Global Public Health

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COVAX and the rise of the ‘super public private

partnership’ for global health

Katerini Tagmatarchi Storeng, Antoine de Bengy Puyvallée & Felix Stein

To cite this article: Katerini Tagmatarchi Storeng, Antoine de Bengy Puyvallée & Felix Stein
(2021): COVAX and the rise of the ‘super public private partnership’ for global health, Global Public
Health, DOI: 10.1080/17441692.2021.1987502

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GLOBAL PUBLIC HEALTH
https://doi.org/10.1080/17441692.2021.1987502

COVAX and the rise of the ‘super public private partnership’ for
global health
a,b a a
Katerini Tagmatarchi Storeng , Antoine de Bengy Puyvallée and Felix Stein
a
Centre for Development and the Environment, University of Oslo, Oslo, Norway; bLondon School of Hygiene &
Tropical Medicine, London, UK

ABSTRACT ARTICLE HISTORY

COVAX, the vaccines pillar of the Access to Covid-19 Tools Accelerator Received 28 June 2021
(ACT-A), has been promoted as ‘the only global solution’ to vaccine Accepted 1 September 2021
equity and ending the Covid-19 pandemic. ACT-A and COVAX build on
KEYWORDS
the public-private partnership (PPP) model that dominates global health Global health governance;
governance, but take it to a new level, constituting an experimental public-private partnerships;
form that we call the ‘super-PPP’. Based on an analysis of COVAX’s Covid-19; vaccines
governance structure and its difficulties in achieving its aims, we
identify several features of the super-PPP model. First, it aims to
coordinate the fragmented global health field by bringing together
existing PPPs in an extraordinarily complex Russian Matryoshka doll-like
structure. Second, it attempts to scale up a governance model designed
for donor-dependent countries to tackle a health crisis affecting the
entire world, pitting it against the self-interest of its wealthiest
government partners. Third, the super-PPP’s structural complexity
obscures the vast differences between constituent partners, giving
pharmaceutical corporations substantial power and making public
representation, transparency, and accountability elusive. As a super-PPP,
COVAX reproduces and amplifies challenges associated with the
established PPPs it incorporates. COVAX’s limited success has sparked a
crisis of legitimacy for the voluntary, charity-based partnership model in
global health, raising questions about its future.

Introduction
COVAX and the Covid-19 pandemic
COVAX was established as the vaccines pillar of the Access to Covid-19 Tools Accelerator (ACT-
A), which describes itself as ‘a ground-breaking global collaboration to accelerate the development,
production, and equitable access to Covid-19 tests, treatments, and vaccines’ (Gavi, 2020e). COV-
AX’s original aim was to secure access to a diverse portfolio of vaccine doses for at least 20% of
participating countries’ populations, delivered as soon as they became available, in order to end
the acute phase of the pandemic and rebuild economies (WHO, 2021a). Its leaders claimed it
was ‘the only global solution’ for vaccine equity, i.e. the fair distribution of vaccines to all popu-
lations (Gavi, 2020e).
COVAX quickly helped establish normative acceptance of the need for a global collaboration
to accelerate vaccine development and access, mobilising resources from government and

CONTACT Katerini Tagmatarchi Storeng [email protected]

© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://
creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the
original work is properly cited, and is not altered, transformed, or built upon in any way.
2 K. T. STORENG ET AL.

philanthropic sources to stimulate research and development (R&D) and facilitating large-scale
vaccine procurement and distribution. COVAX delivered its first dose in Ghana on 24 February
2021 – less than three months after the UK became the world’s first country to start a mass vacci-
nation campaign. It reached over 100 countries with vaccine doses within 42 days, many of which
would not otherwise have gained access to vaccines (WHO, 2021b).
However, COVAX soon turned out to be insufficient to bring about global vaccine equity. At the
time of writing, in June 2021, COVAX had distributed less than 5% of its 2 billion target (89 million
vaccine doses) (Covax, 2021). Meanwhile, 90% of Covid-19 vaccines had been administered in the
richest G20 countries, leading Dr Tedros Adhanom Ghebreyesus, Director-General of the World
Health Organization (WHO), to conclude that, ‘the rapid development of Covid-19 vaccines is a
triumph of science, but their inequitable distribution is a failure of humanity’ (UN, 2021).
In this paper, we argue that COVAX’s failure so far to ensure global vaccine equity is not merely
the result of outside forces but results from limitations related to its governance structure. As we
show, COVAX is not just another global ‘collaboration’; It is an extraordinarily complex multista-
keholder public-private partnership (PPP), co-led by existing PPPs as one pillar of an even more
complex PPP, ACT-A. We show that it constitutes an experimental institutional form for dealing
with global health crises that we call the ‘super-PPP’, which structurally resembles a series of Rus-
sian Matryoshka dolls of decreasing sizes nested inside each other.

PPPs: The main governance mechanism for addressing global health challenges
PPPs can be thought of as lasting institutional arrangements in which private and public sector enti-
ties share decision-making power (Andonova, 2017; Buse & Harmer, 2004, 2007; Rushton & Wil-
liams, 2011). The rise of PPPs over the past two decades marks a revolution in the governance of
global health, away from ‘international’ health cooperation between nation states through forums
and channels set-up by multilateral organisations such as the WHO or the United Nations Chil-
dren’s Fund (UNICEF), towards a much more fragmented field of ‘global’ health incorporating
non-state actors (Brown et al., 2006). Philanthropic foundations, non-governmental organisations
(NGOs) and businesses played a key role in implementing international health programmes in the
twentieth century, yet overall responsibility and coordinating power lay with public entities (Birn,
2006). This was in line with the post-World War II multilateral cooperation system of the United
Nations, centred on nation states. Yet, at the end of the 1990s, non-state actors radically gained
power, their influence formalised through the establishment of global health PPPs. This shift was
driven by the systemic underfunding of existing national and multilateral health institutions and
the ideology of new public management, which promoted modelling public institutions on actual
and perceived virtues of the private sector.
Gavi, the Vaccine Alliance and the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria,
established in 2000 and 2002 respectively, quickly became models for public-private cooperation to
address health challenges affecting poor countries, often with substantial philanthropic support
from the Bill & Melinda Gates Foundation. In Gavi’s own words, it ‘combines the technical exper-
tise of the development community with the business know-how of the private sector’ (Gavi,
2020a). Today’s global health PPPs vary significantly in size, budget, and institutional structure.
For example, both the Global Fund and Gavi are institutionalised as their own legal entities,
with independent secretariats, a large degree of autonomy and substantial budgets, and influence
rivalling that of the WHO. Other partnerships are less autonomous, and may be hosted by inter-
governmental agencies, sometimes as mere programmes (Andonova, 2017). Though most focus
on providing access to health technologies in low-income countries, newer partnerships, like
CEPI, which funds vaccine development to stop future epidemics, espouse the notion of ‘global
public goods’ to emphasise a joint benefit for countries everywhere.
As a governance ‘innovation’, PPPs have raised unprecedented political will and resources to
address neglected health challenges, bringing with them a focus on individual diseases, a business
 GLOBAL PUBLIC HEALTH 3

