The Fund supports several networks of state health policymakers to help identify, inspire, and inform policy leaders.
The Fund identifies and shares policy ideas and analysis on topics important to state health policymakers, particularly on issues related to state leadership, primary care, aging, and health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
December 9, 2020
Early View Perspective COVID-19
Reidar K. Lie
Franklin G. Miller
Back to The Milbank Quarterly
More than 100 vaccine candidates are now in development to prevent infection from SARS-CoV2 or serious disease from COVID-19; many have entered clinical trials; and several are in or ready for Phase III efficacy testing. Two mRNA vaccines have been found to be more than 90% effective based on interim data analysis. The identification and development of vaccine candidates has been an extremely fast process, because of the urgent need for a vaccine to control the pandemic. In addition, when effective vaccines are identified, logistical challenges must be faced, as it will take time to produce enough to cover the world’s population. At least for the first couple of years, the demand will be much higher than the supply, and not everyone who needs a vaccine will get one. Because low-income countries are likely to lose out in the scramble to get access to the vaccine, there have been calls for global solidarity. For example, the Group of 20 (G20), consisting of countries with the largest economies, issued the following statement: “We will expand manufacturing capacity to meet the increasing needs for medical supplies and ensure these are made widely available, at an affordable price, on an equitable basis, where they are most needed and as quickly as possible.”1
But there are worries that these are only empty promises. Even though the G20 statement emphasizes an equitable distribution of medical supplies, it does not actually commit funds to the poorest countries for supplies, including a global distribution of an effective vaccine; it recommends only capacity building and technical assistance and commits only to “mobilize” funds.
We are gravely concerned with the serious risks posed to all countries, particularly developing and least developed countries, and notably in Africa and small island states, where health systems and economies may be less able to cope with the challenge, as well as the particular risk faced by refugees and displaced persons. We consider that consolidating Africa’s health defense is a key for the resilience of global health. We will strengthen capacity building and technical assistance, especially to at-risk communities. We stand ready to mobilize development and humanitarian financing.1
In the race to develop an effective vaccine, many experts have called for a more coordinated global approach, in which individual countries agree to abandon their national interest in securing vaccines for their own populations and hand over the responsibility to distribute the vaccine globally based on need. A group of bioethicists proposed what they term the “Fair Priority Model” advocating vaccine distribution in three phases.2 The first phase would be devoted to reducing premature deaths and irreversible direct and indirect health impacts; the second to reducing serious economic and social deprivations; and the third to reducing community transmission. They argue that all countries should go through the three phases “approximately simultaneously.” In this model, the distribution principles are based strictly on medical and economic criteria that identify the effects of the vaccine and wealthy countries would not receive the vaccine earlier just because they have the resources to buy it.
Another influential approach, proposed by the World Health Organization (WHO), similarly envisages a distribution scheme in which the vaccines are distributed to countries based on the number of high-risk groups in each country. A country should first obtain enough vaccine to cover frontline health care workers, covering 3% of the highest-risk individuals first and then continue with other high-risk groups such as the elderly and people with comorbidities, until 20% of each country’s population has been covered.
Both the Fair Priority Model and the WHO proposal seem to disregard the relevance of national borders; that is, all countries should receive a supply of vaccines simultaneously in accordance with country-independent criteria. Here we argue that both these approaches are untenable and that national governments have both a right and a duty to secure access to a COVID-19 vaccine for their citizens first. Accordingly, we propose a middle-ground policy perspective based on two premises: (1) a “cosmopolitan” approach that rejects entirely nation-state priority is not only unrealistic but also fails to recognize that countries have a legitimate responsibility to give priority to their own citizens and residents; and (2) unbridled vaccine nationalism, without an adequately funded effort to ensure the equitable global allocation of an effective vaccine over time, is unethical and likely to be counterproductive.
We present three interdependent arguments for our position. First, we believe that a prioritization framework should include a distribution scheme that can be implemented, rather than one that simply proposes general principles of distribution. Second, any viable prioritization scheme needs to start with nation-states’ responsibility to secure the health of their populations. Third, appropriate weight needs to be given to national obligations of international assistance for low-income countries to mobilize resources for health. We argue that the COVAX partnership provides a framework that approximates the right balance between national responsibilities for health and international commitments to global justice.
