Welcome to the second episode in our series exploring issues related to COVID-19 vaccines in our region, as we plan Australia's $500 million Regional Vaccine Access and Health Security Initiative.
In the week before the Global Health Security Agenda Ministerial Meetings in November this year, the Indo-Pacific Centre for Health Security hosted a side event on COVID-19 vaccine financing. The Centre represents Australia as one of the leads on the Sustainable Financing for Preparedness Action Package.
Why this side event on vaccine financing? Well, when safe and effective vaccines for COVID do become available, they will be needed for both preparedness and response. There might be sufficient funding available in the short term, but not enough vaccines to go around. In the medium term, we might have the reverse problem, insufficient funding, and too many COVID-19 vaccines. So the purpose of this event was to bring together some key partners in vaccine financing.
There are already several mechanisms established, including the COVAX Facility, and recent announcements from the multilateral development banks for vaccine financing. In this space, we see opportunity, and as always, risk. So we brought together six panelists from around the world to discuss what successful coordination looks like, with our principal goal being that developing countries get equitable, affordable and timely access to safe and effective COVID-19 vaccines.
We heard from Aparnaa Somanathan, the Practice Manager for Health, Nutrition and Population for the East Asia Pacific Region at the World Bank. Patrick Osewe, Chief of the Health Sector Group at the Asian Development Bank, and Saul Walker, the Deputy Director for Vaccines, Therapeutics and Diagnostics at the UK Foreign Commonwealth and Development Office. Santiago Cornejo from Gavi has recently been appointed as the Director of the Country Engagement for the Office of the COVAX Facility. And for a pharmaceutical industry perspective, we were joined by Adrian Thomas, Global Vice President of Global Health at Johnson and Johnson.
We are pleased to bring you the highlights of our hour long discussion.
For more information about the Indo-Pacific Centre for Health Security, visit our website https://indopacifichealthsecurity.dfat.gov.au.
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Dr Stephanie Williams 00:01
Welcome to Contain This, I'm pleased to host the second episode in our series exploring issues related to COVID-19 vaccines in our region, as we plan Australia's $500 million Regional Vaccine Access and Health Security Initiative. In the week before the Global Health Security Agenda Ministerial Meetings in November this year, we hosted a side event on COVID-19 vaccine financing. We being the Indo-Pacific Center for Health Security, representing Australia as one of the leads on the Sustainable Financing for Preparedness Action Package.
Why this side event on vaccine financing? Well, when safe and effective vaccines for COVID do become available, they will be needed for both preparedness and response. There might be sufficient funding available in the short term, but not enough vaccines to go around. In the medium term, we might have the reverse problem, insufficient funding, and too many COVID-19 vaccines. So the purpose of this event was to bring together some key partners in vaccine financing. There are already several mechanisms established, including the COVAX Facility, and recent announcements from the multilateral development banks for vaccine financing. In this space, we see opportunity, and as always, risk. So we brought together six panelists from around the world to discuss what successful coordination looks like, with our principal goal being that developing countries get equitable, affordable and timely access to safe and effective COVID-19 vaccines. We heard from Aparnaa Somanathan, the Practice Manager for Health, Nutrition and Population for the East Asia Pacific Region at the World Bank. Patrick Osewe, Chief of the Health Sector Group at the Asian Development Bank, and Saul Walker, the Deputy Director for Vaccines, Therapeutics and Diagnostics at the UK Foreign Commonwealth and Development Office. Santiago Cornejo from Gavi has recently been appointed as the Director of the Country Engagement for the Office of the COVAX Facility. And for a pharmaceutical industry perspective, we were joined by Adrian Thomas, Global Vice President of Global Health at Johnson and Johnson.
I'm pleased to bring you the highlights of our hour-long discussion.
Our first question really is what needs to happen for the COVAX AMC to be successful. And to start the response here we'll throw to Santiago.
