Seminars in Immunopathology (2024) 45:469–480

https://doi.org/10.1007/s00281-023-00998-0

REVIEW

Causes and costs of global COVID‑19 vaccine inequity

Received: 9 February 2023 / Accepted: 22 September 2023 / Published online: 23 October 2023
© The Author(s) 2023

Abstract
Despite the rapid development of safe and effective COVID-19 vaccines and the widely recognized health and economic
benefits of vaccination, there exist stark differences in vaccination rates across country income groups. While more than 70%
of the population is fully vaccinated in high-income countries, vaccination rates in low-income countries are only around
30%. The paper reviews the factors behind global COVID-19 vaccine inequity and the health, social, and economic costs
triggered by this inequity. The main contributors to vaccine inequity include vaccine nationalism, intellectual property rights,
constraints in manufacturing capacity, poor resilience of healthcare systems, and vaccine hesitancy. Vaccine inequity has
high costs, including preventable deaths and cases of illnesses in low-income countries, slow economic recovery, and large
learning losses among children. Increasing vaccination rates in low-income countries is in the self-interest of higher-income
countries as it may prevent the emergence of new variants and continuous disruptions to global supply chains.

Keywords Vaccination · Equity · COVID-19 · Nationalism · Vaccine hesitancy · Socioeconomic costs

Introduction the largest global economic crisis seen in a century [10]. The
pandemic ushered in school and workplace closures to con-
The COVID-19 pandemic triggered staggering health, trol the spread of infections, driving massive unemployment,
social, and economic costs. As of July 2023, there have permanent business closures, disruptions in global supply
been more than 6.9 million confirmed COVID-19 deaths chains, and increasing learning gaps between rich and poor
worldwide [1], although estimates of excess mortality sug- children [11–15]. The International Monetary Fund (IMF)
gest that the total number of deaths caused by the pandemic estimates that global gross domestic product (GDP) dropped
(i.e., including also deaths from other causes) is two to three by 3.1% during 2020 [16]. Even though the global economy
times larger than the official count [2, 3]. The discrepancy recovered during 2021 (with global GDP growing by 6%)
is due to likely under-reporting of COVID-19 deaths [4], thanks to access to COVID-19 vaccines and the relaxation
but also to the broad health impacts of the pandemic, which of social and economic restrictions, the negative socioeco-
encompassed the overtaxing of healthcare systems [5, 6], nomic effects of the pandemic are lingering and contribute to
the disruption of routine immunization and medical testing the economic slowdowns experienced in 2022 and projected
[7], delays in treatments [8], and reduced willingness to seek for 2023 [17].
care out of fear of infection or pandemic-related negative The rapid development of effective and safe COVID-19
income shocks (e.g., unemployment and health insurance vaccines played a key role in containing the health and soci-
loss) [9]. The COVID-19 pandemic is also responsible for oeconomic costs of the pandemic [18]. Vaccination allowed
countries to control the spread of infections and to reduce
hospitalizations, mortality, and morbidity. It has also allowed
This article is a contribution to the special issue on: Global countries to reopen their economies and to ease mobility
Pandemics - Guest Editors: Simone Pecetta & Rino Rappuoli
restrictions. While the health and socioeconomic benefits
* Maddalena Ferranna of COVID-19 vaccines are unquestionable [19], COVID-19
ferranna@usc.edu vaccination rollout has proceeded at heterogeneous paces
1
throughout the world. As of July 2023, approximately 65%
Department of Pharmaceutical and Health Economics,
Alfred E. Mann School of Pharmacy and Pharmaceutical
of the global population has completed the initial COVID-
Sciences, University of Southern California, Los Angeles, 19 vaccination protocol (i.e., two shots for most vaccines).
CA, USA