In service of international coordination, COVAX is a partnership among the GAVI Alliance (Global Alliance for Vaccines and Immunizations), CEPI (Coalition for Epidemic Preparedness Innovations), and WHO.3 Its purpose is to accelerate the development and manufacture of COVID-19 vaccines and to guarantee fair and equitable access for every country in the world. COVAX has three important features, which jointly embody a middle ground between a cosmopolitanism with no regard for national borders and an unbridled vaccine nationalism that disregards international obligations.
First, COVAX proposes a scheme for pooling resources and distributing the risk of vaccine development among participating countries. COVAX operates by asking countries to underwrite the development of a vaccine for COVID-19 by paying into a central fund. This fund is then used to finance vaccine candidates being developed in a number of countries. Each participating country pays for a certain number of dosages, which translates into a dollar amount sufficient to cover up to 20% of its population. Half of this is paid up front and is used as a push mechanism to promote vaccine development. The other half is paid if a successful vaccine is found. The countries that pay are self-financing countries, which means that they are wealthy enough to pay for their own vaccines. As of September 21, 2020, 64 higher-income countries had signed on and an additional 38 are expected to join.4 China joined in October 2020, but the United States has so far explicitly refused to do so.
Those countries participating in the first “bidding” will be guaranteed a protected number of dosages of a successful vaccine candidate. That is, countries will receive a proportion of the vaccines produced according to their initial commitment until the required number of committed dosages has been allocated. Countries also are free to enter into individual arrangements with companies for additional vaccines.
The advantage for individual countries is that they are not committed to a particular vaccine, so they will not lose out if that particular vaccine is shown to be ineffective. From an equity point of view, the vaccine will not go to the country where this vaccine is produced or that has individual advance market commitments (AMCs) but instead will be distributed to participating countries as production increases.
The COVAX partnership is an attempt to coordinate both the development and the distribution of a possible effective vaccine. Such a collaboration would benefit everyone by pooling resources and ensuring a rollout of the vaccine so that high-priority individuals in all countries would receive the vaccine first. The alternative is that those countries investing in a vaccine that turned out to be effective will have access to it first. Only when the demand in these countries has been fully satisfied will the vaccine start to be distributed to other countries.
The second important feature of COVAX is that wealthy countries may also choose to finance successful vaccine candidates for distribution to countries that cannot afford to pay the full cost. This funding pool would be used to secure vaccine dosages in a distribution scheme in which low- and lower-middle-income countries receive enough money to cover high-priority individuals in their countries, up to a maximum of 20% of their population. Ninety-two countries are eligible for this scheme, and at least $5 billion is needed before the end of 2021 if a vaccine becomes available that year for distribution. So far, around $1.8 billion has been raised from voluntary contributions by higher-income countries.
Third, countries that participate in COVAX are free to decide how much of their resources they will contribute to COVAX. Countries that contribute more will receive more if a successful vaccine is developed, but they also will lose more if there is no successful vaccine. Countries are free to fund the development of additional vaccine candidates and to enter into agreements with companies for additional dosages and with companies that do not participate in COVAX. The contributions to fund vaccine procurement to low- and lower-middle-income countries are voluntary. It is not clear, for example, whether China has contributed to this voluntary fund.
In sum, the COVAX partnership is basically a mechanism through which individual (wealthy) countries can contribute and fulfill their (self-interested) obligation to promote the health of their own citizens as well as fund and distribute vaccines to low-income countries. But, crucially, for COVAX to be able to fulfill WHO’s distributional requirements that 20% of all countries’ populations must be covered before any country can cover additional population groups, three conditions must be met.
First, all higher-income countries must commit to cover 20% of their populations, either through direct procurement from pharmaceutical companies or through COVAX. This condition is likely to be satisfied, with or without the COVAX mechanism, although countries will have additional advantages if they pool their resources and risks instead of exclusively entering into individual arrangements with pharmaceutical companies.
Second, and more important, sufficient funding must be secured through COVAX from wealthy countries to cover 20% of the populations in all low- and lower-middle-income countries that are not able or willing to secure vaccines through their own funding.
Third, also important, rich countries must agree that vaccines will be distributed by COVAX independently of whether they belong to the self-financing group of rich countries or to the group of countries relying on donated funds to COVAX. The existing documents do not clarify the relationship between these two groups of countries regarding the distribution of vaccines.