ethos prioritising measurable results and a penchant for technological solutions such as vaccines
(Birn, 2005). While also associated with the promotion of ‘vertical’ disease-specific initiatives
that erode broader health system development and donor-driven decision-making challenging
‘country ownership’, they are generally considered an efficient way of achieving health targets
(WHO, 2009). The Sustainable Development Goals (SDGs) in 2015 called for more multi-stake-
holder partnerships (goal #17), providing the PPP model with even greater international endorse-
ment (UN, 2015). It is thus not surprising that it became the blueprint for global cooperation during
the Covid-19 pandemic too.

The Covid-19 pandemic as the age of the super-PPP

When the Covid-19 pandemic struck, global health policy makers deployed considerable political
and diplomatic efforts to institute global coordination mechanisms. From the start, the Gates
Foundation and the World Bank argued that this could not be achieved without the close invol-
vement of existing global health PPPs and the private sector (Yamey et al. 2020). This led them
to draft plans for another global PPP for Covid-19 medical technologies, ACT-A, which was
announced at a G20-meeting on 24 April 2020, by the European Commission (EC) and the
Gates Foundation, with separate pillars for diagnostics, therapeutics, and vaccines and a health
systems ‘connector’. Many world leaders quickly embraced this development. Writing in The
Guardian in June 2020, Gro Harlem Brundtland, former Director General of the WHO, and Eli-
zabeth Cousens, President of the UN Foundation, called for us ‘to embrace the unprecedented
scale of partnership between governments, business, international organisations such as the
UN and WHO, non-profits, and scientists and researchers’, seeing them as essential to ending
the pandemic (The Guardian, 2020).
In bringing together actors from the public and private sectors to focus squarely on techno-
logical solutions (diagnostics, therapeutics, and vaccines) for a single disease, ACT-A has the key
features normally associated with PPPs. However, we argue that its creation signals a new phase
or iteration of this model, as the first example of an ‘alliance’ of major established PPPs intended
to benefit not just developing countries, but the entire world. Under ACT-A’s umbrella struc-
ture, several established PPPs have responsibility for overseeing different pillars, drawing on
their established ‘comparative advantage’: Gavi and CEPI the vaccines pillar; Unitaid the thera-
peutics pillar; Find the diagnostics pillar; and The Global Fund the crosscutting health systems
connector. These PPPs work alongside multilateral organisations (WHO, UNICEF, the Pan
American Health Organization (PAHO) and the World Bank), as well as the largest global
health philanthropic foundations (the Wellcome Trust, the Gates Foundation) and governments
to ‘accelerate’ the development and equitable distribution of Covid-19 tools (Figure 1).
How does global governance change when various PPPs are combined and set to work together
at this unprecedented scale and scope? Which dilemmas arise? What are the strengths and weak-
nesses of the experimental form we call a super-PPP? Below, we address these questions by honing
in on ACT-A’s vaccines pillar COVAX, its most prominent and best-funded pillar. Based on an
analysis of COVAX’s governance structure as a super-PPP, we unpack how this structure has
enabled national and corporate interests to take precedence over genuine ‘partnership’, challenging
COVAX’s vision of global cooperation. Specifically, we discuss how COVAX failed to institute safe-
guards against its government partners pursuing policies that directly undermine its goals, namely
‘vaccine nationalism,’ i.e. privileging vaccination on a national scale to the detriment of multilateral
vaccine efforts, and ‘vaccine diplomacy’, sharing excess vaccine doses in the pursuit of direct pol-
itical gains. Moreover, we show how its voluntary, partnership-based model has given too much
power to pharmaceutical companies, doing little to dissuade them from using their privileged pos-
ition to boost profit and shareholder value by keeping vaccine supply limited. Rather than consti-
tuting mere outside forces, however, we argue that these challenges were enabled by COVAX’s
institutional design and the nature of the super-PPP model itself.
4 K. T. STORENG ET AL.

Figure 1. COVAX within ACT-A’s structure (simplified). Source: ACT-A Accelerator Impact Report Summary, available at https://
www.who.int/publications/m/item/act-accelerator-impact-report-summary.

Based on this, we identify core features of the super-PPP model. First, it aims to coordinate a
fragmented global health field by bringing together existing PPPs under one umbrella, making pub-
lic representation, transparency, and accountability elusive. Second, it attempts to scale up a gov-
ernance model designed for donor-dependent countries to tackle a health challenge affecting the
entire world, pitting it against the immediate self-interest of its wealthiest partners. Third, it is
so complex that it obscures the vast differences in mandate and public accountability between its
constituent partners, imbuing corporate partners with substantial power.
In conclusion, we discuss how the limited success of COVAX has created a crisis of legitimacy
for the notion that voluntary partnership between public and private actors is the obvious solution
to global health crises. A growing contingency of civil society actors and world leaders reject its
charity-based model as a sign of complicity between wealthy country governments and ‘Big
Pharma’, and advocate instead for alternative solutions, including for a ‘People’s Vaccine’. While
focused on the governance of global health, our analysis holds lessons for other highly fragmented
and partnership-dominated governance fields such as nutrition and environment (Andonova,
2017).

