The SARS-CoV-2 virus has disrupted the lives and livelihoods of people everywhere in the world. But for some, the toll has been far greater than for others.

Preexisting health inequities have been exposed and exacerbated by the COVID-19 pandemic. To account for past injustices and ensure that their effects do not persist, every effort must be made to ensure that local, national and global responses to COVID-19 have equity at the core of their design.

Through an unprecedented global effort, the scientific, philanthropic, private and public sectors have partnered in innovative ways to develop and produce diagnostic tools, treatments and vaccines in record time. However, the potential effects of these immense accomplishments are blunted if these interventions are not rapidly distributed and widely deployed to all those in need. Over a year into the pandemic, many of the tools necessary to combat COVID-19 remain concentrated among the wealthiest nations and groups, while low- and middle-income countries (LMICs) and other vulnerable populations still struggle to find access.

The supply of testing and diagnostic tools—critical for determining the scale of the COVID-19 burden and how to best target and prioritize treatments and vaccines—remains inadequate in LMICs. Despite multiple vaccines receiving widespread regulatory approval and production capacity increasing, lower-middle- and low-income countries combined have less than 20% of total confirmed available doses worldwide, despite making up nearly half of the global population. This is largely due to bilateral advance market agreements between wealthy nations and vaccine manufacturers that have resulted in over 1 billion excess doses for those countries.

The Sabin Vaccine Institute’s (Sabin) mission is to make vaccines more accessible, enable innovation and expand immunization across the globe. Sabin’s programs prioritize protecting those most vulnerable from vaccine preventable diseases and over the past year this has involved responding to the effects of the COVID-19 pandemic. Among other actions, Sabin actively supports the World Health Organization-led Access to COVID-19 Tools (ACT) Accelerator and COVAX facility. While these mechanisms have made considerable progress, they alone are not sufficient to ensure global, equitable vaccine distribution.

Beyond issues of vaccine supply, numerous structural and programmatic barriers stand in the way of effective vaccine rollout. Public and private sector organizations from across the Global South must reflect on and apply the lessons from decades of immunization efforts to inform national and regional programs. Leveraging assistance from the Global North, expanded capacity must be established to distribute, administer and monitor the impact of vaccines that extends protection to even those hardest to reach.

Vaccines in vials cannot prevent infection. But when they are given to people, the power to eradicate disease and end pandemics is unleashed. Widespread vaccination provides the surest route of escape from the grips of the global pandemic. To ensure this path, Sabin recommends the following critical actions.

COVID-19 vaccine products must be distributed equitably among countries. Available vaccines have different storage and delivery requirements, safety profiles and efficacy rates against SARS-CoV-2 and emerging variants. Country-level decisions on which vaccines to secure for their populations should be based on their need, immunization infrastructure, preparedness level and predominant variant, rather than price and not hindered by bilateral manufacturing deals. High-income countries should share vaccines that are most amenable to low-resource settings with LMICs in parallel to their own national vaccination campaigns to speed up global delivery. The ACT-A COVAX facility has developed a framework to facilitate vaccine donations from wealthy countries and distribute them to countries struggling to acquire doses. Channeling vaccines through the COVAX facility will ensure that they are shared in a strategic, coordinated manner with equity as a primary goal.

Vulnerable and high-risk communities should be prioritized within local, national and global vaccine allocation strategies. Data indicates that certain groups have an increased likelihood of contracting, becoming severely ill and dying from COVID-19 because of societal injustices. These groups include those living in poverty, those with a physical or mental disability, and groups marginalized because of their racial, religious and/or ethnic origins, among others. To promote equity through COVID-19 vaccine distribution, these disadvantaged groups must be explicitly identified as priority populations for vaccination. If able to, countries should commit to collecting data on who is being vaccinated and make it publicly available to help encourage equitable distribution through accountability. If unable, they should identify inadequate data-gathering infrastructure as a barrier to equitable vaccination that must be addressed before the next pandemic. Aligning national government distribution and population prioritization strategies with the WHO SAGE Framework for the Allocation and Prioritization of COVID-19 Vaccination will help ensure equity.

