## sdnea2021004 — Executive summary and proposal to end the COVID-19 pandemic

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### Context and overarching findings
- It is over a year into the COVID-19 pandemic; new cases worldwide are higher than during any previous phase.
- Ending the pandemic is a solvable problem but requires coordinated global action; "The pandemic is not over anywhere until it is over everywhere."
- No durable end to the economic crisis without an end to the health crisis; pandemic policy is thus economic policy.
- Estimated benefits of a faster end to the pandemic: around $9 trillion.
- Advanced economies stand to gain around $1 trillion in additional tax revenues from a faster end to the pandemic.

### Proposal targets, costs, and financing rationale
- Vaccination targets:
  - Vaccinate at least 40 percent of the population in all countries by the end of 2021.
  - Vaccinate at least 60 percent by the first half of 2022.
- Overall estimated cost of the proposal: $50 billion.
  - Strong case for grant financing of at least $35 billion.
  - ACT Accelerator identified grant funding gap: about $22 billion.
  - At least $15 billion available from COVID-19 financing facilities created by multilateral development banks (MDBs).
  - Remaining additional grant contributions needed: $13 billion.
- Financing mix recommended:
  - Nearly-all financing for steps 4, 5, and 7 and the majority for step 6 should be grants to ACT Accelerator arms.
  - Upfront financing, upfront vaccine donations, and at-risk investment are essential and must be available immediately.

### Key numerical production and coverage projections (business-as-usual and checks)
- As of end-April 2021: more than 1.1 billion vaccine doses administered globally.
- Industry projection cited (IFPMA): close to 10 billion doses by end-2021.
- Conservative business-as-usual estimate used: at least 6 billion vaccine doses produced and administered worldwide by end-2021.
  - 6 billion doses translate to about 3.5 billion vaccine courses (accounting for single-dose shots).
  - 3.5 billion courses would be sufficient to cover about 45 percent of the world’s population by end-2021.
- Global vaccination pace reached 20 million doses per day as of end-April 2021, equivalent to 0.25 per 100 people in the world.
- Top-down dose projection check: 1.1 billion + 245 days * 20 million = 6 billion doses by end-2021.
- Bottom-up projection: about 3.5 billion vaccine courses administered by end-2021 (consistent with top-down).

### Country grouping, inequality, and key population figures
- AMC91: 91 low- and middle-income countries requiring explicit global support; combined population about 2.5 billion.
- Other upper-middle-income countries group population: about 1.1 billion.
- India population noted as 1.4bn; China population noted as 1.4bn.
- LMIC total population used in analysis: about 6.5 billion.
- Worldwide high-risk population (older adults plus those with underlying conditions): about 22 percent of world population.
- With prioritization, 6 billion doses would allow universal coverage for the worldwide high-risk population.

### Downside scenarios (disproportionately harm LMICs)
- Scenario 1: Persistent shortages of raw materials and export restrictions → longer delays; Serum Institute of India delays could reduce access for 4 billion people in 91 developing countries plus India relying on COVAX.
- Scenario 2: Safety concerns in a class of vaccines (adenovirus-based) → example shock where 30 percent of global vaccine supply in 2021 is compromised, reducing supply from 3.5 billion courses to 2.5 billion courses; AMC91 and India coverage by end-2021 could decline from about 26 percent and 33 percent to 10 percent and 12 percent, respectively.
- Scenario 3: HICs administer boosters and vaccinate children (and/or reduced efficacy vs. variants) → reallocation of about 425 million vaccine courses from AMC91 countries to high-income countries; AMC91 and India coverage may fall to around 10 percent by end-2021.

### Core operational steps (summary of recommended actions)
- Achieving the vaccination targets:
  1. Provide additional upfront grants to COVAX of at least $4 billion to increase vaccine coverage goal from 20 percent to 30 percent for AMC91 countries (91 LMICs).
  2. Ensure free cross-border flows of raw materials and finished vaccines; eliminate export restrictions on all critical inputs.
  3. Donate surplus vaccines through COVAX: projection that at least 500 million vaccine courses (equivalent to around 1 billion doses) can be donated in 2021; donating 500 million courses would result in close to 40 percent vaccine coverage in all countries by end-2021.
- Insuring against downside risks:
  4. Make at-risk investments to diversify and increase vaccine production capacity by 1 billion doses in early 2022. Cost estimate: about $8 billion. Proposed portfolio: 50 percent allocated to mRNA vaccines; pricing assumptions: $6 per dose for half the capacity (e.g., Novavax-like) and $10 per dose for mRNA vaccines. Financing modality: 100 percent grant-financed by donor community.
  5. Scale up genomic surveillance and systemic supply chain surveillance with contingency plans. Budgeted estimate: $3 billion.
- Managing the interim period when vaccine supply is limited:
  6. Ensure widespread testing, sufficient therapeutics, and adequate public health measures, and prepare for vaccine deployment. Budget estimate referenced in summary: $30 billion.
- Dose-stretching and delivery innovations:
  7. Urgently evaluate and implement (where approved) dose-stretching strategies and invest in delivery-easing products.
    - Dose-stretching options: First Doses First (delay second shot to 12 weeks or more; evaluate up to 24 weeks for subsets), Fractional Dosing (half-doses), Single dose for previously infected (first dose + prior infection may be as or more effective than two doses).
    - Impact claim: dose-stretching strategies could increase global supply by 50 percent in 2021 relative to business-as-usual and could allow all countries to reach 60 percent coverage by end-2021 under that scenario.
    - Public funding needed for clinical trials and lab studies evaluating these strategies and vaccine efficacy against variants.

