00:00 Um,
00:01 well,
00:01 welcome everybody.
00:02 Uh,
00:02 good morning,
00:03 good afternoon,
00:03 good evening.
00:04 Uh,
00:04 my name is Dion Filmer.
00:05 I'm the director of the World Bank's Development Research Group.
00:08 Um,
00:09 uh,
00:09 it's my pleasure to welcome you to this
00:11 June edition of our policy research talk series.
00:13 Um,
00:14 these talks provide us an opportunity to present work
00:16 coming out of the World Bank's research department,
00:19 uh,
00:19 with the goal of sharing the findings with colleagues inside and
00:22 outside the department along with others outside the World Bank.
00:25 That I'd like to welcome our online audience,
00:27 both on Webex as well as YouTube.
00:30 Um,
00:31 today,
00:31 my colleague,
00:32 Tristan Reid,
00:33 who's an economist in the macroeconomics and growth team.
00:37 We'll discuss the responses of multilateral organizations,
00:40 uh,
00:40 in the face of the COVID-19 pandemic.
00:44 The talk will draw on 5 research papers
00:46 that Tristan completed with co-authors during the pandemic,
00:49 although we're still ongoing.
00:51 Uh,
00:51 including a synthesis article that is forthcoming
00:53 in the Oxford Review of Economic Policy.
00:56 Um,
00:56 he'll be highlighting successes,
00:58 misunderstandings,
00:59 and lessons learned,
01:00 and then Tristan will reflect on
01:02 how multilateral institutions can more effectively respond to
01:05 future public health emergencies of international concern.
01:09 Uh,
01:09 Tristan's research is generally focused on topics
01:11 in industrial organization relevant to public policy.
01:15 Alongside his research activities,
01:16 he's served World Bank clients in Africa and Asia in particular,
01:20 with a focus on developing strategies to
01:22 achieve structural transformation through export diversification.
01:26 As you can tell,
01:27 he has a diverse set of interests,
01:28 although there's a common thread to everything.
01:31 Um,
01:31 we're extremely grateful to have Michael Kent Ranson as our discussion today.
01:35 Uh,
01:35 Michael is a senior economist in the Health GP,
01:38 a global practice,
01:39 based in the World Bank office in Geneva.
01:42 He is the World Bank's focal point for engagement with GAI and COAs,
01:46 who've been big players in the COVID-19 pandemic,
01:49 uh,
01:49 era,
01:50 of course,
01:51 and has served as Gavi Bo alternate and on
01:53 the GAVI Program and Policy Committee since 2018.
01:58 He's part of the team that developed a new
01:59 mechanism that allows countries to use World Bank financing
02:02 to purchase COVID-19 vaccines beyond the fully donors
02:06 subsidized doses they are already receiving through COVAC.
02:10 Um,
02:10 I'll ask Tristan to talk for approximately 40 minutes,
02:13 after which we'll hear from Kent for up to 1015 minutes.
02:17 Uh,
02:18 we'll conclude the sessions with,
02:19 uh,
02:20 questions and answers from the audience.
02:21 If you have a question,
02:23 please use the raised hand option in Webex or signal
02:27 to me in the chat that you have a question,
02:28 and I will try to call on you and ask you to,
02:30 to
02:31 uh pose your question out loud.
02:33 Uh,
02:34 if you're following on YouTube,
02:35 please submit your question in the chat and it will be relayed to me.
02:39 Uh,
02:39 just a reminder,
02:40 we're recording the session,
02:42 um,
02:43 and please mute if you're not speaking.
02:46 Uh,
02:46 with that,
02:47 over to you,
02:47 Tristan.
02:49 OK,
02:49 thanks very much,
02:49 Dion.
02:50 Um,
02:51 let me just share my screen.
02:58 There we go,
02:59 you should have
03:00 the,
03:00 the presentation.
03:01 Um,
03:02 all right,
03:02 so let me get started.
03:03 Um,
03:04 so,
03:04 so just as a roadmap,
03:05 um,
03:06 I want to talk about three things today.
03:08 Uh,
03:08 so the first will be just to describe,
03:10 um,
03:11 international inequality and both the,
03:13 the human and economic effects of COVID.
03:15 Um,
03:15 you know,
03:15 it's,
03:16 we're 2 years into the pandemic,
03:17 it's not over.
03:18 Um,
03:18 and I just want to start by,
03:19 by showing how that's affected countries,
03:22 um,
03:22 very differently.
03:23 Um,
03:24 I then want to talk about how countries cooperated,
03:28 uh,
03:29 to respond to the pandemic.
03:30 So,
03:30 this is the,
03:31 the word multilateralism,
03:33 that's,
03:33 you know,
03:34 3 or more countries
03:35 working together.
03:37 Um,
03:37 and,
03:37 you know,
03:38 I think it,
03:38 it's been made very clear that,
03:40 you know,
03:41 the part of the recovery of
03:43 COVID-19 and to any pandemic,
03:45 uh,
03:46 requires cooperation with countries because,
03:48 um,
03:49 Uh,
03:49 for,
03:49 for 22 key reasons.
03:51 One is that,
03:52 uh,
03:52 the,
03:53 um,
03:53 you know,
03:54 that there won't be a recovery in,
03:56 in economic,
03:57 uh,
03:57 sort of growth globally unless all countries are,
04:00 are sort of relatively secure from the,
04:02 from the virus.
04:03 Um,
04:04 but also that,
04:05 you know,
04:05 as we've seen,
04:05 you know,
04:06 new variants,
04:07 uh,
04:07 can emerge,
04:08 uh,
04:08 in other countries and,
04:09 and,
04:09 and harm,
04:10 uh,
04:11 other,
04:11 other countries.
04:12 And so for these reasons,
04:13 you know,
04:13 countries have a strong incentive to work together.
04:16 Um,
04:17 to,
04:17 to stop a pandemic and we want to assess,
04:19 you know,
04:19 how,
04:19 how well they did,
04:20 uh,
04:21 this time.
04:22 And then,
04:22 uh,
04:22 the last,
04:23 and,
04:23 you know,
04:24 this is based off the,
04:25 the most recent paper on,
04:26 uh,
04:26 in the Oxford Review of Economic Policy.
04:29 Um,
04:29 I,
04:29 I claim,
04:30 and,
04:31 and you can,
04:31 you know,
04:31 tell me if you believe this at the end,
04:33 uh,
04:34 that a faster and more equitable,
04:36 uh,
04:36 response is possible
04:37 to the next pandemic,
04:38 but,
04:38 but also with about the same resources that we had,
04:41 uh,
04:42 in COVID-19.
04:43 So,
04:43 I want to sort of
04:44 take us,
04:44 you know,
04:45 hindsight is always 20/20,
04:46 but,
04:46 you know,
04:46 I want to learn from the experience of COVID-19.
04:49 to see how we could do better,
04:51 uh,
04:51 next time.
04:52 Um,
04:52 and I'll just say,
04:53 you know,
04:53 as a,
04:54 as a caveat,
04:55 um,
04:55 you know,
04:56 uh,
04:56 I,
04:56 I'm an economist,
04:57 I'm not a,
04:57 a clinician or uh epidemiologist.
05:00 Um,
05:00 but I'm gonna try my best,
05:02 um,
05:02 you know,
05:02 in this talk to,
05:03 to give you,
05:04 you know,
05:04 both the health perspective,
05:05 uh,
05:05 a little bit and also just be very clear about the,
05:07 the economics.
05:08 OK?
05:08 So,
05:09 thanks.
05:09 So,
05:10 to,
05:10 to start,
05:10 I wanna,
05:11 um,
05:12 share this,
05:12 this picture from the Proceedings of the National Academy of Sciences,
05:16 um,
05:16 which gives very good context.
05:18 It just shows the probability over time,
05:21 uh,
05:21 of a disease outbreak that's worse than the 1918,
05:25 uh,
05:25 influenza or the,
05:26 the Spanish flu as it was,
05:27 was called.
05:28 Um,
05:29 you know,
05:29 in,
05:29 in 1600,
05:30 1700,
05:31 um,
05:31 you see that probability is about,
05:33 uh,
05:33 you know,
05:34 0.5%. So,
05:34 it's a basically a 1 in 2.
05:36 100 year
05:37 event.
05:38 By 1918,
05:39 it's about a 1 in 100 year event,
05:41 and by 1959,
05:43 it's almost a 1 in 50 year event.
05:45 And so,
05:45 so there's a lot of,
05:47 of literature on this,
05:48 but I think the basic takeaway is that this is largely due
05:51 Uh,
05:52 to increasing population density,
05:54 uh,
05:55 and economic growth,
05:56 um,
05:56 interactions between humans and animals,
05:59 uh,
05:59 interactions between humans and other humans.
06:01 Um,
06:01 you know,
06:02 we've learned a lot from the,
06:03 the pandemic about how that can increase,
06:05 uh,
06:05 you know,
06:05 how,
06:06 how diseases are transmitted,
06:07 uh,
06:08 and we've really seen that,
06:09 that over time.
06:10 Um,
06:11 another thing though that's interesting is that you see this massive drop off,
06:14 uh,
06:14 in the probability after 1950.
06:17 And so what happened then?
06:18 Well,
06:18 it was a,
06:18 a new technology,
06:19 the,
06:20 the polio vaccine.
06:21 was developed in the 50s and,
06:23 and became widespread and,
06:24 and vaccine technology broadly has,
06:27 has been,
06:28 um,
06:28 you know,
06:28 distributed and,
06:29 and,
06:29 you know,
06:30 made sort of almost,
06:31 you know,
06:31 compulsory for,
06:32 for young people uh across,
06:34 uh,
06:34 you know,
06:34 a number of diseases.
06:36 And so,
06:37 you know,
06:37 we see that actually because of vaccines and other,
06:40 you know,
06:41 public health responses.
06:42 Um,
06:43 actually,
06:44 disease outbreaks,
06:45 even though
06:46 they're happening more frequently,
06:47 we,
06:47 we control them earlier.
06:49 And,
06:49 you know,
06:50 there's,
06:50 I think that COVID is a,
06:51 a great example of this.
06:53 You know,
06:53 now,
06:54 two years into the pandemic,
06:55 there are over,
06:56 um,
06:57 666 million people,
06:59 uh,
06:59 have died.
07:00 Um,
07:01 an upper bound of,
07:02 you know,
07:02 accounting for,
07:03 for measurement,
07:04 you know,
07:04 could say 8,
07:05 up to 18 million.
07:06 But that's still less than died during the influenza pandemic where the range is,
07:11 uh,
07:12 you know,
07:12 20 to 25 to 50.
07:14 Um,
07:14 and,
07:14 you know,
07:14 this is every,
07:15 every death matters,
07:16 but
07:17 because of vaccines,
07:18 um,
07:18 you know,
07:19 we've been able to,
07:20 uh,
07:21 avoid,
07:21 you know,
07:21 sort of the,
07:22 a pandemic as bad as the 1918 flu.
07:25 So,
07:26 you know,
07:26 the,
07:27 the policy context for this whole talk is say,
07:29 well,
07:30 you know,
07:30 because
07:31 Everyone is living closer together and these diseases,
07:34 you know,
07:35 do,
07:36 uh,
07:36 emerge more frequently.
07:37 How can we best
07:39 prevent them,
07:39 to prevent these,
07:40 uh,
07:41 disease outbreaks from,
07:42 from growing very large.
07:44 And then also,
07:45 when they do grow large,
07:46 how can we make sure we respond
07:48 Quickly.
07:48 So,
07:48 in,
07:48 in the case of
07:50 uh the coronavirus pandemic,
07:51 could we have had vaccines
07:53 earlier
07:54 in larger quantities and,
07:56 and to have more access across countries,
07:58 um,
07:59 uh,
07:59 is gonna be an important question.
08:01 OK.
08:01 So,
08:01 so that's just um high level context.
08:04 Um,
08:05 just to say,
08:05 you know,
08:05 where we are with the coronavirus pandemic.
08:08 So it,
08:08 it was devastating,
08:09 as I said,
08:10 um,
08:10 you know,
08:10 66 to 18 million people lost.
08:14 Um,
08:14 but,
08:14 but it's also abating.
08:16 Um,
08:16 so,
08:16 so for some time now,
08:18 diseases,
08:18 uh,
08:19 sort of new daily deaths have been lower than they ever have been before.
08:23 Um,
08:23 you know,
08:23 I wrote a paper in,
08:25 uh,
08:26 early,
08:26 uh,
08:27 2021,
08:28 which said,
08:28 you know,
08:29 how to end the pandemic by March 2022.
08:33 Uh,
08:33 you know,
08:33 the goal there was to say,
08:35 well,
08:35 if there's no mutation,
08:37 uh,
08:37 and you,
08:38 uh,
08:38 immunize or,
08:39 or about 60% of every population,
08:42 you could get herd immunity.
08:43 Now,
08:44 as we,
08:44 you know,
08:44 caveated the disease could mutate it,
08:46 it did mutate,
08:47 which means that,
08:48 you know,
08:49 there's even some more,
08:50 uh,
08:51 immunity from,
08:51 from prior infections,
08:52 and more fatalities,
08:53 but also immunity from prior infection.
08:56 And,
08:56 you know,
08:56 so still,
08:57 even with mutation,
08:58 we have the Africa WHO,
09:00 the European Union,
09:02 other regional agencies saying,
09:04 you know,
09:04 the emergency phase of this is over.
09:06 The disease will,
09:07 you know,
09:07 continue,
09:07 we'll have,
09:08 we'll have outbreaks,
09:09 but it's,
09:09 it's no longer the,
09:11 the crisis it was,
09:12 um,
09:13 in,
09:13 you know,
09:14 the,
09:14 the last two years,
09:15 uh,
09:15 and that's largely due,
09:17 uh,
09:17 to vaccines.
09:19 Um,
09:19 vaccine,
09:20 as I said,
09:21 it's,
09:21 it's driven the recovery.
09:22 It's,
09:22 it's driven the response to lots of outbreaks since the 1950s.
09:26 Um,
09:26 but coverage has still been highly unequal.
09:28 So this is something that is continuously highlighted,
09:31 um,
09:32 you know,
09:33 in,
09:33 in Africa,
09:34 especially,
09:34 so I'll,
09:34 I'll say,
09:35 you know,
09:35 there are many countries that now have,
09:37 uh,
09:38 two doses,
09:39 uh,
09:39 administered for every,
09:40 uh,
09:41 person in the country.
09:42 That's the sort of middle
09:43 green color.
09:44 You see Canada,
09:45 parts of South America,
09:46 China,
09:47 Australia,
09:47 Europe.
09:48 Um,
09:49 US also,
09:50 you know,
09:50 relatively has,
09:51 has pretty good
09:52 coverage,
09:53 um,
09:54 India and Russia a little bit less so.
09:56 Uh,
09:56 but then
09:56 largely in Africa and in other,
09:58 um,
09:59 other
09:59 regions,
09:59 you see Afghanistan,
10:00 um,
10:01 we,
10:01 we still have very low coverage.
10:02 So that's sort of less than 50 doses per 100,
10:05 uh,
10:05 people.
10:06 And in Africa in particular,
10:08 there,
10:08 there,
10:09 there in total there are about 18 countries that
10:10 have yet to vaccinate even 10% of the population.
10:13 So,
10:14 you know,
10:14 one question is,
10:15 you know,
10:15 how,
10:16 how could we have accelerated this.