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However, while in high-income countries, more than 70% of and exacerbated socioeconomic inequities both within and
their population have completed the initial protocol; among between countries, among other factors. Low vaccination
low-income and lower-middle-income countries, vaccina- rates make countries vulnerable to the risk of new infec-
tion rates are falling behind. In particular, only 2% of total tion waves in the future, with the resulting stream of health,
COVID-19 vaccine doses (including boosters) have been social, and economic burdens.
administered in low-income countries [20]. The objective of the paper is to examine the health, social,
Low-income and lower-middle-income countries have and economic costs caused by COVID-19 vaccine inequity
relied mostly on vaccine donations from developed coun- and to draw lessons for pandemic preparedness. Using
tries and on support from COVAX (COVID-19 Vaccines results from the literature and publicly available datasets, the
Global Access), a global vaccine sharing scheme led by the paper will first describe patterns of COVID-19 vaccine allo-
Coalition for Epidemic Preparedness Innovations (CEPI), cation across countries and over time and characterize the
Gavi the Vaccine Alliance, and the World Health Organiza- degree of inequity in the distribution of vaccines. The paper
tion (WHO) [21]. As of July 2023, COVAX has delivered will then discuss the factors that contributed to inequity in
almost 1.9 billion doses of COVID-19 vaccines to 146 coun- the global allocation of COVID-19 vaccines and examine the
tries, mostly low- and lower-middle-income countries [22]. health, social, and economic costs caused by this inequity.
Nonetheless, vaccination rates have proceeded at very differ-
ent speeds across countries’ income groups. Several factors
have undermined the effective delivery of vaccines through Inequity in the global allocation of COVID‑19
COVAX, including vaccine hoarding, manufacturing con- vaccines
straints, export bans, and logistical issues [23]. Spreading
vaccine hesitancy due to misinformation or mistrust con- COVID-19 vaccination coverage varies starkly across coun-
tributes to low vaccination uptakes [24]. tries. Figure 1 depicts the percentage of people fully vac-
The persistent global inequity in vaccination rates has cinated against COVID-19 by countries’ income group:
daunting health, social, and economic consequences [25]. For each income group and date, I divided the cumulative
Low vaccination rates have caused preventable deaths and number of fully vaccinated individuals by the total popula-
illnesses, slowed down the economic recovery process, tion of that income group. Individuals are considered fully

Fig 1  Percentage of fully vaccinated individuals by income group. Source: Our World in Data [20]. The classification of countries by income is
based on the 2021 World Bank definition of income groups

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vaccinated if they completed the initial vaccination protocol coverage level is still informative about the large inequality
(three doses in three-dose vaccines, two doses in two-dose in vaccination coverage across countries.
vaccines, and one dose in one-dose vaccines). As of July Figure 1 looks at full vaccinations. Instead, Figure 2
2023, 75% of people in high-income countries and 79% of depicts the number of COVID-19 vaccine boosters admin-
people in upper-middle-income countries have been fully istered per 100 people across income groups. Note that the
vaccinated. In lower-middle-income countries, the percent- number of individuals who have received at least one booster
age of fully vaccinated individuals is around 59%. In con- is lower than the number of boosters administered since
trast, in low-income countries, only 27% of the population some people might have received more than one booster
has been fully vaccinated. The time profile of vaccinations dose. In addition, the decision to administer booster doses,
also differs markedly across countries, with higher-income the timing of administration, and the eligible population
countries starting the vaccination process earlier than lower- differed across countries. Notwithstanding all these facts,
income countries. Note that Figure 1 is based on countries’ the graph shows that the administration of booster doses is
official reports of vaccinations. The discontinuities in the highly regressive. In low-income countries, the number of
time patterns of vaccination reflect discontinuities in the administered boosters covers less than 4% of the popula-
timing of reports. tion, while in high-income countries, the number of admin-
In 2021, the World Health Organization recommended istered boosters could cover 66% of the population. This
that countries should have at least 70% of their popula- comparison highlights an additional element of inequality
tion fully vaccinated by the end of June 2022 [26]. This in the global allocation of COVID-19 vaccines, as one could
target was set to guarantee global COVID-19 protection easily argue that some of the booster doses could have been
as 70% was considered a good estimate of the herd immu- used to increase primary vaccination rates in lower-income
nity threshold (i.e., the minimum proportion of COVID-19 countries.
vaccinations that would allow interruption of the chain of The previous figures speak about the inequality in global
transmissions). As Figure 1 shows, only high-income and COVID-19 vaccination rates. To what extent is the une-
upper-middle-income countries achieved that goal. Even qual distribution of COVID-19 vaccines also inequitable?
though COVID-19 herd immunity is now considered an To answer this question, I take an ex-ante perspective and
elusive goal due to the continuous emergence of new vari- reflect on what would have been an equitable global alloca-
ants that escape infection-acquired and vaccination-acquired tion of COVID-19 vaccines in the initial phases of the vac-
immunity [27], the comparison with the 70% vaccination cination campaign given the information available at that

