The Lancet COVID-19 Commission calls for three urgent actions in the COVID-19 response
(our broader overview is available on our website). First, all regions with high rates
of new COVID-19 cases, including the USA and the European Union (EU), should intensify
measures to minimise community transmission alongside rapid deployment of COVID-19
vaccines. Second, governments should urgently and fully fund WHO and the Access to
COVID-19 Tools (ACT) Accelerator,
1
including COVAX. Third, the G20 countries should empower the International Monetary
Fund (IMF) and multilateral development banks to increase the scale of financing and
debt relief. Success on all three priorities—containment of transmission, rapid vaccination,
and emergency finance—will require improved global cooperation.
The high rates of community transmission (>100 new COVID-19 cases per million per
day)
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in the USA, Europe, South Africa, and other countries show the emergence of new variants
of SARS-CoV-2, such as lineage B.1.1.7 in the UK,3, 4, 5, 6, 7 501Y.V2 in South Africa,
8
and additional variants emerging in California, USA,9, 10 and in Brazil.11, 12 New
lineages are increasing transmission of infection and raising risks in regions that
have been less affected by COVID-19, including in sub-Saharan Africa.13, 14, 15 Additionally,
acquired immunity from earlier COVID-19 infections might be less protective against
reinfection with some of the new SARS-CoV-2 variants.
16
Mutant lineages might also reduce the efficacy of COVID-19 vaccines and require adapted
vaccines or boosters.17, 18
The numbers of new COVID-19 cases in east Asia and the Pacific (<10 new cases per
million per day in most countries) have been consistently below those of Northern
America and Europe. The lower numbers of COVID-19 cases in these countries result
from the successful implementation of comprehensive containment measures: border restrictions
and other limits on movement; behavioural changes including widespread use of face
masks and physical distancing; active surveillance by public health systems, including
mass testing, backward tracing (to identify the sources of outbreaks), and forward
tracing (to identify the contacts of new cases); and the quarantine of all suspected
cases and the use of facility-based isolation of confirmed cases of COVID-19. The
USA and the EU failed to implement such comprehensive measures, and there was generally
excessive decentralisation of containment efforts across the 50 US states and 27 EU
members in 2020. Lack of centralised coordination undermined control of COVID-19,
not least because of interstate travel in the USA and intercountry travel in the EU.
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Both the USA and EU need to step up more top–down coordination in 2021.
Stronger health systems that incorporate universal health coverage and community-based
health workers are vital in the response to COVID-19. At least half of the world's
population lacks access to essential health services.
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Strengthening community-based and gender-responsive health systems will be essential
to implement inclusive and comprehensive COVID-19 immunisation campaigns.
The global roll-out of COVID-19 vaccines to date is neither inclusive nor adequately
planned. COVAX has targeted immunisation coverage of at least 20% of the population
in each participating country by the end of 2021,
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and has contracted for 2 billion doses of COVID-19 vaccines. Yet the timely supply
of vaccines to COVAX is in question, as high-income countries (HICs) step to the front
of the queue for limited supplies of COVID-19 vaccines.
As of Feb 9, 2021, 148·08 million COVID-19 vaccine doses had been delivered, of which
115·67 million were delivered in the USA (43·21 million), China (40·52 million), the
EU (18·36 million), and the UK (13·58).
22
Other countries in Africa, Latin America and the Caribbean, and Asia (not including
China) have received very few vaccine doses or none at all.
22
This unequal access to COVID-19 vaccines is partly due to the difficulty of managing
the ultracold supply chain needed for the two mRNA vaccines, but it is also due to
the vaccine supply deals negotiated by HICs directly with the vaccine producers, rather
than through COVAX.
© 2021 James Oatway/Panos Pictures
2021
Since January 2020 Elsevier has created a COVID-19 resource centre with free information
in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre
is hosted on Elsevier Connect, the company's public news and information website.
Elsevier hereby grants permission to make all its COVID-19-related research that is
available on the COVID-19 resource centre - including this research content - immediately
available in PubMed Central and other publicly funded repositories, such as the WHO
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If COVAX is provided with more guaranteed funding, it could incentivise expanded production
and delivery of COVID-19 vaccine doses for low-income and middle-income countries
(LMICs) and assure COVAX's place in the vaccine queue. To achieve meaningful results
in 2021, COVAX should have guaranteed funds in 2021 of US$20–40 billion, which it
would turn into firm agreements on expanded vaccine production. Moreover, members
of the Developing Countries Vaccine Manufacturers Network should be engaged with the
efforts of COVAX to produce low-cost vaccines at scale. India and South Africa have
called for an urgent waiver of the World Trade Organization (WTO) Agreement on Trade-Related
Aspects of Intellectual Property Rights (TRIPS) on intellectual property related to
COVID-19 prevention, containment, or treatment.
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The Lancet COVID-19 Commission supports the emergency waiver of TRIPS in all circumstances
that would facilitate the rapid scale-up of production and distribution of life-saving
COVID-19 vaccines and therapeutics, noting that it is in the interest not only of
LMICs but also of the entire world to suppress the pandemic as rapidly as possible.
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During the COVID-19 pandemic, the revenues of governments have plummeted at a time
when higher government spending is urgently needed.
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As a result, the need for emergency deficit financing is unprecedented. HICs are able
to finance large deficits by borrowing in the capital markets together with open-market
operations by the central banks that partly monetise the new debt. If LMICs run deficits
and open-market operations equivalent as a share of gross domestic product to those
in the USA and Europe, most LMICs would incur steeply rising interest rates, depreciating
currencies, and high inflation. Thus, while HICs are running huge budget deficits,
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the poorest countries are reducing investment spending to make room for urgent social
spending.
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Even worse, many of the poorest countries cannot cover the costs of urgent social
needs.
The IMF and multilateral development banks (the World Bank and regional development
banks) were created for such emergencies. In 2020, the IMF lent about $105·5 billion
of emergency financing to 85 countries.
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We welcome the possibility of a new allocation of Special Drawing Rights (SDRs), the
reserve currency of the IMF. As the IMF supplements the international reserves of
IMF member states, a new SDR allocation would be particularly important for countries
that face balance of payment shortfalls in the context of COVID-19 and could be mobilised
in innovative ways to increase the financing capacity for COVAX. If an additional
SDR allocation of about $650 billion were agreed, the amount available to LMICs would
be of significant macroeconomic benefit. The multilateral development banks should
similarly be supported to substantially increase long-term financing of infrastructure
to ensure that COVID-19 does not derail the Sustainable Development Goals and other
development objectives, such as mass electrification with renewable energy and universal
access to digital technologies.
Now more than ever the multilateral system must be supported to work effectively to
deliver know-how and COVID-19 vaccines, therapeutics, and other vital supplies (eg,
personal protective equipment and COVID-19 test kits) to all nations. Multilateral
cooperation should include technical training and cooperation, active sharing of best
practices, and the full deployment of international policy instruments, including
emergency multilateral financing, flexibilities under the WTO-TRIPS agreement, and
active cooperation in global institutions, including WHO, the ACT Accelerator, and
COVAX.