Cosmopolitanism embodies laudable principles that express what many people would intuitively agree to. The following are two typical examples of statements expressing such aspirations: A vaccine must be allocated based on the best evidence of what will stop transmission and protect the most vulnerable groups—no matter in which nation they reside.5
As soon as the first COVID-19 vaccines get approved, a staggering global need will confront limited supplies. Many health experts say it’s clear who should get the first shots: health care workers around the world, then people at a higher risk of severe disease, then those in areas where the disease is spreading rapidly, and finally, the rest of us. Such a strategy “saves the most lives and slows transmission the fastest,” says Christopher Elias, who heads the Bill & Melinda Gates Foundation’s Global Development Division.6
These statements convey a legitimate concern to avoid “unbridled nationalism,” in which each country does what it can to secure access to its own population. This will push low-income countries to the end of the line,7 with access to vaccines for everyone in rich countries but very little access in low- and middle-income countries. Without translating these lofty principles into effective distribution mechanisms, however, they will remain empty. This problem is exemplified by an earlier global attempt to distribute vaccines fairly.
The much-heralded Pandemic Influenza Preparedness Framework (PIP) was set up and agreed to by WHO member countries in 2011 after a long and difficult preparation process. PIP was based on the WHO-coordinated development of seasonal influenza vaccines, which has been in existence for decades. Samples from different parts of the world, in particular from Asian countries, are distributed within the network so that an appropriate vaccine can be produced each year for the annual influenza season. The network was and is used also to monitor influenzas with pandemic potential. In 2007 the Indonesian health minister refused to share her country’s samples with the network unless there was a mechanism to ensure that Indonesia would get access to a vaccine should there be an influenza pandemic. She complained, rightly, that Indonesia shared its samples freely, whereas both public and private entities in rich countries could develop a vaccine that would provide them with both profits and benefits for their populations but that no countries that donated the samples would receive benefits. During the discussions between 2007 and 2011, opinions were divided between a group of low- and middle-income countries demanding that standard material-transfer agreements contain provisions for mandatory benefits from recipient countries and high-income countries that resisted such provisions. The final PIP framework, which was introduced in 2011, contains aspirational language about benefit arrangements but no mandatory provisions. It also is severely limited in scope and expressly does not include non-influenza pathogens. In Lawrence Gostin’s words,
Although the agreement’s stated objective is a “fair, transparent, equitable, efficient, effective system” that places virus sharing and benefits “on an equal footing,” in reality it secured the norm of virus sharing while providing only weak benefit sharing in return. The PIP Framework will likely fall short in meeting vaccine demand during a pandemic, and it provides no guidance on equitable rationing during scarcity.8
The experience with the H1N1 pandemic flu in 2009 illustrates the failure to supply low-income countries with vaccines in a timely manner. Then, as now, a pandemic was declared by WHO and there was a race to develop a vaccine. Because flu vaccines are designed every year for the prevalent subtypes of the virus, it is relatively easy to develop a vaccine quickly. Wealthy countries immediately secured access to a vaccine by buying enough doses to cover their populations. Only when it turned out that there was not an urgent need for all these doses did they start to offer their supplies to WHO for distribution to low-income countries. Even countries that normally are quick to talk about global solidarity, such as Norway, made sure that their own country populations were completely covered before they even considered providing anything to low-income populations. But by the time the unused doses were offered to low-income countries, they were basically useless, leading cynics to say that even at that stage, rich countries tried to make money from less fortunate countries. Although the PIP agreed on in 2011 is supposed to prevent this in the future, it does not contain any enforcement mechanisms.
We now see a repeat of the H1N1 experience. Both wealthy and middle-income countries are entering into agreements with pharmaceutical and biotech companies to ensure that they will get access to the vaccines first. Countries such as the United States, the United Kingdom, and members of the European Union have entered into agreements to buy dosages from several manufacturers should their vaccines turn out to be effective. China is developing its own vaccine and has explicitly stated that it will give priority to its own citizens first. India and Brazil have been doing the same.
The models proposed for the global distribution of COVID-19 vaccines, including the Fair Priority Model proposed by Emanuel, do not describe how the model can be translated into a workable distribution mechanism. COVAX is the only model that addresses the core issues of how to mobilize resources and distribute successful vaccines.
There will be no effective vaccine without substantial investment in research and development. The first priority therefore must be to mobilize resources for research. Only national governments have the resources to fund such research, either directly or through commitments to buy vaccines developed with private funding. Such investments are risky because they do not guarantee that they will result in effective vaccines or other interventions. Without such investments, there will be no vaccines, but if they are successful, then not only funding governments and their populations will benefit, but so will everybody else, at least over time. The United States has been, and is, the biggest national funder of global health research, both in absolute terms and in percentage of GDP. Realistically, any additional major players will be rich countries and large low- and middle-income countries, such as China, India, Brazil, and South Africa.
