When Wealth Decides Who Gets Vaccinated, Every Country Pays the Price

The next pandemic may be shaped as much by who receives the first vaccine doses as by how quickly those doses are developed. When supply follows purchasing power instead of transmission risk, the result is not only greater inequality; it is a longer, more dangerous global emergency.

In "Equity and Pandemic Influenza Vaccine Response: The PIP Framework as a Model for an Efficient Pandemic Influenza Response Through Equitable Vaccine Access," published in Vaccines, WHO authors Kate S. Rawlings, Olga Kim and Anne Huvos examine how advance supply agreements under the Pandemic Influenza Preparedness (PIP) Framework could prevent low- and middle-income countries from being pushed to the back of the queue.

Vaccine equity is often framed as a moral obligation toward poorer countries. The paper argues that this framing is incomplete: equitable and timely allocation is also an efficiency strategy. Vaccinating populations where incidence and transmission are highest can reduce spread, lower the risk of viral evolution and shorten the emergency for everyone.

COVID-19 Showed What Happens When Wealth Sets the Queue

The COVID-19 vaccine rollout demonstrated the consequences of allowing national purchasing power to determine access. According to the paper, high-income countries were able to fully vaccinate roughly 70% of their populations within the first 12 months of vaccine availability. Over the same period, only 4% of people in low-income countries were fully vaccinated. The gap weakened the global response.

When large populations remain unvaccinated, transmission continues for longer. Continued circulation creates more opportunities for illness, death and viral mutation. New variants can then threaten countries that secured early vaccine supplies, including by reducing vaccine effectiveness or driving additional waves.

The authors cite modelling suggesting that more equitable vaccine sharing during the first six months could have reduced infections by an estimated 25.9% in low-income countries, 12.6% in lower- and middle-income countries and 15% in high-income countries. The figures underline a point that pandemic policy repeatedly overlooks: countries do not necessarily protect themselves by holding the largest possible share of early supply.

COVAX was created to improve access, but it entered the crisis after wealthy countries had already negotiated major bilateral purchasing agreements. It also depended heavily on procurement arrangements, donations and cooperation from governments facing intense domestic pressure.

The result exposed the weakness of trying to negotiate solidarity during an emergency. By the time governments confront shortages, rising deaths and political anxiety, the incentives favour stockpiling rather than sharing.

The PIP Framework establishes commitments in advance, before a new influenza pandemic begins and before vaccine nationalism reaches its peak.

PIP's Advantage Is Not Charity

Adopted by WHO's 194 Member States in 2011 after the H1N1 influenza pandemic, the PIP Framework links the sharing of influenza viruses with access to the vaccines and other benefits developed from them. Its most important feature is a set of legally binding advance supply agreements between WHO and vaccine manufacturers. Under these agreements, manufacturers that receive biological materials through the WHO-coordinated influenza surveillance system commit a proportion of future pandemic vaccine production to WHO.

The paper reports that WHO has concluded 17 such agreements with manufacturers estimated to represent 87% of future pandemic influenza vaccine capacity. Together, those commitments provide WHO access to approximately 11% of expected global production as vaccines are being manufactured.

Under a best-case production scenario, that could translate into around 940 million doses during the first 12 months. The timing matters as much as the volume. If a manufacturer has committed 10% of production, WHO is entitled to 10 of every 100 doses produced, not only to surplus vaccines made available after national orders have been filled. The arrangement distinguishes PIP from mechanisms relying primarily on voluntary donations. It gives WHO a contractual claim to supply during the early stages of production, when doses have the greatest potential to interrupt transmission.

Allocation is also intended to follow public-health risk and need. The framework directs priority toward developing countries, particularly those most affected, rather than automatically placing low-income states behind wealthier buyers. This does not guarantee that every country will receive all the doses it wants. Eleven percent of global output would still represent a limited pool during a severe pandemic. Difficult decisions would remain over which countries and populations should receive vaccines first.

However, the framework changes the starting point. It creates a supply channel that is not dependent on a government's ability to outbid competitors in the global market.

A Vaccine Allocation Is Useless If Countries Cannot License, Deliver or Defend It

The authors also avoid treating access as the whole solution. A country may receive a vaccine allocation and still struggle to turn doses into population protection. Vaccines must be authorized by national regulators, imported, stored, distributed and administered. Governments need deployment plans, trained workers, cold-chain capacity and communication systems capable of responding to misinformation and public concern.

These barriers often weigh most heavily on low- and middle-income countries. Delays in authorization or distribution can erase the advantage of receiving doses early.

The PIP Framework thus includes a second benefit-sharing mechanism: annual financial contributions from influenza-product manufacturers to support preparedness. The paper states that more than US$350 million has been collected and used to strengthen pandemic influenza capacity in 86 countries.

Those funds have supported practical readiness. According to the authors, 37 WHO Member States updated pandemic preparedness plans, 16 reached maturity level 3 under WHO's regulatory classification system, and 11 developed or revised national vaccine deployment plans.

The investments also generated benefits beyond influenza. During COVID-19, 47 of 48 countries that had received PIP-supported regulatory strengthening authorized at least one vaccine. Eight countries that had not received vaccines during the H1N1 pandemic licensed a COVID-19 vaccine within 15 days of WHO emergency listing.

These examples reinforce a broader development lesson: equitable access requires absorptive capacity. A global allocation mechanism cannot succeed if countries lack regulatory institutions, logistics systems or public trust.

For development agencies and international financial institutions, this means preparedness investment should not begin when a pandemic is declared. Strengthening regulators, supply chains, health workforces and risk-communication systems is part of vaccine equity, not a separate agenda.

The same applies to regional manufacturing. Expanding production in Africa, Latin America and Asia could diversify supply and reduce dependence on a small number of exporting states, but manufacturing capacity alone will not guarantee equitable access unless contracts, allocation rules and delivery systems are also in place.

Global Rules Meet National Power

The PIP Framework is stronger than a voluntary appeal, but it is not immune to geopolitics. The advance supply agreements are contracts between WHO and manufacturers. The physical movement of vaccines, however, remains subject to national customs and export regulations. A vaccine-producing government can still restrict exports during a crisis.

PIP has not yet been tested during an influenza pandemic under political and supply pressures comparable to COVID-19. The estimate of 940 million doses is explicitly a best-case scenario, dependent on production capacity, manufacturer performance and the absence of major trade barriers.

The article is also a WHO-authored perspective, commissioned and supported through the PIP Framework Partnership Contribution. It offers detailed operational evidence, but it is not an independent impact evaluation or an empirical test of how the system would perform during a full-scale crisis.

Future research should model different production, export-control and allocation scenarios. Independent analysis is also needed on whether 11% of global output would be sufficient to alter transmission trajectories, how WHO should prioritize simultaneous outbreaks, and what enforcement options exist when governments obstruct contracted supply.