Fig 2  COVID-19 vaccine boosters administered per 100 people by country income group. Source: Our World in Data [20]

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time concerning COVID-19 epidemiology and anticipated Second, and related to the previous issue, overall harms
effectiveness of COVID-19 vaccines. In other words, sup- can be reduced by increasing the resilience of healthcare
pose we are back at the beginning of 2021, and we have to systems and welfare programs. For example, a country
decide how to globally allocate the first batches of COVID- with a large share of older adults but a good healthcare
19 vaccines. Which factors should we consider to determine system may face overall lower mortality rates than a coun-
an equitable global outcome? try with a smaller share of older adults but a less resilient
The United Nations defines global vaccine equity as the healthcare system. Similarly, the coverage and generosity
situation where vaccines are “allocated across countries of welfare programs (e.g., unemployment subsidies) can
based on needs and regardless of their economic status” substantially reduce the socioeconomic costs of the pan-
[28]. The crucial issue here is how to characterize “needs” demic, thereby weakening the economic argument in sup-
for COVID-19 vaccines. I am going to take for granted that port of vaccination prioritization. This calls for skewing
the populations with the largest need are those who are the allocation of vaccines towards low-income countries,
expected to suffer the most from COVID-19 if not vacci- as they are less likely to be able to cope with the negative
nated. However, harm can be measured in multiple ways. effects of a pandemic.
Direct harms of COVID-19 include deaths, disabilities, and Third, the optimal allocation of COVID-19 vaccines is
hospitalizations caused by COVID-19 infections. Thus, complicated by the potential effectiveness of the vaccine in
countries with the largest need may be those that anticipate reducing transmission risks. Given the network of relations
the largest health burden if their population is not vacci- and contacts among countries and populations, protecting
nated. But COVID-19 causes also indirect harms, includ- the needs of the most vulnerable may call for vaccinating
ing additional deaths and disabilities due to strains in the first less vulnerable, but highly connected populations. For
healthcare system, unemployment, business closures, edu- example, debates about the optimal allocation of COVID-
cational gaps, and the risk of falling into poverty. Therefore, 19 vaccines within a country were shaped by the trade-off
countries with the largest need may be those that anticipate between vaccinating the older people first (high risk, low
the largest socioeconomic burden if their population is not contacts) or the working-age population first (lower risk,
vaccinated. high contacts) [35]. The same argument can be extended
At least four additional factors complicate the definition at the global level: Should vaccines be allocated to coun-
and measurement of “needs” for COVID-19 vaccines. First, tries that are facing the largest harm (however defined) or to
the lack of COVID-19 vaccination creates both health and countries that are more likely to transmit the virus to the rest
non-health harms. This requires a methodology for weighing of the world? Even if one believes that poorer countries have
the relative importance of qualitatively different harms [29]. less need for COVID-19 vaccines due to their demograph-
For instance, since the beginning of the pandemic, it was ics (i.e., low share of older people), distributing vaccines in
clear that mortality and severe health consequences were low-income countries could in principle prevent the surge
positively associated with age [30]. On the other hand, the of new variants and new waves of infections, whose nega-
socioeconomic burden of the pandemic fell largely on chil- tive impacts will likely be transmitted to wealthier countries.
dren and working-age adults from low socioeconomic back- Finally, countries’ relative “need” for COVID-19 vac-
grounds due to disruptions in the education system and labor cines is not a static concept, but it changes over time depend-
markets [31–33]. In addition, less resilient economies are ing on the proportion of people already infected or vacci-
expected to suffer more from the pandemic (and less resil- nated (i.e., the proportion of people that are presumed to be
ient economies typically coincide with younger and poorer protected at least in the short-term), on the characteristics
populations) [34]. Should the distribution of COVID-19 of the dominant virus variant (e.g., its transmissibility and
vaccines aim at reducing the health burden first and fore- lethality), on the expected future trends of virus transmission
most, or should it aim at saving livelihoods and reducing channels, and on the capacity of a country to sustain new
the economic burden? The former would justify sending the pandemic waves from both socioeconomic and healthcare
vaccines first to countries with an older population, while perspectives (e.g., the experienced degree of disruption of
the latter would justify sending the vaccines first to countries the healthcare system and the state of public finances after
that face the largest risk of poverty due to COVID-19. Note prolonged public economic support).
also that income reductions tend to have detrimental effects Determining the optimal and equitable global allocation
on population health (e.g., individuals forego prevention of COVID-19 vaccines is beyond the scope of the paper. A
activities and treatments because of liquidity issues, thereby few contributions have considered this issue and proposed
putting them at higher risk of morbidity and mortality in the frameworks to guide the distribution of vaccines and to
future). Thus, there is not only a trade-off between saving judge its reliance on principles of fairness. A noteworthy
lives and saving livelihoods but also between saving lives proposal is the “fair priority model” that suggested replac-
now and saving lives in the future. ing the proportional allocation (by population size) from