Countries and private companies have already invested in vaccine research and manufacturing capacity at unprecedented speed and amounts. They can do this by directly funding research, as the United States has done to support the Moderna company’s clinical trials. Or countries can commit to buy a certain number of vaccine doses from a specific company should its vaccine turn out to be effective. This gives vaccine companies an incentive to invest their own funds in research because they are guaranteed a market for their vaccine if it is effective. Both the United States and European countries have used this mechanism, entering into agreements with a number of companies, which sometimes amount to billions of dollars. The rapid mobilization of substantial funds for research demonstrates nation-states’ ability and power to invest in health research and intervention development when it matters. No international organization can match this ability, an economic and political situation supporting the argument that any global distribution scheme should rely on and work with national government initiatives.
From a normative point of view, national governments have the responsibility and duty to promote health for their populations—a responsibility recognized in international human rights documents. Unlike international organizations, national governments have the ability to mobilize and redirect resources to address health emergencies and can be held responsible if they do not. Just as countries have legitimately taken extraordinary measures to protect their populations during the current pandemic, such as closing borders and providing economic relief, they also have the right and the duty to try to secure access to an effective vaccine for their citizens and residents.
Apart from this normative foundation, given the failure of previous attempts to implement a global scheme for vaccine development and allocation, there is no alternative to accepting that national governments will seek to cover their own populations first. Rich countries like those in the EU and the United States, big countries like India and China, and even African countries have already realized this. John Nkengasong of the Africa Centres for Disease Control and Prevention stated, “We need to take charge of our own destiny. . . . We need to come together as a continent of 1.3 billion people to not be left behind.”7 A successful rollout of an effective vaccine would have to build on the ability of national governments to effectively mobilize scientific, financial, and industrial resources for promoting health. Countries and companies have made substantial investments and are taking substantial risks to develop an effective vaccine against COVID-19. Governments or pharmaceutical companies must be willing to commit funds, with uncertain future benefits. The obvious reaction from those who have taken the risks is that they also deserve the benefits of early access. Politically it will be difficult, if not impossible, to convince countries’ populations that they need to wait until health care workers in low-income countries have been immunized. In an ideal world, rich countries, through government or private investments, would mobilize enough funds to cover a rational and equitable worldwide rollout of an effective vaccine, but previous attempts to establish such coordination have not been successful. Therefore, the realistic alternative is for each country to do what it perceives as being in its best interest, which means acting in such a way that it can maximize the benefits for its own population. This provides us with an additional motivation to seek a middle ground between cosmopolitanism and unbridled nationalism.
There are, however, downsides to an exclusive focus on national interests. The funded research and development activities do not guarantee success, and there are risks involved for everyone involved, especially in view of the substantial funds devoted to developing manufacturing capacity before demonstrating the vaccine’s efficacy. Even if countries commit to buying a successful vaccine, companies may end up investing in the development of a vaccine that leads nowhere. Moreover, one country may have committed to a vaccine that turns out not to be effective, so it will lose out, at least initially, to other countries that have placed their bets on a different vaccine that is effective.
Countries may also want to hedge their bets. The United States has spent several billion dollars to develop a vaccine as well as advance market commitments (AMCs) to buy dosages of an effective vaccine from several companies, such as Astra-Zeneca, GSK/Sanofi, Johnson & Johnson, Moderna, and Pfizer. While the US investment now seems to be successful with respect to vaccines developed by Moderna and Pfizer, these efforts might not have turned out to be worthwhile, and the Chinese vaccine or the German vaccine developed by CureVac, might have turned out to be the winner. Then the United States would have wasted its money and would not have immediate access to an effective vaccine, because rival companies have committed their initial production to other countries. Similarly, if the Astra-Zeneca vaccine became the first to be demonstrated effective, then the United Kingdom would have a guaranteed access to the first batch, and the United States would have to wait in line. The Moderna and Pfizer vaccines are also not ideal because they require storage and transport at very low temperatures, making them unsuitable for mass vaccinations in many locations.
