Characteristics of selected articles

The included publications comprised 23 perspective/opinion or commentaries, 4 editorials, 3 policy documents, 2 reviews and 1 book chapter. In terms of research tradition(s), 23 articles were categorised under ‘public health/medicine’, 15 under ‘ethics’, 12 ‘law’ and 3 ‘philosophy’. The countries of origin were diverse, including authors from 27 different countries. Notably, 17 articles (51.5%) had author(s) from high-income countries only, 12 (36.4%) had representation from both high-income countries and LMICs and only 1 was solely from an LMIC.

Online supplemental material 2 summarises the unfolding storylines and their conceptualisation of vaccine equity, in chronological order of publication. By publication date, the articles span the period from June 2020 to September 2021. Overall, 11 of the 33 articles (33.3%) were written before the introduction of approved COVID-19 vaccines and the other 22 (66.7%) after.

Definition of vaccine equity

Most of the articles did not state an explicit definition of the term ‘vaccine equity’. Two articles published in August 2021 gave an implicit definition of equity, both referring to equity as means of minimising disparities.25 26 One article published in May 2021 referred to equity as proportionality but did not give its explicit definition.27 In the context of worldwide vaccination in a global pandemic, vaccine equity was generally implied to refer to equitable vaccine coverage across high-income countries and LMICs. This was a notion that was widely and uncritically adopted. Each article regarded equity using a distinct disciplinary approach, on the basis of which the author(s) based their recommendations on how vaccine equity could be accomplished. The five interconnected meta-narratives are discussed below and illustrated in figure 3.

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Figure 3

Meta-narratives (the number of articles assigned to the meta-narrative) and the corresponding subthemes on vaccine equity in the context of the COVID-19 pandemic. Meta-narratives (the number of articles assigned to the meta-narrative) and the corresponding subthemes on vaccine equity in the context of the COVID-19 pandemic.

Meta-narrative 1: frameworks and mechanisms for vaccine allocation

In 11 articles included in this meta-narrative, the issue of vaccine equity is considered in the context of the need for an effective and equitable global distribution mechanism.7–10 13 28–32 These authors attempted to propose solutions—either new frameworks or suggestions to strengthen existing ones—for the global distribution of COVID-19 vaccines. Such propositions appeared in the published literature from August 2020, while COVID-19 vaccines were still in development and before any had been approved by regulators.9 The WHO published its proposal of the COVAX Facility mechanism on 9 September 2020.8 Early consideration of this matter, particularly from a logistical standpoint, reflects the overall cognizance that without a predefined set of principles and mechanisms in place, equitable distribution among countries of this life-saving intervention in a global pandemic was unlikely to be achieved.

The awareness of logistical difficulties stems from past experiences in the management of public health crises. The need to equitably distribute medical and public health resources, including medications, treatments, tests and vaccines, has been a recurring theme in global health before COVID-19 vaccination came into the picture. Delayed distribution of antiretroviral treatment cost 330 000 lives in South Africa between 2000 and 2005.2 Efforts to expand access to influenza H5N1 and H1N1 vaccines were embroiled in protracted negotiations.1 A common trend is that the vulnerable in low-income countries are often the last to receive these interventions. Experiences during these crises meant that, once COVID-19 became widespread enough to warrant the development of a vaccine, the WHO prioritised working pre-emptively towards a global distribution mechanism. Academics, most prominently in the fields of public health/medicine,7 9 10 28–32 began to devise relevant recommendations.

Liu et al9 propose a ‘multivalue ethical framework’, which stratifies countries into groups based on three guiding principles: ability to provide care, ability to implement and reciprocity. This was the only selected article published prior to WHO’s introduction of the COVAX mechanism.8 The COVAX framework proceeds in two stages: phase 1 focuses on proportional allocation for all countries once 20% of population per country is covered; phase 2 expands access using weighted allocation based on risk assessment. In close succession, Emanuel et al7 published the Fair Priority Model to supplement COVAX. The model proceeds in three phases: (1) reducing premature deaths; (2) reducing serious economic and social deprivations; and (3) returning to full functioning. Prioritisation at each of these stages is based on a specific metric, namely: (1) standard expected years of life lost (SEYLL) averted; (2) SEYLL averted, reduction in absolute poverty and declines in gross national income averted; and (3) transmission rates. The authors argue for prioritising countries that are more severely affected, rather than pure proportional distribution. This view is echoed by Garfinkel et al,28 who highlight that the rigid geographical distribution key of COVAX fails to take into account optimal global health impact and the respective medical or economic needs of member countries.