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COVAX with an allocation based on the urgency of needs reducing transmission were deemed to be positive. Instead,
[36–38]. The fair priority model envisions three phases of prospective evaluations (i.e., how COVID-19 vaccines
vaccine allocation, with the goals, respectively, of reduc- or other pandemic vaccines should be distributed in the
ing premature deaths, reducing serious economic and future) should account for the most recent information on
social deprivation, and reducing community transmission. the characteristics of vaccines.
Among the factors to consider in determining the equi- Although inequality is not necessarily synonymous with
table global allocation of COVID-19 vaccines, I listed inequity, the stark differences in vaccination rates across
also the potential effectiveness of vaccines in reducing country income groups, the large health and economic toll
transmission. The importance of the transmission-reducing suffered by unvaccinated populations, and the current lack
goal in COVID-19 vaccine allocation is nowadays an open of constraints in global vaccine supply all indicate that
question. Although existing COVID-19 vaccines were the unequal distribution of COVID-19 vaccines and vac-
found to be partially effective at preventing transmission of cination rates has indeed been inequitable and suboptimal.
the initial virus strains [39], vaccine-associated reductions To reinforce this argument, Figure 3 shows the number of
in transmission of the new variants are considerably lower fully vaccinated individuals as a percentage of the popula-
and rapidly wane over time [40], leading to larger num- tion aged 65 and over by country income group. The share
bers of breakthrough infections. On the other hand, even of older people is an imperfect metric of the population at
if not perfectly shielded from infectiousness, vaccinated highest risk of COVID-19 hospitalization and death. Mor-
individuals appear to be less infectious than unvaccinated tality from COVID-19 is correlated not only with age, but
individuals and present reduced and faster-disappearing also with the presence of comorbidities, pollution levels,
infectious viral load [41–43]. All this considered, should and living arrangements, among other factors [45–47]. Due
differences in transmission risk across countries matter to the nature of their job, frontline healthcare workers and
in determining the largest need for COVID-19 vaccines? other essential workers were also more likely to get infected
I argue that a retrospective evaluation of the inequity in and suffer severe health consequences independently of their
global COVID-19 vaccinations should reflect the infor- age [48]. In addition, as previously discussed, COVID-19
mation available in the initial phases of vaccine distribu- mortality and morbidity encompass only a fraction of the
tion when the potential effects of COVID-19 vaccines on possible harms caused by the pandemic.

