical companies in advance. Predictably, the current projected supply has been carved up and claimed by countries with the highest financial capacity and political clout, leaving resource-poor countries in the lurch. A study in September 2020 showed that countries representing 13% of the global population had purchased more than 51% of the vaccine supply (Oxfam, 2020). The United Kingdom was one of the worst among these, purchasing the equivalent of 5 vaccines for each of its citizens. The COVAX facility will be competing with these countries for stock and price, and the proportion of vaccines available to them may be significantly reduced.

Several commentators have noted the varying capacity of low and lower-middle income countries to pay for GPGs (Gartner, 2012; Moon et al., 2017). In suggesting potential funding mechanisms for these goods, these discussions presume that there is a sufficiently large supply of the good, and the only barrier that exists is how it would be paid for. The COVID-19 vaccine, however, poses an additional problem. Even when a vaccine is approved by regulatory agencies, only a limited supply will be available for global use. It is estimated that enough doses to vaccinate the global population will not be available till at least 2024 (Duffy, 2020). Till then, decisions would have to be made at the global and national levels about how this limited supply will be distributed. As previous experiences with AIDS and SARS demonstrate, efforts to make the vaccine available will amplify the stark disparities between countries in the Global North and South.

The inclusion of high-income countries, presuming that they will join the initiative, introduces an additional problem: that of inequities between Global North and South countries. The COVAX facility intends to include all countries in its distribution program irrespective of their income level. It would then have to procure and distribute vaccines for the global population at an unprecedented scale. Most importantly, it proposes to form a common pool for all countries, while previously it’s ‘subjects’ were only low and lower-middle income countries. Many countries in the North already possess the capacity to individually negotiate access to the vaccine with pharmaceutical companies. Any commitments to fund vaccines for other countries could mean less vaccines for their own people. The task before the COVAX facility therefore is not simply to distribute, but to claim the stocks that would ordinarily be available to countries in the North and redistribute these equitably around the world.

Monopoly powers of pharmaceutical companies

Multiple barriers exist to accessing these vaccines despite their crucial role in saving lives. Many of the leading candidates for the vaccine have been developed in academic research centres and universities located in the Global North. Despite this, even before it can be proved that these vaccines are effective, they have been patented by pharmaceutical corporations. This gives these companies monopoly over the vaccine and the ability to decide who can access it and at what price.

Through these patent rights, pharmaceutical companies also control the know-how for manufacturing these vaccines. Unlike traditional pharmaceutical drugs, vaccines are composed of complex molecules which can be difficult to replicate or re-engineer in the same way as generic drugs. For instance, Moderna and Pfizer are developing RNA vaccines using a mechanism that has never yielded a vaccine approved for human use (Wood & Spiegel, 2020). This strengthens the monopoly power of the pharmaceutical companies running the vaccine trials.

It is unclear what price pharmaceutical companies will set for vaccines for which they own the intellectual property and manufacturing know-how. It was estimated that the ACT Accelerator would need $38 billion to function. However, as of September 2020, only $2.6 billion has been raised (Ravelo, 2020). Given the limited funding available to the COVAX facility, a high price per unit will also proportionately reduce the number of vaccines it can purchase. Therefore, in some ways, the scarcity of the vaccine is artificially created.

Near the beginning of the pandemic, Costa Rica proposed the creation of the COVID-19 Technology Access Pool (C-TAP) to facilitate access to technologies to counter the disease (WHO, 2020c). Through this initiative pharmaceutical companies would be invited to voluntarily share COVID-19 related knowledge, intellectual property and data. Unless provisions for compulsory licensing are invoked, these initiatives will only be successful to the extent that pharmaceutical companies choose to engage with them.

