For the past year, experts and global health officials have warned that failure to ensure all nations have access to efficacious vaccines against COVID-19 would increase the risk of outsized death tolls, uneven economic recovery, and emergence of new variants capable of evading the protection conferred by existing vaccines.
On November 25, South African researchers may have just validated such concerns. We do not know yet whether the new variant those researchers sequenced emerged in Southern Africa, but omicron—with cases now reported in more than 30 countries—has sparked global panic and has demonstrated how variants may upend the hard-earned progress against COVID. Within days of identification, highly vaccinated countries across the Americas, Asia, and Europe moved to tighten their borders and called for broader uptake of boosters. Vaccine-makers Moderna, Sinovac, and Pfizer-BioNTech are preparing to reformulate (and redistribute) their vaccines if necessary.
As high-income countries worry whether their third doses will hold up against omicron, concerns are particularly grave for the 94 percent of people in low-income countries who have yet to receive even a first dose. With most vaccine donors slow to turn existing pledges into reality and the multilateral vaccine sharing initiative COVAX struggling [PDF] to procure doses, U.S. President Joe Biden has demanded other high-income countries step up their donation efforts. But given that previous meetings—such as the recent Global COVID-19 Summit, G7 Summit, and G20 ministerial—have been long on commitments and short on deliveries, if, where, and when these doses will materialize is unclear.
Ninety-four percent of people in low-income countries have yet to receive a first dose of COVID vaccine
Based on government websites, official statements, COVAX information, and media reports, Think Global Health has identified 76 countries that have donated 1.16 billion doses to 151 nations. The first third of this tracker will explore how higher-income countries have followed through on their commitments to donate doses. The tracker will then analyze how donated doses have been distributed, both bilaterally and through COVAX. Finally, the tracker will conclude by looking at specific vaccine donation and diplomacy efforts by leading donors: the United States, China, Europe, and Japan.
A full database with sources is included below. This tracker will be updated regularly.
Unrealized Promises
As of November 29, higher-income countries have collectively committed to donate 2.74 billion doses around the world. Seventy percent of these doses—1.95 billion—have been committed by just two nations: the United States and China. China recently octupled its commitment from 100 to 850 million doses with new pledges to African and Asian nations. Germany, France, and the United Kingdom follow distantly behind, each having pledged to donate between 100 and 175 million doses.
Though these pledges are necessary and welcome, 2.74 billion doses are a far cry from the estimated additional 6 to 14 billion outstanding doses needed to vaccinate 70 percent of the world, depending on uptake of boosters. Furthermore, the speed at which these commitments have been translated into deliveries has been glacial for most donors. Think Global Health has found that just 20.7 percent (or 567 million doses) of the 2.74 billion committed shots have been delivered. At the extremes, Belgium has shipped 112 percent of its promised 7.3 million doses, while China has delivered just 10 percent.
In general, European nations have, so far, lagged far behind the United States and China in donations and generally have opted to donate funds through COVAX rather than share their purchased doses. While Team Europe (the European Union, Norway, and Iceland) has administered 645 million doses at home, these nations have collectively delivered just 111.5 million doses, or 22.3 percent of their total pledged donation of 500 million doses. Germany, one of the leading EU donors in terms of absolute doses, has already warned it may miss its 2021 donation goal. The United Kingdom has notably fallen behind Team Europe, shipping just 15 percent of its promised doses.
Though the exact reasons for donations delays are not clear, a focus on first reaching full domestic coverage, pursuit of booster shots, and legal and transport hurdles could have all had spoiling effects. Additionally, some delay might lay with COVAX and recipient nations. Spain, for instance, has already handed over 30 million doses to COVAX, of which just 8 million doses have been delivered, while Germany said roughly 82 million of its donated doses are still being "prepared for dispatch." COVAX has not stated why these doses have yet to be moved. However, COVAX, the World Health Organization, and the African Union have all warned that ad hoc donations threaten to overwhelm domestic absorptive capacities, while lack of syringes and other supplies have hampered rollout of donated doses in places like Kenya and Rwanda.
