A path to finding global equity in the world of COVID-19

Such striking inequality brought the topic of vaccine equity to the spotlight. It became very newsworthy across a plethora of platforms including journalism, peer-reviewed literature, global think tank reports, and international and governmental policy documents. However, despite the media and academic interest, the way vaccine equity is conceptualised in the literature had not yet been investigated. This could have implications for the quality of vaccine research and its applications to global vaccination.

Our study aimed to give a comprehensive summary of how COVID-19 vaccine equity is referred to and investigate how, and from which angles, researchers have considered it so far. We also explored any potential differences in the understanding of the concept of vaccine equity by distinct research groups and looked at how the differences could have affected the practical solutions proposed.

Since the concept of vaccine equity is complex in nature and it cannot be measured purely by numbers, we selected a meta-narrative approach, allowing us to summarise overarching themes on a scope broader than conventional systematic reviews.

Looking at vaccine equity

From 33 articles that we included in the review, five meta-narratives were constructed:

1. Frameworks and Mechanisms for vaccine allocation
2. Global Health Law
3. Vaccine Nationalism
4. Ethics and Morality
5. Reparative Justice

We found that most of the articles did not state an explicit definition of the term ‘vaccine equity’. They assumed that equity in the context of worldwide vaccination in a global pandemic referred to equitable vaccine coverage across HICs and LMICs. This view was widely, although, uncritically adopted.

Each article used a distinct disciplinary approach to base the recommendations on how vaccine equity could be accomplished. Researchers mostly focused on mechanisms for achieving global health equity. Certain themes were especially prominent including ‘practical frameworks’, ‘vaccine cosmopolitanism’, ‘global health law’ and ‘human rights’. These were explored as reasons for achieving equity or factors contributing to the global vaccine distribution process.

Things can change

Certain events influenced the meta-narratives’ development (e.g., deployment of vaccines and thefunding of COVAX - COVID-19 Vaccines Global Access, a worldwide initiative aimed at equitable access to COVID-19 vaccines). Articles published before the deployment of vaccines viewed vaccine nationalism (where countries prioritise the pursuit of vaccines for themselves) as a component of justice. Those published after, likely influenced by strikingly unequal vaccine distribution, criticised it. Similarly, after the publication of the three ethical frameworks (Emanuel et al., 2020; Liu et al., 2020; World Health Organization, 2020), we witnessed a shift in the literature from framework creation to critiques of the existing ones. Academic publishing models should be acknowledged as influencing which authors and themes are prominent in the peer-reviewed literature.

Vaccine equity is not only about distribution

Understandably, most of the articles focused on vaccine distribution. However, some of them recognised vaccine equity is not just about distribution. In a commentary, Graaf et al. point out that there is a scope for vaccine equity to extend to the full vaccine life cycle, taking research, production, intellectual property, distribution and health-systems contexts into account. Papers that did not expand their definition of vaccine equity beyond distribution often advocated policies centred around charity-like donation models such as COVAX and they failed to address the structural inequalities that entrench health inequalities. This shows how important it is to recognise that our definition of ‘equity’ can influence the recommendations proposed. In the future, we should recognise the multi-faceted nature of vaccine equity that extends beyond the distribution.

What are the next steps?

Our review identified the need for more systematic reviews comparing the existing frameworks. We need to look at how our perception of vaccine equity can influence our perspective and thus recommendations we make. Perhaps, reaching consensus about vaccine equity is unrealistic, as too many stakeholders with contrasting agendas are involved in the decision-making process. However, for policy formation and establishing a working allocation framework, a consensual definition of ‘equity’ is crucial. Nonetheless, we will not achieve it without further discourse on what vaccine equity is or should be. To bear any fruit, we need to keep the discussion transparent by improving reporting our understanding of vaccine equity and the sociopolitical context from which it stems.

It is likely that the COVID-19 pandemic will not be the last global pandemic we will have to endure. We should learn our lessons and preemptively prepare ourselves for another crisis. Before we establish a global allocation framework of scarce resources for future pandemics, we need to revisit the definition of equity and be transparent about what it means to us in our research outputs.