Health and care workers, particularly immunization professionals working at the point of care, should be prioritized within national and global vaccine allocation strategies. Health and care workers are at heightened risk of exposure and have made significant sacrifices to protect others over the past year. While hundreds of thousands of health and care workers have felt this burden in the form of mental, emotional and relational stress, thousands of others have paid with their lives.  While the exact number of health and care workers who have died from COVID-19 is unknown due to incomplete data from most countries, independent tracking by various organizations has made it clear that the true number is unacceptably high. Health and care workers are a vital component of health system infrastructure. If they are not adequately protected, the downstream consequences on health systems will be felt for years to come. Sabin supports the WHO Year of the Health and Care Worker campaign and has endorsed its Vaccine Equity Declaration, which emphasizes the imperative to prioritize health and care workers.

Local, community-level leaders, especially from low- and middle-income countries (LMICs), must be included as equals in global and national discussions regarding vaccine delivery and distribution. Estimates that some low-income countries may not be fully vaccinated until 2023 or 2024 are unacceptable. As of April 17, 2021, low-income countries have received less than 0.2 percent of the total number of vaccines that have been administered globally.

Part of the solution to reach these populations must be to ensure that experts from LMICs are represented and engaged in global vaccine supply allocation decisions. These individuals have the best on-the-ground understanding of which vaccine product is best suited to the communities they serve, and their expertise must be considered equally alongside that of other global leaders.

Another critical step towards reaching vulnerable populations living in LMICs is for national and subnational decision-makers to bring together a diverse set of stakeholders, including community leaders, when making national vaccine delivery and distribution decisions. Community leaders are uniquely positioned to hold national leaders accountable, ensuring that vaccine delivery and distribution plans are designed to be equitable and accessible for all communities that they are expected to reach.

Targeted investments must be made in primary health care systems to support life course immunization both for COVID-19 and beyond. Ensuring that all communities have access to COVID-19 vaccines will require bolstering immunization infrastructure and primary health systems in some LMICs.

Recent reports indicate that lack of adequate health system infrastructure will be among the most significant barriers to vaccine access in 2021,  alongside vaccine manufacturing capacity. Smart, sustainable investments in these systems are needed to ensure the success of COVID-19 vaccination campaigns now and to launch similar responses faster and more efficiently in the future. Doing so will mitigate the damage caused by future outbreaks by allowing local health systems to react faster and more effectively.

Global regulatory harmonization, local vaccine manufacturing capacity and sustainable, in-country research and development (R&D) infrastructure must be addressed to expand equitable access to COVID-19 vaccines and vaccines against future pandemics. Delays in vaccine development, procurement and introduction in many resource-constrained countries are often due to slow, sequential regulatory approval processes or the absence of emergency use authorization mechanisms. Global or regional regulatory harmonization through alignment between national regulatory authorities and the WHO pre-qualification process could greatly expedite vaccine introduction by alleviating some of the strain placed on national regulatory mechanisms. This is especially true in the case of a new vaccine introduced during a pandemic, when significant resources are required to monitor vaccine safety and effectiveness in a rapidly developing scenario.

The COVAX Facility was developed to fill the critical role of delivering initial doses of COVID-19 vaccine to LMICs. Nearly half a billion doses are contracted to be shipped through the middle of 2021, and the COVAX facility is currently working to secure funding for 1.8 billon doses into 2022 and beyond, enough to protect nearly 30% of the population for 92 participating countries in the COVAX Advance Market Commitment. In order to reach remaining populations however, individual countries must implement parallel procurement processes. While some regional efforts are already underway, such as those by the African Union, many countries and regional bodies do not have the resources to procure sufficient vaccine doses for their entire population. The need to rely on external supply networks for vaccine products would be greatly diminished by introducing more manufacturing facilities with large-scale capacity (100 million doses or more). Countries such as India, with multiple large-scale vaccine manufacturing plants, are able to produce vaccines that will go directly towards protecting their domestic population, while countries throughout the African continent must wait while the rest of the world is vaccinated. Efforts to strengthen national or regional vaccine manufacturing capacity, particularly among LMICs, must be supported by multilateral bodies and national governments alike so that vaccine procurement will not hinder future pandemic responses.

While there are many issues related to the COVID-19 pandemic and access to vaccines that are not represented above, the recommendations offered here are critical to promoting equitable distribution of COVID-19 vaccines worldwide. Global, collective action from stakeholders across all levels of influence is needed to act on these recommendations – everyone must commit to doing what they can. Sabin remains dedicated to expanding equitable access to vaccines, including COVID-19 vaccines, and commits to advocating for these recommendations and supporting them through our programming in the coming months and years.