“Vaccines and medicines must no longer be thought of as profitable commodities but as public goods.“
The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) have just published their annual update on global immunisation coverage. This shows that some recovery has been achieved from the backsliding trend in childhood and adolescent immunisation that happened during the pandemic. But challenges ahead are certain. One of those is timely, affordable and sustainable access to vaccine supply.
In an open letter on access to vaccines, tests and treatments, published in March, world figures called on governments never again to allow profiteering to come before the needs of humanity: 2021 saw a preventable death from Covid-19 every 24 seconds, when vaccines were not targeted to those who needed them most.
Unfortunately, this is an everyday reality, beyond pandemics. Take cervical cancer, which causes hundreds of thousands of deaths among women every year. A vaccine has been available since 2006, yet we are reminded today that only 21 per cent of the global female population is protected. Many poorer countries have been waiting years for access, while scarce doses were delivered in richer settings with lower mortality.
These inequities do not only concern lower-income countries. Stark inequalities exist among developed states too: in several eastern-European countries many anti-cancer medicines have been unavailable due to prohibitive cost, whereas in most western-European countries these drugs have been subsidised. The high price of some health products and the associated hardship continue to impede progress towards universal health coverage.
Covid-19 did put a spotlight on access to such life-saving products. And governments, pharmaceutical companies, UN agencies, civil-society organisations and various international institutions are engaging in diversification of manufacturing capacity across different regions to reduce dependency on a handful of suppliers. A hub has been launched to build capacity in poorer settings to produce messenger-RNA vaccines. An intergovernmental body convened by the WHO is working through a pandemic accord, looking into real-time sharing of products, for example. Finally, the WHO, the World Intellectual Property Organization (WIPO) and the World Trade Organization (WTO) are pursuing a trilateral co-operation on public health, innovation and intellectual property.
While these are key concerns, the profound underlying problem is receiving much less attention—the balance of responsibility and power between the public and private sectors along the product path, from research to distribution of medical counter-measures. Yet a primary cause of lack of access is the management of manufacturing, distribution and pricing plans by pharmaceutical companies which exist to maximise profits for their shareholders, not to optimise public health.
In the feverish burst of excitement of the past few decades about public-private partnerships (PPPs), we seem to have forgotten that it is governments—not privately-owned, profit-seeking enterprises—which should be providing basic human rights for their citizens. Our societies treat masks, vaccines, oxygen, medicines and vaccines as if commodities. This despite repetition of commitments to public health and access to medical counter-measures—with their known, immeasurable power to protect societies and economies—as a fundamental human right.
Even less credible is that large volumes of taxpayers’ contributions are invested in the discovery and development of medical counter-measures, yet the return is smaller for societies and larger for pharmaceutical companies than should be so.Take pandemic-related products, where a few companies enjoyed considerable manoeuvre to exploit public funding and fuel extraordinary profits.
Significant public investment went into the development, production and purchasing of mRNA vaccines, while clinical trials of Covid-19 therapeutics were in large part also funded by public sources. Nevertheless, pharmaceutical companies have largely determined manufacturing and distribution plans for these products, as well as their prices, now expected to rise exponentially. This type of public-private ‘partnership’ epitomises the ‘privatisation of gains and socialisation of losses’.
Significant progress has been made in recent decades on timely access to vaccines, diagnostics and drugs. New vaccines developed and distributed globally have saved millions of lives and averted disease. The dramatic drop in the price of drugs that combat Hepatitis C has allowed countries to make tangible advances towards its elimination.
The current paradigm however remains centred on a profit-based dynamic, rather than an access imperative: it presumes that development, production and distribution of counter-measures will align with the public-health agenda through a mix of market forces and corporate social responsibility. It just does not work.
The affordability and availability of diagnostics in poor countries remains a major barrier to treatment scale-up. Out-of-pocket expenditures for medicines force around 100 million people into poverty. Vaccines for responding to outbreaks of deadly disease, such as cholera, face frequent supply risks. Investment related to the diseases and needs of the poor remains very limited.
Protecting a child from a vaccine-preventable disease, providing oxygen to a patient, giving protective equipment to healthcare workers or protecting adults from major killers, such as cancer and diabetes, are all basic human needs. So access is a fundamental right. Governments must foster rapid scientific discoveries and make them accessible to all—set the vision, invest more and have stronger oversight over the fruits of such investment—while being held accountable in so doing.
Public responsibility reinstated
If public responsibility is to be reinstated, the lessons of the pandemic can be adduced to implement that in practice. Some have argued that governments can legitimately intervene when company decisions do not reflect public-health needs, and indeed some governments have acted on that. Others have proposed the introduction of access clauses for host countries participating in clinical trials to test interventions before they are brought to market. Similarly, national and regional regulatory agencies could have more say in the distribution of medicines, given their investments to assess quality and safety.
The list of solutions to shift the balance of decision-making from Big Pharma into public hands is long: prize mechanisms have long been discussed as a solid alternative to ‘intellectual property rights’, in the spirit of rewarding investments while protecting access. In a constructive interpretation of PPPs, a government-owned, contractor-operated (GOCO) model has been proposed, achieving complementarities between the public and private sectors to increase equity and efficiency.
Idealistic? Maybe, until it becomes real. Acknowledging the big challenges ahead, and at the same time not shying away from them, can render all this very feasible. If we agree that universal access to medical countermeasures is a non-negotiable human right and that vaccines—one of the most iconic and cost-effective life-saving interventions—should be available to every person on this planet, it is our responsibility to find ways to do this.
Equitable access can be achieved when citizens and governments work together and hold the reins. The future should not come down to a plea for better intentions from industry, donors and philanthropists: we need to shape it ourselves.
The views expressed in this article are the responsibility of the authors alone—they do not reflect an official position of the World Health Organization
Tania Cernuschi is head of immunisation agenda, policy and strategy at the World Health Organization. She has 20 years experience in the political economy of health, focusing on access to health technologies and designing and managing related programmes with Gavi, UNDESA, the Italian Government, UNICEF and NGOs.