Ensuring equitable vaccine access during the next pandemic

Next week at the World Health Assembly in Geneva, 193 member countries of the World Health Organization (with the U.S. notably absent) are expected to adopt the Pandemic Prevention, Preparedness and Response Agreement, also known as the Pandemic Treaty. In anticipation of its adoption, the final agreement has been celebrated as a triumph of multilateralism. The co-chairs of the negotiations described the agreement as a plan to “protect future generations from the suffering and losses [experienced] during the COVID-19 pandemic” and to ensure that in the next pandemic, “the response will be faster, more effective and more equitable.”

But after three years of negotiation, the agreement does little to solve the very problem it set out to address: the lethal delay low‑ and some middle‑income countries face in getting access to vaccines, tests, and treatments when a new pathogen strikes.

The agreement tries to fix inequities exposed by Covid‑19 in two ways. First, it proposes that manufacturers share 20% of their vaccines and other countermeasures “in real time” in exchange for access to pathogen samples and sequences. Second, it urges (but does not require) wealthy nations to push their manufacturers to voluntarily transfer manufacturing technology to poorer countries during a crisis, enabling local production.

These ideas sound reasonable but are riddled with practical and political challenges that will make them ineffective at best and counterproductive at worst.

The proposal for a Pathogen Access and Benefit-Sharing (PABS) system hinges on manufacturers agreeing to share vaccines in return for access to pathogen samples. But in a highly globalized world with fast-moving outbreaks, pathogens mutate and evolve rapidly, so access alone is not a strong point of leverage. Furthermore, manufacturers were not part of the negotiations and may be unlikely to enter deals that commit them to obligations in perpetuity, without clarity on the cost or benefit of those agreements. Even if some manufacturers agree to participate, they will negotiate the provisions with WHO directly, which might change the scope of their obligations.

More importantly, manufacturers will always prioritize their highest-paying customers — typically governments in wealthy countries — and will be under pressure from their home governments. It is hard to envision a scenario in which access to pathogens offered such a significant advantage that many companies would be motivated to strike deals with the WHO. And given uncertainty about which company will end up manufacturing the vaccines (or medicines) needed in a pandemic, even some sign-ons may not get us much closer to equity.

Similarly, technology transfer may sound promising, but it works only when recipient countries already have high-quality manufacturing facilities that can accept that transfer. Few low-income countries have that capacity for vaccines today. Successful examples of voluntary licensing and technology transfer exist, including during the Covid-19 pandemic, but the recipients have been heavily concentrated in middle-income countries like Brazil, India, and China that are less likely to need help in a pandemic than low-income nations.

What’s more, technology in this case isn’t just some software code or manual that can be easily shared. Unless manufacturers already have an existing partnership, transferring vaccine technology often involves sending a large team of experts to the recipient facility, which can slow production in the home country. While this may help distribute manufacturing, the primary goal in an emergency is likely to be producing as much vaccine as quickly as possible. That means Brazil, India, and China will likely be first in line for technology transfer, not the countries, many of them in Africa, that waited longest for vaccines during the Covid-19 pandemic. Perhaps there will be support for new partnerships during emergencies, but counting on this as a voluntary strategy seems unlikely to be effective.

Rather than rely on voluntary sharing or vague cooperation, we need to fix the root causes of inequity with long-term investments in manufacturing, regulation, and market incentives.

The African Union has laid out a series of sensible steps that are a model for how to make progress everywhere. It recently renewed its call from the Abuja Declaration for each country to dedicate 15% of their national budgets to health. This substantial increase in health spending, if implemented, would create the market for more manufacturers to invest in building facilities on the African continent. Countries in other regions should take on this mantle as well.

Second, it is critical to build regulatory systems that create predictability for manufacturers. A regional authority such as the African Medicines Agency can accelerate approvals across multiple countries, making each manufacturer’s viable market large enough to matter. Parallel efforts in Latin America and Southeast Asia would do the same and are urgently needed.

Third, global purchasers like Gavi should commit to buying a portion of their vaccines from regional manufacturers for strategic, not charitable, reasons. The African Union’s goal to produce 60% of Africa’s vaccines domestically by 2040 is a good start, though it would be good to see that timeline further shortened. Advance purchase agreements for routine vaccines and medicines would provide the steady demand that keeps facilities viable and workers skilled so they can pivot to pandemic shots on short notice.

Finally, it is critical we keep innovators at the table. In the past, the vaccine scientists who built the countermeasures were almost exclusively in the U.S. or Europe. That is now changing rapidly. India and China both developed home-grown vaccines for Covid. There is no reason that more low- or middle-income countries, especially in partnership with existing scientific experts, can’t develop their own intellectual bench to build home-grown vaccines during the next crisis. This means investing in scientific training and capacity in research and development now, before a crisis hits.

The Pandemic Treaty may be a diplomatic achievement — but also a mirror. It reflects a global health system still reliant on charity and unrealistic optimism. That model cost at least 1.3 million lives due to delayed vaccine access. Repeating those mistakes would be indefensible.

After Geneva, the real work begins. Governments must treat the agreement not as a finish line but as a mandate: to build regional manufacturing, streamline regulation, and invest in sustainable funding. If we want equitable access in weeks — not years — this is the only way forward.

Stephanie Psaki is a senior fellow at the Brown University School of Public Health and former U.S. coordinator for global health security at the National Security Council. Ashish Jha is the dean of the Brown University School of Public Health and former White House Covid-19 response coordinator.