The COVID-19 pandemic upended global supply chains for many goods and services. But it also shed new light on how to improve vaccine supply chains for increased health equity.
Disrupted global supply chains were a prominent theme in 2020, persisted throughout 2021, and—although not as prominent—remain in 2022. Pandemic-driven supply shocks in China—combined with trade wars, sanction policies, and geopolitical rivalries—amplifieFd economic nationalism that also disrupted global health diplomacy. From the beginning, it was clear that no country alone could efficiently produce all the goods it would need to fight the virus. However, this did not prevent the key medical supplies—masks and other personal protective equipment, tests, and vaccines—from becoming a part of competitive policies. The political and economic pressures to increase domestic production of these necessary goods, to implement export policy restrictions, and to rethink manufacturing strategies—all of which were undermined by unprecedented state interventions—resulted in vaccine nationalism and vaccine geopolitics. Joint state actions were hampered by a lack of data that was driven simultaneously by commercial and national security interests. By evaluating what went right—and what did not—with COVID-19 vaccine supply chains, and by identifying missing information gaps, we can ensure a smoother, more equitable vaccine response for future pandemics.
First, an overview of vaccine supply chains.
Vaccine supply chains
According to the World Health Organization, or WHO, vaccine supply chains are an essential part of all successful immunization programs. End-to-end supply chain systems enable effective vaccine storage, distribution, handling, and management. This includes rigorous temperature controls in the cold chain and logistics management and information systems to promote resilience and efficiency. From manufacturer to service delivery, the goal is to ensure the uninterrupted availability of high-quality vaccines.
Immunization supply chains—the network of staff, equipment, vehicles, and data needed to get vaccines safely from the manufacturer to the people who need them—were first developed in the late 1970s, with the launch of the Expanded Program on Immunization. The Immunization Supply Chain and Logistics systems, which were designed in the 1980s, have supported vaccination coverage worldwide. In 2012, the World Health Assembly committed to the Global Vaccine Action Plan, and its goal to extend the benefits of immunization to all people by 2020. Between 2010 and 2020, new goals increased the volume of global vaccine production fourfold. These developments spurred scholars to study vaccine supply chain sustainability and resilience, and to focus on the “critical role of supply chains in closing the immunization gap,” considering complexities related to different populations, mapping supply shortages, and evaluating the policy environment for health equity.
Vaccine design and technology are both parts of the production process. Ideally, vaccine supply chains are determined long before the vaccine is ready for market, because the design of a drug is often tightly connected to its supply chain. The main steps to bring a new vaccine to market are research and development, clinical trials, vaccine manufacturing, product creation, and distribution. Beyond the vaccine itself, as a critical supply, other materials are also needed for its production: vials and rubber stoppers for the vials, bioreactors, filtration pumps, lipids, and the like. If access to any of the raw materials for the “vaccine kit” is disrupted, so is the vaccine.
The making of a pandemic-driven vaccine supply chain
It normally takes years to identify vaccines, but that was not the case with COVID-19. Clinical trials were processed with unprecedented speed with accelerated design and regulatory reforms, and enormous governmental financing. The manufacturing process was also expedited. Because of this extraordinary speed, supply chains for many COVID-19 vaccines were not predetermined, and the production capacities were both unclear and limited. Before COVID-19, the global health community had not planned to vaccinate more than half the world’s population at once. All these factors led to a chaotic rush to identify and create new vaccine supplies and immunization approaches.
Scholars identified 15 common challenges to COVID-19 vaccine supply chains, grouping them into blocks: manufacturing, organizational, last-minute delays, cold chain, and behavioral.
In 2020–21, COVID-19 vaccines and associated supply chains emerged amid this global rush. The economic historian Adam Tooze pointed out that, remarkably, while the mRNA COVID-19 vaccines were the most innovative vaccines to date, they were not able to meet the global immunization demand. The difficulty of sharing and expanding their production was in part due to the vaccines’ sophisticated technology. Patent waiver debates from within the World Trade Organization also caused gridlock. Lower-tech vaccines were better designed for production, storage, and distribution.
According to the WTO-IMF Vaccine Trade Tracker—which shows the supply of vaccine doses from facilities where the vaccines are made to where they are administered—China supplied a total 6,077.3 million doses of vaccines, for both domestic use and for export. That is more than the total number of vaccine doses supplied by the US (1,609.8 million) and the EU (3,721.0 million) combined. How did this become possible, especially when considering that China had no experience leading global health and vaccine policies? This feat was made possibly in part by Chinese critical supply and leadership strategies, and that vaccine policies and practices were designed both domestically and internationally around them, and then gradually evolved throughout the pandemic.