Methods
This paper is part of a Research Council of Norway-funded project that examines the rise of new
forms of cooperation between public authorities and private actors in pandemic preparedness
and response, focusing on Norway. Norway plays an important role in promoting such
cooperation. It hosts CEPI and was central to forming the COVAX initiative and co-leads
(with South Africa) the ACT-A Facilitation Council, and plays a significant role in Gavi, with
the current Norwegian Ambassador of Global Health being a Gavi Board member. We draw
on data from three main sources: an analysis of COVAX’s governance structure; a literature
and media review; and in-depth interviews with individuals associated with COVAX.
Our quantitative analysis of the institutional and demographic make-up of COVAX was con-
ducted in March 2021, using publicly available datasets from Gavi’s website on COVAX, notably
 GLOBAL PUBLIC HEALTH 5

COVAX’s Structures and Principles document (Gavi, 2021b). We analysed the level of represen-
tation of different institutions and countries across COVAX’s workstreams and committees.
To identify whether a country was self-financing, ‘potentially self-financing’ or eligible for donor
subsidy, Gavi’s source was used (Gavi, 2021a). Where individuals or countries were listed as repre-
sentatives of certain workstreams, we conducted a Google search to identify individuals’ roles, for
example, whether a representative was an MP, a health minister, or a private businessperson in their
country.
Our media and literature review focused on COVAX documents and press reports, and expert
analysis of COVAX published between May 2020 and July 2021 in leading international newspapers
and periodicals (e.g. The New York Times, Washington Post, The Guardian, Le Monde, The Atlan-
tic), editorials in scientific journals (e.g. The Lancet) and specialist online reporting (e.g. Geneva
Health Files, Development Today, Devex). We also observed evolving debates about COVAX,
gleaned from expert and public consultations, webinars, exchanges with civil society organisations
and social media discussions.
We interviewed 26 prominent actors involved in COVAX or in the wider global pandemic
response between September 2020 and February 2021. Interviewees included CEPI, Gavi and
COVAX staff, government ministers and diplomats involved in ACT-A, public health authorities,
pharmaceutical company representatives and members of international civil society organisations
involved in debates about vaccine equity. This includes 10 Norwegian actors directly involved in
ACT-A and COVAX. All interviews were recorded with interviewees’ consent and transcribed ver-
batim. We approached the Gates Foundation multiple times for an interview given their significant
role in shaping both ACT-A and COVAX (The New Republic, 2021) but were denied and only
received a succinct email reply to our questions.
Our sources allow us to provide a first overview of the emergence of COVAX and its super-PPP
structure, but it is beyond the scope of the paper to consider in-depth the internal political processes
within each constituent organisation, or the interaction between ACT-A’s different pillars.

COVAX’s governance structure as a super-PPP

Fifteen years ago, Buse and Harmer identified as a key shortcoming of global health PPPs their con-
tested legitimacy, due to private sector involvement, and failure to provide legitimate stakeholders a
voice in decision-making, most notably constituencies from low- and middle-income countries
(LMICS) and civil society, who are under-represented on governing bodies relative to the corporate
sector (Buse & Harmer, 2004, 2007). In the years since, PPPs have made piecemeal efforts to redress
some of these imbalances by increasing the diversity of board members and enlisting civil society
‘engagement’ through formal representation for example (Puyvallée & Storeng, 2017; Storeng, 2014;
Storeng & de Bengy Puyvallée, 2018). Nevertheless, our analysis shows that COVAX reproduces at
the super-PPP scale many of the issues identified in previous analyses of the PPPs it incorporates,
including dominance by wealthy governments and philanthropic foundations, significant pharma-
ceutical company influence, and circumscribed roles for the WHO or other UN agencies (Shiffman,
2017). It even amplifies these challenges, because they are in part hidden within an overly complex
governance structure.
COVAX is loosely organised but institutionally complex (Figure 1). Its structure is in flux, and
we describe its makeup at the time of writing, in June 2021, roughly one year after its formation. It
combines Gavi, CEPI and the WHO as ‘co-leads’, with UNICEF and PAHO as ‘implementing part-
ners’. It does not have its own board or its own budget. Instead, donations to COVAX are funnelled
to its leading entities, most notably Gavi and CEPI, who by late June 2021 had received 80% and
13% of its mostly public donations respectively (WHO, 2021). COVAX’s main decision-making
forum is the ‘COVAX Coordination Meeting’ (CCM), co-chaired by CEPI and Gavi board chairs
Jane Halton and Jose Manuel Barroso. Halton and Barroso are formally accountable to their
respective boards rather than to COVAX partners. Permanent CCM members include the co-leads’
6 K. T. STORENG ET AL.

executive directors (CEPI’s Richard Hatchett, Gavi’s Seth Berkley and WHO’s Chief Scientist Sou-
mya Swaminathan); workstream leaders (listed below), two representatives of the pharmaceutical
industry, a member of UNICEF and a civil society representative.
COVAX has three main workstreams each overseen by a co-lead organisation and with both
direct and indirect ties to the pharmaceutical industry (Figure 2). CEPI oversees the ‘Development
and Manufacturing’ workstream that decides which vaccine candidates are worthy of financial sup-
port and subsequent procurement. This workstream is led by CEPI’s Melanie Saville, who pre-
viously worked for the UK’s National Health Service and various pharmaceutical companies.
Voting members in this workstream’s main decision-making body, called the ‘Research and Devel-
opment and Manufacturing Investment Committee’, include representatives of Gavi, CEPI, the
Gates Foundation and the Africa CDC, as well as five individuals who are venture capitalists and
current and former pharmaceutical company executives. Civil society is not represented on this
committee.
Gavi leads COVAX’s second workstream for vaccine ‘Procurement and Delivery at Scale’ with
Aurélia Nguyen, a former pharmaceutical executive and subsequent Gavi employee as managing
director. It is based within the Gavi Secretariat and the Gavi Board has ultimate responsibility
for the decisions and implementation of this workstream. The final workstream, which focuses
on vaccine ‘Policy and Allocation’, is led by WHO’s Strategic Advisory Group of Experts
(SAGE) on Immunization. The workstream advises other workstreams, as well as the WHO and
its member states on vaccine science and ethics. It consists of members of universities, public health
bodies, UN organisations, CEPI, Gavi, the Gates Foundation and NGOs. COVAX’s three work-
streams are further divided into 31 sub-committees or working groups. The top five institutions
represented as chairs of these committees are WHO, CEPI, Gavi, UNICEF and the Gates
Foundation.
Publicly available documents list 464 individuals as part of COVAX’s governance structure
(Gavi, 2021b). Only 63 (14%) of these represent governments. Remarkably, an overwhelming
majority of country representatives (81%) are from self-financing countries (HICs and UMICs).