Sharma et al30 compared COVAX’s allocation mechanism with a targeted allocation based on need (eg, the Fair Priority Model). They concluded that although, in theory, a targeted distribution in proportion to a country’s need would be more morally justifiable, when political realities are taken into account, an equal distribution seems more likely to avert a greater number of deaths and reduce disparities.

Similar to Sharma et al,30 later published papers (post introduction of approved COVID-19 vaccines) do not propose a novel framework, but evaluate existing frameworks (mainly COVAX) and/or offer recommendations for implementation, which may extend beyond the allocation mechanism to aspects such as healthcare delivery. Most advocate maintaining commitments to global cooperation through COVAX.10 29 33 Herlitz et al29 offer three suggestions to strengthen existing proposals for fair vaccine allocation. Such proposals should: address health problems for individuals; explicitly focus on both direct and indirect health effects of COVID-19; and assist countries with their vaccine distribution, production and consumption. Binagwaho et al10 further recommend sharing of technologies by pharmaceutical companies and ensuring logistical capacity for mass vaccination. According to Asundi et al,32 the first step should be the redistribution of surplus in some high-income countries, while true global vaccine equity will require a long-term, global effort to expand vaccine production capability, facilitate technology transfer and develop regulatory systems that support vaccine innovation. Once COVID-19 vaccination was underway, more emphasis was placed on the emerging inequalities in global vaccination. Wouters et al highlight national procurement strategies (ie, purchasing vaccines directly from developers and not via COVAX, a practice which began with high-income countries) as one of the most significant threats to equitable allocation.13 In this way, the concept of vaccine equity centres on the disparities in global distribution, particularly between high-income countries and LMICs.

In summary, papers included in this meta-narrative focused on the proposed mechanisms for global vaccine distribution, as well as the pragmatic aspects of achieving equitable allocation. Three frameworks emerged: the multivalue ethical framework,9 the WHO’s COVAX Facility8 and the Fair Priority Model.7 COVAX (proportional allocation in the initial stage) and the Fair Priority Model (need-based allocation from the outset) represent the two most prominent schools of thought. Other papers review these frameworks or evaluate other actionable recommendations.10 28–32 34 Papers in this meta-narrative tended to envisage the world as divided into high-income countries and LMICs.

Meta-narrative 2: global health law

Although public health has always involved international cooperation, global health law as a field has expanded significantly in response, in part, to the need for international legal cooperation to address emerging global health threats such as pandemics.35 The nine included articles broach the topic of vaccine equity in COVID-19 by considering the concept of global health law and governance.25 28 36–42 These authors have academic backgrounds predominantly in law or foreign relations.36–38

Gostin et al37 explore the global health law reforms necessary to the progressive realisation of universal vaccine access. This will require: facilitating funding and benefit sharing, easing intellectual property (IP) protections and harmonising national vaccine regulations. A key issue arising from such discourse in the context of COVID-19 vaccination is that of intellectual property. Vanni38 argues that the development discourse often touted by developed nations to help countries in the Global South ‘catch up’ is empty when essential medicines are deliberately denied and weaponised, and calls for an overhaul of the ‘dysfunctional global IP system’. Frequently invoked in the debate is the World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement). The United Nations Committee on Economic, Social and Cultural Rights (CESCR),40 for one, urges member states to maximise the production and equitable deployment of vaccines using flexibility of TRIPS agreements internally as well as voluntary licensing, technology pools and waivers. Various authors also suggest that a temporary IP waiver is essential but not sufficient; this must be further supplemented by knowledge and technology transfer.39 42 Overall, there is widespread agreement that ‘global IP rules must not stand in the way of research, production, technology transfer or equitable access to essential health tools, and in context of pandemics to achieve increased manufacturing without discouraging innovation.’25

Other concepts in the discourse include global health security39 and access to medicines.41 Krikorian et al argue that the current health innovation and access ecosystem is ill-suited to provide equitable access to life-saving medical interventions. They call for the current market-based innovation policies to be replaced by public–private collaboration for the public interest.41 Šehović et al broach the concept of global health security, which they note has no unified definition, but rather can be considered from ‘two perspectives that operate in tension: that of state security prioritising individual national(s) safety and security, and that of human security-centred population security that also applies beyond borders’.39 Such discussions tend to arise post development of approved COVID-19 vaccines, as the focus shifts towards future pandemic preparedness and the improvement of overarching systems of governance.