10:18 Um,
10:19 you know,
10:19 I think at the moment,
10:20 uh,
10:20 vaccine supply is not a constraint.
10:23 So low income countries have covered,
10:26 they've immunized about 12% of their population on average,
10:29 uh,
10:29 but vaccines have actually been delivered for 24% of the population.
10:33 So it's that,
10:34 you know,
10:34 the challenge of last mile delivery that,
10:36 that's really binding.
10:37 Um,
10:38 but you know,
10:38 earlier,
10:39 uh,
10:39 supply was,
10:40 was a constraint.
10:41 Um,
10:41 and so one question is,
10:42 you know,
10:42 could we have got that supply
10:44 delivered sooner,
10:45 uh,
10:45 so that the health systems that existed could,
10:47 could,
10:48 um,
10:48 take it on.
10:50 Um,
10:50 so,
10:51 uh,
10:51 you know,
10:52 I just wanna,
10:53 you know,
10:54 talk a little bit about the,
10:55 the inequality of health effects across countries.
10:58 Um,
10:58 so very early in the pandemic,
11:00 uh,
11:00 many believe that both the economic and
11:02 health effects would hit low-income countries,
11:04 uh,
11:04 the hardest.
11:05 Um,
11:06 and,
11:06 and this really hasn't been the case.
11:07 So this is a chart that Penny Goldberg and I made for the Brookings panel in summer
11:12 2020,
11:12 but I've,
11:12 I've added the new data.
11:14 And it shows,
11:15 you know,
11:15 deaths per million,
11:16 so we're normalizing by,
11:18 by population,
11:19 uh,
11:19 for different income groups,
11:21 uh,
11:21 of countries,
11:21 high income,
11:22 lower middle income,
11:23 upper middle income,
11:24 and low income.
11:25 And then I've also separated out both China and India because,
11:28 you know,
11:28 together they're about a third of the world's population,
11:30 they're both middle income countries,
11:32 um,
11:33 you know,
11:33 just as,
11:33 just to give you some flavor of the,
11:35 the country's specific experiences.
11:38 Um,
11:38 and,
11:38 you know,
11:39 what you find in this picture is,
11:40 is quite clear is that this has been a pandemic that where
11:44 on a per capita basis,
11:45 it's high income countries and upper middle income countries,
11:48 excluding China,
11:50 uh,
11:50 that have,
11:50 have borne the brunt,
11:52 uh,
11:52 of mortality.
11:53 Um,
11:54 You know,
11:54 in regression analysis,
11:55 uh,
11:56 Penny Goldberg and I found that this was due,
11:58 you could attribute this entirely to demographic risk factors.
12:01 So,
12:02 um,
12:02 an older population in,
12:04 uh,
12:04 high-income countries,
12:06 uh,
12:06 or,
12:06 and also greater obesity,
12:07 which is quite high,
12:09 especially in,
12:09 in upper middle income countries.
12:11 Um,
12:12 and,
12:12 you know,
12:12 in low-income countries,
12:13 you have half the population under age 20,
12:15 um,
12:15 about a third of the obesity.
12:17 Um,
12:17 and so that,
12:18 you know,
12:18 I think can explain a lot of this.
12:20 Um,
12:21 you know,
12:21 we found this as,
12:23 so,
12:23 so,
12:23 you know,
12:23 they're still vulnerable people in every country,
12:26 and so they need care.
12:28 But
12:28 still,
12:29 I think this was early on a,
12:30 a cause for optimism because it meant
12:32 the countries with the weakest health systems,
12:34 the poorest ones,
12:35 would not have,
12:36 you know,
12:36 as much pressure,
12:38 uh,
12:38 on them,
12:38 at least relative to high income countries.
12:41 Um,
12:41 and it also meant that,
12:42 you know,
12:42 lockdowns,
12:43 which could be costly,
12:44 especially for poor households with no buffer savings.
12:47 Um,
12:47 you know,
12:48 that,
12:48 that could be released earlier.
12:49 And others made this argument too,
12:50 like Moshevik Mubarak at Yale said,
12:52 you know,
12:52 you,
12:53 you,
12:53 especially in low-income environments,
12:55 people need to be able to go out and work.
12:56 So the,
12:57 the policy of closing down the economy was not as,
13:00 uh,
13:01 you know,
13:01 it
13:02 has to be treated differently than,
13:03 than in a high-income country.
13:05 Um,
13:05 so,
13:06 so we found this as a case for optimism,
13:07 but at the same time,
13:08 it raised,
13:08 uh,
13:08 an issue.
13:09 So,
13:10 if pandemic response is a,
13:11 a public good,
13:12 and we say,
13:13 you know,
13:14 every country's not safe until everyone is safe.
13:16 Then,
13:17 you know,
13:17 if the,
13:18 the disease burden is higher
13:20 in,
13:20 or lower in certain places for demographic reason,
13:22 those countries might,
13:23 you know,
13:24 underinvest,
13:25 uh,
13:25 for instance,
13:25 in vaccination.
13:26 And so,
13:27 uh,
13:28 you know,
13:28 the,
13:28 the international community took it on itself to,
13:31 to,
13:32 uh,
13:32 deliver,
13:33 um,
13:33 you know,
13:34 um,
13:34 uh,
13:35 vaccines and other,
13:36 um,
13:36 uh,
13:36 health,
13:37 health products.
13:38 Uh,
13:38 uh,
13:39 to low income countries to,
13:40 to keep the,
13:41 the burden,
13:42 uh,
13:42 lower in those,
13:43 those places.
13:44 Um,
13:44 and that's what I'll talk about in the paper.
13:46 Um,
13:47 I wanna just,
13:48 you know,
13:48 in the next,
13:49 um,
13:50 uh,
13:50 slide,
13:50 I wanna talk about,
13:52 or just,
13:52 you know,
13:52 obviously confirmed deaths are not,
13:54 uh,
13:55 all the deaths that happened,
13:56 uh,
13:56 in New York's,
13:57 you know,
13:58 remember there was underreporting of deaths in retirement homes.
14:00 Um,
14:01 the WHO has actually estimated,
14:03 um,
14:03 you know,
14:04 how much
14:05 deaths was,
14:05 was missed by the confirmed statistics.
14:08 Um,
14:08 and I'm showing you these now on the same scale.
14:11 And then here,
14:12 you know,
14:12 you see especially in upper middle income countries,
14:14 excluding China,
14:15 uh,
14:15 and in India,
14:17 you know,
14:17 there were,
14:17 you know,
14:18 much more,
14:19 uh,
14:19 mortality than,
14:20 than was recorded.
14:22 Um,
14:22 but at the same time,
14:23 you do see the same pattern that the low income countries,
14:25 the,
14:26 the blue and the,
14:27 uh,
14:27 the purple,
14:28 uh,
14:29 and the lower middle income countries had the lowest,
14:31 uh,
14:31 excluding China,
14:32 um,
14:32 the sort of,
14:33 oh,
14:33 excuse me.
14:34 Um,
14:34 lowest deaths.
14:35 So that's just giving you a flavor of the pattern.
14:37 Um,
14:37 I also want to highlight
14:39 one thing that,
14:40 you know,
14:40 so if you look at India and China,
14:42 you see how,
14:43 you know,
14:43 very different choices of governments can lead to,
14:46 to different
14:47 outcomes.
14:47 Um,
14:48 so here in,
14:49 in both India and China,
14:50 you see that early in the pandemic,
14:52 actually they had fewer deaths than were expected,
14:54 so from other causes.
14:56 Um,
14:56 that could be attributed to the,
14:58 the,
14:58 the lockdowns,
14:59 um,
15:00 you know,
15:00 which,
15:00 which,
15:01 you know,
15:01 on net,
15:01 uh,
15:02 maybe,
15:02 maybe,
15:03 uh,
15:03 saved some lives.
15:04 Um,
15:05 you know,
15:05 there was a lot of debate about that actually.
15:06 Um.
15:07 But,
15:07 but then,
15:08 you know,
15:08 you see later,
15:09 uh,
15:09 you know,
15:10 India took a very different path,
15:11 right?
15:12 So,
15:12 and that,
15:12 that could be a combination of,
15:14 you know,
15:14 releasing lockdowns,
15:15 but also,
15:16 uh,
15:16 limited access to vaccines.
15:17 China,
15:18 um,
15:18 you know,
15:19 invested much earlier
15:20 and had supply,
15:21 uh,
15:22 much earlier.
15:22 So,
15:23 so one question we're gonna answer here is,
15:25 you know,
15:25 for all these groups,
15:26 regardless of the inequality,
15:28 how could we have
15:29 brought the medical countermeasures,
15:31 especially vaccines earlier,
15:33 uh,
15:34 and,
15:34 and,
15:34 and reduce this,
15:35 this excess death.
15:36 OK.
15:37 Um,
15:37 I want to say a bit about the economic effects.
15:40 We've talked about the human effects.
15:42 Um,
15:43 again,
15:43 there was a lot of,
15:44 uh,
15:44 inequality.
15:45 So,
15:45 you know,
15:46 before the pandemic
15:47 in,
15:48 uh,
15:48 2019,
15:49 um,
15:50 there was what's called income convergence.
15:52 So,
15:52 mid,
15:53 middle income and low-income countries,
15:55 uh,
15:55 where you can see this in the blue box,
15:57 uh,
15:57 were growing faster on a per capita basis than high-income countries.
16:01 So that meant that,
16:01 you know,
16:02 it'll take a very long time,
16:03 but income,
16:04 you know,
16:04 everyone will eventually have the same.
16:06 Income.
16:07 Uh,
16:08 during the pandemic,
16:09 uh,
16:10 you know,
16:10 the,
16:10 the costs,
16:11 you know,
16:12 consistent with the,
16:13 the mortality effects being higher in,
16:15 in high-income countries,
16:17 um,
16:17 the economic costs were also much greater there.
16:19 Uh,
16:19 so,
16:19 on a per capita,
16:20 so there's still a global recession,
16:22 income per capita goes down in every country,
16:25 uh,
16:25 most in,
16:26 in all,
16:26 in all,
16:27 in the global economy,
16:28 um,
16:29 including these three groups.
16:30 Um,
16:31 Uh,
16:32 uh,
16:32 but the,
16:33 the decline was,
16:34 you know,
16:34 worse in,
16:35 in high income countries.
16:36 Then in 2021,
16:37 you had also this unequal recovery.
16:39 So,
16:40 high income countries spent a lot of money,
16:42 you know,
16:42 accelerating their,
16:43 their growth,
16:43 and,
16:44 and so they recovered a lot of the losses.
16:46 Um,
16:46 low income countries also grew,
16:48 you know,
16:48 faster,
16:48 but,
16:49 but not as much.
16:50 Um,
16:51 and then,
16:51 you know,
16:52 how,
16:52 how is it looking forward?
16:53 So in,
16:53 in 2022,
16:55 so these,
16:55 these are all,
16:56 by the way,
16:56 the recent numbers from the World Bank's,
16:58 uh,
16:59 Global Economic prospects,
17:00 which were just released,
17:01 uh,
17:01 last week.
17:02 Um,
17:02 so the forecasts are,
17:03 are current.
17:04 Um,
17:06 before the,
17:06 uh,
17:07 Ukraine war,
17:08 uh,
17:09 actually the forecast for 2022 was that every region,
17:13 uh,
17:13 so every,
17:14 every income group
17:15 would grow faster than in 2019.
17:17 So that,
17:18 that in my view is a pretty positive,
17:20 uh,
17:20 recovery.
17:21 You know,
17:21 we've seen now that the
17:23 Ukraine war has had some effects,
17:24 uh,
17:25 so,
17:25 uh,
17:25 low and middle income countries will be growing.
17:28 Uh,
17:28 slower,
17:29 uh,
17:29 than 2019 and also slower than 2020,
17:32 uh,
17:33 than high-income countries.
17:34 But that recovers in,
17:35 in 2023 and 2024.
17:37 So,
17:37 you know,
17:38 looking,
17:38 uh,
17:39 in a little bit of a long term at 2023,
17:41 2020204,
17:41 we,
17:42 we can still expect growth that's faster than 2019,
17:46 uh,
17:46 and,
17:46 and also income convergence.
17:48 So,
17:48 I think this is a pretty good,
17:49 pretty positive story overall,
17:51 uh,
17:51 if you,
17:52 you know,
17:52 take a,
17:52 a slightly,
17:53 uh,
17:54 longer term view.
17:55 OK.
17:56 So now I want to talk about the,
17:57 how countries responded together to,
18:00 to COVID,
18:01 uh,
18:01 and what the lessons are for,
18:03 for future pandemics.
18:04 Um,
18:05 this is a,
18:06 a chart,
18:06 and I think this was the main economic,
18:09 immediate economic effect,
18:10 uh,
18:11 of,
18:11 of the crisis is that in March 2020,
18:14 uh,
18:15 global investors just sold,
18:17 uh,
18:17 all of their,
18:18 uh,
18:18 EMs,
18:19 not all,
18:19 but
18:20 more than,
18:20 than ever before at one time.
18:22 Uh,
18:22 the EM stocks and bonds.
18:24 So it's called a sudden stop.
18:25 Everybody's selling,
18:26 uh,
18:26 bonds and securities.
18:28 The consequence of this,
18:30 uh,
18:30 is that,
18:31 um,
18:31 the financing costs for governments in emerging markets balloon.
18:35 So you,
18:35 you sell
18:36 bonds,
18:37 the,
18:37 the price of those falls,
18:39 and then the interest rate goes up because the interest rate and the price move,
18:42 you know,
18:42 in different directions.
18:43 And so this is just,
18:44 you know,
18:44 for a lot of,
18:45 uh,
18:46 group of countries,
18:46 500 years,
18:47 5 5% points,
18:48 these are in basis points.
18:50 It's just showing,
18:51 you know,
18:51 this incredible jump,
18:53 uh,
18:53 in borrowing costs for some countries.
18:55 So this is
18:55 at a time of global emergency,
18:57 the private market is saying,
18:59 you know,
18:59 we don't want,
19:00 uh,
19:00 to help,
19:01 uh,
19:02 you know,
19:02 governments in,
19:03 in low and emerging countries,
19:04 or,
19:04 or at least we need to be compensated a lot.
19:06 Uh,
19:06 to do it.
19:07 Um,
19:07 so this was a,
19:08 an early focus of the multilateral response.
19:10 So the G20 economies,
19:12 um,
19:12 the finance ministers had a call,
19:14 uh,
19:14 and they announced,
19:15 uh,
19:15 in,
19:16 in March that they were going to support countries.
19:18 Um,
19:18 immediately this provided some relief,
19:20 uh,
19:21 to,
19:21 uh,
19:22 develop.
19:22 country to these emerging markets,
19:24 you can see the,
19:24 the prices,
19:25 uh,
19:26 fell,
19:26 uh,
19:27 in,
19:27 in a lot of them.
19:28 Uh,
19:28 so,
19:29 so that,
19:29 just,
19:30 just announcing support,
19:31 uh,
19:31 was helpful.
19:32 Um,
19:33 but then,
19:33 this is,
19:34 this is interesting and I think it shows a bit of the limits of the,
19:37 the multilateral response.
19:39 So in,
19:39 uh,
19:40 later in,
19:41 in April,
19:41 they announced,
19:42 uh,
19:42 what would,
19:43 what is called debt forbearance.
19:44 So they said,
19:45 you know,
19:46 you can,
19:47 you're gonna owe us interest,
19:48 but,
19:49 uh,
19:50 you know,
19:50 you,
19:50 you can delay paying that interest.