Figure 2. COVAX’s three workstreams (simplified & subject to change due to COVAX’s evolving nature). Source: Gavi (2021b).
 GLOBAL PUBLIC HEALTH 7

Industry representatives account for 6% of COVAX listed participants, and only 16 individuals
(3.4%) represent NGOs or civil society. There is no publicly available information about how com-
mittee members are selected, and several sub-committees have been established on paper only, as
their membership is yet ‘to be determined’.
While Gavi, CEPI and the Gates Foundation strongly influence decision making within COVAX
by leading and dominating the key working groups where decisions are taken, UN agencies widely
populate working groups and sub-committees, but seem to hold more marginal normative and
technical roles. Like the PPPs it incorporates, COVAX was also initially reluctant to include civil
society in its decision-making structures. Ahead of Gavi’s board meeting on 30 July 2020, over
175 civil society organisations and individuals, including the Médecins Sans Frontières (MSF)
Access Campaign, wrote an open letter to the Gavi board noting the complete absence of civil
society in COVAX and demanding better representation (MSF, 2020). By end of October 2020,
however, Gavi welcomed civil society representatives to COVAX working groups, including
from MSF, Save the Children, the International Rescue Committee (Gavi, 2020b).
In the next section, we analyse how despite COVAX’s efforts to improve representation, its com-
plex and fragmented governance structure has enabled national and corporate interests to take pre-
cedence over the genuine partnership.

COVAX and vaccine nationalism

Trying to cater to wealthy and poor countries alike, COVAX invited HICs and UMICs to join a
‘buyers’ club’ called the COVAX Facility and purchase a shared portfolio of vaccines (Eccleston-
Turner & Upton, 2021). This promised them lower vaccine prices and a reduction of all kinds of
risks to do with vaccine development and procurement (Stein, 2021). 92 low income and lower
middle-income countries (LICs and LMICs) were grouped into a separate purchasing club called
the COVAX Advance Market Commitment (Gavi COVAX AMC), subsidised by donors’ overseas
development budgets, a model originally developed for purchasing pneumococcal vaccines for low-
income countries eligible for Gavi support.
Although public funders have supported COVAX generously, COVAX simultaneously allowed
its members to strike bilateral vaccine purchase agreements that undermined its supply and
reduced its purchasing power. Shortly after COVAX was created, the US, Canada, the EU (Euro-
pean Union), the UK, Israel, and oil-rich Gulf countries engaged in a race to sign bilateral deals
with Western pharmaceutical companies, while China, Russia and India secured early contracts
with their own domestic vaccine industries. As in previous pandemic outbreaks (Eccleston-Turner
& Upton, 2021), COVAX’s high-income country partners used advance purchase agreements to
secure early and extensive vaccine access for domestic populations. They paid higher prices per
vaccine dose than COVAX was able to, often combined with legal concessions, vast corporate sub-
sidies, unforeseen public data provision to vaccine companies and sometimes export restrictions.
They bought up global vaccine production capacity even before COVAX secured its first financial
instalments and was fit to start negotiation with industry. By November 2020, a widely reported
analysis found that HICs and UMICs had already reserved 3.8 billion doses, with options for 5
billion more, even before any vaccine candidates had been approved (Duke Global Health Inno-
vation Centre, 2021). This was rapidly condemned by global health leaders within the WHO and
the African Union as a form of ‘vaccine nationalism’ and a betrayal of COVAX’s vision of vaccine
equity.
Some high- and middle-income countries (e.g. Canada, New Zealand, Japan, Australia South
Africa, and Mexico) bought vaccine options from COVAX’s self-financing window alongside
their bilateral deals. Within Europe however, only the UK and Norway did. ‘Team Europe’ (the
European Commission (EC) and some EU member states) approached vaccine procurement in a
paradoxical manner by first taking the initiative to launch COVAX, but then deciding not to buy
their vaccines through the global procurement mechanism. Opting instead to develop a joint EU
8 K. T. STORENG ET AL.

procurement mechanism in June 2020 (Schaik et al., 2020), ‘Team Europe’ only supported the
COVAX Gavi AMC fund for LICs and LMICs. In the words of a middle-income country diplomat
whom we interviewed in the summer of 2020:
[Europeans] made a huge effort in this pledging event in May [2020] […] with all heads of state and everybody
giving this declarations or solidarity, pledging millions and billions of dollars. This whole event was based on
this idea of solidarity and equitable universal access to the vaccine. And very soon after that, the very same
countries that led that pledging event broke the agreement and went their own way. I mean they betrayed
their own leadership […] in my opinion that was very serious, that was a big treason, a big betrayal of
multilateralism.

