Historically, the Americas have been the world leader in routine vaccination, vaccine introduction, and implementation of mass vaccination campaigns against infectious diseases. It was the first region to eliminate rubella and measles, eradicate smallpox, and be declared polio-free.
Several key assets are associated with this public health success. The Pan American Health Organization (PAHO) Revolving Fund is a mechanism that has aggregated demand and procured quality-assured vaccines for more than 40 years, procuring shots, syringes, and cold chain equipment for a total value of $769 million in 2019. Another example are the eight national regulatory authorities of regional reference built on decades of effort to strengthen and benchmark national regulatory authorities—a system that was first of its kind for the World Health Organization (WHO) and its regions. The region also built vaccine manufacturing capacity as the home of two of the seven non-high-income countries currently producing WHO-prequalified vaccines (Brazil and Cuba).
But even this history and assets have not enabled an adequate response to the pandemic or equitable access to COVID-19 vaccines. Instead, the region—particularly Latin America and the Caribbean (LAC)—has been hit harder than any other part of the world, with over 1.8 million COVID-19 deaths and more than 69.7 million cases by June 2021, and a staggering 6.8 percent contraction in gross domestic product in 2020. And while Uruguay and Chile have managed to fully vaccinate at least half their populations by July 30 (around 63 percent in both cases), in countries like Honduras, Nicaragua, and Guatemala, the share of fully vaccinated people is below 4 percent. Even Brazil, despite a strong history of successful vaccination campaigns, has only vaccinated 18 percent of its population fully.
Six factors help explain this alarming situation:
- The Pan American Health Organization (PAHO) was undermined by lack of political support and funding. The US and the Brazilian administrations reportedly halted annual contributions to PAHO in 2020—more than half the agency’s core budget. PAHO also opted not to use its regional vaccine procurement mechanism and instead encouraged countries to buy into COVAX, reasoning that the COVAX Facility would give LAC countries access to the world’s largest and most diverse portfolio of vaccine candidates and that countries participating in the COVAX Facility through the PAHO Revolving Fund would be recognized as a regional bloc. COVAX initially limited countries’ volumes to the doses equivalent to 20 percent of their eligible population; this policy was relaxed by the end of 2020, enabling countries to purchase doses for up to 40 percent of their populations. However, COVAX’s policy of distributing its procured doses to meet 20 percent of the population in the 92 low- and middle-income countries participating in its advance market commitment first created a disincentive for the middle-income countries to procure via COVAX, as did its initial decision (now reversed) to exclude mRNA vaccines from its portfolio. The PAHO stuck by its decision to NOT use its own regional purchasing mechanism even when it became clear that COVAX would be unable to act as a clearinghouse for the world’s vaccines due to unmet supply commitments from Serum Institute of India, late registration of Sinovax and Sinopharm, and general supply constraints. As a result, LAC countries pursued separate bilateral arrangements (see item 2, below).
- LAC countries decided to pursue bilateral rather than regional or global responses. Although most LAC countries joined COVAX, they did so at a late stage, after first pursuing bilateral contracts with Chinese and Russian producers, in part due to lack of supply from Western manufacturers. As of July 2021, bilateral agreements were by far the most prevalent mechanism to access COVID-19 vaccines, representing 1.44 billion doses, or enough to vaccinate 115 percent of the LAC population. LAC countries, in comparison, have acquired 32.4 million doses through COVAX. This approach has resulted in a portfolio that’s not adequately diversified, with a lot of lower-efficacy vaccines, resulting in slow rollout and huge inequities. Some countries, like Chile, have enough doses to vaccinate their population more than twice (243 percent of population coverage) while others, such as Honduras, Haiti, and Nicaragua, rely almost fully on COVAX and therefore have only secured enough doses to cover 20 percent of their population.
- Lack of leadership and voice with regional institutions undermined by geopolitical divides has led to paralysis and inaction. Although the region has multiple—maybe too many—mechanisms (CARICOM, SICA, MERCOSUR, OAS, the Pacific Alliance, PROSUR, and UNASUR to name a few), cooperation, coordination, and joint action have not materialized. This is in part due to the rampant disinformation and public health negligence in the region’s largest economies embodied by Jair Bolsonaro in Brazil and Andres Manuel Lopez Obrador in Mexico. But it also reflects the highly political rather than technical nature of these bodies, and the political polarization between widely divergent ideological approaches within the regional bodies that made agenda-setting and consensus difficult. The leadership of the regional entities is also missing in action and voice; the leader of the Inter-American Development Bank (IDB) focuses on recovery when the emergency is far from over and the region’s governments are in fiscal distress. The region’s voice is missing from global fora.
- Production agreements with LAC manufacturers have been insufficient and have not delivered on original promises, despite initial capacity to scale. Eight manufacturers in five LAC countries have signed agreements to either manufacture active ingredients or put the vaccine into vials or syringes (fill and finish) for five COVID-19 vaccines. However, only around 120 million doses have been produced so far and there is an overreliance on active ingredients produced in Russia and China. No mRNA vaccine deals have been agreed and agreements have not been supported by key global brokers like the Coalition for Epidemic Preparedness Innovations (CEPI) or the multilateral development banks.