19:52 It's still gonna accrue,
19:53 so you're gonna owe it in the future.
19:55 But,
19:55 but you don't have to pay,
19:57 you know,
19:57 this,
19:57 this year.
19:58 Um,
19:59 and,
19:59 you know,
20:00 that was,
20:00 you know,
20:00 I,
20:01 I think a useful thing.
20:01 It helped give countries some room to,
20:03 to think about how to respond to the pandemic.
20:06 Um,
20:07 but what's interesting is that there's actually
20:09 Immediately after you see in a lot of the countries,
20:11 uh,
20:11 so,
20:12 in Nigeria,
20:12 for example,
20:13 actually,
20:13 the interest rate goes back up.
20:15 So,
20:15 one way to interpret that is that the,
20:17 the market actually evaluated,
20:19 you know,
20:19 it,
20:20 it didn't think Nigeria was going to default.
20:22 It thought it was going to pay on time.
20:23 So,
20:23 now,
20:24 when Nigeria,
20:25 you know,
20:25 if it delays payments,
20:26 uh,
20:27 to the,
20:27 on the private bonds,
20:28 you know,
20:28 that,
20:28 that's an increased risk for the,
20:31 um,
20:31 for the bondholders.
20:32 So,
20:33 so,
20:33 you know,
20:33 this is,
20:34 I think,
20:35 you know,
20:35 shows that just by changing,
20:38 you know,
20:38 the,
20:38 um,
20:39 The interest schedules,
20:40 let's say,
20:41 um,
20:41 there,
20:42 there's probably a limited ability to,
20:44 to,
20:44 um,
20:45 you know,
20:45 affect,
20:45 uh,
20:46 sort of the borrowing costs for countries and still,
20:48 you know,
20:49 today this only goes to 22,
20:50 sorry,
20:50 July,
20:51 uh,
20:51 2020.
20:52 Um,
20:53 but even today,
20:54 these,
20:54 these costs are still higher for countries.
20:56 So countries are having to pay more to,
20:58 to respond.
20:59 Um.
21:00 Where
21:01 the,
21:01 uh,
21:02 I think the multilateral institutions were very successful was providing,
21:05 uh,
21:06 a huge amount of finance on their scale,
21:08 uh,
21:09 much cheaper than the market.
21:10 So,
21:10 you know,
21:10 the World Bank,
21:11 uh,
21:12 delivered $204 billion to governments in the calendar years 2020 to 2021.
21:18 Um,
21:19 over half of this was to governments.
21:21 And,
21:21 you know,
21:21 the key thing to highlight here is that the
21:23 interest rates on these loans were much lower,
21:25 so 65% to around 1%.
21:28 Um,
21:29 65 basis points to 115.
21:32 Um,
21:32 and which is much lower than those earlier rates I've showed you.
21:35 So,
21:35 you know,
21:36 it,
21:36 it was said in public,
21:37 uh,
21:37 recently that,
21:38 you know,
21:38 the World Bank has a,
21:39 a,
21:39 a fetish for,
21:40 uh,
21:41 its high,
21:41 it's AAA credit rating,
21:42 and it should maybe,
21:44 you know,
21:44 be riskier.
21:45 You know,
21:45 in an emergency,
21:46 the attractiveness of,
21:48 uh,
21:49 a,
21:49 uh,
21:50 low interest rate is exactly that.
21:51 So,
21:51 the bank was able to,
21:53 you know,
21:53 provide very cheap.
21:54 Credit,
21:54 um,
21:55 in this time,
21:55 if it,
21:56 you know,
21:56 didn't have a AAA credit rating,
21:57 it would have to,
21:58 you know,
21:58 offer more expensive
22:00 credit.
22:00 Um,
22:01 and I think it's,
22:01 it's also important to highlight that this,
22:03 you know,
22:04 didn't just support health,
22:05 it,
22:05 it helped countries,
22:06 um,
22:07 you know,
22:07 maintain all their other programs.
22:09 And,
22:09 and one thing people might say is say,
22:11 well,
22:12 you know,
22:12 you're coming in with cheap finance,
22:13 you know,
22:14 maybe you're just allowing them to pay off the Uh,
22:16 you know,
22:17 the private bondholders that are getting higher interest rates,
22:19 you know,
22:20 that's still good,
22:20 right?
22:21 If you lower the cost of financing for a government that,
22:24 that frees up money to do
22:26 all sorts of things.
22:27 So,
22:27 I think,
22:27 you know,
22:27 this is where,
22:29 um,
22:29 you know,
22:29 I think the,
22:30 the multilateral system,
22:31 you know,
22:31 really worked as it's supposed to.
22:33 It,
22:33 it provides cheap capital in an emergency,
22:36 that's,
22:36 that's especially useful.
22:38 Um,
22:39 so now I want to get into the,
22:40 the public health crisis,
22:41 uh,
22:41 and response.
22:42 Um,
22:43 So the main thing here,
22:44 you know,
22:45 on a global scale,
22:47 uh,
22:47 was this initiative,
22:49 uh,
22:50 of the,
22:50 the Act A or the Access to COVID tools,
22:53 uh,
22:54 Accelerator.
22:55 I,
22:55 I,
22:55 I'm pretty sure the name was invented by management consultants.
22:58 So,
22:58 um,
23:00 tools,
23:00 tools are,
23:01 are vaccines,
23:02 therapeutics,
23:02 and diagnostics,
23:03 and also personal protective equipment.
23:05 Um,
23:06 and,
23:06 and the idea behind this was to say,
23:09 let's pool money together.
23:11 And,
23:12 you know,
23:12 part of it was intended to develop new vaccines,
23:15 you know,
23:15 because,
23:16 you know,
23:16 that,
23:16 very early on,
23:17 you know,
23:17 we didn't even have vaccines.
23:19 But then,
23:20 uh,
23:20 it was also intended to,
23:23 uh,
23:23 purchase those vaccines and other,
23:24 other health products,
23:26 um,
23:26 and then deliver them for free,
23:28 uh,
23:28 to,
23:28 to low and lower middle income countries.
23:31 Um,
23:32 so here,
23:32 you know,
23:32 you just see how that evolved,
23:34 you know,
23:34 they pitched,
23:35 uh,
23:35 38 billion.
23:36 Um,
23:37 there were some cost adjustments,
23:38 which I think highlights how,
23:39 how difficult,
23:40 you know,
23:41 Figuring out a real number for these things is.
23:43 Uh,
23:43 and then,
23:44 you know,
23:44 in the end,
23:44 they,
23:45 they raised,
23:45 uh,
23:46 about 18 billion,
23:47 um,
23:47 most of which was for,
23:49 uh,
23:50 purchases of vaccines.
23:51 And I should say 2/3 of,
23:53 oops,
23:53 excuse me,
23:54 um,
23:54 2/3 of these commitments came from the G7,
23:56 uh,
23:57 economies of the US.
23:59 Uh,
23:59 Germany,
24:00 uh,
24:00 Japan,
24:01 and others.
24:02 Um,
24:02 and it's interesting to compare the numbers
24:04 relative to what those countries spent,
24:07 you know,
24:07 on their own,
24:08 um,
24:08 own supplies.
24:09 So the US actually spent,
24:11 uh,
24:11 $55 billion
24:12 you know,
24:12 in total on vaccines.
24:14 It's an estimate from the economic report of the president.
24:16 Um,
24:17 but,
24:17 actually it only spent
24:18 12 billion actually purchasing vaccines.
24:21 A lot of the other money went to either,
24:23 you know,
24:23 just rolling out the vaccines,
24:25 uh,
24:25 or subsidies for,
24:27 um,
24:27 uh,
24:28 development and research early on.
24:30 Um,
24:30 and so,
24:31 you know,
24:31 one interesting point is that,
24:33 uh,
24:33 you know,
24:34 the
24:35 Because the US and other countries,
24:37 you know,
24:37 spent so much on development,
24:39 uh,
24:39 this,
24:40 you know,
24:40 uh,
24:41 uh,
24:42 for these purchases for,
24:43 for other countries,
24:44 you know,
24:44 could restrict their purchases to a certain extent,
24:47 uh,
24:47 to just,
24:48 uh,
24:48 advanced procurement because they had been,
24:50 you know,
24:50 developed,
24:51 um,
24:52 Uh,
24:52 already.
24:53 Um,
24:53 and so,
24:54 you know,
24:54 just to summarize,
24:54 you know,
24:55 this,
24:55 this,
24:56 uh,
24:56 amount of money,
24:57 I think,
24:57 you know,
24:57 I showed in a paper early on with Ruchir Agarwal that this,
25:00 you know,
25:01 this amount of money about would be enough to vaccinate,
25:03 um,
25:03 60% of the population of low and lower middle income countries.
25:06 So,
25:07 those,
25:07 those groups I showed you,
25:09 uh,
25:09 before.
25:10 Um,
25:11 I,
25:11 I want to have a slight interlude on sort of testing.
25:14 So,
25:14 you know,
25:14 testing as,
25:15 as you saw back here,
25:16 you know,
25:16 it only received
25:17 a diagnostic 1.4 billion,
25:19 um,
25:20 relative to diagnostics.
25:21 Um,
25:21 so why is that?
25:23 Um,
25:23 so,
25:24 so I think,
25:24 so I did a,
25:25 a cost benefit analysis here with a,
25:27 a big research team.
25:29 Uh,
25:29 early on.
25:30 And,
25:30 and what we did is we highlighted,
25:31 um,
25:32 you know,
25:32 5,
25:33 use cases,
25:34 uh,
25:34 for,
25:35 uh,
25:35 vaccinations.
25:36 So this is clinical triage,
25:37 that's someone coming in and saying,
25:39 you know,
25:39 do,
25:39 do you have COVID?
25:40 If so,
25:41 I'll put you in a,
25:42 a room with other COVID people so you don't infect other patients.
25:45 Um,
25:45 at-risk worker screening,
25:46 that's for healthcare workers or transportation.
25:50 Um,
25:50 one is just measuring,
25:52 uh,
25:52 the rate of,
25:53 of infection in the population to trigger or avoid.
25:56 Uh,
25:56 a lockdown,
25:58 uh,
25:58 test,
25:58 trace and isolate,
25:59 um,
25:59 and also border screening,
26:01 which could,
26:01 you know,
26:02 um,
26:02 uh,
26:02 protect,
26:03 protect people at the border,
26:04 but also protect,
26:05 uh,
26:05 a country from,
26:06 from a large outbreak.
26:08 Um,
26:08 and so,
26:09 you know,
26:09 what we found to,
26:10 to Peter Sands at,
26:11 at the Global Fund,
26:12 you know,
26:12 asked us,
26:12 uh,
26:13 to,
26:13 to convert this into
26:15 Uh,
26:15 a return on investment.
26:16 Well,
26:16 let me say first,
26:17 so,
26:17 we calculate for each of these scenarios that,
26:19 you know,
26:20 the number of tests you need to save one life
26:23 is relatively small.
26:24 So even for border screening,
26:26 you know,
26:26 8000 tests,
26:27 let's say they're 10,000,
26:28 or sorry,
26:28 they're 1010 bucks a test,
26:30 you know,
26:30 that's 80,000,
26:32 uh,
26:32 90,000 to save a life,
26:34 which is,
26:35 you know,
26:35 I think a pretty good value.
26:36 Um,
26:37 Peter Sands asked us to turn that into a return on investment.
26:39 So if you value life in some way,
26:41 you can say this is,
26:42 uh,
26:42 You know,
26:43 33 to 41%,
26:45 uh,
26:46 sorry,
26:47 3 to 41 times,
26:49 um,
26:49 uh,
26:50 rate of return,
26:51 um,
26:51 you know,
26:51 which is really high.
26:52 So these are all
26:54 really good investments.
26:55 So,
26:55 so the question is,
26:56 you know,
26:56 why,
26:57 why didn't we do this as much?
26:58 And,
26:58 and I think the answer,
27:00 I mean,
27:00 11 answer is that countries,
27:02 you know,
27:02 have budget constraints and they have to allocate them across things.
27:05 Um,
27:06 but
27:06 consistent with that is this thing which we show in the,
27:08 in the lower corner here,
27:09 which is that
27:10 The returns really vary a lot with prevalence.
27:13 So,
27:14 if you have very low prevalence of a disease,
27:17 um,
27:17 you know,
27:17 it's the,
27:19 you know,
27:19 the tests you need to save one life are many,
27:21 many,
27:21 many.
27:21 And so,
27:22 you can imagine how countries that felt,
27:24 you know,
27:24 OK,
27:25 we have something under control,
27:27 you know,
27:27 might not make advance purchases,
27:29 uh,
27:29 for diagnostic.
27:31 that they need,
27:31 you know,
27:32 6 months into the future that,
27:33 uh,
27:33 you know,
27:34 requires,
27:34 um,
27:35 you know,
27:35 I think some,
27:36 some foresight and some ability to,
27:37 to,
27:38 to stomach the uncertainty.
27:39 So,
27:40 you know,
27:40 that's just some ideas there.
27:42 Um,
27:42 but I think,
27:42 you know,
27:43 overall,
27:44 there should be more investment,
27:45 uh,
27:45 in diagnostics,
27:46 but we can understand,
27:47 I think,
27:47 about why countries may not have,
27:49 uh,
27:49 because of the sensitivity.
27:51 Um,
27:52 So,
27:52 you know,
27:53 back to vaccines,
27:54 um,
27:55 you know,
27:55 I showed you earlier coverage today.
27:56 This was in August.
27:57 Um,
27:58 and this was where,
27:59 you know,
27:59 this hashtag came out called vaccine equity with one E.
28:03 Uh,
28:03 and,
28:04 and,
28:04 you know,
28:04 it really was true at the time that,
28:06 you know,
28:07 only a few countries had access,
28:09 uh,
28:10 to vaccines.
28:11 China had a lot,
28:12 um,
28:12 the United States and,
28:13 and Europe and,
28:14 and,
28:14 uh,
28:15 Chile,
28:15 um,
28:16 and a few others,
28:18 Arab Emirates.
28:19 Um,
28:19 you know,
28:20 had,
28:20 but,
28:20 but many of the countries,
28:21 uh,
28:21 couldn't get access.
28:22 Um,
28:23 so,
28:24 you know,
28:24 uh,
28:24 in a paper,
28:25 uh,
28:26 at that time,
28:27 uh,
28:27 Momta Murthy,
28:28 uh,
28:28 the World Bank,
28:29 uh,
28:29 and I,
28:30 you know,
28:30 tried to describe
28:31 sort of why,
28:33 you know,
28:33 why could this be?
28:34 Uh,
28:34 and,
28:35 and one hypothesis was that,
28:36 well,
28:37 uh,
28:37 only a small number of countries
28:40 have,
28:40 uh,
28:41 vaccine production capabilities.
28:43 We call these the G10.
28:44 So it's the G7,
28:45 the US and Japan and some European countries,
28:48 Canada.
28:49 Um,
28:50 and then China,
28:50 the EU and India,
28:52 uh,
28:52 have most of the production capacity.
28:54 And we said,
28:55 well,
28:55 maybe they're prioritizing their own,
28:58 uh,
28:58 populations.
28:59 This is,
28:59 uh,
29:00 the,
29:00 the export restriction hypothesis.
29:02 And we said simply,
29:03 you know,
29:03 at the current production rate,
29:05 if they said,
29:06 you know,
29:07 we're gonna reserve as much as we need for 80% of our populations,
29:11 how long will it take?