Other scenarios are also suboptimal if international collaboration is not embraced. For example, the first vaccine might not have been very effective but still effective enough to be useful and therefore might receive emergency authorization or standard approval for use. Another, more effective vaccine might then become available. If a country is committed to buying both if approved, it might end up with more dosages than needed for an optimal vaccination strategy of its own population. But the less effective vaccine might be immensely useful in low-income settings, or even in wealthy countries with a greater number of new infections. Accordingly, international coordination in the distribution of a vaccine once it is found to be effective is desirable even from a purely national point of view.
The COVAX partnership is an attempt to motivate wealthy countries to pool their resources for vaccine development in a consortium that will benefit all participants. The core of this partnership is based on the enlightened self-interest of high-income countries.
National governments also have responsibilities for global assistance as recognized in international human right instruments but also generally accepted by most people. The crucial issue is therefore how countries should balance their obligations to secure the health of their own populations against these possibly conflicting obligations of global assistance. Emanuel and colleagues have suggested how this could be done: “Reasonable national partiality does not permit retaining more vaccine than the amount needed to keep the rate of transmission (Rt) below 1, when that vaccine could instead mitigate substantial COVID-19-related harms in other countries that have been unable to keep Rt below 1 through public health efforts.”2
However, the Fair Priority Model is inconsistent with this principle when the authors suggest that all countries proceed through the model’s first two stages simultaneously before they all reach the third stage, which they identify as “reducing community transmission.” But keeping the rate of transmission below 1 is precisely what is meant by “reducing community transmission,” which is their third phase of distribution. This means that this principle is not very helpful for balancing legitimate national versus international commitments. Specifically, it is not realistic in recognizing that wealthy countries will strive to provide vaccinations for all, or a high proportion, of their citizens and residents, regardless of the rate of transmission at a particular point in time. A much better balancing mechanism is a proposal suggested by the COVAX partnership.
COVAX establishes a different, more plausible, link between wealthy governments’ interests and the interests of low-income countries. In COVAX, participating self-financing countries agree to additional contributions to fund the distribution of vaccines in the 92 eligible low- and lower middle-income countries. COVAX is a concrete and implementable framework for shared responsibility for the development and distribution of health care interventions of global importance. Unlike the PIP framework and international declarations such as the G20 statement, it not only is aspirational but also contains specific mechanisms to ensure that an effective vaccine is identified and distributed as quickly as possible. It therefore can serve as an illustration of the challenges and difficulties with which any realistic distribution mechanism will have to deal, but more important, it provides a useful model for how governments can balance national against international obligations.
As of November 2020, COVAX has already received a commitment of $2 billion, with the goal of raising an additional $5 billion for AMCs in 2021. This amount, together with the initial contributions from self-financing countries, will be used as an AMC for participating countries.9
The COVAX partnership, therefore, deserves the support of both higher-income countries and big middle-income countries like China, India, Brazil, and South Africa. In particular, the United States should reverse its decision to not join the COVAX partnership, as has recently been recommended by the report on the equitable allocation of COVID-19 vaccine by the US National Academies of Science, Engineering, and Medicine.10
Valuable as it is, it is unclear whether a collaborative scheme such as COVAX will be able to mobilize enough support for a joint and coordinated approach. Important countries such as the United States and India are not on board, and even the EU countries are making their own, separate, arrangements. With these individual approaches, there is some uncertainty as to which country or group would get priority if they have committed to the same vaccine, with an indication that it would be on a “first come, first served” basis. That is, those that committed first would receive the first batches of vaccines once production had started. But if the estimate that two billion doses can be produced during the first year is correct, even with the relatively large number of AMCs, there should be enough production capacity during the first year to cover all of them. These AMCs, however, basically cover only wealthy countries, leaving a gap of several billion people in low- and middle-income countries. It is not clear how COVAX would distribute the available vaccines between the self-financing countries and the eligible low- and lower middle-income countries. Additional resources are therefore urgently needed.
The number of vaccine dosages available to low-income countries in the early stages of production could be increased in ways that would not be burdensome for high-income countries. Even with the AMCs already in place, high-income countries probably will not be able to use all the dosages of effective vaccines available to them. There are also indications of likely considerable resistance among some population groups to be vaccinated, further reducing the use of vaccines in these countries. In Britain, according to one survey, one in six would refuse a COVID-19 vaccine.11
The report published by the US National Academies recommends that the United States devote 10% of its vaccine procurement to low-income countries. If all countries participating in the COVAX partnership adopted this proposal, both for the funds that they have committed to COVAX and the separate, individual, AMCs that they have negotiated with pharmaceutical companies, they would move the goal of an equitable global allocation closer. Indeed, these shortcomings of the COVAX partnership are not a reason to abandon it but rather should provide additional motivations to strengthen it.