Unlike the EU joint procurement mechanism, for example, COVAX membership did not require
countries to refrain from striking bilateral deals, competing directly for the same doses COVAX was
trying to purchase. On the contrary, the head of Gavi had actively promoted COVAX as a fallback
option for those who had struck bilateral deals, to broaden their vaccines portfolio and in case such
bilateral deals were to fall through (Gavi, 2020e).
The concessions that COVAX made to its self-financing country members must be seen in light
of its struggle to garner support from the world’s major geopolitical powers. ‘Team Europe’ was an
early sponsor and promoter, along with Japan, the UK, Canada, and Norway, which was appointed
co-chair of ACT-A’s Facilitation Council together with South Africa. However, the US under Pre-
sident Donald Trump refused to join COVAX, pursuing instead an ‘America First’ policy to vaccine
development and procurement through its own domestic PPP, Operation Warpspeed. It was only
once President Biden was inaugurated in 2021, that the US joined COVAX and became its single
biggest donor, followed by ‘Team Europe’, Japan, the UK, Canada, and Norway. Together they
account for around 89% of ACT-A’s public funding commitments (WHO, 2021).
Individual countries justified their decision to purchase vaccines directly from manufacturers
rather than through COVAX with reference to the initiative’s slow start (it took over four months
for contract negotiations to begin as countries first had to join and fund COVAX), their responsi-
bilities to prioritise their own populations, and claims that doing so was not at odds with showing
global solidarity. ‘Team Europe’, for example, defended itself against accusations of vaccine nation-
alism by pointing to its substantial financial pledges to the Gavi COVAX AMC and to the fact that it
had exported over half of the vaccines produced in its territory by mid-2021 (EEAS, 2020). This
contrasts with the US, which only lifted export bans on vaccines and essential vaccine components
in May 2021, and the UK, which, at the time of writing, has not exported any domestically produced
vaccines (Development Today, 2021a).
In practice, wealthy countries’ vaccine purchasing outside of COVAX meant that the initiative
quickly became, in the eyes of global health leaders, commentators and its European founders,
reduced from a global procurement mechanism to an aid project for subsidising vaccine pur-
chase for poor countries. This helps to explain why Canada, as the first G7 country to purchase
vaccines through COVAX in February 2021, was branded a ‘vaccine pirate’ stealing from the
poor, even though it was purchasing doses it was technically entitled to as a self-financing mem-
ber (Toronto Sun, 2021; Usher, 2021).
Combined with trade restrictions that constrained manufacturing and supply to COVAX, high-
and middle-income countries’ hoarding of vaccine doses is now widely acknowledged to have
undermined COVAX’s capacity to secure timely access to vaccine doses in sufficient quantities.
In January 2021, COVAX nevertheless forecasted that it would roll out 2.3 billion vaccine doses
in 2021, with an expected 1.8 billion doses for the 92 lower-income economies (the Gavi
COVAX AMC-eligible countries), at least 1.3 billion of these being offered at no cost to their gov-
ernments (Gavi, 2021d). During the spring of 2021, however, COVAX faced huge supply issues
after the Serum Institute of India (SII), which it had been heavily relying on for delivery of Astra-
Zeneca vaccines, diverted doses to deal with India’s domestic Covid-19 crisis. Even with large parts
of their populations vaccinated, wealthy governments continue to sign advance purchase
 GLOBAL PUBLIC HEALTH 9

agreements with vaccine manufacturers for the delivery of booster shots in 2022 and 2023 that com-
pete with COVAX for supply (Reuters, 2021b). To our knowledge, these confidential agreements,
which are treated as trade secrets still do not include clauses on equitable access.

COVAX and vaccine diplomacy

Without the means to stop its wealthy country partners from pursuing vaccine nationalistic pol-
icies, COVAX asked countries who had ‘hoarded’ vaccines to at least share excess vaccine doses
with it. The COVAX secretariat developed ‘principles’ for how countries could do so shortly
after the first vaccines had been approved for use, in December 2020. These principles entailed
five main requirements: vaccines should be safe and efficacious (WHO approved); available early
on (preferably first half of 2021); rapidly deployable; unearmarked (to comply with COVAX’s equi-
table allocation mechanism); and available in high quantities. COVAX also expected donor
countries to finance vaccine donations (Gavi, 2020d). However, complying with these principles
was voluntary, as COVAX lacked any enforcement mechanism and has had to rely on the variable
goodwill of its wealthiest partners.
In December 2020, EU countries tried, but failed, to reach agreement on how to implement a
plan to share 5% of their reserved doses (Reuters, 2020), In January 2021, Norway became the
first country to transfer its options to buy vaccines through COVAX to the Gavi COVAX AMC,
though this fell short of transferring vaccine doses from its own vaccination programme (Develop-
ment Today, 2021b). In April 2021, France decided to proceed independently despite the absence of
a joint EU sharing scheme, announcing an initial donation of 105,600 vaccine doses taken from its
vaccination programme to the Gavi COVAX AMC and committing to share 500,000 doses by mid-
June, and up to at least 5% of its total doses by the end of 2021 (Gavi, 2021c). Throughout spring
2021, the US was heavily criticised for having millions of unused doses in storage (including the
AstraZeneca vaccine that was not authorised by the US regulator) (The New York Times, 2021).
At the G7 meeting of June 2021, President Biden announced that the US would be purchasing
500,000 Pfizer doses to donate to COVAX (The White House, 2021) – more than half of the
870 million doses pledged by G7 countries. Critics derided the G7, claiming their pledges were
just a drop in the ocean (Buse & Bertram, 2021), and noted that the US donation of Pfizer-
doses was partly financed by USD 2 billion already pledged to COVAX in February 2021 (Reuters,
2021c).
Vaccine donations have been difficult for three main reasons. First, domestic political pressure
on leaders to prioritise their own population has been a major impediment. In Norway, for
example, the news in early 2021 that the government had transferred its COVAX options to
the Gavi COVAX AMC led opposition politicians to argue that these options should have
been used for Norway’s domestic vaccination programme (Development Today, 2021). Second,
in some cases vaccine producers have imposed contractual conditions and other legal barriers
preventing resale or donations of doses. The US decision to ‘loan’ doses of AstraZeneca vaccine
to Canada and Mexico in March 2021 for example was reportedly a workaround to evade such
conditions (Vanity Fair, 2021). Third, and most importantly, countries have opted to donate vac-
cine doses bilaterally instead of through COVAX to reap diplomatic and geopolitical benefit, an
approach that has been coined ‘vaccine diplomacy’ and that directly competes with COVAX.
Although initially used as a pejorative term to describe Russia, China, and India’s vaccine
donation policies, vaccine diplomacy is also practiced by COVAX’s largest funders – including
the US and EU. Besides pledging to channel excess doses through COVAX, the EU has also
set up its own vaccine sharing mechanism for allied and neighbouring countries. Potentially
in breach of its principles for vaccine donations, COVAX has been forced to accept smaller
donations made at the latest stages of wealthy countries’ vaccination programmes and has
allowed individual donor countries branding visibility through, for example, national flags on
shipments.
10 K. T. STORENG ET AL.