Santiago Cornejo 04:20
Thank you, Stephanie. And as I mentioned, COVAX is a global effort to ensure equitable access to COVID vaccine for all. So what I would like to focus on three key elements that we need. One is demand. We need a broad participation from all economies, all countries to in the COVAX Facility, so we need all 92 AMC eligible countries to confirm their participation and the demands that they need. But this is not just about only AMC eligible countries. We also need self-financing countries to participate. We need to remember that no one is safe until everyone is safe. But that leads to my second topic which is supply. We need rapid development of a safe and efficacious vaccine that is appropriate and affordable to all settings. We have an unprecedented pipeline that is moving very, very fast, which is great news. But also, we need to remember that while speed is very important, development takes time, because safety is paramount. But once we have a vaccine that is safe and efficacious, then what AMC will be doing is seeking to have access to early doses, for those countries that are eligible, and we aspire to do it at a not-for-profit price, particularly during this acute phase of the pandemic. Of course, this will allow us to maximize the donor resources that we have, in order to have a broader ability to purchase more doses. Which leads to the third topic, that is quite what we need, which is funding, we need adequate financing to secure the supply for all AMC economies, who have no other means to purchase the vaccines. And we need this predictable financing in order to ensure a wide range of a portfolio of vaccine for countries. We don't know yet which vaccine will be successful. So we need to ensure that we will have a wide portfolio of several candidates that countries will have access.
Our target, as Saul mentioned was to reach by the end of this year $2 billion, we are very close to that target, which is great news. And we're very thankful all of our donors and including Australia and the UK for your support. But also we need to mobilize next year, an additional $5 billion in order to secure this access to every country. Which leads to my fourth point of what we will need, which is country readiness. We need everyone to support these countries to ensure that they're ready to roll out their vaccines once they're available. The scale and the speed of the introduction is unprecedented. Also, we need to remember that the platform how this vaccine will be rolled out will be different to what has been experienced with other vaccines. This is why we need all partners to work together in the support of countries. And I will encourage all countries to start the preparation and the planning for the rollout of the vaccine at this moment now, because we don't want anyone to be left behind.
Dr Stephanie Williams 07:43
Because we're talking about the AMC in particular, and we started off by talking about demand, of the 92 eligible AMC countries, how many are yet to express a demand? How are you going in defining the demand?
Santiago Cornejo 07:59
So we will be sending what we will call the vaccine request next week to all eligible 92 economies. And countries then will send us this vaccine request where they can identify what will be the demand. Also there we highlight some critical issues that they need to be aware in terms of rolling out these vaccines, such as the supply chain, and the different steps that they will need about to think in order to start preparing right now.
Dr Stephanie Williams 08:31
Thanks, Santiago. Saul, I would welcome your reflections on what looks like success for the AMC.
Saul Walker 08:38
So the first thing I would say was just the importance of just getting the supply and the demand working together. There is a huge piece of work by CEPI and Gavi and putting together the largest portfolio of vaccines in the world. We're now seeing deals done with companies, and three announced already. And also Adrian's mentioned how companies are stepping up to commit to global access. That needs to go further. I think we actually need to see the deals get done now. GAVI and COVAX does have money in the bank. So it's really now time I think time to begin to see those deals announced. And as far as companies can to, to push the envelope a little bit on pricing, such as J&J has done, such as a AstraZeneca have done on nonprofit and ideally flat pricing where possible. On the demand side, I think we are a little bit behind the curve there. We really do need to get moving on actually characterizing demand in countries. As we know, probably the target groups for COVID vaccination are going will be non-standard. They're not childhood vaccines. How do we reach those populations? How do we identify them? How do we prioritize them? Is going to be important and adapting that as we know more about the characteristics of whichever vaccines are successful. Countries also, I think all of us, need to commit to the equitable access approach. We are going to have supply constraints at least in the first 12-18 months, two years, of this. So we do have to make sure that we're working to make sure that countries get vaccines to vaccinate their priority constituencies and target groups effectively. I think the demand side will be more complex in countries than perhaps we've kind of gripped at the moment, both in terms of which populations countries will want to vaccinate, where they are in terms of their outbreaks, what their supply and delivery challenges will be in countries, how they mobilize population support.
So working with countries and putting countries and communities at the center of understanding those immunization strategies on a country by country basis, is going to be really important. And I think the work that that GAVI is now doing and the World Bank is doing to support countries around immunization introduction planning is really crucial. And I think one of the key things there is to make sure that we're coordinated across the different international partners here. I know, for example, Gavi's vaccine readiness tool and the Bank's vaccine readiness tool are slightly different. So we should try and see that coordination there, that countries don't get asked the same questions repeatedly, but slightly differently. Second, cooperation, coordination and adaptability. As I noted there, you know, this is going to be an unparalleled complexity of supply and delivery, we really haven't seen anything like this done as fast as this or across as many countries as this. And it's really going to be incumbent on all of us to try and make this as streamlined as possible for countries to be a bit more forgiving in in what they expect in terms of specificity. From vaccines in terms of whether it's packaging, or whether it's approaches to procurement, to try and reduce the complexities of companies who are trying to support to plan their supply and delivery schedules. And then also for countries to know what they can expect from Gavi, from donors from COVAX, from other partners in helping them to deliver on this.
