Where a Vast Global Vaccination Program Went Wrong

Deaths from Covid-19 were surging across Africa in June when 100,000 doses of the Pfizer-BioNTech vaccine arrived in Chad. The delivery seemed proof that the United Nations-backed program to immunize the world could get the most desirable vaccines to the least developed nations. Yet five weeks later, Chad’s health minister said, 94,000 doses remained unused.

Nearby in Benin, only 267 shots were being given each day, a pace so slow that 110,000 of the program’s AstraZeneca doses expired. Across Africa, confidential documents from July indicated, the program was monitoring at least nine countries where it said doses intended for the poor were at risk of spoiling this summer.

The vaccine pileup illustrates one of the most serious but largely unrecognized problems facing the immunization program as it tries to recover from months of missteps and disappointments: difficulty getting doses from airport tarmacs into people’s arms.

Known as Covax, the program was supposed to be a global powerhouse, a multibillion-dollar alliance of international health bodies and nonprofits that would ensure through sheer buying power that poor countries received vaccines as quickly as the rich.

Instead, Covax has struggled to acquire doses: It stands half a billion short of its goal. Poor countries are dangerously unprotected as the Delta variant runs rampant, just the scenario that Covax was created to prevent.

The urgent need to vaccinate the world goes far beyond protecting people in poor nations. The longer the virus circulates, the more dangerous it can become, even for vaccinated people in wealthy countries.

Without billions more shots, experts warn, new variants could keep emerging, endangering all nations.

“Covax hasn’t failed, but it is failing,” said Dr. Ayoade Alakija, a co-chair of the African Union’s vaccine delivery program. “We really have no other options. For the sake of humanity, Covax must work.”

More supplies are finally on the way, courtesy of the Biden administration, which is buying 500 million Pfizer doses and delivering them through Covax, the centerpiece of a larger pledge by wealthy democracies. The donated doses should begin shipping this month.

But the Biden donation, worth $3.5 billion, comes with a caveat: To help fund it, the administration is diverting hundreds of millions of dollars promised for vaccination drives in poorer countries, according to notes from a meeting between Covax and American officials. Short on funding, those countries have had a hard time buying fuel to transport doses to clinics, training people to administer shots or persuading people to get them.

Even as Covax officials scramble to fill that funding gap, the overriding question is whether the program can move beyond its mistakes, and beyond an imbalance of power that has left it at the mercy of wealthy countries and pharmaceutical companies. Pfizer, for example, balked at a direct deal with Covax this spring, interviews reveal, instead reaching an agreement through the Biden administration, an arrangement that hurt Covax’s credibility as an independent vaccine purchaser.

The program has struggled with delays and infighting. According to interviews and records from Covax, bureaucratic barriers imposed by its leadership have held up the disbursement of $220 million to help countries administer vaccines.

Driven by a nonprofit funded by the Gates Foundation, Covax is a creation without precedent.It has gotten vaccines to poorer countries faster than was previously typical and developed a system to compensate people for serious post-vaccine reactions and protect vaccine makers from legal liability — a plan that saved those countries months of negotiations.

Still, the 163 million doses it has delivered — most free to poorer nations, with the rest to countries like Canada that paid their way — are a far cry from plans to have at least 640 million doses available by now.

Dr. Seth Berkley, the chief executive of Gavi, the nonprofit at Covax’s heart, said insufficient early financing made supply shortages inevitable. When distribution problems of the type in Chad and Benin emerge, Covax tries to “move those vaccines to other countries, but then to work with those countries to try to improve capacity,” he said.

Supporters and critics agree that the program must improve, rapidly. As of early July, confidential Covax documents indicated that 22 nations, some with surging fatalities, reported being nearly or entirely out of doses from the program.

“The way Covax was packaged and branded, African countries thought it was going to be their savior,” said Dr. Catherine Kyobutungi, who directs the African Population and Health Research Center. “When it didn’t meet expectations, there was nothing else.”

Rich and Poor

In the frantic early months of 2020, health experts strategized on how to equitably inoculate the world. Covax was the answer, bringing together two Gates-funded nonprofits, Gavi and the Coalition for Epidemic Preparedness Innovations, or CEPI; the World Health Organization; and UNICEF, which would lead delivery efforts. It hoped to be a major global vaccine buyer, for both rich and poor nations, giving it the clout to bully vaccine makers.

But if rich nations pledged donations, they did not make obliging partners. Britain negotiated for wealthier participants to be given a choice of vaccines to purchase through Covax, creating delays, said Kate Elder, senior vaccines policy adviser for Doctors Without Borders’ Access Campaign.

Most important, rich nations became rivals in a vaccine-buying race, paying premiums to secure their own shots while slow-walking financial pledges that Covax needed to sign deals.

“You can’t be passing the tin cup in the middle of a pandemic,” said Dr. Nicole Lurie, the U.S. director at CEPI, referring to the desperate scramble for financing.

Initially, Covax planned on giant deliveries from the Serum Institute, an Indian manufacturer. But after the virus surged in India in March, the Indian government halted vaccine exports. Many poor countries were rattled. They had banked on Covax, despite often being left out of its decision-making.

Dr. Alakija, who is leading African delivery efforts, said health officials in Africa were scarcely consulted in mid-2020 when the program set an initial target of vaccinating at least 20 percent of poorer countries’ populations. Dr. Alakija recalled that people involved in Covax had said they believed Africa was at low risk and mass immunizations were unnecessary, a claim a Gavi spokesman denied.