The Fair Priority Model requires that all countries complete the initial phase of reducing premature deaths and irreversible health impacts before countries reduce serious economic and social deprivations associated with the pandemic. This, however, is unjustifiable because it rejects the right and duty of national governments to set priorities. For example, countries may want to balance the relative importance of these two considerations differently from how a group of bioethicists would. An important consideration in such balancing, at both the national and international levels, is the availability of infrastructure to deliver vaccines effectively.12 While there may not be significant differences between the availability of delivery mechanisms in large urban areas of low- and high-income countries, it would be much less cost-effective to deliver vaccines to health care workers in remote areas in low-income countries than to other population groups in high-income areas. Transportation, cold-storage, and other infrastructure need to be in place as well. Many more health care workers can be covered using the same resources in urban areas compared with rural areas of low-income countries. If the goal of a priority-setting strategy is to maximize population health with the available resources, vaccinating all health care workers everywhere before anyone else will likely not be the optimal strategy. At least during the initial distributions of a vaccine, when the production is much lower than is needed even for minimal global coverage, giving priority to countries or regions with the necessary infrastructure for delivery can be justified even from a cosmopolitan point of view. This argument is likely strengthened if we include nonhealth benefits in a general cost-benefit analysis of alternative strategies, in which we would include the general economic benefits of vaccine strategies, not just the health benefits. The cost savings, both direct and indirect in terms of return of normal activities, can be used to finance further production and delivery of vaccines for low-income countries. The Fair Priority Model does not appear to provide room for such balancing. The COVAX partnership, however, does allow national governments to make such individual balancing judgments.
Distribution—no matter how it is handled—is less consequential during the first year of a new vaccine’s production. How the billions of dosages needed for worldwide coverage are distributed after the first year is what matters most. As a longer-term objective, therefore, we need to focus more on these long-term commitments, and wealthy countries ought to commit funding commensurate with their economic status to produce and distribute sufficient vaccine for low-income countries. While the amount of money needed for this objective would be substantial, it would be a small fraction of what wealthy countries have been spending in economic aid for their populations during the pandemic. The framework for such a long-term commitment will depend crucially on the vaccine’s characteristics: how many dosages are needed for full immunity and how long the immunity lasts. The COVAX framework is a modest but important step in the direction of global justice in a world of nation-states and vast inequalities in access to health-promoting resources.
A cosmopolitan approach to an equitable distribution of an effective vaccine against COVID-19 has an intuitive appeal. It would be a collective international commitment to equitable access for all people around the world, according to agreed-on distribution criteria, without priority to the citizens/residents of better-off countries. If health care workers were given first priority for a vaccine, then health care workers everywhere would be covered before any other groups in any country. In reality, though, such a priority-setting strategy is neither desirable nor feasible.
The H1N1 pandemic in 2009 and the current COVID-19 pandemic have amply demonstrated that countries’ default position will be to do whatever is necessary to obtain full coverage for their own populations first. Wealthy countries with both weaker and stronger commitments to global justice have taken this more national approach. But as the funding by wealthy countries for research on poverty-related diseases has shown, if the perception is that funding projects that benefit low-income countries is also in their own interest, then even a country like the United States would be willing to contribute more than any other country, in both absolute and relative terms to GDP.13 Given the absence of a global enforcement mechanism for global priority setting, we have to rely on the willingness of high-income nation-states to underwrite health interventions in low-income countries. Even cosmopolitans should accept that an allocation scheme that actually has a chance of being implemented is preferable to an ideal scheme that might trigger the adoption of nationalist schemes that they would find morally inferior. Conversely, nationalist theories of justice should accept an implementable scheme that prevents a wasteful allocation when each country follows its unrestrained self-interest. This was the case in the 2009 pandemic, in which the surplus vaccines were simply wasted. Rather than insisting on an unworkable global allocation scheme, a more sensible alternative would be a middle-ground approach that utilizes the existing national commitments to vaccine development but insists that a portion of the national commitments be distributed through an international framework like COVAX.
Read on Wiley Online Library
Get the Latest from the Milbank Memorial Fund
The Milbank Quarterly’s multidisciplinary approach and commitment to applying the best empirical research to practical policymaking offers in-depth assessments of the social, economic, political, historical, legal, and ethical dimensions of health and health care policy.