Fig 3  Number of fully COVID-19 vaccinated individuals as a per- ulation aged 65 and over is from United Nations World Population
centage of people aged 65 and over. Source: Numbers of fully vac- Prospects 2022 (2021 data) [44]
cinated individuals are from our World in Data [20]. The total pop-

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The figure shows that, by the end of April 2021, high- have been some investments in vaccine manufacturing in
income countries had distributed enough vaccines to cover lower-income countries (e.g., the WHO’s vaccine technol-
the population aged 65+ (i.e., presumably the population ogy transfer hub at Afrigen Biologics and Vaccines in Cape
at highest risk). In contrast, low-income countries reached Town that allowed the replication of mRNA vaccines in
that goal only 8 months later, and middle-income countries 2022 [53]), manufacturers’ reluctancy to share the know-
about 3 months later. Considering the smaller proportion how has constrained the overall production capacity as well
of older people in lower-income countries (3.1% in low- as hampered global access to COVID-19 vaccines [54]. As a
income countries and 6.0% in lower-middle-income coun- consequence, poor countries with no manufacturing capacity
tries compared to 18.9% in high-income countries and 11.8% have to rely on international vaccine supplies, encompassing
in upper-middle-income countries), the difference in protec- both vaccine donations and market purchases.
tion is remarkable. Of course, not all vaccine doses were The affordability of vaccines is another constraint to
administered preferentially to older people. Some of those increasing vaccination in lower-income countries. The
initial vaccine doses were given to frontline healthcare work- cost of COVID-19 vaccines varies widely across countries,
ers, individuals with comorbidities, and other individuals depending on the product characteristics and bilateral agree-
who were considered essential or worthy of prioritization. ments between pharmaceutical companies and countries.
Still, the graph shows that, for many months, the number According to WHO’s estimates, the price per vaccine dose
of fully vaccinated people in lower-income countries was ranges from US$2 to US$40 [55], while the cost of deliver-
substantially lower than the number of people considered at ing COVID-19 vaccines in low- and middle-income coun-
most risk. Data from COVAX confirm that by August 2021, tries is around US$3.70 per vaccinated person [56]. Delivery
only 33 million COVID-19 vaccine doses were delivered costs include planning and coordination, outreach initiatives,
to low-income countries compared to 1.6 billion in high- cold chain equipment, vaccine transport and training, and
income countries [22], thereby suggesting that the slow vac- accounting for possible wastage. Considering that health
cine uptake in low-income countries in the first half of 2021 expenditures per capita in low-income countries are around
was foremost due to supply issues. US$35 [57], COVID-19 vaccines represent a significant
financial burden. The WHO estimates that vaccinating an
additional 40% of the population in low-income countries
Barriers to vaccine equity would require on average between 10% and 25% of their
annual healthcare budget [58].
Different factors contribute to global inequity in COVID- Differences in healthcare systems capacity, including
19 vaccination rates. Vaccine nationalism, i.e., the stockpil- health workforce, vaccine supply chains, and infrastruc-
ing of vaccines by high-income countries, has been a major tures, contributed to global vaccine inequity. For instance,
issue since the beginning of the COVID-19 vaccination COVID-19 vaccines based on mRNA technologies require
rollout [49]. Facing a limited global supply of COVID-19 ultra-cold chains; maintaining a cold chain is problematic
vaccines, countries with manufacturing capacity and other for hard-to-reach rural areas with irregular electricity supply
high-income countries tended to prioritize their populations [59]. It is worth noting that mRNA technologies contrib-
rather than slowing the spread of COVID-19 elsewhere [50]. uted to the accelerated development and manufacturing of
Despite pledges from developed countries to donate vaccines COVID-19 vaccines, and, in their absence, the pandemic
to low- and middle-income countries, only a fraction of the would probably have had more devastating impacts on the
promised doses has been delivered due to export bans on global population and exacerbated existing health inequi-
vaccines and vaccine ingredients [51]. The lack of a glob- ties [18]. However, the ultra-cold chain requirements are
ally coordinated approach to vaccine allocation implied clearly an obstacle to global vaccine equity. Another barrier
that vaccination in lower-income countries started months to vaccine equity is the potential shortage of equipment (e.g.,
later and has proceeded at a slower pace than vaccination syringes), which constantly threatens vaccination efforts,
in higher-income countries. The emergence of new vari- especially in lower-income countries [60, 61]. Support from
ants and the waning of vaccination-acquired immunity have local health workers is also pivotal for delivering vaccines in
strengthened vaccine nationalism, with vaccines directed to countries with less resilient healthcare systems [62]. Lack of
higher-income countries for booster doses, thereby further resources for continuous training, compensation, and tech-
delaying their availability in lower-income countries. nical support of the health workforce can thus undermine
A deeper problem underlying vaccine inequity is the une- vaccination efforts.
qual distribution of vaccine manufacturing capacity. With a Although supply constraints were the main barriers to
few exceptions (e.g., China, Cuba, India), low- and middle- vaccine equity in the first months of the COVID-19 vacci-
income countries did not have manufacturing capacities in nation rollout, vaccine hesitancy contributes to the current
place at the beginning of the pandemic [52]. Although there inertia in vaccination rates. Vaccine hesitancy is fueled by