29:13 Uh,
29:13 for supply to be available to other countries.
29:16 And,
29:16 and we,
29:16 we forecast that actually by the end of 2021,
29:21 uh,
29:21 there'd only be about 270
29:24 million doses if they choose not to export
29:27 anything to other countries.
29:28 Um,
29:29 And then,
29:29 so,
29:29 so,
29:30 you know,
29:30 that,
29:31 that,
29:31 I think,
29:32 highlights that,
29:33 you know,
29:33 it,
29:33 it is important
29:35 where,
29:35 you know,
29:35 that countries can secure their,
29:37 their supply.
29:37 And if you're relying on only a few countries,
29:39 that can be a problem.
29:41 At the time,
29:42 you know,
29:42 there were really limited ways to,
29:45 to expand supply to other countries.
29:46 And so,
29:47 we,
29:47 we charted out these six scenarios.
29:49 So,
29:49 one would be just to
29:50 approve effective vaccines.
29:52 So,
29:52 that was at the time,
29:53 you know,
29:53 Novavax had
29:55 these phase 3 trials,
29:56 um,
29:57 That were successful,
29:58 uh,
29:58 as well as some,
29:59 some vaccines in China,
30:00 but they hadn't yet been given regulatory approval.
30:03 So,
30:03 you know,
30:03 that,
30:04 that was one thing.
30:05 Um,
30:05 another,
30:05 the second highest impact would have been,
30:07 um,
30:08 you know,
30:08 for,
30:09 uh,
30:09 a,
30:09 a Curvac vaccine,
30:11 which was sort of found to be ineffective.
30:13 Um,
30:14 you know,
30:14 we said,
30:14 well,
30:14 you could take the
30:15 manufacturing capacity from that and,
30:17 and give it to
30:18 either,
30:19 um,
30:19 Pfizer or,
30:20 or Moderna,
30:20 you know,
30:21 that,
30:21 that could be effective,
30:22 but that didn't happen,
30:23 uh,
30:23 in the end,
30:23 I think,
30:24 you know,
30:24 for respective property rights.
30:26 Um,
30:27 And then the other ones was,
30:28 was to,
30:28 you know,
30:29 delay boosters,
30:30 uh,
30:30 delay second doses,
30:32 you know,
30:32 for those with prior infection,
30:34 um,
30:34 as this was done in France,
30:36 um,
30:37 delaying,
30:37 uh,
30:38 you know,
30:38 the,
30:39 uh,
30:39 the youth who have a lower,
30:40 lower,
30:41 um,
30:41 lower mortality rate,
30:43 um,
30:43 and then authorizing.
30:44 Half doses,
30:45 you know,
30:45 which,
30:45 which some research showed that basically you could get the same effect of,
30:48 of Moderna,
30:49 for example,
30:49 by cutting the dose in half.
30:51 And they've actually done that one now.
30:53 Um,
30:54 but,
30:54 but the point from this is that,
30:55 you know,
30:55 there were sort of,
30:57 uh,
30:57 very few things that could be done
31:00 in 2021,
31:01 uh,
31:01 to expand supply,
31:03 uh,
31:03 for low,
31:04 low-income countries.
31:05 Um,
31:06 and so,
31:06 so,
31:07 I wanna ask in the,
31:08 in the next slide,
31:08 sort of,
31:09 what,
31:09 what could we have done about that?
31:10 So,
31:11 um,
31:12 you know,
31:13 uh,
31:14 I think it was clear,
31:15 uh,
31:15 at the time that,
31:16 and this is from the,
31:17 the paper in,
31:18 um,
31:19 uh,
31:19 Oxford Review of Economic Policy,
31:20 also just released as a World Bank,
31:22 uh,
31:22 working paper.
31:23 It's called Financing Vaccine Equity.
31:25 Um,
31:27 Uh
31:28 You know,
31:29 and,
31:29 and what we do there is we say,
31:31 uh,
31:31 OK,
31:31 so the data don't,
31:33 uh,
31:33 there,
31:33 there's two hypotheses.
31:34 So,
31:34 one is that,
31:35 uh,
31:36 the countries that were producing were hoarding the vaccines and they were,
31:40 you know,
31:40 restricting exports and,
31:41 and
31:42 it was impossible for lower middle income countries,
31:45 LMICs to get
31:46 vaccines at all.
31:47 But another hypothesis is that,
31:49 well,
31:50 the market was open.
31:52 But supply was scarce and it was rationed through queuing.
31:55 So,
31:56 you know,
31:56 if you,
31:56 uh,
31:57 if you place,
31:58 you,
31:58 you,
31:59 the people who placed orders earlier got orders.
32:01 Uh,
32:01 and this is actually what,
32:03 you know,
32:03 CEOs of,
32:04 of,
32:05 uh,
32:05 vaccine companies said.
32:06 So,
32:06 uh,
32:07 Doctor Borla at Pfizer said,
32:08 you know,
32:08 I had asked heads of state
32:10 by letter,
32:11 uh,
32:11 to place order,
32:12 um,
32:13 uh,
32:13 uh,
32:13 but,
32:14 but,
32:14 you know,
32:14 when they,
32:15 when they finally did order,
32:16 the doses had already been allocated.
32:18 So,
32:18 um,
32:19 You know,
32:20 this is,
32:20 uh,
32:20 this is one,
32:22 another hypothesis.
32:22 It's just that countries didn't order,
32:24 uh,
32:25 early enough.
32:25 And
32:26 so,
32:26 uh,
32:26 in this paper with Ruchir Agarwal,
32:28 we,
32:28 we collected data on over 460,
32:31 um,
32:32 uh,
32:32 vaccine,
32:33 uh,
32:33 contracts,
32:34 sorry,
32:35 almost uh 460.
32:37 Uh,
32:37 advanced purchase agreements,
32:38 and we do find actually that low and lower middle income countries ordered
32:42 later.
32:43 So,
32:43 you see on average,
32:44 low-income countries,
32:45 you know,
32:45 some of them did order for themselves,
32:47 um,
32:48 uh,
32:49 rather than relying on,
32:50 uh,
32:50 multilateral agencies,
32:51 but they ordered in May 2021.
32:53 Um,
32:54 uh,
32:54 upper middle income countries as well order in,
32:57 in February.
32:57 So,
32:57 there's this,
32:58 there's this gap in that
32:59 high-income countries were moving
33:02 ahead.
33:03 Um,
33:03 we,
33:04 we use a regression analysis actually to decompose
33:07 the delay
33:08 into,
33:09 uh,
33:10 you know,
33:10 the,
33:10 these effects.
33:11 So,
33:11 there's,
33:11 there's two effects here.
33:12 One is that,
33:13 well,
33:14 if you're a low-income country,
33:15 you,
33:16 you get delays later,
33:17 you know,
33:18 it takes longer to deliver regardless of the time you order.
33:21 The other is the part that's attributed
33:22 to this fact that low-income countries ordered,
33:25 you know,
33:25 5 months later on average,
33:27 uh,
33:27 than high-income countries.
33:29 Um,
33:29 and,
33:29 you know,
33:30 we find actually in our regression analysis that only 25% of the delay
33:35 happens regardless of the time you ordered and 75% of the delay
33:39 is attributed to the month,
33:40 uh,
33:41 the contracts,
33:42 uh,
33:42 were signed.
33:43 So,
33:43 so this says,
33:44 you know,
33:44 I think pretty conclusively that the market was actually relatively free.
33:48 You could get vaccines,
33:50 uh,
33:50 but,
33:50 but it depended on when you ordered them.
33:52 And high income countries had
33:54 You know,
33:54 some advantage,
33:55 which was that they had production and they could control exports and so forth.
33:58 But most of the advantage came from just putting money,
34:01 uh,
34:01 into the companies,
34:02 uh,
34:03 earlier.
34:03 And they often did this,
34:04 you know,
34:04 before the vaccines were even licensed.
34:06 So,
34:06 in December 2020,
34:08 um,
34:08 you know,
34:08 there are very few,
34:09 um,
34:10 authorizations,
34:11 um,
34:11 you know,
34:11 low-income countries waited until after vaccines were,
34:14 um,
34:16 Approved.
34:16 So,
34:17 you know,
34:17 I,
34:18 I,
34:18 I wrote a blog in,
34:19 in 2021 saying,
34:20 uh,
34:20 you know,
34:21 the problem is not supply but demand.
34:22 And that,
34:23 that was intended to be a bit provocative,
34:25 but I,
34:25 it was to illustrate this point.
34:26 So,
34:27 you get what you pay for when you pay for it.
34:29 If,
34:29 if supply is
34:31 constrained a bit,
34:32 the,
34:32 the people who
34:33 who order first,
34:34 uh,
34:34 are going to get it.
34:35 And,
34:35 and you see,
34:36 and,
34:36 and even as well,
34:38 you know,
34:38 if you have capacity or you waive patents or something like that,
34:42 um,
34:42 that doesn't mean you'll get supply unless there are purchase orders.
34:45 You see this now in South Africa where,
34:47 um,
34:48 Aspen Pharma has,
34:49 has the COVID vaccine plant,
34:51 and they have,
34:51 you know,
34:52 no,
34:52 no orders to buy vaccines.
34:53 So,
34:53 so there's a
34:56 capacity will only get you so far.
34:57 Um,
34:58 and so,
34:59 so,
34:59 I want to claim,
35:00 here's my claim.
35:01 Is that if low and middle income countries had ordered earlier,
35:05 you know,
35:05 they might have secured a better place in
35:07 line and you could have had vaccine uh equity
35:10 earlier.
35:11 Now,
35:11 there's a big caveat to that.
35:12 So what if,
35:14 you know,
35:14 they all ordered earlier and then high income countries just,
35:17 you know,
35:17 bid higher and ordered.
35:19 Uh,
35:20 you know,
35:21 and then the prices would go higher.
35:22 So that means there'd be a,
35:23 a transfer to the pharma companies,
35:25 but,
35:25 uh,
35:26 vaccines might not arrive any,
35:27 any slower,
35:28 any faster.
35:29 Um,
35:30 you know,
35:30 I think there may be something to that.
35:32 We,
35:32 we did see that in
35:34 2021 when
35:36 Uh,
35:37 prices when,
35:37 when orders actually scaled up,
35:39 so you had more demand at that time.
35:41 Prices stayed,
35:42 stayed the same or,
35:43 or even fell.
35:44 Uh,
35:44 so it's,
35:45 it's not clear that that,
35:46 you know,
35:46 extra demand was increasing prices,
35:48 um,
35:49 though it,
35:49 it did increase deliveries.
35:51 Um,
35:52 uh,
35:53 uh,
35:53 but,
35:53 you know,
35:54 even more than that,
35:55 there's,
35:55 there's some work by Susan Athee and,
35:57 and Michael Kramer and others,
35:58 um,
35:59 Chris Snyder at,
36:00 at,
36:00 at Dartmouth,
36:01 you know,
36:01 that shows that you can actually write contracts that say,
36:03 OK,
36:04 you know,
36:04 if I
36:05 Uh,
36:05 if I pay for this,
36:06 you,
36:07 you have to,
36:07 you know,
36:08 invest in manufacturing capacity to,
36:10 to scale it and that,
36:11 that could benefit other people.
36:12 So I,
36:12 I really do think
36:14 that if we had,
36:15 you know,
36:16 demand earlier,
36:17 that would,
36:17 that would both
36:18 give low and lower middle income countries a place in line,
36:21 but also could,
36:23 you know,
36:23 expand aggregate supply because it gave the companies certainty,
36:27 uh,
36:27 to invest,
36:28 um,
36:28 and scale,
36:29 uh,
36:29 and scale supply for everybody.
36:31 OK?
36:32 Um,
36:33 so,
36:33 now I want to go with some hypothesis.
36:35 So,
36:35 so why didn't the low and middle income countries order earlier?
36:38 So,
36:38 you know,
36:38 one first is a sort of limited perceived benefit.
36:41 As I,
36:41 as I showed and spoke about before,
36:44 you know,
36:44 there are these big differences in the age distribution.
36:46 Uh,
36:47 so low income countries have,
36:48 you know,
36:48 many,
36:48 you know,
36:49 half the population is under.
36:51 Uh,
36:51 20.
36:52 Um,
36:52 and they had lower,
36:53 uh,
36:53 fatality rates.
36:54 Um,
36:54 you know,
36:55 this is just a chart from The Lancet of the,
36:57 showing you that,
36:58 how fatality,
36:59 uh,
36:59 increases by age.
37:01 And,
37:01 you know,
37:01 just as a benchmark,
37:02 um,
37:03 you know,
37:03 mortal malaria,
37:05 you know,
37:05 can have a fatality rate of 110,000,
37:08 uh,
37:08 for infants.
37:09 But for COVID,
37:10 that,
37:10 that fatality rate is 1 in 10,000.
37:12 So it's,
37:13 it's,
37:13 it,
37:14 it wouldn't make sense for a country to reallocate budget from,
37:18 you know,
37:18 it's infant
37:19 uh malaria program
37:21 to COVID.
37:22 You could see why they,
37:23 they might want to create some budget for healthcare workers or,
37:26 or the Elderly,
37:27 but,
37:28 you know,
37:28 this age distribution can explain why,
37:31 you know,
37:31 some,
37:31 uh,
37:32 you know,
37:32 resources weren't,
37:33 weren't reallocated towards COVID.
37:35 Now,
37:35 of course,
37:35 if you could,
37:36 you could borrow and,
37:37 and you had access to finance,
37:38 then,
37:38 you know,
37:39 you,
37:39 you'd still want to do this to save lives.
37:41 Um,
37:41 but under a constrained budget,
37:43 uh,
37:43 you might not want to.
37:44 Um,
37:45 another hypothesis is that countries had,
37:47 you know,
37:48 limited bargaining power or capacity.
37:50 So,
37:51 Um,
37:51 you know,
37:51 if you're a small economy with a few,
37:53 uh,
37:54 20 million people,
37:55 you know,
37:55 it's gonna be harder to get the attention of,
37:57 of vaccine developers who are selling to the US,
38:00 uh,
38:00 you know,
38:01 with,
38:01 uh,
38:01 330 million,
38:03 um,
38:04 uh,
38:04 or the EU.
38:05 Um,
38:06 I,
38:06 it's also the case that low,
38:07 low-income countries often,
38:09 um,
38:09 rely on,
38:10 on,
38:11 uh,
38:11 donor agencies to deliver free vaccines,
38:13 so they may not have the institutional experience.
38:16 Um,
38:17 uh,
38:17 of,
38:18 of purchasing vaccines.
38:19 So that's one hypothesis.
38:21 Um,
38:22 but,
38:22 uh,
38:23 at the same time,
38:24 um,
38:24 a,
38:24 an agency was set up as part of this accelerator called COVAX,
38:28 um,
38:29 the AMC Advanced Market Commitment.
38:31 A lot of,
38:31 a lot of language here.
38:32 But that was set up specifically to overcome this problem.
38:35 So,
38:35 they,
38:35 they were gonna supply vaccines for low and lower middle-income countries.
38:39 And that was,
38:40 you know,
38:40 potentially demand as large as,
38:42 uh,
38:42 you know,
38:42 the G7 or the,
38:44 the EU.
38:45 Um,
38:45 and importantly,
38:46 this facility could also buy vaccines,
38:49 you know,
38:49 early on.