Accommodating corporate interests

The lack of safeguards within COVAX against participating countries pursuing policies that under-
mine its goals is reproduced in its voluntary approach to ‘partnership’ that has struggled to enlist
for-profit pharmaceutical companies as genuine ‘partners’. COVAX has accommodated corporate
concerns for profit and shareholder value, providing major pharmaceutical companies with a range
of push and pull subsidies and amplifying the already substantial public sector financing for R&D
and manufacturing both before and during the pandemic (Stein, 2021). Public subsidies are widely
understood to have been a major driver of the impressive innovation that resulted in several safe
and effective vaccines being developed at record speed. According to interviewees, the unprece-
dented levels of public sector support and the scale of the crisis had led many to hope that ‘industry
partners’ would, at least temporarily, forfeit established profit-maximising business practices in the
interest of equitable access to the gains of vaccine innovation and marketing. Doing so would
strengthen their brands, improve their research, and live up to their frequently altruistic rhetoric.
However, the pharmaceutical industry has not fulfilled these expectations. Oxford University,
which developed the vaccine produced by AstraZeneca, originally pledged ‘to donate the rights
to its promising coronavirus vaccine to any drugmaker’ through open licensing (Medscape,
2020). In the end, AstraZeneca obtained exclusive rights to produce the vaccine, facilitated by
the Gates Foundation who provided substantial funding to expand manufacturing capacity and
technology transfer to SII, the world’s largest vaccine manufacturer (Gavi, 2020c, 2021e). Although
Astra-Zeneca had pledged that it would make its vaccine available ‘at cost’ during the pandemic, its
commitment to vaccine equity took a blow after leaked revelations that South Africa has paid more
than double the EU price for the AstraZeneca Vaccine, in a bilateral deal outside of the COVAX
Facility (The Guardian, 2021a). Campaigners who gained access to Astra-Zeneca’s contracts have
shown that its claim to provide fair prices to developing countries ‘in perpetuity’ is ‘full of holes’
(Fortune, 2020).
Nevertheless, AstraZeneca and Johnson & Johnson, which signed an advanced purchase agree-
ment with COVAX in May 2021, scored better than mRNA vaccine manufacturers Moderna and
Pfizer on rankings such as the ‘vaccine access test’, which grades how world leaders and companies
are improving access by supporting global cooperation, including COVAX, and increasing supply
for all (One.org, 2021). Moderna reserved most of its doses for bilateral deals with wealthy
countries, even though it received a grant from CEPI early in the pandemic (January 2020) that
included provisions on equitable access, as well as substantial US public funding (The Washington
Post, 2021). The company only entered a deal with COVAX on 3 May 2020, for up to 500 million
doses to be delivered in the second half of 2021 through 2022 – and only after committing to deli-
vering billions of doses first in bilateral deals (Gavi, 2021f).
Pfizer, in turn, initially claimed that its motivation for developing a Covid-19 vaccine was to find
a medical solution to the crisis, rather than a return on investment. However, in July 2020, its CEO
Albert Bourla was quoted saying it was ‘radical’ to suggest pharma should forego profits on future
Covid-19 vaccines (Fierce Pharma, 2021). Pfizer subsequently reported to the US Securities and
Exchange Commission that it expected a profit margin ‘in the high twenty percent’ on its Covid-
19 vaccine and over USD 15 billion in revenues for 2021 only (Pfizer, 2021). The founders of
Pfizer’s biotech partner BioNTech became billionaires within just a few months, and BioNTech
is reportedly ‘on track to give the German economy an extraordinary boost’, contributing about
half a percentage point in German gross domestic product in 2021 (Bloomberg, 2021).
Pfizer has consistently prioritised bilateral deals with wealthy country governments and did not
agree to supply COVAX before the end of January 2021, initially offering a meagre 40 million doses
(2% of its projected 2021 supply) (Reuters, 2021a). Pfizer subsequently agreed to sell 500 million
doses (for 2021 and 2022) to the US for donation to COVAX ahead of the G7 in June 2021, announ-
cing in a full-page ad in the New York Times that equity was its ‘North Star’. This claim, however, is
undermined by Pfizer’s negotiation tactics vis-a-vis poor and middle-income countries who have
 GLOBAL PUBLIC HEALTH 11