Invariably, global health law is not considered in isolation, but in tandem with closely interrelated themes of vaccine nationalism and human rights. Aspirations to global governance and multilateralism runs counter to the phenomenon of vaccine nationalism. Gostin et al,37 as previously noted to be focusing on vaccination access through global governance, also examine the human rights foundations of global health law, conceptualising vaccination access as a universal human right. Šehović et al39 also call for advancing the human rights front, including through international human rights law and International Health Regulations. The CESCR similarly frames vaccine equity in view of the UN Sustainable Development Goals and human rights obligations.40

In essence, articles in this meta-narrative considered vaccine equity through the lens of global health law. A key issue in this regard is the IP system, wherein there arises a mismatch in the policy design of IP protection and the policy requirements of an effective pandemic response. Global health law was also discussed in conjunction with vaccine nationalism and human rights.

Meta-narrative 3: vaccine nationalism

Five included articles discussed vaccine nationalism.27 33 43–45 ‘Vaccine nationalism’ is a term frequently used in the press and research when discussing COVID-19 vaccine distribution.46 47 It is directly related to the ethical dilemmas arising from the pandemic and stems from the self-interest of nation states. In essence, it describes the situation in which countries take on responsibilities solely concerning the situation within their borders. It is often contrasted with the position of ‘vaccine cosmopolitanism’.45

According to Tandon,45 vaccine nationalism and cosmopolitanism originate from different political ideologies. Vaccine nationalism stems from communitarianism as it is shaped by the idea that belonging to different communities informs moral obligations. In contrast, vaccine cosmopolitanism relies on utilitarianism, which measures the outcome of vaccination by general global well-being without division into separate parties.45 However, other authors challenge definitions that are based solely on utilitarian perspectives. Two articles included in this meta-narrative pair it with the term ‘distributive justice’.27 43 Ferguson and Caplan43 define vaccine cosmopolitanism as a view in which community membership (eg, citizenship) is irrelevant in achieving distributive justice. This relates directly to the distribution of vaccines distinguishing between what is equitable and what is equality. According to Bolcato et al,27 ‘equitable’ in the context of distributive justice refers to proportionate distribution according to need, hence it refers to the process itself and priorities must be set in proportion to the reduction of risk for the greatest number of people in a given population at a given time. Equality (vaccine administration for all) is defined as guaranteeing the entire population equal protection against infection through vaccination campaigns that take into account equitable access in line with needs of populations, communities and individuals.27

Three articles included in this meta-narrative were published post-COVID-19 vaccine deployment27 44 45 and relate to the current state of COVID-19 vaccination. The two included articles published before COVID-19 vaccine distribution33 43 sought to find the middle ground between vaccine nationalism and cosmopolitanism. Furthermore, they validate vaccine nationalism as an instinctive response and urge research and political bodies to recognise these conflicting agendas when designing the ethical framework for just vaccine allocation. Ferguson and Caplan43 point out that some research groups and policy-makers condemn vaccine nationalism as an obstacle. However, the authors argue that governmental bodies have certain justice-based obligations towards their citizens, which cannot be dismissed in the discussion on global vaccine distribution. Lie and Miller33 adopt a similar view, criticising the Fair Priority Model for its ineffectiveness in the real world. They contend that COVAX provides the right balance between national and global responsibilities.

Bolcato et al27 recognise the difficulties in the implementation of equitable vaccine distribution owing to differing perceptions of equity and opinions on ways of adopting it, and because vaccine nationalism applies chiefly to the policies of rich nations. The authors also define equity as proportionality according to individual countries’ needs that, when applied to vaccine distribution in a time-sensitive manner, helps to accomplish equality.27 They also recognise the need for change in the predominant vaccine nationalism culture in rich countries as do other publications.44 45 Katz et al44 discuss the existing organisations such as COVAX and emphasise the need for multilateral partnerships. Tandon45 proposes scrutiny of the reasons that underpinned the widespread adoption of vaccine nationalism.