And of course, the other key thing that we have to take into account here is adaptability. We don't know which vaccines will be effective. Even with the best planning in the world, there will be hiccups in supply, there will be delays on occasion, there will be delays on the demand side as well as on the supply side. And we're going to need to be able to adapt to that. So good communication, actually a commitment to working together on this are going to be crucial in making this work. Immediate but sustained financing. So Santiago ran through some of the numbers there. $2 billion to secure supply capacity for AMC countries, probably five to seven billion dollars next year for procurement depending on which vaccines are ultimately successful. And then additional financing to then deliver those vaccines in-country. I think one of the things we should be doing as we deliver and learn from COVAX, is actually building systems and approaches that will help us in the future. No, this will not be the last pandemic that we deal with. We've done an amazing job the world has done an amazing job in bringing COVAX together and companies stepping up and donors and countries stepping up. But we are playing catch up a little bit. And we're particularly playing catch up on some of the manufacturing capacity that we have available and how we approach this equitable access approach. So how do we learn the lessons as we go with COVAX to build a system that will help us respond more effectively and more quickly next time? And again, I think key to that is going to be sustainable financing, not just during pandemics, but actually in between pandemics as well.
Dr Stephanie Williams 13:58
Thanks, Saul. Great points. I will go to Adrian now, for your perspective.
Adrian Thomas 14:05
What people don't often think about is what do you actually put a vaccine into to deliver to someone? And this is not really talked about very much, but in terms of what we call fill and finishing, or taking drugs substance or vaccine substance and making a product, which is either in a vial or syringe, you know, there's probably not enough glass vials in the world to satisfy the total demand if it were if 100% realized. And so those upstream technologies that need to be scaled very, very rapidly, are a challenge. And that's why I think it's so important, though, in terms of de-risking the financing of this, that we find ways to accelerate those manufacturers; we recognize and give clarity on what the demand is to companies like ours so that we can allocate the right resources against it. I mentioned that we were doing development and upscaling work in three continents, that has its challenges in itself. Like, which plant to which continent will be acceptable for which government for what delivery? So that takes me sort of to the next thing which is around, and which we mentioned, but the demand management, dynamic allocation and reallocation of vaccines will be critical. And one of the things, again, that we really need to have attention on is, when people say, vaccine delivery, preparation or preparedness, the vast bulk of vaccine globally is probably not going to be available until the end of 2021 in terms of realizing scale up without any manufacturing hiccups, which, as we know, is always a risk in this sort of speed of a business. And, therefore, if companies have to work with 150 plus individual governments one on one, for a vaccine that may or may not arrive first or second, that becomes complex. And so the role of a COVAX Facility, and particularly those higher income countries, who are helping steer and guide the debate is paramount to us, so that we can take issues of equity off the table.
Dr Stephanie Williams 16:21
Thanks, Adrian. It's terrific to have private sector perspective, and just some of the mentions of dynamic allocation and reallocation and seeing how industry sees a market and a vaccine and its interaction being critical. I think Santiago would like to respond to you, Santiago.
Santiago Cornejo 16:39
Yes, thank you, I but I think what's important is to understand the limitation at the moment - it's not going to be demand, it's supply. We need to ... So if countries go bilaterally, then we're still reaching for the same supply. We don't know which vaccine is successful yet. We don't know. And as Adrian mentioned, it will take some time, even after we have we know that it's efficacious and safe, to really reach that scale of production to ensure that the whole world it will be vaccinated. So this is where for us, from the COVAX Facility, and I think something that Saul mentioned, which is critical, we need a global solidarity effort. This is not that we believe that only 20% of the population should be vaccinated, what we are trying to say is we hope and we aspire to have 2 billion doses by next year. If we do that, then we can assure that those are need it the most will have access to the to the vaccines.