Donations as Diplomacy: Asia Remains a Priority
As of today, 76 countries have donated 1.16 billion doses to 151 nations, of which 567 million have been delivered. Due almost exclusively to the efforts of six high-income donors (the United States, France, Germany, Italy, Japan, and Spain), roughly three-quarters of these doses are now going through COVAX. In theory, distributing donations through COVAX should make donations more likely to advance global equity or provide relief to those most in need, rather than be distributed in a manner that cements donors' traditional spheres of influence, as occurred with bilateral donations earlier in the pandemic.
However, when making vaccine commitments, many donors have earmarked their COVAX contributions to go to specific countries or regions. France, for instance, intends its 120 million doses to go primarily to Africa. Meanwhile, Portugal has prioritized Portuguese-speaking nations, and Spain has tagged most of its doses for Latin America. Similarly, the United States released its own allocation plans for donations through COVAX.
These earmarked donations are not inherently inequitable. If donors coordinated their efforts to ensure global coverage, countries could still pursue an equitable approach to vaccine donations overall, even while advancing their national interest. But so far, that has not been the case.
One method of equitably distributing vaccines is according to population size. The World Health Organization, for instance, has called for the distribution of doses to cover 40 percent of each nation by the end of 2022. However, many small nations, particularly in the Caribbean and Pacific, have received enough donations to vaccinate their entire populations. In contrast, more populous recipient countries—including the Democratic Republic of Congo, Ethiopia, and Venezuela—have received enough donations to fully protect no more than 10 percent of their populations.
Conversely, some countries have received sizable donations regardless of whether their domestic governments have already secured and administered a high number of doses. For instance, Malaysia and Sri Lanka have received donations from multiple donors, despite having fully vaccinated more than 60 percent of their populations. Cambodia has similarly fully vaccinated a higher share of its population (78 percent) than the United States, Canada, and the European Union, yet has received the tenth largest delivery of vaccine donations to date. In fact, Cambodia has received so many doses that it has begun re-donating those shots elsewhere in Asia. At the other extreme, there are 42 low- and middle-income countries, representing 1.1 billion people, that have administered fewer than 25 doses per 100 people. These 42 nations have collectively received enough donations to fully vaccinate only 10 percent of their populations.
Top Fifteen Recipients
Donations have not been going to the nations with the highest current or projected COVID-19 case burdens. Instead, Asian and Pacific countries are receiving 49.6 percent of all donated doses, despite accounting for just 25.3 percent of total global cases since November 2020. In fact, more than one out of every four donated doses has been delivered to either Indonesia, Bangladesh, Pakistan, or Vietnam. Partially because of the donations it has received, Vietnam has already fully vaccinated 50 percent of its population.
Sub-Saharan African nations have received donations disproportionate to their current case burden, but the region also faces the world's lowest vaccination rates. In contrast, Latin America, non-EU nations in Eastern and Central Europe, and Central Asia continue to receive fewer donations than a need- or risk-based approach to donation would suggest.
The Donors: Cementing Spheres of Influence
If donors are not distributing COVID-19 vaccines solely according to need or equity, what is driving donations? Despite claims by donor governments that their donations are apolitical, donation patterns by the four largest donors, the United States, China, Europe, and Japan, suggest donated doses are still being used for strategic purposes.
Out of its promise to share 1.1 billion doses, United States has earmarked 548 million doses for 112 countries, of which 271.6 million doses have been delivered. As such, the United States has donated nearly one out of every two gifted doses worldwide.
U.S. officials have stressed that their donations come without strings attached and are primarily intended to increase global coverage. To their credit, U.S. officials have prioritized Latin American and sub-Saharan African nations to a greater extent than other donor nations, providing doses to 71 countries across the regions. The relative volume of doses allocated among those countries, however, has not always accorded to the population size, case burden, vaccines already administered, and projected risk.