The articles in this meta-narrative construct the concept of vaccine equity around two opposing concepts: vaccine nationalism and cosmopolitanism. The authors envision a world that faces the COVID-19 pandemic through these two ideologies often dividing the globe into two groups: developed countries which thrive on vaccine nationalism and LMICs which fall victim to it. The authors tend to be based in the Global North and have legal/public health academic backgrounds. Some of them give a direct opinion on the negative aspects of vaccine nationalism and find solutions in cosmopolitanism.27 44 45 Those authors often refer to the state of global vaccination listing its possible current and future consequences. Articles were mostly published once the vaccines were approved and deployed. Two articles published prior to vaccine development33 43 acknowledged the inevitability of vaccine nationalism and argued that to achieve equitable distribution, vaccine nationalism should be recognised and partially incorporated by the global allocation frameworks. Overall, the articles in this narrative focus on the consequences of vaccine nationalism and they view vaccine equity through the lens of purchase and distribution of vaccines.

Meta-narrative 4: ethics and morality

Ten articles included in this review consider the issue of equitable COVID-19 vaccine distribution from a moral point of view, justifying the need for it.11 26 30 37 44 48–52 These considerations often stem from human rights, with reference to the 1948 Universal Declaration of Human Rights53 and the WHO Constitution (1948) that envisaged ‘the highest attainable standard of health as a fundamental right of every human being’.54 Pinpointing numerous failures of humanity to execute this idea (eg, influenza H1N1,48 antiretroviral treatment for HIV in the early 2000s1), researchers also highlight the practical importance of equitable vaccine distribution in ending the COVID-19 pandemic.

Identification and analysis of the values underpinning the moral obligation to strive for COVID-19 vaccine equity were published during the vaccine discovery phase and predeployment in September 2020. The WHO Strategic Advisory Group of Experts on Immunization (SAGE) values framework49 recognised six values-informed principles for guidance in the global vaccine allocation process. Similarly, an article published postdeployment of vaccine identifies a set of moral values that underpin the universal notion of vaccine equity—Adejumo et al26 refer to Sustainable Development Goals and the principle of Universal Health Coverage, and define vaccine equity as a process of ‘striving to eliminate disparities in health between more and less-advantaged social groups occupying different positions in the social hierarchy’. The WHO SAGE framework49 also highlights that the global vaccine allocation needs to consider special epidemic risks of each country individually to address the human rights claims to vaccines. It also specified the need for special attention to LMICs and considered COVID-19 vaccine a public good.

The idea of a COVID-19 vaccine being recognised as a global public good was widely adopted in the months leading up to and following vaccine deployment.11 55 56 Smith et al57 in 2004 concluded that global public goods could offer ‘guidance in improving collective action at the international level’ regarding communicable diseases control. Two articles11 49 suggested that the concept of COVID-19 vaccine as a global public good will be necessary in ensuring its equitable distribution, whereas Gostin et al37 recognised its role in the global health law reforms as crucial to the progressive realisation of universal vaccine access. Despite referring to COVID-19 vaccines as global public goods,11 37 49 articles often failed to give a definition of this term. According to a previously established definition by Musgrave and Samuelson, a global public good must fulfil two criteria: non-rivalry and non-excludability.57 Persad and Emanual argue that the attention focused on the fair distribution of available COVID-19 vaccines confirms that they are not global public goods because they are rival (when one person receives it, another is denied it) and excludable (countries can decide to vaccinate only citizens and residents).58 They argue that if COVID-19 vaccines were really global public goods, the focus would be on maximal production. They advocate for understanding vaccines as a humanitarian entitlement rather than a global public good.

Another issue that arises from the discourse on moral obligations in COVID-19 vaccine distribution is the juxtaposition of fair and feasible distribution. Many articles give ethical reasons for prioritising LMICs. Jecker and Atuire50 draw on African ethics and the characterisation of COVID-19 crisis. They introduced ethical criteria to guide global distribution, arguing that the difficulties that LMICs face in obtaining vaccines mean that they should be prioritised. Emanuel et al7 also adopted the view that, given the gravity of the pandemic and the number of lives at stake, it is not possible to justify the self-interest of nation states and lack of global responsibility. Sharma et al,30 however, argue that fair distribution might not be the best solution in terms of political feasibility. A morally defensible vaccine allocation mechanism would involve distributing doses to those whose need is greatest. It should ensure the greatest reduction in harm and disparities which they classify as a main goal for global COVID-19 vaccination. However, the authors claim that targeted distribution based on countries’ needs might not yield the desirable result due to its political unfeasibility. As one of the articles published post vaccine deployment in March 2021, it criticises the WHO’s failure to acknowledge the reality of current vaccine distribution and the self-interestedness that guides the current allocation process. This resonates with the meta-narrative of ‘vaccine nationalism’ considered in meta-narrative 3.