Dr Stephanie Williams 17:42
And I think this is a good point to segue because we have heard a lot of support for the essential nature of the COVAX Facility and multilateral solutions, and a characterization of short term and medium term dynamics which will be different for supply and demand of COVID-19 vaccines. The next part, the next question is really about with the other actors, the other external financing for COVID vaccine that is available public and announced. How are the institutions with that funding, working to complement efforts and to minimize duplication and really, and minimize competition in a way for the scarce supply in the early in the early months to years?
Aparnaa Somanathan 18:31
The discussions that we've had with governments and partners to date indicate that the banks are well placed to provide the health system strengthening investments that are needed to deliver the vaccines. So as we've already heard a few times today, purchasing vaccines is just one step in a complex multi-dimensional effort that involves detailed planning, implementation of vaccine deployment, programs in specific country-level contexts and health systems. And the banks tend to have a network of technical and implementation support capacity already working on the ground due to previous engagements in the health sector, which reflects some comparative advantage in providing this hands-on systems-strengthening support, in addition to direct financing of vaccine purchases. And this type of system support can build easily on existing COVID support projects like with the World Bank's previous MPA, as well as the broader health portfolio. We know that in the AP region, the economic shock due to COVID and its implications for health financing has nothing to do with the level of COVID itself. Pacific Island States that have managed to avoid COVID altogether are going to be some of the worst hit. And with economic shock, comes a decline in revenues and a hit on health financing.
Dr Stephanie Williams 19:55
Thanks, Aparna. And it's a good reminder that we can never isolate a single commodity in a health system and talk about it in isolation. So thank you for those remarks.
Let's talk about financing that's available beyond the advanced market commitment. The AMC is critical, and it's clear it's needed for the acute phase of the pandemic. We also think it's important that developing countries have some agency around what they might need to best finance their vaccine needs.
And so, additional financing is needed for a range of reasons. As we understand today, there may be a requirement for countries to co finance their vaccine doses through the events market commitment. With such a big global economic shock, countries may need financing to even enter into commitments under the AMC. In addition, there's going to be a real need to make sure countries can cover populations beyond 20% in the short term, if they choose to do so. I know the COVAX facility has ambitions beyond 20%. But we need to work collectively to see how that can be made possible for countries. We also think it's important countries have a degree of agency choices between different financing mechanisms to enable greater control over vaccine selection of vaccine quantities and vaccine types.
Within the AMC, we know GAVI is making best endeavours to meet country preferences, however they as well acknowledged, there will be limitations given the scarcity of supply.
As a developed country, Australia has entered into advanced purchase agreements already, we've also entered into the COVAX facility. So we've been given a choice about the different mechanisms to meet our domestic needs. It's important when we think about partner governments in the region and globally in the same way, offering the opportunity of choice of vaccines and vaccine financing mechanisms. At the same time, it's critical, we don't drive up vaccine price, we need to make sure we're not crowding out the space between different mechanisms that are available, which really speaks to why we're talking together today.
So I think the best way to do that is engagement between major mechanisms that already exist in the multilateral development banks, GAVI, UNICEF, major donors and being transparent with each other about respective initiatives and resources available and how those resources may be allocated. And ensuring that coordination is something we do continuously, not just globally, but regionally and at the country level and early engagement with our partner governments. Assessing need in a coordinated fashion is critical.
And that brings us to the new initiative that Australia has recently announced a 500 million Australian dollar initiative to support procurement of vaccine doses for countries in Southeast Asia and the Pacific.
It will enable critical Technical Advisory and support work to support immunization rollout. So when we're talking about financing, we can't talk about in isolation, it's about more than the dollars. We're talking about critical preparedness work, which makes sure that doses don't get dropped off at wards or airports. And we are all invested collectively in the preparedness measures that we need to take well in advance of doses coming off manufacturing belts, and even looking at cold chain storage, training and health workers, early risk communication with communities and getting ahead in the preparatory work in the regulatory space. Australia's new initiative will be a comprehensive package targeting Southeast Asian and Pacific.
Dr Stephanie Williams 25:22
Open to the panel for any other reflections on the complementarity of additional mechanisms. Saul?
Saul Walker 25:42
So I think, to the degree that we can put countries at the centre of this, help countries do their planning, make sure countries have good information about vaccines, about some of the costs and potential impacts of different products is going to be essential. I would also say I suspect that actually countries are going to have to make health allocation decisions as well, there will be other things that will have higher public health impact for them, then getting to, you know, above 20%, for COVID vaccination. Whether that be through other vaccine preventable diseases or other health issues in countries and actually helping countries make those allocative decisions, of course, their health portfolio is going to be really important and just coming in with financing that is only available for COVID vaccines, I think will skew some of those decisions.