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misperceptions of COVID-19 vaccine safety and effective- lack of access to good-quality healthcare often translates
ness, misperceptions about the protection afforded by pre- into larger age-specific COVID-19 infection fatality rates
vious exposure, and mistrust in the institutions responsible in developing countries compared to developed ones [72].
for vaccine communication and delivery [63–65]. A recent Global fair distribution of vaccines could have reduced
World Bank report found that about 20% of adults in devel- the health burden in lower-income countries, and it may
oping countries are hesitant about getting COVID-19 vac- prevent future burdens. For instance, it was estimated that
cination [66]. The reported COVID-19 vaccine hesitancy COVID-19 vaccine hoarding might have cost more than
is also higher than hesitancy towards other vaccines prob- 1 million lives in 2021 [73]. If countries had started to
ably because of the novelty of the disease and the associated share vaccines at the beginning of the vaccination rollout,
vaccines. and vaccines had been distributed proportionally to the
size of the adult population, fewer infections would have
occurred in low- and middle-income countries and, as a
Costs of vaccine inequity result, fewer COVID-19 deaths. These outcomes are coun-
terbalanced by an increase in infections in high-income
Costs of vaccine inequity fall both on the countries with low countries (although not necessarily an increase in deaths if
COVID-19 vaccination rates and on the rest of the world high-risk populations are vaccinated first) and, potentially,
that is already experiencing high vaccination rates. A slow an increase in economic costs in high-income countries if
and delayed vaccine rollout in lower-income countries has nonpharmaceutical interventions are enforced for a longer
left them exposed to new surges of the virus and a slower period.
economic recovery from the pandemic. In addition, low vac- Low vaccination rates in lower-income countries have
cination rates in poorer countries may produce global health also been responsible for a slower recovery. In countries
and economic negative externalities. with early and fast vaccine rollout, COVID-19 vaccination
Although high-income countries have larger shares of allowed a progressive reopening of the economy, with asso-
older people (i.e., the individuals considered more vulner- ciated increases in consumer spending, employment rates,
able to COVID-19), low-income countries have less resilient and overall gross domestic product (GDP) [74, 75]. In con-
healthcare systems, which make them more vulnerable to trast, countries with low vaccination rates endured relatively
disruptions in access and delivery of healthcare, and, as a longer periods with economic lockdowns and containment
result, to increasing morbidity and mortality burdens. For measures in place [25]. While advanced economies suffered
example, COVID-19 has caused substantial negative impacts larger economic losses at the beginning of the pandemic,
on the management of endemic diseases (e.g., HIV, malaria, lower-income countries bear the brunt of the COVID-19
neglected tropical diseases), and on childhood immuniza- economic burden in 2021. Figure 4 depicts the annual GDP
tion programs [67–71]. The future health burdens of these growth rate across country income groups. Low-income
disruptions (e.g., the number of healthy life years lost due countries enjoyed a slower GDP growth compared to the
to COVID-19) are yet to be determined. Furthermore, the rest of the world, and the GDP growth rate in 2021 was

