Deliver, together: Partnerships to deliver vaccines in a pandemic

Dec 17, 2023

World

Recommendations for a medical countermeasures delivery support mechanism based on lessons learnt from the COVID-19 vaccine delivery support mode

Introduction

The development and rollout of COVID-19 vaccines were the fastest in immunization history. The pandemic, however, also surfaced massive structural inequities, including a lack of equal access to COVID-19 vaccines for all countries. One year after the introduction of vaccines, 47% of the global population had received the primary series, but coverage was only 36% of the population in low- and lower middle-income countries. In low-income countries, coverage was even lower, with only 6% of the population vaccinated. By January 2022, 34 countries remained at or below 10% primary series coverage. The fluctuation and lack of visibility over the supply of vaccines and other products made planning and preparation at the country level difficult in many low- and middle-income countries (LMICs). Additionally, many LMICs had limited experience with vaccination programs for adults, especially older adults as well as other priority groups, at such scale and with novel vaccine products.

Two years after COVID-19 vaccines first became available, and after supply in large and predictable volumes was finally available by the fourth quarter of 2021, the consolidated efforts of countries and their partners resulted in the narrowing of the vaccine equity gap between low-income and lower-middle income countries and global averages. This is true for primary series coverage of the general population as well as of high-priority groups, though inequities still exist between and within countries.

Countries were supported by a wide range of partners at the regional and global levels, including the United Nations Children's Fund (UNICEF), the World Health Organization (WHO) and Gavi, the Vaccine Alliance. Early in the pandemic, the three agencies started supporting countries to ready themselves and to introduce, rollout and scale up vaccination through the Country Readiness and Delivery (CRD) workstream of COVAX, the vaccines pillar of the Access to COVID-19 Tools Accelerator. The delivery support of CRD was instrumental in providing evolving guidance and technical assistance needed for readiness and early rollout. This support included the provision of tools and technical guidance in an uncertain environment, e.g., a vaccine introduction readiness assessment, global guidance for the development of strategic national deployment and vaccination plans, and establishment of data reporting metrics and frameworks. Additionally, the CRD created mechanisms to coordinate information flows across key partners, access to early funding, training of national and subnational staff, building of data systems, and oversee programmatic monitoring of rollout and leverage country insights to inform vaccine allocation.

Between 2020 and 2021, the three agencies worked through their country, regional and global offices within their respective mandates, but with tighter and more frequent coordination. As the pandemic evolved, they sought ways to move streamlining decision-making. In January 2022, the three agencies adapted a more structured model for delivery support globally with the establishment of the COVID-19 Vaccine Delivery Partnership (CoVDP), building on emergency practices and existing relations including those in place through the Gavi Alliance. The CoVDP partnership aimed to support vaccine delivery in the COVAX 92 "Advance Market Commitment" countries (AMC92), representing mainly low- and lower-middle income countries, with a particular focus on providing operational support to the sub-set of 34 countries that were at or below 10% primary series coverage in January 2022, to accelerate scale-up and coverage. In CoVDP, agencies were brought together under one organizational ‘umbrella’ for strategic alignment, led by a global lead coordinator with strong connections to senior leadership within the agencies and capacity for political engagement at the highest levels of political decision-making within countries.

Additionally, CoVDP supported countries with specialized technical assistance, quick impact funding that could be deployed flexibly and rapidly, demand planning, and a dedicated country engagement channel collapsing different layers of global, regional and country-level support. Objective criteria agreed upon across partners were used to prioritize countries that would get this concerted operational support first (e.g., high-level political advocacy at the highest levels of government, quick impact delivery funding, and specialized technical assistance) while offering a broader range of support to a wider range of countries (e.g., technical guidance on product choice and vaccination strategies, and knowledge sharing between countries). Partners also agreed on the core principle of national ownership and the centrality of countries, and to coordinate support to countries as one support team supporting one country team led by government in-country.

The present report documents this global delivery support model for COVID-19 vaccine delivery, highlights the key functions that were needed for delivery support, and synthesizes key learnings for the design, development and implementation of a future vaccine (and other medical countermeasures) delivery mechanism in emergency settings. While explicitly recognizing that many partners provided support and were critical in driving countries’ successes, this report focuses on the CRD and CoVDP as multilateral partnership arrangements at the global level for delivery support that complemented and supported country-level and regional efforts.

The recommendations in this report focus on a medical countermeasures delivery support mechanism. Such a mechanism should be part of any global "end-to-end" medical countermeasures (MCM) platform developed which in turn should be integrated within the broader pandemic preparedness and response architecture, the health emergency incident management system coordinated by WHO and the pandemic accord. It is also important to scale up access and delivery capacity including through strengthening health systems and primary health care (PHC), such as capacity building of health workforces at the community level, and routine delivery systems, as well as investments into sustainable regional manufacturing of vaccines and other medical essentials – all of which are needed to improve equitable access and uptake in pandemic responses.

The report is based on interviews with 50 stakeholders across the agencies that were closely involved in COVID-19 vaccine delivery support, as well as an extensive review of material documenting the operating model for COVID-19 vaccine delivery support over a three-year period. The recommendations in this report are forward-looking and build on best practices as well as lessons learnt during the COVID-19 response. A summary of the bottlenecks or issues encountered by CRD and CoVDP during the response that were not fully addressed can be found in the annex.