38:50 It,
38:50 it actually
38:51 made a purchase for the AstraZeneca vaccine
38:54 in June 2020 before it was licensed,
38:57 um,
38:57 and,
38:57 and secured,
38:58 you know,
38:58 a place in line for,
39:00 for that vaccine.
39:01 Um,
39:02 but what we see though,
39:03 and,
39:03 and this points to a third hypothesis,
39:05 is that COVAX actually didn't have access to the same resources
39:10 that rich countries,
39:11 uh,
39:11 did,
39:12 at least early on in the pandemic.
39:14 So while rich countries,
39:16 you know,
39:16 were putting,
39:17 you know,
39:17 they could borrow at very low interest rates,
39:19 COVAX actually,
39:20 you know,
39:20 only raised $300 million
39:23 you know,
39:23 in its first fundraising.
39:24 And so here in this chart,
39:25 you can see.
39:27 The blue line shows,
39:28 and,
39:28 and the left axis show,
39:29 you know,
39:29 how much money it had access to.
39:32 And you can see that the,
39:33 the purchases of,
39:34 of vaccines actually track that,
39:35 you know,
39:35 fairly
39:36 quickly.
39:37 So,
39:37 so,
39:37 you know,
39:37 one hypothesis is to say,
39:39 well,
39:39 if,
39:40 what if they had,
39:40 you know,
39:41 11 or 12
39:43 billion in June 20,
39:44 you know,
39:44 they could have gotten uh an earlier place in line.
39:48 Um,
39:48 and so this,
39:48 you know,
39:49 points to the third,
39:50 um,
39:50 hypothesis.
39:51 So I,
39:51 so I already mentioned this,
39:52 so COAXx didn't have
39:54 You know,
39:54 finance,
39:55 um,
39:55 you know,
39:56 they,
39:56 there was even a specific problem,
39:57 which is that,
39:58 you know,
39:59 donors would say,
39:59 OK,
40:00 we'll give you this money,
40:00 but then they wouldn't give them cash.
40:02 And so,
40:03 actually,
40:03 you know,
40:03 the European Investment Bank actually set up this thing where it,
40:06 it would lend them cash
40:08 against these commitments of donors.
40:10 Um,
40:11 And,
40:11 uh,
40:12 uh,
40:12 but,
40:13 you know,
40:13 the many multilateral
40:15 development banks other than the,
40:16 the European Union didn't,
40:17 uh,
40:17 sort of take this on.
40:18 They've led more on a country by country basis,
40:20 and they didn't loan to,
40:21 to COVAs.
40:22 Um,
40:23 you know,
40:23 there is an example,
40:24 so in Africa,
40:25 they,
40:25 they set up a regional agency,
40:27 this Africa Vaccine Acquisition Trust,
40:29 uh,
40:30 to,
40:30 to borrow.
40:31 Um,
40:32 uh,
40:33 and,
40:33 uh,
40:34 and,
40:34 and it,
40:35 it borrowed to buy vaccines.
40:37 Um,
40:37 you know,
40:37 the World Bank,
40:38 um,
40:38 you know,
40:39 did have this policy where it said,
40:41 you know,
40:41 while COVAX and the high-income countries were purchasing,
40:44 you know,
40:44 in advance of regulatory approval,
40:46 the World Bank actually said early on
40:48 that,
40:48 you know,
40:49 we need approval of,
40:51 uh,
40:51 you know,
40:51 from 3 regulatory,
40:53 multiple regulatory agencies before we'll finance a purchase.
40:55 So,
40:55 there was actually a point when
40:57 Uh,
40:57 AstraZeneca was being administered in the UK but
40:59 had not been authorized by multiple authorities,
41:01 so the World Bank wouldn't finance it.
41:04 Um,
41:04 and the Asian Development Bank and World Bank broadly also,
41:07 um,
41:07 you know,
41:08 didn't,
41:08 even when they said,
41:09 OK,
41:09 we'll,
41:10 we'll finance,
41:11 uh,
41:12 if the WHO approves it,
41:13 um,
41:14 we won't finance prepayments,
41:15 you know,
41:16 that could maybe secure you a place in line.
41:18 Um,
41:18 and I'll get back to that.
41:19 So,
41:19 so what are the lessons for the future?
41:20 I realized I'm,
41:21 I'm going a bit,
41:22 uh,
41:23 uh,
41:23 slow,
41:24 so I'll,
41:24 I'll,
41:24 I'll try to speed this up.
41:25 Um,
41:26 So,
41:27 you know,
41:28 now,
41:28 with the pandemic,
41:29 there's extraordinary interest,
41:30 uh,
41:31 in pandemic preparedness.
41:32 Um,
41:33 so,
41:33 it,
41:33 it,
41:34 it's good to kind of think back a little bit to,
41:36 to 2017.
41:37 So,
41:37 Jim Kim,
41:38 the president of the World Bank at the time,
41:40 you know,
41:40 raised this fund for pandemic emergency financing,
41:43 and he raised only $181 million
41:46 which is so small compared to this $18 billion
41:49 that I showed you was raised during the pandemic.
41:51 Um,
41:52 and you know,
41:52 that,
41:52 that project was actually pretty successful.
41:54 It actually,
41:54 it bought insurance,
41:56 uh,
41:57 uh,
41:57 against,
41:58 uh,
41:58 pandemics,
41:58 which paid out during COVID.
42:00 So it actually paid out,
42:01 uh,
42:01 258 million,
42:03 so more than it,
42:03 it took in.
42:04 Um,
42:05 but,
42:05 but obviously,
42:06 this was still a very small amount of money,
42:07 you know,
42:08 you,
42:08 you need to buy more insurance to,
42:10 to,
42:10 to have a big response.
42:11 Um,
42:12 and so,
42:12 kind of channeling this idea,
42:14 there was this independent panel,
42:16 uh,
42:16 of the G20 which said,
42:18 OK,
42:18 we should have a new fund.
42:19 Uh,
42:20 they want to put $10 billion a year into it,
42:22 uh,
42:23 uh,
42:24 and,
42:24 you know,
42:24 to,
42:24 to fund,
42:25 um,
42:25 pandemic preparedness.
42:27 And a lot of the things we've talked about here are sort of pathogen surveillance,
42:31 uh,
42:31 interruption of wild animal trade and,
42:33 and maintenance of,
42:34 of
42:34 manufacturing capacity.
42:36 And so far,
42:37 about a billion dollars has been committed.
42:39 So far less than,
42:40 than the $10 billion per year asked,
42:42 uh,
42:42 but still more than people were investing in,
42:44 in 2017.
42:46 And,
42:46 you know,
42:46 the point I want to make in this talk is that,
42:48 you know,
42:49 if you want to avoid
42:50 the vaccine access,
42:52 uh,
42:52 inequity,
42:53 you know,
42:53 we need to invest in strong health systems and so forth.
42:56 But we,
42:56 we also need kind of surge funding to,
42:58 to purchase,
42:59 uh,
42:59 vaccines and,
43:00 and secure a place in line
43:02 during,
43:02 you know,
43:03 wartime.
43:03 So,
43:03 you can say,
43:04 you have this dichotomy of,
43:06 of prevention is,
43:06 is peacetime activities,
43:07 but then,
43:08 you know,
43:08 when,
43:09 when you do get that
43:10 1 in 50 year,
43:12 uh,
43:12 flood,
43:13 uh,
43:13 you know,
43:13 you need resources to,
43:15 to deal with it.
43:16 Um,
43:16 so,
43:17 here's how that could work.
43:17 So,
43:17 this is again in this new paper.
43:19 Um,
43:20 we say countries could establish a,
43:22 uh,
43:22 an advanced commitment fund.
43:24 Um,
43:24 it would have minimal operations.
43:26 But then,
43:27 as soon as a pandemic is declared,
43:28 so either when the
43:29 WHO declares it or there's some,
43:32 you know,
43:32 deaths,
43:33 uh,
43:33 above a number,
43:34 a certain number,
43:35 um,
43:36 uh,
43:36 you know,
43:36 you might want to do the deaths threshold because,
43:39 you know,
43:39 once you create a fund and then if the WHO
43:42 You know,
43:42 then they have an incentive to release the money by declaring a pandemic.
43:45 So you could guard against that by,
43:46 by,
43:47 uh,
43:47 by having a number of,
43:48 uh,
43:49 death threshold.
43:50 Um,
43:51 uh,
43:51 so that's,
43:52 that's what the fund does.
43:53 Uh,
43:53 step two is that a financer,
43:55 financier establishes a credit line to the fund.
43:57 So,
43:58 a loan that says,
43:58 you know,
43:59 this becomes active and you can borrow.
44:01 Uh,
44:01 when,
44:02 uh,
44:02 the pandemic starts,
44:03 and,
44:04 and a notional value for that is 18
44:06 billion.
44:06 So the exact amount of money that Act A raised,
44:09 uh,
44:10 by 2021,
44:11 we've,
44:11 all we're saying is just say,
44:12 you know,
44:13 donors will give that again,
44:14 let's lend against that,
44:15 so it's available on day zero of the pandemic.
44:18 Um,
44:19 and so,
44:19 you know,
44:19 with that credit line,
44:20 step 3,
44:21 the fund is able to invest,
44:22 uh,
44:22 to secure a place in line,
44:24 so it can invest in R&D,
44:25 uh,
44:26 support manufacturing,
44:27 and also purchase vaccines.
44:28 The,
44:28 the key point with all of these is that all the contracts should have
44:32 an option to purchase with a guaranteed
44:34 place in line.
44:35 So,
44:35 it secures,
44:36 you know,
44:36 the,
44:36 the position of low and middle-income countries to buy
44:39 vaccines.
44:41 Um,
44:41 you know,
44:41 so just to talk a bit about the financier,
44:43 so this is just general,
44:44 right?
44:45 This is,
44:45 any financier could do this,
44:46 you know,
44:47 the World Bank is a financier,
44:48 could also be a commercial bank,
44:50 private,
44:50 uh,
44:51 foundation.
44:52 Um,
44:52 and so,
44:53 we highlight in the paper
44:54 four options,
44:55 uh,
44:55 for them to do this,
44:56 which can be used separately or in combination.
44:58 So,
44:58 one,
44:58 which I mentioned is to say just donors say,
45:01 in advance,
45:01 you know,
45:02 we're gonna do the same thing,
45:03 uh,
45:03 as we did during COVID-19.
45:05 Um,
45:06 that's enough for the financier to lend against that.
45:08 Another would be for low-income countries to,
45:10 to actually guarantee a credit line.
45:12 So they say,
45:12 OK,
45:13 our agencies maybe,
45:15 uh,
45:15 like the Africa Vaccine Trust,
45:17 um,
45:17 are gonna do these purchases,
45:18 you can lend against that.
45:20 A third would be insurance.
45:21 So,
45:21 this was the,
45:22 you know,
45:22 experiment,
45:23 um,
45:24 of this emergency financing facility.
45:26 It can be a bit expensive,
45:27 but in this case,
45:27 it paid off.
45:29 Um,
45:29 and then D would be just that the shareholders
45:31 of the financier permit them to bear the risks.
45:33 So,
45:33 just say,
45:34 you know,
45:34 we're gonna take the,
45:35 no one promises anything.
45:37 But will,
45:37 will lend the money.
45:38 And,
45:39 you know,
45:39 what's interesting is that,
45:40 so in the,
45:41 um,
45:42 you know,
45:42 just from the World Bank,
45:43 in the uh pandemic of COVID-19,
45:46 uh sort of B and C were the main options.
45:49 So we,
45:49 we have these insurance payouts and then also lending to,
45:53 uh,
45:53 you know,
45:54 middle-income countries and low-income countries directly.
45:56 Um,
45:57 but previously,
45:57 we've actually used other,
45:58 uh,
45:59 options.
45:59 So,
46:00 there was this,
46:00 um,
46:01 advanced commitment fund for,
46:03 uh,
46:03 pneumococcal,
46:04 uh,
46:05 uh,
46:05 vaccines,
46:06 um,
46:06 which was proposed by Michael Kramer and,
46:08 and,
46:08 and executed in the last decade.
46:10 Uh,
46:11 that was actually a combination of A and D.
46:12 So their,
46:13 uh,
46:14 government,
46:14 governments committed some money to pay for this,
46:16 but they actually didn't pay it.
46:18 You know,
46:18 fully in advance,
46:19 so the World Bank,
46:20 you know,
46:20 put some risk on its own balance sheet,
46:22 uh,
46:22 to pay for that.
46:23 Eventually,
46:23 the donors did,
46:24 you know,
46:24 pay,
46:24 pay the World Bank back,
46:25 but the bank charged a small fee
46:27 to take that risk.
46:29 Um,
46:29 and then the final thing I want to say on this is that,
46:31 you know,
46:32 uh,
46:33 a financier might not want to
46:35 deliver unsafe or ineffective vaccines.
46:37 So one thing they can do is say,
46:39 well,
46:39 I'll finance prepayment to get you a place in line.
46:43 But I will commit to procure the vaccine.
46:45 So pay the full cost
46:47 only after emergency use authorization.
46:49 So,
46:49 I'm not gonna actually,
46:51 uh,
46:52 purchase the vaccines until they succeed.
46:54 So,
46:54 that,
46:54 that gives,
46:55 you know,
46:56 puts some risk on the,
46:57 um,
46:58 on the developer,
46:59 uh,
46:59 and also means that all of your money is not actually,
47:02 uh,
47:02 at risk,
47:03 um,
47:04 you know,
47:04 if,
47:05 if the vaccines don't come through.
47:06 Um,
47:07 just to A few points,
47:07 I'll,
47:08 I'll try to wrap up really quickly.
47:09 Um,
47:09 you know,
47:10 ACTA provides some,
47:12 some examples.
47:12 So,
47:13 so,
47:13 a lot of the orders were,
47:15 um,
47:15 of COVAs,
47:16 uh,
47:16 were concentrated in India,
47:18 which restricted exports,
47:19 um,
47:20 you know,
47:20 as,
47:20 as it has a prerogative to do,
47:22 uh,
47:22 to protect its own people.
47:23 But,
47:23 you know,
47:24 in the next time,
47:25 one approach would be to,
47:26 uh,
47:26 actually invest in,
47:28 uh,
47:28 contracts from smaller countries that can satisfy
47:30 their domes domestic demand more quickly.
47:33 Um,
47:34 uh,
47:34 you know,
47:34 and that,
47:35 uh,
47:36 I think it's part of a broader discussion of,
47:37 say,
47:38 you know,
47:38 if we have vaccine capacity,
47:39 manufacturing capacity in small countries,
47:41 there's a double benefit because that allows countries to meet their needs faster,
47:45 uh,
47:46 factor,
47:46 uh,
47:47 and,
47:47 uh,
47:47 and expand the number of exporters.
47:49 Um,
47:49 and also,
47:49 you know,
47:50 subsidies could be targeted in a more progressive way.
47:52 So,
47:52 let me summarize,
47:53 uh,
47:54 we get to the discussion,
47:55 um,
47:56 So,
47:56 uh,
47:56 you know,
47:57 the international,
47:58 there was a lot of inequality,
47:59 uh,
47:59 internationally,
48:00 um,
48:01 excluding India,
48:02 uh,
48:02 low and lower middle income countries did have lower deaths
48:05 per capita,
48:05 yet vaccine access was also
48:08 unequal.
48:08 So we think that,
48:09 uh,
48:09 actually mortality of older people was higher,
48:12 uh,
48:13 in,
48:13 in low-income countries.