Washington has donated 49.5 percent of all its donated doses to just 22 countries in Asia, mirroring President Joe Biden's strategic focus on the Indo-Pacific. There, the largest donations have gone to countries where the United States is battling with China for influence: Bangladesh, Indonesia, Pakistan, the Philippines, and Vietnam. In a few instances, U.S. doses have been more explicitly linked to political decisions. The United States, for example, delivered 10.3 million doses to Pakistan—the largest recipient of U.S. vaccine donations—just weeks after pulling out of neighboring Afghanistan. The Philippines' President Rodrigo Duterte outright claimed U.S. doses convinced him not to cancel the U.S.-Philippines Visiting Forces Agreement.
Of its 850 million dose commitment, China has earmarked 111.5 million doses for 100 countries, of which 88.5 million doses have been delivered.
Like Washington, Beijing has rejected all claims that it is using vaccines to advance national interests or to compete with geopolitical rivals. However, China has provided 67 percent of all its donations to countries in Asia. All but six of the 100 nations to which China has pledged doses are participants in its Belt and Road Initiative (BRI), an ambitious global infrastructure project that aims to increase Chinese influence. Beijing has even launched a dedicated initiative to promote vaccine cooperation, sharing, and production between BRI members.
Beyond the BRI, another potential motivation for Chinese donations is ensuring or incentivizing support for Beijing's positions on Hong Kong, Taiwan, Tibet, and Xinjiang. China, for instance, attempted to wield vaccines to enforce its One China principle—or the stance that Taiwan is an inalienable part of China—in Guyana and Paraguay. Similarly, Western diplomats alleged that China threatened to withhold vaccines from Ukraine unless it withdrew support for investigation of human rights abuses in Xinjiang. Conversely, sizable donations have often followed or accompanied explicit stances in favor of China's core interests, such as when 3 million doses arrived just before Pakistan's President Imran Khan told President Xi Jinping he would "firmly support" Chinese actions in Xinjiang, Taiwan, and Hong Kong.
Team Europe has committed to donating 500 million doses in total. To date, EU nations have earmarked 366 million doses for 100 countries, of which 111.5 million doses have been delivered.
Though the European Union has presented its vaccine diplomacy efforts as a united front, individual EU countries have taken vastly different approaches to vaccine donation and diplomacy. Many EU donations have been guided by geographic proximity—Austria, Bulgaria, and Lithuania, for example, have largely focused on Eastern Europe. Other countries, such as Portugal, Spain, and France, have moved doses first to former colonies. As a bloc, the European Union has notably not prioritized Asia, though the top recipient of European doses is Indonesia.
The bloc's two largest donors, France and Germany have started to diverge in their donation trends. Over the past month Germany has broken from larger EU trends and donated 54 percent of its doses to countries in the Asia-Pacific region. Additionally, the largest German donations are going to Indonesia, Pakistan, the Philippines, and Vietnam. France, on the other hand, remains focused on Africa, donating 40 percent of all its doses to sub-Saharan Africa and making its largest contribution to Nigeria. Notably, France is the only major donor whose top recipient is an Africa nation.
Of its 60 million dose commitment, Japan has earmarked 37.6 million doses for 33 countries and delivered a total of 31.5 million doses.
Like other large vaccine donors, Japan has indicated that it will not use vaccines as a "diplomacy method." However, unlike other major donors, Japan has not taken a global approach to vaccine donations. Tokyo has directed 88.3 percent of its donated doses to a single region (Asia and the Pacific). Even through COVAX, Japanese donations are overwhelmingly going to Asia. Similar to the United States, Japan is prioritizing countries in Asia where it is battling with China for influence, and the top two recipients of Japanese vaccines—Taiwan and Vietnam—have both fully vaccinated more than 50 percent of their populations.
Vaccine donations remain an essential tool for narrowing the gap between vaccine haves and have-nots. However, donor countries have been both slow to deliver on their pledges of donated vaccines and reluctant to distribute them according to need. Donating through COVAX has not fundamentally changed the politics of vaccine donations either. Rather than advance global equity or provide relief to those most in need, donations continue to cement donors' traditional spheres of influence.
EDITOR'S NOTE: The authors would like to thank Thomas J. Bollyky, as well as Bayan Galal and Kailey Shanks for their work on data gathering for previous iterations of this tracker.
This tracker was first published on September 23, 2021.