- Multilateral development banks and development financing institutions have fallen short in their support to manufacture, procure, and deploy COVID- 19 vaccines in LAC countries. The World Bank and the IDB had approved $595 million by the end of July 2021 for the procurement or deployment of COVID-19 vaccines in 10 LAC countries ($225 million and $370 million, respectively). Despite LAC accounting for around one-third of the COVID-19 deaths to date, this represents only 5 percent of the World Bank’s COVID vaccine financing commitments globally and 30 percent of the IDB’s overall operational support to COVID-19. Neither institution has invested in joint regional procurement or in the expansion of manufacturing capacity in LAC countries, and they have not done much technical or analytical work on manufacturing and supply chains for vaccines in the region—even though the IDB decided to support individual countries and vaccine makers to resolve indemnity obligations to facilitate vaccine contract negotiations. In an assessment of country vaccination readiness, only 23 of the region’s 30 countries had completed an evaluation. Immunization information systems, social engagement, and delivery strategies and related investments and activities remain lacking as evident from the pace of vaccination. Development finance institutions, like the US International Development Finance Corporation (DFC) have likewise not initiated or funded any project to build manufacturing capacity in LAC countries, despite doing so in Asia and Africa and despite the reality that COVID-19 trajectories in LAC remain more important to domestic US outcomes. The Spanish COFIDES has also remained silent on expanding vaccine manufacturing in LAC countries, despite ambitious vaccine diplomacy promises made by the Spanish government.
- The United States, the region’s biggest trading and tourism partner and a top destination for LAC immigrants, has been slow to support its own region. Pre-COVID, the US was winding down aid and even public cooperation in the region. When COVID-19 hit, US vaccine donations started late, only included neighbors at first, and have not fully considered supply chain distribution challenges. As of August 3, 36 million doses, or around one-third of total US donations, have been donated to LAC countries. Spain, another traditional regional ally, has also pledged only 7,5 million doses to the region.
Six actions are needed to turn the tide
LAC countries are experiencing a prolonged and unprecedented human and economic catastrophe; six key actions are needed to address the issues above and turn the tide on pandemic response:
- Appoint a regional czar for COVID-19 to assure the region is represented and to create a locus of accountability for vaccine supply, procurement, and delivery. In the regional response, there must be an individual that politicians across the region can recognize and trust and who has a voice and understands multilateral and global health institutions.
- Activate the PAHO Revolving Fund to purchase vaccines. LAC governments, subregional integration mechanisms, and development banks should support PAHO’s recent decision to procure COVID-19 vaccines through the PAHO Revolving Fund. This support involves providing adequate financing, avoiding parallel subregional procurement efforts, and establishing a commitment by LAC countries to move from bilateral to regional arrangements going forward. An empowered PAHO Revolving Fund could leverage the region’s regulatory capacity to consider vaccines before the WHO emergency use listing is completed and COVAX eligibility is obtained, and could secure a robust and diversified portfolio of high-quality vaccines and suppliers. Buying COVID-19 vaccine will likely be a medium- to long-term imperative, and pooling purchases via the PAHO Revolving Fund is an appropriate and efficient solution to the urgent needs of the region.
- Get the IDB to step up for vaccine delivery. As IMF managing director Kristalina Georgieva has put it: “vaccine policy is economic policy”—meaning that recovery will be elusive if full vaccination is not achieved. As the region’s largest single source of external development finance, the IDB, in coordination with PAHO and relevant regional bodies, must play a larger role in assuring and coordinating speedy delivery of high-efficacy vaccines.
- Supercharge Latin American manufacturing. The IDB, the World Bank, the US DFC and the Spanish COFIDES should fund and support private sector licensing and knowledge transfer to ramp up vaccine manufacturing capabilities in Latin America and the Caribbean. These arrangements should build from existing production agreements in the region, expand to incorporate mRNA vaccines, and pave the way to strengthen the innovation ecosystem in the region. Multilateral development banks should also fund studies on alternative approaches to increase vaccine coverage, including clinical trials of alternative dosing and different vaccination strategies based on seroprevalence surveys.
- Boost US engagement and participation in regional entities. This could be done by donating more doses to the region more quickly, especially to those countries that are only relying on COVAX to vaccinate their populations. The Biden administration should also support vaccine delivery arrangements including improving storage and distribution capacity, should strengthen the CDC office in Guatemala, should support joint program of immunizations in border regions and should engage the Food and Drug Administration actively in regional regulatory coordination and harmonization efforts (see point 6).
- Drive further regional regulatory cooperation. The national regulatory authorities of regional reference should further cooperate and work together to strengthen regulatory convergence and reliance. This could involve joint assessments and inspections, shared guidelines and protocols, active information sharing on essential regulatory data,and joint campaigns against mistrust and lack of information about the safety and effects of COVID vaccines.