48:14 So though there was an
48:16 overall,
48:16 you know,
48:17 effect that was,
48:18 was lower,
48:18 uh,
48:19 you know,
48:19 there were still people going without healthcare.
48:22 Um,
48:22 and,
48:22 and also,
48:23 you know,
48:23 income convergence is,
48:24 is forecast to return.
48:25 So there's sort of,
48:26 uh,
48:26 inequality will decline over time,
48:29 uh,
48:29 in the long run,
48:30 uh,
48:30 in aggregate.
48:32 Between countries.
48:33 Um,
48:34 and then,
48:34 you know,
48:34 looking at the cooperation,
48:36 um,
48:36 so there was this forbearance,
48:38 I told you that,
48:38 that doesn't seem to have been particularly effective in lowering costs,
48:41 but the development banks did,
48:43 uh,
48:44 you know,
48:44 provide this cheap finance,
48:45 um,
48:46 but importantly not for at-risk purchases
48:49 of vaccines.
48:50 Um,
48:50 donors committed 18 billion to ACTA,
48:53 um,
48:54 which is a huge amount,
48:54 more than,
48:55 more than
48:56 Uh,
48:56 previously,
48:57 uh,
48:58 uh,
48:58 to prepare for pandemics.
49:00 Uh,
49:00 but this came slowly,
49:01 only after 18 months.
49:02 And so,
49:03 but still,
49:03 you know,
49:04 despite all of this,
49:05 uh,
49:05 you know,
49:05 24 months into the pandemic,
49:07 vaccine supply is not a constraint.
49:09 So there was a,
49:09 a brief window in 2021 where that was an issue,
49:12 but now,
49:12 you know,
49:12 it's,
49:13 it's about,
49:13 uh,
49:14 you know,
49:14 the sort of,
49:15 uh,
49:17 final,
49:17 final delivery,
49:18 um,
49:19 last mile delivery,
49:20 excuse me.
49:21 And then,
49:21 and then see,
49:22 you know,
49:22 this is my claim,
49:23 uh,
49:23 is that the,
49:24 the response could have been even faster and more equitable,
49:27 um,
49:27 had funds been available for ACTA and for countries,
49:30 um,
49:31 earlier,
49:31 uh,
49:31 we could have incentivized,
49:33 uh,
49:33 an earlier expansion of supply,
49:35 uh,
49:35 and also secured countries,
49:37 uh,
49:37 a place in line.
49:38 Um,
49:39 so,
49:39 with that,
49:40 uh,
49:40 I'll stop.
49:40 Thanks,
49:41 thanks so much.
49:45 Thanks,
49:45 Tristan,
49:46 um,
49:46 for that,
49:47 that retrospective and,
49:48 and perspective view.
49:50 Um,
49:51 uh,
49:51 as I mentioned at the beginning,
49:53 we were really pleased to have,
49:54 um,
49:55 Kent uh Ransom here,
49:57 uh,
49:57 as a discussant.
49:58 So Kent,
49:58 over to you for some,
50:00 some reflections.
50:02 Great,
50:02 thanks,
50:02 Dion,
50:03 and thanks Tristan,
50:04 for providing me the opportunity to comment
50:06 on this interesting and highly topical presentation.
50:09 I was asked to comment based on my involvement in
50:11 the World Bank's collaboration with Gabi and the COA facility.
50:15 I'm not an unbiased discussant.
50:17 As an alternate to the World Bank's global director,
50:20 Health,
50:20 Nutrition and Population,
50:22 Juan Pablo Uribe,
50:23 I represent the bank on the board of GABI.
50:26 Uh,
50:26 the board of GABI oversees the GABI Secretariat
50:29 and has the ultimate responsibility for decisions,
50:32 uh,
50:32 uh,
50:33 and effective implementation of the COA facility.
50:37 As Tristan mentioned,
50:38 COVAX is the vaccines pillar of the Act accelerator,
50:41 GAVI,
50:42 SEPI,
50:43 the Coalition for Epidemic Preparedness Innovations,
50:47 and WHO
50:48 co-lead COVAX.
50:51 AV coordinates the COVAX facility,
50:53 which is the mechanism for securing COVID vaccines,
50:57 either by procuring them or through receipt of donated doses
51:01 and equitably allocating these vaccines.
51:05 COVAX has now delivered over 1.5 billion COVID-19 vaccine doses to 145 economies,
51:12 including over 1.3 billion doses
51:15 to AMC countries,
51:16 advanced market commitment countries.
51:18 These are 92 low and middle income economies.
51:22 Contributing significantly to coverage rates achieved in the AMC countries.
51:27 Uh,
51:28 and they currently have
51:29 coverage rates of 50 average coverage rates of 54%
51:34 with at least one dose and 46%
51:37 fully vaccinated,
51:39 uh,
51:39 uh,
51:40 as of 24th of May.
51:42 Although overall coverage between and within countries remains uneven,
51:47 as does the coverage of high-risk populations.
51:51 Um,
51:52 I certainly agree with the primary finding of your,
51:54 your analysis,
51:55 that is,
51:56 that the multilateral vaccines response could have
51:58 been even faster and the results more equitable
52:01 had funds been available in early 2020.
52:04 But earlier orders would also have secured low and middle income countries a
52:09 more equitable place in line benefiting high risk populations in those countries.
52:15 But I'm also glad that your analysis highlights
52:18 that 25 to 40% of the delay in vaccine
52:21 deliveries to low and middle income countries occurred independently
52:25 of the time they were ordered.
52:27 Delays were certainly also
52:29 about policy
52:30 and process
52:32 and power.
52:33 In terms of power you've mentioned the whole market effect,
52:36 which is no doubt significant.
52:38 Delays certainly also had to do with
52:41 setting up regulatory and legal frameworks,
52:44 deployment capacities,
52:46 so long-term investments in routine immunization,
52:48 and vaccine acceptance,
52:50 among other things.
52:52 Your analysis,
52:53 um,
52:53 uh,
52:54 didn't consider,
52:54 uh,
52:55 as,
52:55 as one of your hypotheses,
52:56 whether countries would have been ready to receive and deploy vaccines
53:00 if they had access,
53:02 uh,
53:02 to them six months earlier.
53:05 While countries awaited vaccines,
53:07 they invested in deployment capacity,
53:09 communications to build receptivity,
53:11 training healthcare workers,
53:12 regulatory requirements,
53:14 etc.
53:15 Some of the delay in with which low and middle income countries placed orders
53:21 may have reflected their own readiness to deploy the vaccines,
53:25 having firstly observed the impact of vaccine deployment elsewhere
53:28 while assessing their own perception of need.
53:33 Clearly,
53:33 uh,
53:33 a multilateral pandemic vaccine's response
53:36 should ensure financing not only for vaccine procurement,
53:40 uh,
53:40 which is the focus of your presentation.
53:43 Um,
53:45 I thought it uh uh instructive to
53:47 look at some of what Gay is planning for pandemic
53:51 preparedness as part of ongoing discussions about the global architecture
53:55 and financing for pandemic preparedness and response.
53:59 Gabi's begun to articulate its potential role.
54:03 And this will,
54:03 of course,
54:04 be informed by reviews and independent evaluations
54:07 that are planned for COVAX.
54:10 What Gay proposes is,
54:11 firstly,
54:13 that it has a vital role to play in building countries'
54:16 capacity to respond in emergencies
54:18 by strengthening routine immunization programs,
54:21 increasing their efficiency,
54:23 focusing on equity,
54:24 uh,
54:24 and reaching missed communities.
54:27 Secondly,
54:27 Gabi has a core role
54:29 in addressing inadequate manufacturing diversity in the face of COVID-19
54:35 and calls for support to African vaccine manufacturing.
54:39 Gabi's experience in market shaping for vaccines
54:42 can be leveraged to inform the intentional design
54:45 of a vaccine ecosystem that supports the sustainable sustainability
54:51 of African African vaccine manufacturing facilities
54:54 and the health of the global market more broadly.
54:58 Thirdly,
54:59 Gabi's financial instruments and capacity to innovate at pace
55:03 can play a role in future pandemic response.
55:06 Um,
55:08 I thought it worth mentioning some of Gabi's innovative financing mechanisms
55:12 given their potential role to provide financing for future pandemic response.
55:17 Gabi has a long track record of financial innovation,
55:20 most notably
55:21 forming the International Finance Facility for Immunization,
55:25 IFIM in 2006
55:27 with the World Bank as its treasury manager.
55:30 IFIM's pioneering work to create vaccine bonds through raising
55:34 finance on capital markets backed by long-term donor pledges.
55:38 Meant that a billion dollars front loading tool was
55:41 available to provide additional resources to the Covax AMC.
55:47 Recently,
55:47 Gabi announced a new COA rapid financing facility.
55:51 This is financed by the US Development Finance Corporation.
55:55 This is the first front loading arrangement that Gabby has designed
55:58 that provides access to liquidity from the moment a donor pledge
56:02 is publicly announced
56:04 rather than only when grant agreements are signed.
56:07 This will allow Covas to front load up to $1 billion in donor pledges for up to 2 years
56:12 in
56:12 increments of $350 million at any one time.
56:17 Uh,
56:17 Tristan,
56:18 you also mentioned the EIB facility.
56:20 This is a facility that allows Gay to front load pledge pledges
56:26 and draw down cash,
56:28 but to do so
56:30 on the basis of signed grant agreements.
56:33 The capacity of the EIB facility has recently been expanded from €440 million
56:38 by a further €1 billion.
56:42 And there are conversations about having both a front
56:45 loading and a quasi-contingent capacity to that EIB facility.
56:52 We also established the cost sharing mechanism
56:56 through which countries could procure extra COVID-19
56:58 vaccine doses using their own funding,
57:01 including World Bank financing.
57:03 This mechanism could also potentially be kept
57:06 warm
57:06 for use in a future future pandemic.
57:10 So in fact,
57:10 many of the aspects of the advance commitment fund
57:14 that you proposed
57:15 are already in place at
57:18 at GAI.
57:20 You've not mentioned,
57:21 uh,
57:22 the World Bank White Paper,
57:23 uh,
57:23 on the proposed financial intermediary fund for pandemic prevention,
57:28 preparedness and response.
57:30 So I did wonder to what extent the proposed mechanism,
57:33 uh,
57:33 addresses recommendations that you've made in your presentation.
57:37 Um,
57:37 uh,
57:38 uh,
57:38 my reading of the white paper is that it's,
57:40 uh,
57:40 uh,
57:40 more about the,
57:41 how,
57:42 how the fifth will be governed
57:43 rather than,
57:44 uh,
57:44 uh,
57:45 what it will do or the details of what it will do.
57:48 I do note that they recommend procurement of pandemic countermeasures,
57:52 presumably presumably including vaccines.
57:55 And it's clear,
57:56 uh,
57:57 that in the first instance,
57:58 they are planning for grants in,
58:01 grants out,
58:02 uh,
58:03 with no contingency financing.
58:05 But I'd be interested to hear your reflections
58:07 on that,
58:08 uh,
58:08 on that,
58:09 uh,
58:09 white paper.
58:11 Finally,
58:12 I hope that uh uh your team at DEC and
58:14 others will be involved in drawing lessons on what worked
58:17 and what didn't work in terms of financing.
58:21 At country level in low and middle income countries.
58:25 Faced with little or changing information about disease epidemiology,
58:30 vaccine supplies,
58:31 demand for vaccines,
58:33 how were decisions made about allocating to vaccine procurement and deployment?
58:38 And what impact did this have on financing of health and other sectors?
58:43 What sorts of technical assistance at country level
58:46 might have helped to better prepare
58:48 and respond?
58:50 I think that one of the key lessons learned
58:52 from the COVID pandemic is that when a government,
58:54 uh,
58:54 uh,
58:55 has a say
58:56 in how COVID tools are financed and procured and allocated,
59:00 this ownership and agency is then reflected in
59:03 in-country deployment of these tools.
59:06 So I'd also encourage,
59:08 uh,
59:08 uh,
59:08 the,
59:08 the authors to think about how countries can be involved in consultation
59:12 around your analysis and,
59:14 and papers.
59:16 Thank you very much.
59:21 Thanks so much,
59:22 Ken,
59:23 for those,
59:24 those insightful comments,
59:25 both reflecting and then um
59:27 it's very interesting to learn about all the,
59:29 the,
59:29 the different mechanisms that you,
59:30 that you described
59:32 and interesting to think about them in relation to,
59:34 to what,
59:35 what,
59:35 what Tristan was putting forth.
59:36 Um,
59:38 I'm gonna turn it back to Tristan if you want to pick up on a couple of,
59:41 of,
59:41 of Kent's points,
59:42 but I do want to encourage people,
59:43 if you do have a question,
59:44 please raise your hand using the raise hand function or
59:48 signal in the chat that you'd like to come in
59:49 if you have a question for either Tristan or,
59:51 or Kent.
59:52 I,
59:52 I hope,
59:53 Kent,
59:53 you don't mind if people direct some questions to you.
59:56 Um,
59:57 But with that,
59:58 let me turn it to Tristan for some,
1:00:00 some reactions and then we'll open it up.
1:00:01 Um,
1:00:02 please let me know.
1:00:04 Yeah,
1:00:04 thanks.
1:00:04 Let me,
1:00:04 let me respond quickly and to those three points.
1:00:07 I think I have,
1:00:08 um,
1:00:08 and then we can,
1:00:09 yeah,
1:00:09 I'm,
1:00:09 I'm eager to hear the audience.
1:00:11 Um,
1:00:11 so yeah,
1:00:11 I think on,
1:00:12 on
1:00:13 absorption capacity and the ability of countries to absorb,
1:00:16 you know,
1:00:17 vaccines,
1:00:17 that,
1:00:17 that's certainly an issue.
1:00:19 Um,
1:00:19 and I,
1:00:20 you know,
1:00:20 I should have highlighted it directly.
1:00:21 Um,
1:00:22 but I think,
1:00:22 you know,
1:00:22 one thing that's interesting to point out is that actually,
1:00:25 even low-income countries actually do have a lot of experience with vac,
1:00:29 uh,
1:00:29 mass vaccination campaigns.
1:00:31 So,
1:00:31 you know,
1:00:31 there's an example in 2013 that,
1:00:34 uh,
1:00:34 Burkina Faso immunized,
1:00:36 you know,
1:00:36 the whole population under 20,
1:00:38 uh,
1:00:38 against meningitis in,
1:00:39 in less than a month.
1:00:41 Um,
1:00:41 and now,
1:00:42 that,
1:00:42 that took a lot of planning,
1:00:44 uh,
1:00:44 and additional resources,
1:00:45 but,
1:00:45 but it,
1:00:46 it can be done.
1:00:47 And so,
1:00:48 You know,
1:00:48 part of,
1:00:49 you know,
1:00:49 I,
1:00:49 I worked actually
1:00:51 before the bank on,
1:00:51 on the,
1:00:52 uh,
1:00:53 the polio campaigns in Nigeria.
1:00:55 Um,
1:00:55 you know,
1:00:56 you,
1:00:56 you can do them if you,
1:00:58 if you have planning and,
1:00:59 and resources.
1:00:59 And so,
1:01:00 as long as we,
1:01:01 you know,
1:01:02 make sure that this kind of
1:01:04 surge,
1:01:05 uh,
1:01:06 efforts,
1:01:06 uh,
1:01:06 are,
1:01:06 are part of countries' planning,
1:01:08 I think it's sort of very feasible that,
1:01:10 that in the next pandemic,
1:01:11 everyone will be,
1:01:12 you know,
1:01:12 ready,
1:01:12 can be ready to go.