sought bilateral deals outside of COVAX. The company reportedly demanded that Latin American
governments put up state assets, such as embassy building and military bases, as guarantee against
the cost of any potential legal cases against the firm (The Bureau of Investigative Journalism, 2021).
To justify its high prices relative to manufacturers of other WHO-approved vaccines, Pfizer denied
that its vaccine has benefited from public investment, even though its biotech partner BioNTech
received substantial EU funding to develop the mRNA technology, and advance purchase agree-
ments offset the company’s risk of scaling up production (Storeng & de Bengy Puyvallée, 2020).
Overall, COVAX has had limited success in instilling a commitment among the major vaccine
producers to the ideal of ‘partnership’. In fact, pharmaceutical companies have not only prioritised
bilateral deals over COVAX but have also artificially constrained supply by refusing to share tech-
nology, e.g. via the WHO’s Covid-19 Technology Access Pool (C-TAP) (Project Syndicate, 2021).
They have exploited their powerful position as the suppliers of essential goods (The Loop, 2021) and
engaged in rent seeking by lobbying to keep full patent protection despite WTO (World Trade
Organization) emergency provisions that would suspend those and enable expanded production
(Project Syndicate, 2021).
This helps to explain why growing criticism is being directed towards COVAX’s co-leads Gavi
and CEPI – and the governments that fund and have a major influence within these institutions –
for failing to exercise sufficient leadership in protecting the global public interest (Usher, 2021).
They have accepted industry demands for secrecy around prices and contracts, making it difficult
to ensure accountability for COVAX’s spending. Wealthy countries who say they support COVAX
have, at the same time, contributed billions in funding to R&D and advance market commitments
that offset corporate risk, without imposing sufficiently strong conditions on companies for fair pri-
cing or technology transfer necessary to expand production capacity (Storeng et al., 2021). In Feb-
ruary 2021, for example, ACT-A co-lead Norway published ‘4 principles for urgent pharma action
to combat Covid-19’ (World Economic Forum, 2021) that merely made non-committal recommen-
dations for action, but no actual demands, on rapid registration, fair pricing, expanded production
and transparency. The recommendations were largely unheeded. Strikingly, a year into COVAX’s
existence, even CEPI’s CEO Richard Hatchett conceded that voluntary action is insufficient. At the
COVID-19 Global Research & Innovation Forum in May 2021, he said that ‘the great missed oppor-
tunity of 2020 is that the funders of vaccine development did not include access provisions in their
funding agreements’ and called for different funders to develop common approaches (Geneva
Health Files, 2021).

Discussion: The rise of a new PPP model

The creation of COVAX – and the larger ACT-A structure of which it is part – shows the extent to
which PPPs have become a default solution to fighting global health problems. However, COVAX
and ACT-A do not simply replicate the existing PPP governance model, but also exemplify a new
iteration of it: The super-PPP. The super-PPP is like established global health PPPs in many ways,
which focus on a single disease, privilege technological solutions over attention to health systems
and structural determinants of health, monitor themselves, and heavily advocate their own suc-
cesses. At the same time, the super-PPP comes with distinct strengths and weaknesses, related to
both scale and unprecedented institutional complexity.

Coordinating global health governance?

We propose that a distinctive feature of the experimental institutional super-PPP form is the ambi-
tion to unite several global health PPPs within a single institutional frame, as ACT-A and COVAX
illustrate. In this respect, the super-PPP model constitutes a remarkable attempt to coordinate what
has become a highly fragmented, competition-driven and frequently ineffective governance field, in
which multiple PPPs develop ‘investment cases’ presented at ‘replenishment events’ to convince
12 K. T. STORENG ET AL.

donors to continue their support. Gavi, the Global Fund and the like compete against each other to
attract the largest possible share of donor countries’ official development assistance and philanthro-
pic and corporate donations. Their narrow focus has created blind spots, redundancies and over-
lapping mandates.
There have been previous attempts to coordinate this fragmented field. For example, the Inter-
national Health Partnership (IHP+), which has since developed into UHC2030, brings global health
PPPs together in a multi-stakeholder discussion forum that aims to support health system strength-
ening (Bartsch, 2011; Holzscheiter et al., 2016). However, COVAX and ACT-A, within which it is
embedded, are qualitatively different. They are not only a platform for discussion and advocacy
but work towards a single operational mandate by ‘harnessing’ each constituent PPP’s distinct ‘com-
parative advantage’. It is thus a more tightly institutionalised attempt to coordinate what has been
coined ‘market multilateralism’ (Bull & McNeill, 2007, 2019). The model draws on the democratic
and procedural (input) legitimacy of the WHO, and the results and metrics oriented (output) legiti-
macy of existing PPPs. Their coordinating role at the highest level of governance puts the super-PPP
model in direct competition with the UN and its specialised health agency the WHO, which finds
itself relegated as one of many super-PPP parts and partners, and with no direct authority over them.
So far, the super-PPP model has not resolved core global health governance challenges. Estab-
lished PPPs still compete against each other through investment cases, fund raising, and replenish-
ment events. ACT-A’s different pillars received widely different degrees of support, the vaccines
pillar being by far the most successful at attracting funding. In fact, as a governance approach,
the super-PPP model appears chaotic, extraordinarily complex, and lacks transparency and
accountability mechanisms. Whereas established PPPs are composed of mostly distinct entities
like governments, philanthropic foundations, industry, NGOs and UN agencies, the super-PPP
consist of other PPPs. This adds a layer of complexity (as PPPs themselves are heterogeneous),
and it means that the super-PPP represents various organisations twice or even three times over.
For instance, the WHO and the Gates Foundation are described as ACT-A partners but are also
partners within each of the established PPPs like Gavi, CEPI, the Global Fund etc. ‘Partners’ there-
fore have several channels of influence – both within the super-PPP coordinating mechanism and
within the boards and committees. Therefore, we say the super-PPP structure resembles a series of
Russian Matryoshka dolls.

Scaling up partnerships to the global level

Another important feature that defines the super-PPP model is the vast scale of its mandate, geogra-
phy, and available financing. It emerges out of an ongoing qualitative shift from traditional charity-
based PPPs that aim to solve health challenges in poor countries with support from donors (e.g.,
Gavi) to an attempt to tackle global challenges in ways that benefit wealthy and poor countries
alike. This shift is exemplified by the creation of CEPI in 2017 to tackle epidemic diseases in
poor countries with the potential to spread worldwide, but the super-PPP model takes this a step
further by targeting an acute global health crisis affecting rich and poor countries alike.
The effort to scale-up PPPs to the global level, however, has reinforced power-asymmetries
already present in the traditional aid and charity-based model. Wealthy countries’ immediate
self-interests, which are in traditional PPPs at least partly attenuated by charitable intentions,
have moved centre stage, as COVAX internalised the international competition for the same scarce
commodities – vaccines. To appeal to wealthy governments, COVAX did not implement the safe-
guards necessary to prevent self-financing countries from operating outside of it, and effectively
competing with it for vaccine supplies. Despite high-level political pledges to support COVAX,
these countries have adopted inward-oriented and diplomatic strategies that benefit their national
interests and are at odds with COVAX’s commitment to global collaboration. Pharma partners’
profit-maximising strategies are also at odds with COVAX’s aim of globally equitable vaccine
access.
 GLOBAL PUBLIC HEALTH 13

