COVID-19 vaccination: returning to WHO's Health For All.

The development and distribution of a COVID-19 vaccine has the potential to greatly change the course of the pandemic; however, ensuring equitable access will require countries, organisations, and corporations to place their trust in global health. The COVID-19 vaccine initiative (COVAX) shows how public–private partnerships can exacerbate existing chasms or allow organisations, such as WHO, to guide a realistic and adequate approach.

Development of vaccines that meet regulatory and licensing requirements involves high costs in terms of facilities, equipment, and human resources and is a lengthy process that often fails. The high cost restricts many countries from developing a vaccine, which causes low income and middle-income countries to rely on research and development from more powerful economies. Additionally, research highlights the challenges in reaching population-level effectiveness with a vaccine, regardless of production capacity, because of weak delivery infrastructures and barriers to access that determine uptake.

Many countries still do not have universal health coverage; therefore, existing delivery gaps must be addressed in distribution strategies and networks. Private enterprise could support the search for a vaccine but, because COVID-19 can spread rapidly across countries and disrupt entire communities, transportation systems, economic sectors, and geographical regions, the COVID-19 vaccine must be treated as a global public good. This global need for equitable access to a vaccine is why returning to the WHO so-called Health For All agenda might bring new significance to the organisation and help in planning future steps for managing COVID-19.

Similar to the WHO Science Council (to be established in late 2020), civil, societal, and community representation in COVAX could remain reserved for English-speaking individuals who do not require compensation for their time. Selection mechanisms might be reinforcing traditional structures of participation, in which many countries and stakeholders are under-represented while privileging those who live or work in high-income countries or organisations. Furthermore, public–private partnerships that are similar to COVAX have previously withheld data from WHO.

Public oversight of transnational companies, private–public partnerships, and states will create resistance; however, increased transparency and accountability on decision making at WHO are needed to address setbacks and build on progress in favour of the populations that are most susceptible to COVID-19 and its consequences. A so-called people's WHO providing impartial advice has been proposed to transform and re-legitimise the organisation. At least two instances of civil society engagement (WHO Watch and Global Health Watch) have shown the value of vigilance. Inclusion of a mechanism similar to WHO Watch and Global Health Watch in current and planned WHO initiatives, especially after the COVID-19 pandemic, could also help to build necessary trust for effective global health governance.

The aim to remain neutral might have led WHO to emphasise diplomacy over addressing the risks and effect of global transmission of COVID-19 and prevented the organisation from investigating potentially biased data. After the 2013–16 Ebola virus epidemic in west Africa, it was expected that this outbreak would be an opportunity for WHO to restructure and strengthen local and national health responses; we are now waiting for COVID-19 to become that game changer.

With insufficient capacity for a decisive global health stewardship, mainly because its budget is too small to reach set goals, WHO is at risk of becoming irrelevant and further undermined. Its financing scheme makes it dependent on large economies that are heavily influenced by powerful corporations, many of which work in the health sector and are connected to philanthropic organisations that lead international collaborations. The power of WHO rests in the understanding that it truly represents all its member countries' best interests and is committed to providing a COVID-19 vaccine for all.

Given the challenges of WHO to be reactive, responsive, and reliable during the COVID-19 pandemic, structural reform will be slow and difficult. First, an example could be set by evaluating initial steps, when necessary, to guarantee meaningful inclusion of countries and voices that have been traditionally excluded in WHO's Science Council and in COVAX. Second, formal conditions for organisations to directly oversee the Science Council and COVAX should be set. Finally, we cannot expect a different outcome than what we have already experienced with the response to COVID-19 in many parts of the world without global inclusion and transparency.