In 2020, challenges with vaccine rollouts were largely seen as part of larger global supply chain disruptions. Drawing from pre-COVID routine immunizations, public health officials assumed that immunization would be a smooth process. But once COVID-19 vaccines were successfully developed and approved, new hiccups and bottlenecks in their supply chains emerged. Events in 2021 highlighted unique aspects of the vaccine supply chain: increased vaccine production, standardization among vaccine suppliers, and established regulations in the manufacturing process. The fragility of prepandemic medical supply chains was underestimated.
The year 2022 was one of action, grounded in lessons learned. According to the World Trade Organization, 15.2 billion doses of COVID-19 vaccines were distributed globally as of May 31, 2022. Due to the unprecedented scale and magnitude of the virus, both policy and government played important roles in the development of vaccine supply chains. Strategic government involvement and public investment were pursued on the assumption that a vaccine would be approved, and strategic vaccine goals shaped the evolution of vaccine supply chains. Vaccine design and technology, suppliers across geographies, preexisting partner agreements and networks, and trained health practitioners were also crucial.
As the pandemic went into its third year, vaccine supply chains were the subject of published articles and other research, with topics ranging from the optimization of large-scale supply chains, to resilience and risk management, to the role of artificial intelligence algorithms in vaccine decision-making, and to regional strategies in developed countries. Scholars identified 15 common challenges to COVID-19 vaccine supply chains, grouping them into blocks: manufacturing, organizational, last-minute delays, cold chain, and behavioral. Studies across regional and local areas, and developed and developing countries, showed that barriers to vaccination included distance to vaccine distribution points, socioeconomic and psychological factors (norms, religion, education level), and the patient’s willingness to be vaccinated. Additionally, deep analysis of existing academic research on vaccine supply chains revealed the need to streamline concepts and definitions along the global supply chain to ensure that they would be universally understood.
A recent analysis of global supply chains suggests that the new approach for pandemic preparedness should also include a vaccine strategy within a new multilateral platform—namely, the World Bank’s Finance Intermediary Fund for Pandemic Prevention, Preparedness, and Response, or FIF—supported by united health and finance mechanisms. However, the newly established FIF is not a panacea. Priya Basu, head of the World Bank’s COVID-19 Taskforce Secretariat, recently declared that FIF’s biggest challenge is finding the way to convince governments to invest equally in global and national pandemic preparedness as a part of the infrastructure for this global public good. This is supported by findings from Bown and Bollyky, who extensively researched how COVID-19 vaccine supply chains evolved across Western countries, wondering “would alternative policy choices have made a difference?” How can we urgently balance and align national and global public health goals amid the complexity of vaccine supply chains, limited public health resources, a lack of transparency, an absence of trust, and global health disparities?
Gaps in information
Every country that developed vaccines walked similar paths, taking great risks to invest in public vaccine supply chains, and employing rigorous policies and regulations to defend national public health and national markets. The realpolitik evidence is hard to obtain and evaluate given the multitude of disconnected regulations, creating a disconnected approach to global vaccine supply chains. Redesigned vaccine supply chain case studies and data from national COVID-19 vaccine policies should be collected and investigated transparently in order to inform the evolving global health infrastructure.
There is a dearth of information about exactly how countries created their supply chains. Data collection is not unified across countries; however, accurate data are “essential to understand the pandemic and guide policy decisions.” The dominant narrative is based either on data from Western democracies or meager evidence from other regions. While multilateral evidence is accessible through the Global Vaccine Alliance (GAVI), WHO reports, and the Independent Panel for Pandemic Preparedness and Response materials, national vaccine distribution and manufacturing processes remain in a fog.
A global challenge met with national solutions
Countries used different strategies. US vaccine producers relied on domestic plants and hired European contract development and manufacturing organizations, or CDMOs. Geographically, most CDMOs are based in the US and EU, and some are in Japan. Therefore, low- and middle-income countries in Sub-Saharan Africa were forced to rely on imports because they had little experience manufacturing vaccines. China and Russia relied on domestic capacities, including public–private models of cooperation. We saw large companies—Alibaba and Cainiao—serve as the main delivery agent for Chinese vaccines. The Russian Direct Investment Fund—a sovereign wealth fund—was the legal entity in charge of international distribution for the Russian Sputnik-V vaccine. Repeatedly, we saw unprecedented government involvement quickly activate vaccine supply chains (for vaccine production and distribution). To do this, governments depended on preexisting public health capacities, biomedical science, critical public health infrastructure, the pharmaceutical industry, financing, and regulations, quickly deploying national resources.
