Intended for healthcare professionals


Covax must go beyond proportional allocation of covid vaccines to ensure fair and equitable access

BMJ 2021; 372 doi: (Published 05 January 2021) Cite this as: BMJ 2021;372:m4853

Read our latest coverage of the coronavirus outbreak

  1. Lisa M Herzog, associate professor of philosophy1,
  2. Ole F Norheim, professor of medical ethics2,
  3. Ezekiel J Emanuel, university professor and vice provost3,
  4. Matthew S McCoy, assistant professor of medical ethics3
  1. 2Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
  2. 3Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  1. 1Faculty of Philosophy, Oude Boteringestraat 52, University of Groningen, 9712 GL Groningen, Netherlands
  2. Correspondence to: L Herzog l.m.herzog{at}

International collaboration is key for the fair and efficient distribution of covid-19 vaccines. Lisa Herzog and colleagues’ Fair Priority Model, with its focus on allocating vaccine based on limiting covid-19 harms, realises ethical principles better than Covax’s proposal of proportional allocation based on population

The Covax Facility (Covax) is a multilateral initiative aimed at ensuring that all countries have “fair and equitable access” to covid-19 vaccines. Co-led by Gavi, the Vaccine Alliance (Gavi), the Coalition for Epidemic Preparedness Innovations (CEPI), and the World Health Organization (WHO), Covax is a voluntary arrangement that enables countries to pool their resources and risk by collectively investing in vaccine candidates while developing the political and logistical infrastructure needed for vaccine distribution. Most importantly, Covax ensures that vaccines financed through the initiative will be allocated in a transparent and coordinated manner.

In September 2020, WHO delineated its plan for allocating vaccines through Covax.1 Under the plan, vaccine doses would initially be allocated to participating countries in proportion to their population size. Only after each country receives vaccine doses for 20% of its population would countries’ covid risk profiles be considered in a subsequent phase of vaccine distribution. Countries participating in Covax are permitted to pursue bilateral contracts with vaccine manufacturers like the one between the UK and Pfizer-BioNTech. Many countries, high income and even low-middle income countries, such as Indonesia and Vietnam, have secured vaccine through bilateral agreements.

Proportional allocation of vaccines through Covax is fairer and more efficient than an uncoordinated approach in which countries compete in the market to secure as much vaccine as possible for their own citizens. But proportional allocation fails to meet WHO’s own ethical principles for vaccine allocation. An alternative approach to vaccine allocation, which we call the Fair Priority Model, would be better aligned with WHO’s …

View Full Text