Fig. 4  Gross domestic product

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still substantially lower than pre-pandemic growth rates. the other hand, there is some evidence that infectious viral
Had COVID-19 vaccines been distributed more fairly, poor load is lower among vaccinated than unvaccinated individu-
countries would have experienced a faster recovery. als [42] and that viral load clears faster among vaccinated
Besides health and economic costs, the COVID-19 pan- people [43]. Although the transmission process of COVID-
demic has caused human capital degradation throughout the 19 is complex, viral load is recognized as a strong deter-
world, especially in lower-income countries [15, 77]. Almost minant of transmission risk [86], thereby suggesting that
1.6 billion students around the world were affected by school new variants are more likely to spread among unvaccinated
closures because of the COVID-19 pandemic [78]. Even individuals. This viral load channel would then support the
short disruptions in schooling can have significant negative assertion that global COVID-19 vaccine inequity leads to the
effects on learning, and students in disadvantaged families development of new more dangerous variants. However, to
and communities are more vulnerable to these disruptions my knowledge, there is yet no evidence to support this con-
[79]. Learning losses translate also into long-term productiv- clusion, and the potential global health costs of COVID-19
ity losses, thereby threatening children’s future livelihoods vaccine inequity are an open question.
and countries’ future macroeconomic performance. Poorer
countries reported the longest average duration of school
closure, thereby widening the learning gap between rich and Conclusions
poor countries [80]. Low vaccination rates increase the risk
of school closures and make it harder to overcome the learn- The paper has presented evidence of global COVID-19 vac-
ing losses because of limited financial resources triggered cine inequity and discussed the main factors contributing
by the slow economic recovery. to this inequity and its health, social, and economic conse-
Furthermore, increasing vaccination rates in poorer quences. In particular, the paper highlighted how vaccine
countries produces benefits for the entire world. First of inequity harms both the countries experiencing low vacci-
all, higher-income countries have an economic incentive nation rates and the countries with high coverage. These
to provide equitable access to COVID-19 vaccines [81]. In indirect effects are the result of social and economic con-
an economically interconnected world, preventing waves of nections across countries. Thus, it is in the self-interest of
infections in poorer countries reduces the risk of global sup- high-income countries to improve global access to COVID-
ply chain disruptions, which would negatively impact the 19 vaccines. Yet, vaccine inequity is still an issue.
domestic economy of high-income countries. In particular, Several lessons can be drawn from the analysis of the
potential economic lockdowns in lower-income countries paper. These lessons can be useful for the next stages of
triggered by a lack of vaccination hurt higher-income coun- the COVID-19 pandemic and for preparing for the (likely)
tries by causing a shortage of intermediate inputs, higher next one.
import prices, and weak demand for their exports [82]. First of all, COVID-19 vaccines were developed and man-
In addition, it has been suggested that global COVID- ufactured at accelerated speed. This was in part the result of
19 vaccine inequity translates into an increased risk of the the massive amount of public financial resources dedicated
spread of new immune-evasive variants [83, 84]. The argu- to the project. Taking the USA as an example, estimates sug-
ment is that new strains are more likely to spread in popu- gest that the government invested $18 billion through Opera-
lations with low vaccination rates. These new strains will tion Warp Speed for securing COVID-19 vaccine doses and
then be exported to other countries and cause new waves of for financing development and manufacturing capacity [87].
infections worldwide since the vaccine is expected to offer Public financing of vaccine R&D and manufacturing capac-
only partial protection against new variants. Given the cur- ity has the purpose of partially absorbing the risk of vaccine
rent understanding of the epidemiology of COVID-19 and development, thereby enhancing pharmaceutical companies’
the characteristics of COVID-19 vaccines, the strength of incentives to invest in vaccines. Indeed, vaccines constitute
this argument is debatable. On the one hand, as pointed out a high-risk investment, since their development carries a
earlier, existing COVID-19 vaccines are very effective at substantial risk of failure, and their profitability is linked to
preventing severe disease and death, but not very effective an uncertain demand, often from lower-income countries
at preventing infection and transmission, especially with the with low ability to pay [88, 89]. In addition, vaccine devel-
new variants [39, 40]. Effectiveness also wanes rapidly [85]. opment, testing, manufacturing, and distribution typically
As a result, existing COVID-19 vaccines provide mostly require long and highly variable periods of time, during
direct benefits, while the potential benefits in curbing the which the destructive potential of a pandemic can acceler-
spread of new strains seem to be minimal. In that case, new ate. In preparation for the next pandemic, it is thus essential
strains can emerge and rapidly spread even in populations to pour public funding into accelerating the vaccine devel-
with high vaccination rates, and reducing global COVID-19 opment process, e.g., by investing in pre-pandemic times in
vaccine inequity produces no positive health externality. On the development of prototype vaccines for pathogens with

