Category: Medicine

GAVI, the Vaccine Alliance has saved millions of lives by delivering vaccines to the world’s poorest children at remarkably low cost. It’s frankly grotesque that RFK Jr. cites “safety” as a reason to cut funding—when the result of such cuts will be more children dying from preventable diseases. Own it.

You can find plenty of RFK Jr. criticism elsewhere, however, and GAVI is not above criticism. Thus, precisely because GAVI’s mission is important, I want to focus on a GAVI project that I think is ill-motivated and ill-advised, GAVI’s African Vaccine Manufacturing Accelerator (AVMA).

The motivation behind the AVMA is to “accelerate the expansion of commercially viable vaccine manufacturing in Africa” to overcome “vaccine inequity” as illustrated during the COVID crisis. The problem with this motivation is that most of Africa’s delay in receiving COVID vaccines was driven by funding issues and demand rather than supply. Working with Michael Kremer and others, I spent a lot of time encouraging countries to order vaccines and order early not just to save lives but to save GDP. We were advisors to the World Bank and encouraged them to offer loans but even after the World Bank offered billions in loans there was reluctance to spend big sums. There were supply shortages in 2021 in Africa, as there were elsewhere, but these quickly gave way to demand issues. Doshi et al. (2024) offer an accurate summary:

Several reasons likely account for low coverage with COVID-19 vaccines, including limited political commitment, logistical challenges, low perceived risk of COVID-19 illness, and variation in vaccine confidence and demand (3). Country immunization program capacity varies widely across the African Region. Challenges include weak public health infrastructure, limited number of trained personnel, and lack of sustainable funding to implement vaccination programs, exacerbated by competing priorities, including other disease outbreaks and endemic diseases as well as economic and political instability.

Thus, lack of domestic vaccine production wasn’t the real problem—remember, most developed countries had little or no domestic production either but they did get vaccines relatively quickly. The second flaw in the rationale for the AVMA is its pan-African framing. Africa is a continent, not a country. Why would manufacturing capacity in Senegal serve Kenya better than production in India or Belgium? There’s a peculiar assumption of pan-African solidarity, as if African countries operate with shared interests that go beyond those observed in other countries that share a continent.

Both problems with the rationale for AVMA are illustrated by South Africa’s Aspen pharmaceuticals. Aspen made a deal to manufacture the J&J vaccine in South Africa but then exported doses to Europe. After outrage ensued it was agreed that 90% of the doses would be kept in Africa but Aspen didn’t receive a single order from an African government. Not one.

Now to the more difficult issue of capacity. Africa produces less than .1% of the world’s vaccines today. The African Union has what it acknowledges is an “ambitious goal” to produce over 60 percent of the vaccines needed for Africa’s population locally by 2040. To evaluate the plausibility of this goal do note that this would require multiple Serum‑of‑India‑sized plants.

More generally, vaccines are complex products requiring big up-front investments and long lead times:

Vaccine manufacturing is one of the most demanding in industry. First, it requires setting up production facilities, and acquiring equipment, raw materials, and intellectual property rights. Then, the manufacturer will implement robust manufacturing processes and manage products portfolio during the life cycle. Therefore, manufacturers should dispose of an experienced workforce. Manufacturing a vaccine is costly and takes seven years on average. For instance, it took about 5–10 years to India, China, and Brazil to establish a fully integrated vaccine facility. A longer establishment time can be expected for African countries lacking dedicated expertise and finance. Manufacturing a vaccine can costs several dozens to hundreds of million USD in capital invested depending on the vaccine type and disease indication.

All countries in Africa rank low on the economic complexity index, a measure of whether a country can produce sophisticated and complex products (based on the diversity and complexity of their export basket). But let us suppose that domestic production is stood up. We must still ask, at what price? If domestic manufacturing ends up being more expensive than buying abroad (as GAVI acknowledges is a possibility even with GAVI’s subsidies), will African countries buy “locally” and pay more or will solidarity go out the window?

Finally, even if complex vaccines are produced at a competitive price, we still haven’t solved the demand problem. GAVI again has a rather strange acknowledgment of this issue:

Secondly, adequate country demand is another critical enabler. For AVMA to be successful, African countries will need to buy the vaccines once they appear on the Gavi menu. The Secretariat is committed to ongoing work with the AU and Member States on demand solidarity under Pillar 3 of Gavi’s Manufacturing Strategy.

So to address vaccine inequity, GAVI is investing in local production….but the need to manufacture “demand solidarity” among African governments reveals both the flaw in the premise and the weakness of the plan.

Keep in mind that the WHO only recognizes South Africa and Egypt as capable of regulating the domestic production of vaccines (and Nigeria as capable of regulating vaccine imports). In other words, most African governments do not have regulatory systems capable of evaluating vaccine imports let alone domestic production.

GAVI wants to sell the AVMA as if were an AMC (Advance Market Commitment) but it isn’t. It’s industrial policy. An AMC would offer volume‑and‑price guarantees open to any manufacturer in the world. An AMC with local production constraints is a weighted down AMC, less likely to succeed.

None of this is to imply that GAVI has no role to play. In addition to a true AMC, GAVI could arrange contracts to pay existing global suppliers to maintain idle capacity that can pivot to African‑priority antigens within 100 days. GAVI could possibly also help with regulatory convergence. There is an African Medicines Agency which aims to operate like the EMA but it has only just begun. If the AMA can be geared up, it might speed up vaccine approval through mutual recognition pacts.

The bottom line is that the $1.2 billion committed to AVMA would likely better more lives if it was directed toward GAVI’s traditional strengths in pooled procurement and distribution, mechanisms that have proven successful over the past two decades. Instead, AVMA drags GAVI into African industrial policy. A poor gamble.