A neoliberal approach to access

Historical accounts of the neoliberal project highlight its role in designing international institutions in a way that inoculates the market and private capital against the demands of democracy and human rights (Slobodian, 2018). Supranational judicial bodies such as the WTO serve an important role in this project by overriding any domestic efforts (such as legislation) which may hinder the global rights to capital enforced through these bodies. The WTO emerged in response to successful national movements for decolonisation in the 1950s, where constraining the democratic systems of newly emerged nations (with their ‘clamouring, demanding masses’) became essential to the maintenance of the global economic order (Müller, 2011).

Access to essential medicines and vaccines becomes subject to one such agreement under the WTO– the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS). Under this agreement, countries are obligated to protect the intellectual property rights on claimed inventions. The protection of public health is listed as an exception whose invocation must be justified on limited grounds. The GPG framework, in simply requiring the public provision of the vaccine, does little to support democratic claims of public health against intellectual property rights. Unless the rights of capital can be challenged, national governments will be left to function within a restrictive framework where the monopoly powers of pharmaceutical companies remain unchecked.

Samuelson’s theory of public goods arose out of a need to address market failures when the private sector would not have incentives to provide certain goods under a system of free competition. The role of the state is limited to addressing these failures, and not as the primary provider of these goods (Martinussen, 1997). This indicates a particular capitalist conception of the ‘public good’, where the role of the state is limited to that of a buyer, and not a producer or provider of the good. The focus remains on how individuals can access the vaccine from providers in the market, without considering structural barriers inherent in the marketplace that may prevent such access.

In the alternative formulation of the public goods theory, the role of the state is to maximise positive externalities through the public provision of private goods. Countries determine for themselves what they consider a positive externality. For the COVID-19 pandemic, while the public health benefits of a vaccinated population may be a consideration, the actions of countries show that another consideration- protecting businesses and the market from financial losses- has driven public health policy (Fernholz, 2020). Vaccinating citizens would not only prevent them from developing the disease (direct effect) but would allow its ‘human capital’ to return to their jobs and contribute to the economy (positive externality).

Christening the COVID-19 vaccine a GPG does not address the private nature of vaccines or the monopoly powers of pharmaceutical companies which may control the technology and production of these goods. It simply places obligations on countries and requires that they immunise a significant portion of their population to decrease the threat to global health security. The claims of global justice require that the artificial scarcity created through these monopolies be addressed globally. A recent proposal by countries like India and South Africa to waive intellectual property protections on COVID-19 technologies for the duration of the pandemic is a significant start in this direction (Usher, 2020).

Conclusion

The large toll taken by COVID-19 on human health around the world has highlighted the urgent need for the development and distribution of a vaccine. The threat posed by this pandemic, seen in its geopolitical context, reveals the shortcomings of existing mechanisms for ensuring access to drugs and vaccines. Initial diplomatic attempts at reaching a consensus on the global response to COVID-19 sought to designate the vaccine a ‘global public good’. The phrase, which began to gain currency less than two decades ago, has been applied to a number of goods and services whose benefits are seen at the global scale. However, a closer examination of its aetiology and implications suggest that it may be of limited utility in providing an equitable framework for access to the vaccine.

The phrase was coined and developed in the context of development assistance for health, where funds from private philanthropic organisations and some Global North countries are allocated to countries in the South. The tools used for such allocation have not been designed for the global allocation of a good and would have to explicitly account for inequities between countries. One such way could be through quotas for lower and lower-middle income countries. A parallel for this exists in the national allocation framework proposed by the National Academies of Sciences, Engineering and Medicine in the United States, which recommends the prioritisation of racial minorities who are socioeconomically worse off and bear a higher burden of the disease (Schmidt et al., 2020). A similar justification may exist for prioritising countries in the Global South. An effective public health response would also require countering the artificial scarcity created by patent monopolies to ensure that all countries can act in their own interests and truly ‘global’ access to the vaccine can be ensured.

Acknowledgements

I would like to express my gratitude to the anonymous reviewers and editors of the journal for their incisive comments which helped to improve the arguments in this paper.

Disclosure statement

No potential conflict of interest was reported by the author.