Dr Stephanie Williams 26:34
From your perspective, Patrick, and the work of the ADB, what is your advice to countries in our region looking for assistance in how to get the most out of our combined interest in supporting access to good early technologies such as COVID vaccines? Over to you, Patrick.
Patrick Osewe 26:52
I think that what we see is that there's never been such a strong commitment from governments. I think because of what the pandemic has done on the economies of many countries. I have never been able to get the attention of the Ministers of Finance the way I'm getting right now. I think that there needs to be significant capacity to support countries to be able to decide how much vaccines they want, at what time. Because I think that many countries, sometimes they just think that if, for example, a country like Pakistan, with 220 million population got 150 million doses today, what do they do with it? There will be major significant challenges and so on. So this looking at demand and forecasting what is needed at what time is a critically embedded challenge. And then if you look at the issue of cold chain, UNICEF is very fast to say that the, you know, the existing cold chain is for vaccines, and so on. But now we don't know about adult vaccines. So to what extent do we support UNICEF and COVAX to ensure that the cold chain that exists today reflects the demand that we see on the ground. Because the existing culture for children, perhaps is not 100% sufficient to cover the vaccines that will be will be available. Because we are doing something that has never been done in the history of the world. Trying to vaccinate the 7.8 billion people in the world. 4.6 billion are above the age of 18. And in our region, we have 52% of that population. This is a huge population.
Dr Stephanie Williams 28:42
And Santiago, I feel like I come to you all the time. But really COVAX and Gavi are at the center of these initial efforts, and the other actors have come in behind. And we've heard already that there are ways to play to our comparative advantage, to define our strengths in countries, to coordinate in discussion with countries. But from your perspective, what are some of the ways in which we can work better to put countries at the center of this discussion?
Santiago Cornejo 29:11
Thank you. And you're right, I think countries need to be at the center. So I will start with first what's required for every country. To set up, to form a group that will be responsible for planning this rollout. Saul mentioned and I mentioned during the first, how are we going to roll out this vaccine is not the same way that we were doing our other vaccines. So this would be very different in terms of rollout. So we need to create this group in each of the countries that bring different stakeholders from different ministries to start working together in planning and preparing for this. I think by Adrian by Patrick and by others, that we really need to pay attention to the regulatory aspects. And I think here, also the trust and regulatory aspects, industry is speeding up the process in terms of coming with safe vaccines, donors are coming up also and really making their commitment. I think what we need to make sure is that then there is no bottlenecks at country-level in terms of requirement for approval. We need to trust systems. WHO prequalification, the approval of stringent regulatory agencies, because if every country start requesting its own process, its own labeling, its own characteristics, then there will be even more delays in order to ensure access. So we all need to come together in trying to see how we're going to resolve this issue. Because it will be a shame if we can accelerate on one side and then on the other side, then we found a bottleneck. And then vaccines that potentially will be ready cannot be rolled out because of regulatory requirements and different type of specifications that each country will ask for. So I think this is something that we need to look at.
Dr Stephanie Williams 32:46
This discussion drew out a range of issues around vaccine access and financing. Importantly, all panelists agreed that coordination was essential between financiers. And we had a much broader discussion around what we've achieved to-date as a global community, including through the leadership of the COVAX Facility, and as always a shared view on the importance of equity of access and ensuring efficiencies given scarce resources at this time. In terms of coordination, it seems it's about having clarity around the strategic intent of funding from different agencies, recognizing when might be the most appropriate time for vaccine doses, for technical assistance, or for regulatory support. We also touched on the importance of working to our comparative advantage as agencies. I was pleased to hear Aparnaa Somanathan from the World Bank talk about the need to continue support for essential health services. And Patrick Osewe from the Asian Development Bank, talking about the opportunity and the need to continue sustainable, predictable spending in health, even in the face of broad fiscal downturn. Adrian Thomas from Johnson & Johnson was our private sector representative. He put new ideas on the table. Saul Walker from the United Kingdom represented long term development partners, and finally, Santiago Cornetto from GAVI, and more recently the Office of the COXAX Facility. It's clear we need to act together and forge new ways to cooperate, because while we're narrowly focused on the COVID vaccine, we are building health systems for the future. I hope you can join us next fortnight to Contain This.