1:01:14 Um,
1:01:15 you,
1:01:15 you mentioned the,
1:01:15 the World Bank Financial Intermediary fund.
1:01:17 So I,
1:01:18 you know,
1:01:18 these are,
1:01:18 these are sort of my views as a researcher,
1:01:20 and I don't,
1:01:21 I,
1:01:21 I want to make very clear,
1:01:22 I'm not speaking for,
1:01:22 for World Bank policy.
1:01:24 There's been a lot of
1:01:25 public discussion,
1:01:26 which is ongoing.
1:01:27 Um,
1:01:28 you know,
1:01:28 that fund,
1:01:29 as,
1:01:29 as I said,
1:01:30 is,
1:01:30 is,
1:01:30 there's about a billion dollars that's been raised for it,
1:01:33 and there's a lot of things
1:01:35 that people have proposed and,
1:01:37 as you said,
1:01:37 the,
1:01:38 the discussion is mostly about how it will be governed,
1:01:39 but not actually what
1:01:41 the money will be spent on.
1:01:42 And
1:01:43 Um,
1:01:44 you know,
1:01:44 I,
1:01:45 uh,
1:01:45 Amanda Glassman at,
1:01:46 at CGD actually wrote a,
1:01:47 a nice comment on this,
1:01:48 which I thought was helpful,
1:01:50 which is that,
1:01:51 you know,
1:01:52 the,
1:01:52 the fund can actually be targeted at,
1:01:54 um,
1:01:55 the,
1:01:55 these prevention activities,
1:01:56 so surveillance and,
1:01:58 you know,
1:01:58 in,
1:01:58 you know,
1:01:59 safe,
1:01:59 safety in,
1:02:00 in,
1:02:00 you know,
1:02:00 markets that sell wildlife and so forth.
1:02:03 Um,
1:02:04 but actually,
1:02:04 we can address
1:02:06 the,
1:02:07 uh,
1:02:07 this kind of surge of response
1:02:10 through existing,
1:02:11 uh,
1:02:12 instruments and products as long as we make the right modifications.
1:02:15 So,
1:02:15 you know,
1:02:16 if,
1:02:17 if,
1:02:17 um,
1:02:18 you know,
1:02:18 multilateral development banks like the World Bank would,
1:02:20 would,
1:02:21 you know,
1:02:21 finance,
1:02:22 uh,
1:02:23 prepayments before
1:02:24 licensure of the vaccines,
1:02:26 that would,
1:02:27 you know,
1:02:27 allow countries to,
1:02:28 to buy,
1:02:29 you know,
1:02:29 early on in the pandemic.
1:02:31 Um,
1:02:31 you know,
1:02:32 you mentioned the IFIM and,
1:02:33 and EIB structures,
1:02:35 you know,
1:02:35 those,
1:02:35 those exist and you can lend against donors.
1:02:38 Uh,
1:02:39 commitments,
1:02:39 as,
1:02:39 as I said,
1:02:40 the World Bank has done this before for
1:02:42 the punonococcal,
1:02:43 punococcal,
1:02:44 uh,
1:02:45 um,
1:02:46 uh,
1:02:46 advanced commitments.
1:02:47 So,
1:02:47 so,
1:02:47 I think we actually can,
1:02:49 um,
1:02:50 You know,
1:02:51 respond,
1:02:51 uh,
1:02:52 without using the additional funds from the 5th.
1:02:55 Um,
1:02:55 but we,
1:02:56 we do need to make sure that,
1:02:57 you know,
1:02:57 we don't have restrictions on how money can be used,
1:03:00 uh,
1:03:00 in order,
1:03:01 in order to do that.
1:03:02 Um,
1:03:02 and then third,
1:03:03 you know,
1:03:03 just kind of tying back to what I said about,
1:03:06 um,
1:03:06 absorption capacity,
1:03:07 you know,
1:03:08 there's so much good research coming out of DEC
1:03:10 on last mile health delivery and incentives for healthcare workers.
1:03:15 And,
1:03:15 you know,
1:03:15 this is the bread and butter of,
1:03:17 of
1:03:18 both pandemic response and also,
1:03:20 you know,
1:03:20 global health generally.
1:03:22 And,
1:03:22 you know,
1:03:22 we saw that,
1:03:23 yes,
1:03:23 there was this period in 2021 where we needed
1:03:26 supply and all this financing would have been helpful,
1:03:28 but now we're just kind of back to the same problem,
1:03:30 which is that,
1:03:30 you know,
1:03:30 you need to vaccinate.
1:03:32 Everybody,
1:03:32 and that's,
1:03:33 that's a hard thing to do even in high-income countries.
1:03:35 So,
1:03:36 you know,
1:03:36 I think that the bulk of research that,
1:03:38 that DEC and others are,
1:03:39 are providing can be,
1:03:40 can be really useful there,
1:03:41 um,
1:03:42 uh,
1:03:42 and,
1:03:42 and it's,
1:03:43 it's very important
1:03:44 as long as we make sure we get this,
1:03:45 this response,
1:03:46 response financing correct.
1:03:48 So overall,
1:03:48 I'll,
1:03:49 I'll,
1:03:49 I'll open up to everybody else.
1:03:50 Thanks.
1:03:54 Yeah,
1:03:54 just to pick up on that last
1:03:56 point,
1:03:56 I mean,
1:03:57 Kent,
1:03:57 you're right,
1:03:58 I mean,
1:03:58 I,
1:03:58 I guess we are gonna be going into a phase now of,
1:04:00 of looking back at lessons learned,
1:04:03 but we do have a rich tradition within the
1:04:04 research department of looking at health services and,
1:04:07 and the improving the,
1:04:08 the quality and quality and access to,
1:04:10 uh,
1:04:11 and the,
1:04:11 the quality of service delivery,
1:04:13 um,
1:04:13 that's ongoing and,
1:04:14 and,
1:04:15 and,
1:04:15 and,
1:04:15 and we're obviously very keen to,
1:04:17 to,
1:04:18 to keep doing that.
1:04:19 And,
1:04:20 and as you say,
1:04:21 using this period to look at exactly what happened,
1:04:23 um,
1:04:24 and,
1:04:24 and lessons for the future on that front as well.
1:04:27 Um,
1:04:28 I don't see any hands raised.
1:04:30 Um,
1:04:31 I,
1:04:31 Ryan,
1:04:31 I don't know if we've received any questions through the YouTube,
1:04:34 um,
1:04:35 chat function.
1:04:37 Um,
1:04:41 I want to just give people a chance to
1:04:44 come in.
1:04:47 I see one from Samir Chandra.
1:04:50 Yeah,
1:04:50 Samir.
1:04:51 Go ahead,
1:04:52 Samir.
1:04:56 Hi,
1:04:57 uh,
1:04:57 this is Samir Chandra.
1:04:58 Can you all hear me well?
1:05:00 Yes,
1:05:00 you can.
1:05:00 Oh,
1:05:01 thanks.
1:05:01 Yeah,
1:05:01 this is
1:05:02 Samir from Global Geographic Society.
1:05:04 We are a Virginia-based nonprofit organization,
1:05:05 and I'm an independent researcher working on
1:05:08 poverty alleviation through skill development.
1:05:10 My question is,
1:05:11 what
1:05:12 changes you see in this post-pandemic scenario
1:05:16 on the global supply chain,
1:05:17 especially development of the local supply centers and
1:05:19 local manufacturing
1:05:21 and its impact
1:05:22 on poverty alleviation,
1:05:24 especially in the third world countries.
1:05:27 Um,
1:05:28 yeah,
1:05:28 thank you.
1:05:29 Uh,
1:05:29 so,
1:05:29 so I think that's a super important point.
1:05:30 As,
1:05:31 as I said,
1:05:31 um,
1:05:32 you know,
1:05:33 there,
1:05:33 there's this,
1:05:33 so in international trade,
1:05:34 there's this thing called the home market effect.
1:05:37 And that means if you have increasing returns to scale and production,
1:05:41 That means that actually the,
1:05:42 the countries that do the most exporting will also
1:05:45 be the ones that have the big domestic markets.
1:05:47 And so that's really what you see in health products,
1:05:50 um,
1:05:50 and,
1:05:50 you know,
1:05:51 in vaccines in particular that,
1:05:52 you know,
1:05:52 the US,
1:05:54 China,
1:05:55 uh,
1:05:55 EU are,
1:05:56 are the big producers and,
1:05:57 and India,
1:05:58 they have these big markets.
1:05:59 Um,
1:06:00 at the same time,
1:06:01 those are the countries that will
1:06:03 also,
1:06:04 you know,
1:06:04 they need to supply,
1:06:05 they need to serve their own populations.
1:06:07 And so in emergencies,
1:06:09 because they have big populations,
1:06:10 it will take longer for them
1:06:12 to produce enough to,
1:06:13 to,
1:06:13 to,
1:06:14 to provide for their populations.
1:06:16 And so,
1:06:17 I think from that perspective,
1:06:18 there is actually a lot of benefit.
1:06:21 In,
1:06:21 um,
1:06:22 you know,
1:06:22 subsidies and,
1:06:23 and,
1:06:23 and efforts to,
1:06:24 to,
1:06:25 uh,
1:06:25 make sure that every country has a little bit of,
1:06:28 of vaccine production capacity so they can
1:06:30 both provide for their own populations,
1:06:32 but also,
1:06:33 um,
1:06:34 uh,
1:06:34 you know,
1:06:35 uh,
1:06:35 export.
1:06:36 Um,
1:06:37 you know,
1:06:37 I think the challenge with that though,
1:06:39 is that in order for
1:06:41 Local vaccine production to be sustainable,
1:06:43 it has to have
1:06:44 continued demand.
1:06:45 So you can't just have a factory sitting around for 30 years until the next
1:06:49 coronavirus pandemic.
1:06:50 You know,
1:06:50 you need to actually use it to provide,
1:06:53 uh,
1:06:53 you know,
1:06:53 the,
1:06:54 the basic,
1:06:54 you know,
1:06:55 childhood immunizations,
1:06:56 you know,
1:06:56 measles and,
1:06:57 and yellow fever and,
1:06:59 and,
1:06:59 and these sorts of things.
1:07:00 Um,
1:07:01 and so,
1:07:02 I,
1:07:02 I think that that conversation will,
1:07:04 so there's a lot of effort to
1:07:06 Diversify production capacity,
1:07:08 but that will need to be,
1:07:10 um,
1:07:10 accompanied by,
1:07:11 you know,
1:07:12 a,
1:07:12 a concerted effort
1:07:14 to,
1:07:14 uh,
1:07:15 actually make sure that those,
1:07:16 those local producers have sustained,
1:07:18 uh,
1:07:19 demand,
1:07:19 and,
1:07:19 and they can build their capacities,
1:07:21 uh,
1:07:21 and keep them warm over time.
1:07:25 Thanks,
1:07:26 sir,
1:07:26 and I believe like,
1:07:27 one of the challenges will be of knowing the technical know-how and the
1:07:30 equipments and
1:07:32 other
1:07:33 facilities which can really facilitate or support
1:07:35 these kind of manufacturing in those countries.
1:07:39 Yeah,
1:07:39 I think Ken Ken mentioned that,
1:07:41 that,
1:07:41 uh,
1:07:41 COvax is,
1:07:42 is,
1:07:43 or,
1:07:43 or GAVI in general,
1:07:44 which,
1:07:44 which buys vaccines for,
1:07:46 for low income countries.
1:07:47 You know,
1:07:47 is thinking about how it can procure from,
1:07:50 you know,
1:07:50 a more diverse pool of,
1:07:51 of countries,
1:07:52 exactly,
1:07:52 you know,
1:07:53 in,
1:07:53 in that spirit.
1:07:55 Can I pick up on this and turn this question a little to Kent,
1:07:57 but in a very specific
1:07:59 case which is the South African situation right now
1:08:02 where they seem to be developing this capacity.
1:08:05 But there's,
1:08:05 but there seems to be no demand.
1:08:07 And how,
1:08:07 how do,
1:08:08 how do,
1:08:08 I mean,
1:08:09 do you have any thoughts on that?
1:08:10 And,
1:08:10 and how to,
1:08:12 how to,
1:08:12 um,
1:08:14 How to change that situation such that this capacity actually is sustained,
1:08:17 because if there's no demand,
1:08:18 I mean,
1:08:18 it'll definitely,
1:08:19 it'll,
1:08:20 it'll wither for sure.
1:08:26 I mean,
1:08:26 I,
1:08:26 uh,
1:08:27 the,
1:08:27 the,
1:08:27 the conversation then at,
1:08:29 uh,
1:08:29 at GAI is,
1:08:31 uh,
1:08:32 not just how,
1:08:33 uh,
1:08:33 they can buy,
1:08:34 uh,
1:08:35 uh,
1:08:35 vaccines,
1:08:36 uh,
1:08:37 in a pandemic,
1:08:38 uh,
1:08:38 from manufacturers in low and lower middle-income countries,
1:08:41 uh,
1:08:42 but how there might then be support,
1:08:44 uh,
1:08:44 uh,
1:08:45 um,
1:08:46 vaccines,
1:08:47 uh,
1:08:48 uh,
1:08:48 for routine immunization purchased from,
1:08:51 from those facilities so that the facilities are,
1:08:53 are,
1:08:54 Ever kept
1:08:55 warm.
1:08:56 Um,
1:08:58 on the,
1:08:58 on South Africa,
1:08:59 I'm not sure what the,
1:09:01 what solution there might be for the lack of demand,
1:09:04 uh,
1:09:04 for the vaccines out of,
1:09:05 out of aspen.
1:09:10 Great,
1:09:10 thanks.
1:09:10 Um,
1:09:12 Galina,
1:09:12 did you want to come in and put your question to the group?
1:09:16 I see you've put a question in the chat,
1:09:18 but
1:09:19 There's also Shahai has his
1:09:22 I just want to give Glena a chance to come in if they want to.
1:09:29 OK,
1:09:29 we'll take that as more of a comment then.
1:09:31 Um,
1:09:32 uh,
1:09:32 Shabtai,
1:09:33 do you want to come in?
1:09:35 Yeah,
1:09:35 thank you very much.
1:09:36 I,
1:09:36 I just wanted to ask Tristan if you can maybe expand a little
1:09:38 bit more on what he was talking about with regards to the,
1:09:42 um,
1:09:43 uh,
1:09:43 you,
1:09:44 you know,
1:09:44 getting,
1:09:45 uh,
1:09:45 that the financiers can make it so that
1:09:47 countries can purchase even before there's a,
1:09:49 uh,
1:09:49 uh,
1:09:49 authorization.
1:09:50 And how exactly
1:09:52 that could work with the other problem that he was
1:09:54 talking about that a KOA facility that might be needed
1:09:58 would,
1:09:58 um,
1:09:58 you know,
1:09:59 there's this lend country lending issue.
1:10:01 So how to reconcile on the one hand
1:10:03 this,
1:10:04 this,
1:10:04 um.
1:10:06 The bank has a need to lend specifically to countries,
1:10:08 but then you want to,
1:10:09 maybe you will need more money even if a fund is established.
1:10:12 So how to sort of get around all of those issues,
1:10:15 um,
1:10:16 given the bank's own constraints?
1:10:17 Will this require a policy change?
1:10:19 Will this require some sort of
1:10:22 different view within the bank over,
1:10:23 over whether it lends only to countries or not?