The spokesman said that the target was set in the face of “limited resources” and “a limited understanding of Covid-19 epidemiology,” and that it now had enough money to buy vaccines for almost 30 percent of poorer countries’ populations.

Desperate, 17 countries eligible for free Covax doses, including Rwanda, have struck deals to buy doses from Pfizer directly.

By this May, Covax appeared poised to strike a new deal of its own to buy low-cost doses from Pfizer. It had already ordered 40 million in January; this deal was expected to be bigger.

But behind the scenes, tension was simmering between Pfizer and Covax, two people familiar with the negotiations said. The company wanted the new doses to go to poorer nations alone. As a global purchasing pool, Covax insisted on also fulfilling orders from wealthier countries that had been buying directly at higher prices.South Korea, for example, had received Pfizer doses from the program.

And the two sides had already tangled. In negotiations over the first round of doses, Pfizer had sought liability protections beyond Covax’s model indemnification agreement, Dr. Berkley said, asking countries to sign additional legal letters.

Into the standoff stepped Jeffrey D. Zients, President Biden’s coronavirus response coordinator. To allay Pfizer’s unease about wealthier nations getting the doses, the White House would donate the vaccines to only the program’s poorest countries, as well as the African Union.

The United States is paying about $7 per donated dose, roughly a third of Pfizer’s price for Americans, two people familiar with the deal said. Dr. Berkley said the U.S. purchase allowed Covax to get more doses, and faster, than the program was trying to secure on its own.

A Pfizer spokeswoman, Sharon Castillo, said the company had “a collaborative relationship” with Covax.

Jeremy Konyndyk, the executive director of U.S.A.I.D.’s Covid-19 Task Force, acknowledged that the United States had diverted some distribution funds to pay for Pfizer doses because contributing shots was the priority.

The deal looked good for Pfizer and the Biden administration, positioning the United States as a leader in global vaccinations.

But it also highlighted Covax’s difficulty securing a major supply agreement by itself, people involved with the program said — a reputational blow, even as it needs to wrestle with other manufacturers.

CEPI, one of the nonprofits behind Covax, made critical investments to expand manufacturing of several vaccines. But production issues choked deliveries in June from Covax’s main supplier, AstraZeneca, which said shipments had since picked up. Johnson & Johnson, which also had production struggles, has yet to deliver any doses ordered by Covax.

Several major vaccine makers only recently agreed to supply the program, including Moderna and two Chinese companies.

“The world is making a couple hundred million doses a week, so there’s not a supply problem,” said Dr. Bruce Aylward, a senior adviser to the World Health Organization. Instead, he said, vaccine makers and world leaders were electing to put rich countries first: “There’s a choice problem.”

How to Pay for Freezers

With 1.7 billion more doses expected by December, Covax officials fret that some countries will struggle to make use of the vaccines suddenly available. Facing long delivery droughts and uncertain shipments, some countries delayed major preparations.

“It’s much easier to scale up when you have a steady and predictable supply,” said Lily Caprani, a UNICEF senior adviser.

Covax had counted on World Bank grants and loans to finance poorer countries’ rollouts. But because of Covax’s supply shortages, countries spent most of that money on doses.

Gavi, the nonprofit leading Covax, asked its board in June to approve $775 million in new distribution funding, $500 million of it from the United States as part of a donation unaffected by the Pfizer deal.

But the $1.8 billion available by late June for vaccine delivery was still $1 billion short of what health officials estimate may be needed.

Costs are only rising, given that Pfizer doses must be stored at ultralow temperatures. Covax needs to install 250 to 400 more freezers, and backup generators for them. Some African officials worry that their electrical grids could be overwhelmed. As it is, some countries, like Chad, cannot move Pfizer doses outside major cities.

To buy freezers, Covax plans to draw on $220 million pledged by Germany in February. But a bureaucratic impasse has prevented it from being spent, reflecting broader concerns about delays in ramping up delivery funding.

Germany specified that the money be distributed through UNICEF, while also insisting on giving it first to Covax, whose purse strings are controlled by Gavi.

The country would not send the money until the two agencies submitted a joint spending plan, its development ministry said, delaying the payment until early July. But Gavi, exercising oversight of how it is spent, has not yet transferred the cash to UNICEF.

“Covax is like a group project without a leader,” said Andrea Taylor, a Duke researcher studying global vaccinations. “Everything they do is that much slower.”

A Gavi spokesman said that any donation takes time to be deposited, that Gavi had a long history of releasing money to UNICEF and that it would use a faster process for some new distribution funding.

Some African countries have used the vast majority of their Covax doses. But delivery funding has fallen short of what Covax estimated was needed in dozens of lower-income nations, confidential documents said.

Even as American officials now press Covax to prepare for the crucial Pfizer doses, wealthy countries remain reluctant to fund such work, experts said. The difficulties have prompted calls for Covax to share more power with humanitarian and regional groups on the ground.

“I don’t see a lot of understanding that they will never be able to do this centrally,” said Dr. Mark Dybul, a Georgetown professor. “I’m worried they’re going to end up with a lot of vaccine that’s stuck.”

Reporting was contributed by Sharon LaFraniere, Noah Weiland, Sheryl Gay Stolberg, Mahamat Adamou and Léonce Gamai.