In response to these challenges, COVAX has gradually lowered its ambition. From being a global
procurement mechanism providing access to all countries simultaneously, COVAX has become in
practice an aid-funded scheme primarily providing a limited number of vaccines to protect a small
proportion of the population of its AMC-eligible countries (Usher, 2021). This makes it now func-
tionally similar to Gavi’s traditional focus on subsidising childhood immunisations for countries
unable to afford them.
This narrowing of COVAX’s raison d’être has been buttressed by the skewed representation of
stakeholders in its governance structure. As we have shown, LICs, LMICs and civil society voices
are marginal, whereas governments, organisations and individuals from the global North dominate
COVAX. It is thus not surprising that COVAX has overly accommodated wealthy country and cor-
porate interests. This issue of skewed representation reproduces shortcomings of the PPP model
identified over 15 years ago that remain unresolved to date (Buse & Harmer, 2007; Storeng & de
Bengy Puyvallée, 2018).

Blurring the lines between public and private interests

The super-PPP model includes private actors in its decision-making, in order to use private sector
resources, assumed innovation capacity and skills. However, the institutional complexity high-
lighted above has contributed to a lack of clear safeguards and accountability mechanisms to secure
that private interests do not take precedence over the public good.
First, as our analysis of COVAX shows, the super-PPP model relies on a form of conceptual slip-
page whereby any organisation that is rich or influential enough to claim a leading role in global
health is considered a ‘public health organisation’ or a ‘stakeholder’ and invited to the highest eche-
lons of decision-making. Using the term ‘global health organisations’ to describe philanthropies,
PPPs and intergovernmental agencies obscures their vast differences in mandate and public
accountability, and further blurs the line between public and private spheres. This conceptual slip-
page obscures the critical role that philanthropic partners like the Gates Foundation play in shaping
and governing COVAX (The New Republic, 2021), beyond their self-described role as a mere ‘facil-
itator’ or ‘catalytic’ partner. This further challenges the remnants of democratic representation in
today’s global health governance landscape.
Second, although the global pharmaceutical industry is consistently described as an essential
‘partner’, there are no clear criteria governing the behaviour of COVAX’s partners – and, as we
have seen, the major vaccine producers support policies, and engage in tactics that directly work
against COVAX’s access to vaccines. Finally, COVAX accomodates pharmaceutical industry
requirements and has kept secret most contracts and subsidies provided to the private sector. It
is unclear, for instance, how much COVAX pays for vaccine doses, or what ‘at-cost’ pricing agreed
upon with several providers entails. This lack of transparency and information asymmetry about
the true vaccine production costs and profit margins has been a key issue during the pandemic
beyond COVAX. Inadequate performance monitoring and narrowly selected objectives make pub-
lic scrutiny challenging, if not impossible.

Conclusion
Although COVAX has achieved only limited results so far, its leaders continue to brand it ‘the only
solution’ to vaccine equity, setting the terms of debate and gradually reducing the notion of equity
to its bare minimum, in keeping with other PPPs that have traditionally foreclosed policy alterna-
tives (Storeng, 2014). But unlike other PPPs, COVAX has not solidified confidence in the partner-
ship model, but instead created a crisis for its legitimacy. COVAX’s shortcomings, especially its lack
of transparency and its incapacity to deliver on its promises, have led critics to ask whether it is ‘part
of the problem’ (Devex, 2021), for example arguing that having suppliers on governing boards con-
tradicts the core principle of good governance. An African Union envoy has suggested that
14 K. T. STORENG ET AL.

COVAX’s failure to deliver its promised supply to the African continent is not only ‘a moral failure’,
but a deliberate strategy, saying ‘those with the resources pushed their way to the front of the queue
and took control of their production assets’ (The Guardian, 2021b). Others have argued that
COVAX reproduces a ‘colonial’ mentality whereby poor countries are forced to depend on charity
and leftover doses from wealthy countries (Development Today, 2021c).
A sign of waning trust in the PPP model is that civil society’s major response to the challenge of
vaccine equity has been to work outside of COVAX, developing a global movement known as the
People’s Vaccine Alliance that brings together organisations like Global Justice Now, Oxfam and
UNAIDS to argue that vaccination should be a ‘global public good’. The People’s Vaccine Alliance
has issued demands on Big Pharma to openly share vaccine technology and ‘know-how’. They have
also called on governments to temporarily suspend patent rules at the WTO on Covid-19 vaccines,
treatments, and testing during the pandemic, supporting a proposal first made by India and South
Africa in October 2020. This, they claim, will ‘help break Big Pharma monopolies and increase
supplies so that there are enough doses for everyone, everywhere’ (The People’s Vaccine, 2021).
COVAX’s staunchest supporter, the EU, has consistently opposed this move, maintaining that
patents are not the major barriers to scaling up manufacturing and that removing patents will
deter industry from partnering. However, over 100 countries, more than 60 former heads of
state and Nobel Prize laureates, and even US President Biden now support the proposal on a tem-
porary waiver on Covid-19 vaccines patents, providing credibility to a possible partial solution to
the impasse of ‘vaccine apartheid’. The future of the public-private partnership model may be in the
balance.

Acknowledgements
Thank you to Aurelia India Neumark for excellent research assistance. We would also like to thank our international
advisory board members and the Global Health Politics research group at the Centre for Development, University of
Oslo, especially Desmond McNeill and Thomas Neumark, for thoughtful comments on a draft of this article.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The Research Council of Norway (Norges Forskningsråd) provided funding for this research [grant number 301929].

ORCID
Katerini Tagmatarchi Storeng http://orcid.org/0000-0003-0032-7006
Antoine de Bengy Puyvallée http://orcid.org/0000-0002-5800-3701
Felix Stein http://orcid.org/0000-0002-0123-9895

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