There is another aspect to COVID-19 vaccine equity mentioned in three articles48–50 that are aligned with several meta-narratives including ‘ethics and morality’ and ‘reparative justice’. Ogbogu et al48 discuss equity at each level of vaccine development including open access to research outputs, distribution of benefits and burdens of the research, and access to research resources in biotechnology. This extends the responsibility of states to ensuring progress towards global equitable distribution of biotechnology resources and research. Such a shift towards practical justice could lead to minimising the divide between theory and policies in the real world. Jecker and Atuire50 also extend vaccine equity beyond distribution as they argue, on utilitarian and deontological grounds, for waiving IP protections.

In articles included in this meta-narrative, researchers approached vaccine equity from an ethical perspective, examining the reasons that should guide government bodies and global entities in the process of vaccine allocation. The definition of vaccine equity is often implied, and is characterised as a means to relieve the most suffering and minimise disparities. The authors come from different countries and are experts in various fields including law, ethics, philosophy and public health which results in heterogeneous reasons used to justify the need for equity. Some referred to human rights and moral obligations,11 while others emphasised the practicality of the desired solution30 or the multifaceted nature of the issue.48 COVID-19 vaccine as a global public good is also a recurrent theme. Despite the similarities in the approach to the issue, there is little consistency in agreement on the morality of vaccine equity.

Meta-narrative 5: reparative justice

Four articles were identified under this meta-narrative.25 49 59 60 The three that were published postvaccine deployment both examine a similar side of the COVID-19 vaccination issue that arose after the first months of vaccines rollout.25 59 60 All three articles were published in global health-related journals and included researchers with ethical and law backgrounds. They bring up reparative justice, which entails a different side of equity. This concept seeks to repair harm that has been done to the victims considering the reality they live in and the nature of the harm. Saksena60 argues that in a similar way, the vaccine allocation process needs to account for historical inequities when distributing vaccines. The authors propose the idea of setting up quotas for LMICs, resembling the national allocation framework by the US National Academies of Sciences, Engineering and Medicine, which prioritises racial minorities. The article also criticises patent monopolies that create artificial scarcity. The second article also considers COVID-19 vaccination through reparative justice but applies this concept beyond vaccines. Sekalala et al61 argue that true equity lies in power not distribution, and to achieve that, human rights must be freed from colonial ideology. The authors criticise charitable initiatives such as COVAX and focus their attention, similarly to Saksena,60 on the lack of attention to human rights by corporations holding patents to the vaccine. Sekalala et al61 also point out how IP system protection coerces countries in the Global South to agree to participate in the unjust global economic systems and reinforces colonially established power dynamics. Despite the African Union’s criticism of IP law protection, LMICs were pushed to participate in the charitable model of the COVAX scheme and due to the lack of bargaining power they often could not obtain competitive rates for the COVID-19 vaccines.

Hotez et al25 also apply an expansive meaning of equity that goes beyond distribution. The authors of the article, who come from a range of countries and academic backgrounds, provide a comprehensive set of recommendations that can support LMICs in striving for COVID-19 equity. The article raises the important issue of research of COVID-19 vaccines, including the need for transfer of technology and manufacturing as well as participation of LMICs in randomised control trials. Similarly, the WHO SAGE values framework49 also offers guidance on the COVID-19 vaccine equity on a broader scope than just distribution. It recognises constant change as an inherent element of the pandemic and proposes values that need to be acknowledged to mitigate the consequences of a dynamic situation.

Overall, the articles in this meta-narrative evaluate the concept of equity in COVID-19 from a broader perspective and often refer to the global inequity of power, that in its implications, goes beyond solely the distribution of COVID-19 vaccines. The authors are based in various countries (including LMICs), have diverse academic backgrounds and offer a comprehensive set of guidelines and recommendations that should be introduced in the pursuit of equity to minimise disparities and free LMICs from colonially entrenched power dynamics.