1:10:26 Sorry if that was a bit convoluted,
1:10:27 but,
1:10:28 uh,
1:10:28 right,
1:10:29 no,
1:10:29 that makes sense.
1:10:30 Again,
1:10:30 I,
1:10:30 I don't want to speak about World Bank policies,
1:10:32 so I'll,
1:10:32 I'll speak generally,
1:10:33 but I think there's two separate issues that you raised.
1:10:36 So one is that,
1:10:38 um,
1:10:39 you know,
1:10:39 it,
1:10:40 it
1:10:41 All of the high income countries,
1:10:43 not all,
1:10:43 but most,
1:10:45 took
1:10:46 A risk at the beginning of the pandemic by
1:10:49 paying for vaccines that might never have been successful.
1:10:52 And,
1:10:52 and this really did pan out,
1:10:53 right?
1:10:54 That you had,
1:10:55 you know,
1:10:55 the Cervac,
1:10:55 for example,
1:10:56 which didn't work and,
1:10:57 you know,
1:10:57 that was money and it,
1:10:58 it,
1:10:59 it was,
1:10:59 it was not delivered.
1:11:01 Um,
1:11:01 and somebody has to
1:11:04 pay for that.
1:11:05 Um,
1:11:05 you know,
1:11:05 in,
1:11:06 in this case,
1:11:06 it was the,
1:11:07 the high income countries.
1:11:09 Um,
1:11:10 you know,
1:11:11 the,
1:11:11 the World Bank said,
1:11:12 you know,
1:11:13 we,
1:11:13 we will not finance,
1:11:15 uh,
1:11:16 They they declined to finance purchases or any payment before.
1:11:20 Uh,
1:11:21 licensure,
1:11:21 which,
1:11:22 which,
1:11:22 you know,
1:11:23 means you,
1:11:23 you,
1:11:24 you're not subject to that risk.
1:11:25 Now,
1:11:25 as I said,
1:11:26 you could say,
1:11:27 well,
1:11:28 I'll pay,
1:11:28 you know,
1:11:28 let's say 20% of the cost now
1:11:31 and only 80% once it's authorized.
1:11:33 So you can manage your risk in that way,
1:11:35 but there's still some,
1:11:36 some money that's,
1:11:37 that's put at risk.
1:11:39 Um,
1:11:39 so that's kind of 11 policy where you just have to choose,
1:11:42 you know,
1:11:42 are you gonna let,
1:11:43 uh,
1:11:43 purchases happen?
1:11:44 And,
1:11:44 and,
1:11:45 and this,
1:11:45 this could be either purchases made by an individual country.
1:11:48 So,
1:11:49 say,
1:11:49 you know,
1:11:50 Nigeria wants to,
1:11:51 to buy more vaccines,
1:11:52 but they haven't been authorized yet,
1:11:53 so it's gonna,
1:11:54 you know,
1:11:54 give money to get a place in line.
1:11:56 You know,
1:11:56 you have to decide whether that's OK,
1:11:58 or it could be a loan to a,
1:12:00 a regional,
1:12:01 uh,
1:12:01 group.
1:12:02 Now,
1:12:03 The thing,
1:12:03 the other thing we raised was sort of whether you lend to individual countries or
1:12:08 groups.
1:12:08 Um,
1:12:09 you know,
1:12:10 as
1:12:10 Kent raised,
1:12:12 maybe a lot of countries,
1:12:13 you know,
1:12:13 because they,
1:12:14 you know,
1:12:14 they,
1:12:14 they,
1:12:15 they were seeing,
1:12:16 OK,
1:12:16 maybe I haven't had that many fatalities yet.
1:12:18 Maybe,
1:12:18 you know,
1:12:19 I'm,
1:12:19 I'm
1:12:20 waiting to see how,
1:12:22 um,
1:12:22 uh,
1:12:23 the planning,
1:12:24 you know,
1:12:24 will go.
1:12:25 And so,
1:12:25 so they wait.
1:12:26 Uh,
1:12:27 you know,
1:12:28 In that situation,
1:12:29 I think there is a benefit
1:12:31 to having a global or a regional organization
1:12:34 that takes some risk and moves,
1:12:37 you know,
1:12:37 faster than the other countries.
1:12:38 So,
1:12:38 you know,
1:12:39 COAs,
1:12:39 like,
1:12:40 it,
1:12:40 it,
1:12:40 it kind of,
1:12:41 it,
1:12:41 it did purchase in advance and it was one of the first,
1:12:44 um,
1:12:45 you know,
1:12:45 uh,
1:12:46 uh,
1:12:47 sources of supply that lots of countries had,
1:12:50 um,
1:12:50 because it had moved
1:12:51 so early.
1:12:52 Now,
1:12:52 it,
1:12:52 it had some bad luck,
1:12:53 which was that its first purchase was in a country that later,
1:12:56 you know,
1:12:57 um,
1:12:58 Uh,
1:12:58 restricted exports,
1:12:59 but,
1:12:59 but,
1:13:00 you know,
1:13:00 had it been a more diversified pool or it,
1:13:02 you know,
1:13:02 it just could have,
1:13:03 it could have turned out differently.
1:13:04 So I think,
1:13:05 I think you need both.
1:13:06 I think you need,
1:13:07 um,
1:13:08 you know,
1:13:08 a willingness of,
1:13:09 of finance to,
1:13:10 to lend before,
1:13:11 to,
1:13:12 to lend before vaccines are authorized to get a Place in line and also to incentivize
1:13:17 supply,
1:13:17 but you also need,
1:13:19 uh,
1:13:19 you know,
1:13:19 these kind of global or,
1:13:21 or regional agencies,
1:13:23 um,
1:13:23 you know,
1:13:23 that,
1:13:24 that can,
1:13:25 you know,
1:13:25 make purchases ahead of countries.
1:13:27 Another example of this is,
1:13:28 um,
1:13:29 so PAHO,
1:13:29 the Pan American Health Organization,
1:13:32 um,
1:13:33 uh,
1:13:33 bought vaccines,
1:13:34 you know,
1:13:35 in advance of countries ordering them.
1:13:36 So did,
1:13:37 so did the African Union,
1:13:38 actually.
1:13:38 So,
1:13:38 they said,
1:13:38 our,
1:13:39 our members haven't
1:13:40 You know,
1:13:40 figured out how much they need,
1:13:41 but we're gonna go into the market and secure it.
1:13:44 Um,
1:13:44 that,
1:13:44 that's an area where,
1:13:45 you know,
1:13:46 cooperation and also,
1:13:47 uh,
1:13:47 an independent management that can move faster than countries is,
1:13:50 is beneficial,
1:13:51 but,
1:13:51 but,
1:13:52 you know,
1:13:52 that,
1:13:52 that does have some risk and someone needs to,
1:13:54 to bear the risk associated with it.
1:14:04 Anyone else?
1:14:04 Yeah.
1:14:05 Anybody else have
1:14:07 a question they'd like to put to the group?
1:14:13 Doesn't look like it,
1:14:15 um.
1:14:17 If not,
1:14:18 I suggest I
1:14:19 turn it back to
1:14:21 Tristan maybe,
1:14:22 and then Kent,
1:14:23 if you don't mind,
1:14:23 just last word to our discussant.
1:14:26 Um,
1:14:28 Uh,
1:14:29 yeah,
1:14:29 thanks.
1:14:29 I,
1:14:29 I mean,
1:14:30 I just,
1:14:30 um,
1:14:30 I just want to really emphasize this point that,
1:14:33 you know,
1:14:33 I,
1:14:34 I think
1:14:36 There,
1:14:36 there was huge
1:14:37 inequity
1:14:38 and inequality in access
1:14:40 to vaccines for about a year during COVID.
1:14:43 And,
1:14:43 and that was due,
1:14:45 uh,
1:14:45 as Ken said,
1:14:46 to,
1:14:46 to policies that,
1:14:47 that high-income countries took,
1:14:49 um,
1:14:50 you know,
1:14:50 to,
1:14:51 to,
1:14:51 uh,
1:14:52 secure vaccines for themselves and,
1:14:53 but a lot of that had to do with getting money into the market
1:14:56 earlier.
1:14:57 And,
1:14:57 you know,
1:14:58 it is my hope that in the next pandemic,
1:15:00 you know,
1:15:00 with the new resources and interests that we have,
1:15:03 We'll be better able to get money,
1:15:05 uh,
1:15:05 into the market,
1:15:06 uh,
1:15:06 on behalf of,
1:15:07 of low and middle-income countries.
1:15:09 And,
1:15:09 and I,
1:15:10 I also admit that,
1:15:10 that,
1:15:11 that,
1:15:11 that is a little bit of a competition,
1:15:12 you know,
1:15:13 you need
1:15:14 high-income countries may not want,
1:15:15 uh,
1:15:15 low,
1:15:16 low-income countries bidding,
1:15:17 uh,
1:15:18 against them,
1:15:18 um,
1:15:19 at least early on.
1:15:20 Uh,
1:15:20 but,
1:15:21 you know,
1:15:21 we,
1:15:21 we do need to make sure that,
1:15:22 that resources are available to do that.
1:15:24 Um,
1:15:24 and I think,
1:15:25 you know,
1:15:25 if we do,
1:15:26 uh,
1:15:26 you know,
1:15:27 it will,
1:15:27 it,
1:15:27 it can benefit everybody by expanding supply,
1:15:30 um,
1:15:30 but also,
1:15:31 uh,
1:15:31 increasing equity.
1:15:32 So that's
1:15:33 Thanks.
1:15:35 Thanks,
1:15:35 Tristan.
1:15:36 Uh,
1:15:36 Kent,
1:15:36 any last words from you?
1:15:38 No,
1:15:38 just,
1:15:38 uh,
1:15:39 to again thank Tristan and the,
1:15:40 and the team,
1:15:41 uh,
1:15:42 for
1:15:42 the,
1:15:43 the,
1:15:43 the very timely work.
1:15:44 Uh,
1:15:45 I think this can feed into a lot of the,
1:15:47 the global discussions that are happening right now about,
1:15:49 uh,
1:15:50 financing for,
1:15:51 for,
1:15:52 um,
1:15:52 uh,
1:15:53 any future pandemic.
1:15:55 JP has one question at least.
1:15:56 I see we have a late entry here.
1:15:57 JP,
1:15:58 do you want to go ahead?
1:16:02 Oh you're on,
1:16:02 we can't hear you,
1:16:03 you're on mute.
1:16:05 Oh,
1:16:05 thanks,
1:16:06 thanks,
1:16:06 Dean,
1:16:06 and,
1:16:06 and,
1:16:07 and hello to everybody and to Tristan and Kent.
1:16:09 My,
1:16:09 my appreciation for the,
1:16:11 the very interesting discussion.
1:16:13 I did
1:16:14 want to come out of silence and,
1:16:15 and,
1:16:16 and express my appreciation to,
1:16:18 to both of you and to Deanne for sharing it.
1:16:20 Um,
1:16:21 I do believe that there's some incredible multi-causality here,
1:16:25 many variables connected.
1:16:27 It's very nice to try to dissect them,
1:16:30 but,
1:16:30 uh,
1:16:30 at the end of the day,
1:16:31 when,
1:16:32 when they appeared,
1:16:32 they all happened together.
1:16:34 So,
1:16:35 so we will need to continue thinking on this hypothesis and
1:16:38 the different assumptions and the scenarios moving forward.
1:16:42 I do want to highlight um Kent's point on,
1:16:44 on the country's strengthening capacity in the response.
1:16:47 I think it's a,
1:16:48 a core
1:16:50 element
1:16:50 as,
1:16:51 as we move forward.
1:16:52 It's gonna be very important,
1:16:53 uh,
1:16:54 Kent,
1:16:55 for,
1:16:55 for the evolution of the white paper and more especially
1:16:59 for the,
1:17:00 let's say the shared effort.
1:17:02 That we all bring around in strengthening,
1:17:04 again,
1:17:04 country capacity around PPR.
1:17:07 It's gonna be extremely important.
1:17:09 And I also believe that the overall,
1:17:11 um,
1:17:12 Tristan,
1:17:12 uh,
1:17:13 let's say,
1:17:14 trade variables.
1:17:15 Um,
1:17:16 including
1:17:17 the production and being able to control the national production
1:17:23 of supplies,
1:17:24 not only vaccines,
1:17:24 as we saw throughout
1:17:26 2020 and 2021,
1:17:28 it's a very important variable to also,
1:17:31 uh,
1:17:31 consider in detail.
1:17:33 So,
1:17:33 I wanted,
1:17:33 I wanted the end basically to bring these considerations
1:17:36 at,
1:17:36 at the end and again,
1:17:38 um thank you for,
1:17:39 for the space
1:17:40 and we for sure need to keep on thinking.
1:17:43 And all what we can learn from the past 2 years as we move forward.
1:17:46 Thank you very much.
1:17:49 Thanks,
1:17:50 JP.
1:17:50 I just,
1:17:51 for those who don't know,
1:17:51 JP is the global director for,
1:17:53 for,
1:17:53 for HA Health,
1:17:54 Nutrition and Population here at,
1:17:56 at,
1:17:56 at the World Bank.
1:17:57 So really pleased that you could join us today,
1:18:00 um,
1:18:00 and thanks for that intervention.
1:18:01 Um,
1:18:02 and I,
1:18:03 you know,
1:18:03 we,
1:18:04 I,
1:18:05 as the director of the Research department,
1:18:06 let me just say I really look forward to working
1:18:08 with all of you on thinking about these issues,
1:18:10 uh,
1:18:11 both,
1:18:11 you know,
1:18:12 retroactively,
1:18:12 retrospectively,
1:18:14 learning and,
1:18:14 and looking forward as well.
1:18:16 Um,
1:18:17 what we can do to improve the,
1:18:18 the quality of health services in developing countries,
1:18:21 and,
1:18:21 um,
1:18:22 and,
1:18:22 you know,
1:18:23 this aspect of it as well,
1:18:24 which is this sort of surge capacity that's needed in times of crisis.
1:18:28 Um,
1:18:30 so with that,
1:18:30 let me close this,
1:18:31 uh,
1:18:31 session today.
1:18:33 Uh,
1:18:33 for those of you who follow these policy research talks,
1:18:35 uh,
1:18:35 this is the last one
1:18:37 of,
1:18:37 uh,
1:18:38 of,
1:18:38 of the season.
1:18:39 We're gonna take a hiatus over the summer,
1:18:41 the,
1:18:41 the northern,
1:18:42 uh,
1:18:43 summer months,
1:18:44 and we'll be back in September,
1:18:46 with a new session that'll be announced.
1:18:49 Uh,
1:18:50 uh,
1:18:50 as,
1:18:50 as,
1:18:50 as Ryan has just put in the chat,
1:18:52 you can link to all the event materials at this website.
1:18:56 And,
1:18:56 and just thank you for your attendance and participation and this,
1:19:00 and thanks Tristan for the,
1:19:01 for the talk and,
1:19:02 and Kent really thank you so much for making the time,
1:19:05 uh,
1:19:05 to,
1:19:05 to,
1:19:06 to both come here today,
1:19:07 but also think carefully about,
1:19:08 about how to position this work more generally.
1:19:11 Thank you very much,
1:19:12 everyone,
1:19:12 and,
1:19:12 and have a good rest of your day.
1:19:14 Thank you.
1:19:14 Thank you so much.
1:19:15 Thank you.
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