Global health institutions do not have same the decision-making powers as sovereign states. The greatest example is COVAX—the global platform created to ensure equitable access to COVID-19 vaccines. As an entity, COVAX lacks the resources that wealthy nations put into their own vaccine strategies, including supply chains. However, not all vaccine-producing economies joined COVAX. The Russian vaccine was not approved by WHO; therefore, Russia declined to be a part of the COVAX mechanism. China joined COVAX in 2021; however, in 2022 Chinese epidemiologists criticized the project, saying it failed to address differences in national approaches fighting the pandemic on the global level. The inability to manage the pandemic with a global lens is due in part to the lack of trust between national public- and private-sector entities. Strategic rivalries make it harder for policymakers to see vaccines only as a global health public good.
We must restore trust between countries to create an equitable global vaccine supply chain that benefits all countries.
The limited data from the WTO-IMF COVID-19 Vaccine Trade Tracker show us how different vaccine supply strategies played out. They clearly demonstrate that countries worldwide did not follow international guidelines, highlighting the global health trust crisis through an “every country for itself approach.” The lack of WHO approval did not preclude vaccine use for many countries. Some countries approved almost all available vaccines, even those that still lack WHO approval. The Russian Sputnik-V is a good example. Countries including Mexico, India, Indonesia, Vietnam, Oman, Bangladesh, Turkey, and Egypt “approved, authorized, licensed, gave emergency use status, or made [Sputnik-V] available for use outside of clinical trials via any pathway.”
The same Vaccine Trade Tracker shows that bilateral deals dominated the vaccine supply, accounting for 1,199.5 million doses. The largest numbers of vaccines driven by bilateral partnerships were supplied to South America and Asia. Africa received the largest number of vaccines through multilateral mechanisms—COVAX and the African Vaccine Acquisition Trust (AVAT). Interestingly, China led the use of COVAX, receiving 40,265,000 doses, yet also depended on bilateral partnerships, and was among the countries that most employed bilateral models. Except for China, one could deduce that global health models were seen as less attractive than bilateral relations.
Looking to the future: global health and trust demands
In 2022, the international community appears committed to learning key lessons from the COVID-19 pandemic. Recent reports about vaccine supply chains and national public health systems resilience suggest that sustainable vaccine distribution and delivery models are on the horizon. The WTO and WHO issued a patent waiver for mRNA technology, and a new financial intermediary fund was jointly launched by the Group of Twenty and the World Bank. However, geopolitical rivalry persists and grows.
The fact that every state saw the COVID-19 pandemic as something manageable through preexisting foreign affairs and trade strategies—and not as a joint global action—undermined global COVID-19 vaccine supply chains. Likewise, decades of growing global interconnectedness did not translate to all countries having similar and equal capacities to produce and distribute vaccines. In the COVID-19 aftermath, low- and middle-income countries began to focus on how to acquire vaccine technology and localize manufacturing, signing agreements with either the vaccine economies of China, the EU, Russia, the UK, and the US, or with global vaccine manufacturers. In short, COVID-19’s global health demands did not force countries to prioritize global health needs equally vis-à-vis national interests.
Considerations for a more equitable future response
As we consider the future of global public health and the role of new joint health finance initiatives for vaccine supply chains, we must think carefully about two things. First, how do we prevent a power imbalance between financial and health institutions? When financial systems are included, the potential for conflict-of-interest between parties increases. It is not only the matter of philanthrocapitalism; there is also a growing tendency to unite finance and health multilaterally within developmental ecosystems like the World Bank. These initiatives put health goals in direct conflict with banking principles, which prefer reduced risks and guaranteed interests over social impact. Second, how do we balance national and regional priorities to both stem further commercialization of health and promote health equity—including the social determinants of health—more fully in all pandemic efforts, so that they will become sustainable?
Vaccine supply chains are the core of future pandemic preparedness and response. We must restore trust between countries to create an equitable global vaccine supply chain that benefits all countries. Advancing transparency with health and vaccine data would help create more trusted partnerships among countries, even ones that actively compete in other areas, to help fight global health threats. Nobody expects transparent data-sharing policies on semiconductors or critical minerals; however, data sharing on health should be reestablished, not as a matter of competition but as a matter of shared interests.
Nataliya Shok is a public policy fellow at the Wilson Center's Kennan Institute. She focuses her research on global health, comparative studies in health policies, vaccine, and science diplomacies, with particular attention to interdisciplinary methodology amidst social sciences, history of medicine, and bioethics.
Cover image: Vaccines in packages on conveyor belts. 3d-illustration. Wetzkaz Graphics/Shutterstock.
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