COVAX and the rise of the 'super public private partnership' for global health.

COVAX, the vaccines pillar of the Access to Covid-19 Tools Accelerator (ACT-A), has been promoted as 'the only global solution' to vaccine equity and ending the Covid-19 pandemic. ACT-A and COVAX build on the public-private partnership (PPP) model that dominates global health governance, but take it to a new level, constituting an experimental form that we call the 'super-PPP'. Based on an analysis of COVAX's governance structure and its difficulties in achieving its aims, we identify several features of the super-PPP model. First, it aims to coordinate the fragmented global health field by bringing together existing PPPs in an extraordinarily complex Russian Matryoshka doll-like structure. Second, it attempts to scale up a governance model designed for donor-dependent countries to tackle a health crisis affecting the entire world, pitting it against the self-interest of its wealthiest government partners. Third, the super-PPP's structural complexity obscures the vast differences between constituent partners, giving pharmaceutical corporations substantial power and making public representation, transparency, and accountability elusive. As a super-PPP, COVAX reproduces and amplifies challenges associated with the established PPPs it incorporates. COVAX's limited success has sparked a crisis of legitimacy for the voluntary, charity-based partnership model in global health, raising questions about its future.

COVAX, vaccine donations and the politics of global vaccine inequity.

BACKGROUND: In 2021, donor countries, the pharmaceutical industry, and the COVAX initiative promoted vaccine donation or "dose-sharing" as a main solution to the inequitable global distribution of Covid-19 vaccines. COVAX positioned itself as a global vaccine-sharing hub that promised to share doses "equitably, effectively and transparently," according to rational criteria overseen by independent scientists. This article provides a critical analysis of the principles and practice of "dose-sharing," showing how it reveals the politics at play within COVAX. RESULTS: Donated doses were an important source of COVAX's vaccine supply in 2021, accounting for 60% of the doses the initiative delivered (543 million out of 910 million). However, donations could not compensate fully for COVAX's persistent procurement struggles: it delivered less than half of the two billion doses it originally projected for 2021, a fraction of the 9.25 billion doses that were administered globally in 2021. Donor countries and vaccine manufacturers systematically broke COVAX's principles for maximizing the impact of dose-sharing, delivering doses late, in smaller quantities than promised, and in ad hoc ways that made roll-out in recipient countries difficult. Some donors even earmarked doses for specific recipients, complicating and potentially undermining COVAX's equitable allocation mechanism. CONCLUSIONS: COVAX's pivot from global vaccine procurement mechanism to dose-sharing hub can be seen as a "win-win-win" solution for COVAX itself (who could claim success by having access to more doses), for donor countries (who could rebrand themselves as charitable donors rather than "vaccine hoarders"), and for the pharmaceutical industry (maintaining the status quo on intellectual property rights and protecting their commercial interests). Although dose-sharing helped COVAX's vaccine delivery, its impact was undermined by donors' and industry's pursuit of national security, diplomatic and commercial interests, which COVAX largely accommodated. The lack of transparency and accountability mechanisms within COVAX's overly complex governance structure as a global public-private partnership enabled these practices.

The Smartphone Pandemic: How Big Tech and public health authorities partner in the digital response to Covid-19.

Digital technologies harnessed through smartphones have been deployed widely to support the response to Covid-19 internationally, often through partnerships between 'Big tech' and telecoms corporations and public health authorities. This paper provides an overview and critical analysis of the rapid rise of such new forms of public-private cooperation, focusing on their manifestation in the European region in the first phase of the pandemic. Drawing on a review of international media and documents, we discuss three main domains of public health action in which private technology companies and public health authorities have converged: contact-tracing, epidemic modelling and public health communication to manage the 'infodemic' of misinformation about the new coronavirus. Critics have raised concerns about how the digital response to Covid-19 may threaten privacy and enable greater state surveillance and control, and the possibility that semi-automated decision-making may exacerbate existing discrimination and inequalities. Our analysis extends such critiques by considering what the digital response to Covid-19 reveals about tech corporations' growing power to influence public health agendas. We discuss how they promote technical solutions to public health challenges that are politically seductive, but that have uncertain effectiveness and societal implications that warrant critical scrutiny.

Civil society participation in global public private partnerships for health.

The growth of global public-private partnerships for health has opened up new spaces for civil society participation in global health governance. Such participation is often justified by the claim that civil society organizations, because of their independence and links to communities, can help address democratic deficits in global-level decision-making processes. This article examines the notion of 'civil society engagement' within major public-private partnerships for health, where civil society is often said to play a particularly important role in mediating between public and private spheres. How do major global health partnerships actually define 'civil society', who represents civil society within their global-level decision-making bodies, and what formal power do civil society representatives hold relative to other public and private-sector partners? Based on a structured analysis of publicly available documents of 18 of the largest global public-private partnerships for health, we show that many of them make laudatory claims about the value of their 'civil society engagement'. Most use the term 'civil society' to refer to non-governmental organizations and communities affected by particular health issues, and state that they expect these actors to represent the needs and interests of specific populations in global-level decisions about strategies, funding models and policies. Yet, such civil society actors have a relatively low level of representation within the partnerships' boards and steering committees, especially compared with private-sector actors (10.3 vs 23.7%). Moreover, there is little evidence of civil society representatives' direct and substantial influence within the partnerships' global-level governing bodies, where many decisions affecting country-level programmes are made. Rather, their main role within these partnerships seems to be to implement projects and advocate and raise funds, despite common discourses that emphasise civil society's watchdog function and transformative power. The findings suggest the need for in-depth research into the formal and informal power of civil society within global health governance processes.