Humanitarians struggle to get Covax jabs: ‘Months of negotiations in vain’

“Five months of pain.” That’s how Sarah Chateau, Doctors Without Borders’ (MSF) program manager for Syria, describes the process of trying to obtain 160,000 Covid-19 vaccines via the Covax Humanitarian Buffer. The scheme is meant to guarantee access to vaccination for the most vulnerable population. But rather than an emergency mechanism, MSF came across a complex and opaque legal framework. The vaccines were never delivered, enraging the NGO.

From a lack of transparency, to unequal distribution of financial and legal responsibilities, to countless intermediaries and contracts, for MSF, the vaccine distribution system failed to meet its emergency response mission, more so as the vaccines are actually available and the target populations are in regions with limited hospital resources.

A last resort

In a humanitarian crisis, states must ensure access to Covid-19 vaccines for their populations – an obligation enshrined in a UN Security Council resolution. Vulnerable people, including the elderly, refugees, displaced persons, stateless persons and detainees should be included in national vaccination plans.

In this context, Covax aims to ensure free access to Covid-19 vaccines for low- and middle-income countries, which can submit a request. The initiative is led by WHO, the Vaccine Alliance (Gavi) and the Coalition for Innovations in Epidemic Preparedness (Cepi).

GAVI’s communications office stated: “Covax was created with the fundamental goal of providing access to those who cannot otherwise benefit. It is the primary source of Covid-19 vaccines in humanitarian settings – the mechanism provides national governments with over 50 per cent of the doses used in these settings.”

But vaccination campaigns continue to miss certain groups of people. This is the case in areas controlled by non-state armed groups, where the government has no access, or during mass, unforeseen population displacements.

To address these gaps, a special vaccine stockpile was created in March 2021, called the Covax Humanitarian Buffer. Governments can use it as a last resort, but also local and international humanitarian organisations such as the UN agencies and the International Committee of the Red Cross.

To date, no NGO has used vaccines from this humanitarian stockpile. The only two states that have are Iran, which acquired 800,000 doses for Afghan refugees, and Uganda, which requested doses for around 680,000 refugees and migrants “in hard-to-reach areas”, according to GAVI.

NGOs, such as MSF, have also begun the application process. But it is painful and leads to nothing, said Chateau.

One crisis, four contracts

“We were dealing with a textbook case,” she explained. “MSF has been active for eleven years in Syria. For two years, we have been intervening in the northwest on a Covid response. At the end of 2021, we observed an increase in the number of cases. In Afrin, one of our hospitals was full because of the severity of the Delta variant. We were concerned about the Tell Abyad and Ras Al Ain area.”

“This area is not included in any vaccination campaign, as it is militarily occupied by Turkey since 2019 and this occupation is not recognised by the international community. As a result, it was neither included in the UN cross-border mechanism for the delivery of humanitarian aid, nor covered by the Syrian government's national plan.”

She added: “So we thought, 'Bingo, we'll call on the Covax humanitarian stockpile to vaccinate 150,000 people’.”

Early November 2021, MSF put in a request for 160,000 vaccines, which is near the end of December. “We were thrilled. A month and a half is a bit long for an emergency mechanism, but we were the first to have such a quick response,” she said.

But the jabs never came through. The actors involved – MSF and GAVI, as well as UNICEF and the manufacturer (whose name is confidential) – could not agree on the clauses of the four contracts that had to be concluded.

Complex, opaque and unfair

Covax legal framework is opaque and inflexible, with “unacceptable negotiation timeframes, excessive complexity of contracts, lack of transparency and unbalanced distribution of responsibilities”, Chateau said.

“Our lawyers had to juggle between three different counterparts. Covax’s coordination alone was only put in place one month after we had obtained the agreement in principle. We were denied access to some of the legal documents of the procurement process, even though they were necessary for risk assessment. We had the contracts, but not the annexes, which were passed on in tidbits. It was impossible to sign anything under these conditions.”

“They say, ‘sign this and you'll be covered by this mechanism described in this document in case of damage”, but you don't have the document in question. Three weeks ago, when we stopped everything, we were still missing some documents.”

Beyond the “information gap”, the responsibility of the different parties also posed a problem, according to Chateau.

“There was a complete imbalance between what was asked of us and the commitment of the other actors. They were completely disclaimed responsibility for any side effects and problems stemming from the injection of the vaccine, for example. They asked MSF to waive the right to certain legal claims against Covax partners in the event of any problem, and in some cases to compensate the partners for losses and third-party claims,” she said.

“Imagine, if the company transporting the vaccines waives liability if the cold chain is broken during transport, we would have potentially had to take responsibility for the serious faults of others.”

MSF is now calling for the system to be simplified. Chateau said: “We hope that these five months will not have been for nothing and that our unfortunate experience will allow the system to evolve. As it stands, it clearly does not meet the challenges of an epidemic. Since our request, the dominant variant has had time to change. We need to be faster, more equitable in accountability and more transparent.”

GAVI's response

When questioned about the claims, GAVI’s communications office sidestepped the issue: “The ‘buffer’ humanitarian stockpile was put in place to reach the most vulnerable (...).  Allowing access in these contexts, where systemic problems are the norm, is technically, operationally and logistically complex. It is even more difficult to do so during a pandemic, with ongoing conflicts and increased needs for vital services. Overcoming these obstacles requires innovation, concerted interagency efforts, and mutual commitment to support unimpeded access to those in need.”

GAVI said it is working with all stakeholders to “minimise the complexity of processes wherever possible”.

“Gavi has secured indemnification and liability waivers for seven vaccines in the Covax portfolio, helping to shift responsibility for these products from humanitarian agencies to manufacturers to reach these vulnerable groups. Discussions are underway for two additional vaccines (...) However, a significant challenge remains in translating these waivers into deliveries, particularly in areas facing long-term systemic problems,” the vaccine alliance said.

“Manufacturers, civil society humanitarian agencies, UN agencies, the Red Cross and Red Crescent, and national governments must play their part in helping to remove remaining barriers to access, including compensation during transport and delivery, removing import barriers, and working together to ensure that doses can be delivered and administered.”

Back to Syria

MSF finally reached an agreement with GAVI. After submitting its request in November and after bitter negotiations and several amendments of the original version, the humanitarian organisation finally resigned to sign three of the four contracts in April – five months later.

In the meantime, the Turkish authorities decided to take matters into their own hands and use their own stock, which was at risk of expiring given the lengthy process. After having accepted it, the Turkish authorities finally declined the jabs from MSF and its Syrian partner NGO, Al Ameen.

“We realised that the mechanism is completely disproportionate and unreasonable for an emergency response and the needs of the affected populations,” Chateau concluded.