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pandemic potential and by enhancing global vaccine manu- Funding for such an initiative should be managed by a supra-
facturing capacity (independently of its location) [90, 91]. national authority that receives contributions from multi-
These investments reduce the risk of global vaccine supply ple countries and allocates pandemic preparation spending
constraints when the next pandemic strikes. In particular, across different projects, along the lines of the recently
by easing the global supply constraints, there will be less established WHO- and World Bank-supported Financial
international competition for limited doses and, as a result, Intermediary Fund for pandemic prevention, preparedness,
more vaccines for lower-income countries. and response [95].
Although funding the accelerated global production of Future pandemics may be more devastating than the
vaccines against the next pandemic may reduce global vac- COVID-19 one, especially for lower-income countries.
cine inequity by itself, the development of local manufac- Effective pandemic preparedness requires, among other
turing capacity will further enhance global vaccine equity. things, strategies to overcome existing barriers to global
Indeed, less developed countries need to have access to local vaccine equity. Failing to do that could be tragically
manufacturing capacity to avoid being dependent on dona- shortsighted.
tions and excessive production of higher-income countries.
Acknowledgements The author would like to thank the editor and the
The development of local manufacturing capacity requires reviewers for their valuable comments.
the waving of intellectual property rights and technology
transfer agreements, despite potential resistance from phar- Funding Open access funding provided by SCELC, Statewide Califor-
maceutical companies. The WHO vaccine hub in South nia Electronic Library Consortium
Africa is an example of mRNA technology transfer [53], Data availability The data used in this study are derived from public
but more initiatives are imperative. Underinvestment in local domain resources. References to those sources are available within
manufacturing capacity perpetuates the inequity in access the article.
to vaccines and other medical products and, as a result, has
the potential to trigger global health and socioeconomic Declarations
costs. As stated by the Managing Director of the Interna- Conflict of interest The author declares no competing interests.
tional Monetary Fund, Ms. Kristalina Georgieva, “support
for Africa’s vaccine production is good for the world” [92]. Open Access This article is licensed under a Creative Commons Attri-
Moreover, investments to strengthen healthcare systems bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
are necessary to allow effective and timely delivery of vac- as you give appropriate credit to the original author(s) and the source,
cines. Logistical barriers, such as maintaining ultra-cold provide a link to the Creative Commons licence, and indicate if changes
chains and reaching remote areas, have hampered the process were made. The images or other third party material in this article are
of vaccine distribution in lower-income countries. Strong included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
health systems require investments in new and improved the article’s Creative Commons licence and your intended use is not
equipment, infrastructure, monitoring and surveillance sys- permitted by statutory regulation or exceeds the permitted use, you will
tems, data collection, and training of healthcare workers. need to obtain permission directly from the copyright holder. To view a
The benefits of these investments are clearly huge and go copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
beyond the realm of pandemic preparedness.
Strategies to overcome vaccine hesitancy are also wel-
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