### Manufacturing, licensing, and supply-chain recommendations
- Make at-risk investments to secure 1 billion additional doses by first half of 2022 to handle downside risks or LMIC long-term needs.
- Direct a subset of additional capacity toward mRNA vaccine candidates where appropriate; use COVAX as a natural vehicle for at-risk investments.
- Encourage voluntary licensing, technology transfer, and cross-border/cross-company partnerships to scale manufacturing regionally (examples cited: AstraZeneca deals in India, China, Brazil; U.S. efforts to get J&J and Merck to collaborate; Quad vaccine initiative in India).
- Develop a global database of critical raw materials, manufacturing capacity and utilization; establish a centrally coordinated COVID-19 database (vaccine contracts, disease surveillance) to enhance transparency.

### Diagnostics, therapeutics, public health measures, and interim priorities
- Increase testing and tracing capacity in LMICs: scale AgRDTs, PCR, genomic sequencing, and self-tests; advance purchases could lower Rapid Antigen Test costs to about $2-3 per test.
- Expand procurement and distribution of treatments (e.g., dexamethasone, oxygen) and PPE; accelerate uptake through technical assistance and procurement support.
- Maintain social distancing, masking, ventilation, and targeted non-pharmaceutical interventions until acute phase ends; strengthen communication and fight misinformation.
- Maintain and strengthen social safety nets (in-kind and cash transfers) and support viable firms while the virus is brought under control.

### Budgeting, MDB facilities, and financing mechanisms
- Total cost of the proposal: about $50 billion (Annex VI budgeting details referenced).
- Strong case for grant financing of at least $35 billion to avoid large debt burdens for AMC91 countries.
- Existing financing landscape:
  - ACT-Accelerator grant funding gap: about $22 billion.
  - At least $15 billion available from MDB COVID-19 financing facilities (World Bank and Asian Development Bank).
  - Estimated additional grant contributions needed to reach $50 billion: $13 billion (mainly for raising COVAX coverage to 30 percent, procuring additional tests, and expanding production capacity).
- World Bank: $12 billion envelope for developing countries; about $2 billion utilized as of end-April 2021.
- Asian Development Bank: $9 billion vaccine initiative (APVAX).
- IMF role: support countries to create fiscal space; explore SDR allocation channels (IMF Executive Board considering an SDR allocation of $650 billion) and options to channel SDRs from countries with strong external positions to global public policy goals.
- Operational urgency: all pledges need to be delivered immediately; some financing should be converted to up-front cash.

### Annex highlights and operational details
- ANNEX III (coverage calculations) assumptions:
  - High-coverage countries: 85 percent of eligible (15+) population.
  - AMC91 administration rate assumption: 60 percent of eligible delivered doses.
  - Low-income (not AMC) assumed coverage: 25 percent of eligible population.
  - Middle-income assumed coverage: 55 percent of eligible population.
- ANNEX VII (at-risk investment design):
  - AMC91 population: 2.5 billion.
  - Projected manufacturing capacity in 2022 (current approved vaccines): over 16 billion doses.
  - Proposed initial at-risk investment: 1 billion vaccine doses targeted to AMC91 in 2022; estimated cost: about $8 billion.
  - Timing: additional supplies should be available in the first half of 2022; estimated lag up to 9 months to bring additional capacity online.
  - Contracting approach: prefer an all-in cost estimate for expanding capacity by 1 billion doses (simplicity and reduced delays), with contract provisions requiring manufacturers to demonstrate capacity and supply-chain augmentation ahead of time.

### Caveats, uncertainties, and data gaps
- Many vaccine contracts remain unavailable publicly; contracts with China and Russia may be undercounted.
- Vaccine pricing estimates: reference price used in analysis: $12 per course (compared to base price of $10.4 used by COVAX internally).
- Uncertainty around costs for vaccine delivery, diagnostics, therapeutics, and PPE; estimates rely on agency work.
- Biological and behavioral uncertainties and unknown unknowns remain (virus biology, human behavior, supply chain complexity).
- Need for greater data disclosure by country authorities and private sector participants to enhance surveillance and policy effectiveness.

### Key concrete numbers and prioritizations (selected)
- Proposal total cost: $50 billion.
- Strong case for grant financing: at least $35 billion.
- ACT Accelerator grant funding gap: about $22 billion.
- MDB financing available (at least): $15 billion.
- Additional grant contributions needed: $13 billion.
- Upfront grant requested to COVAX AMC: at least $4 billion (raise AMC91 coverage goal from 20 percent to 30 percent).
- Donate at least 500 million courses (equivalent to 1 billion doses) of surplus vaccines in 2021.
- At-risk capacity target: 1 billion doses by first half of 2022; cost about $8 billion.
- Genomic and supply-chain surveillance scale-up: $3 billion.
- Interim testing, therapeutics, public health measures and preparedness: $30 billion (budget referenced in summary).
- Business-as-usual dose projection: 6 billion doses by end-2021 → 3.5 billion vaccine courses by end-2021.
- Upside/alternative target scenarios referenced: 4.25 billion vaccine courses (equivalent to about 7.5 billion doses) would facilitate more than 40 percent coverage in all countries by end-2021; 5.5 billion vaccine courses or more by April 2022 would facilitate minimum 60 percent coverage in all countries.

_International Monetary Fund — sdnea2021004 (excerpted content)._

### EXECUTIVE SUMMARY __________________________________________________ 4

### EXECUTIVE SUMMARY

### Context and overarching findings
- It is over a year into the COVID-19 pandemic, and new cases worldwide are higher than during any previous phase of the pandemic. Urgent steps are needed to arrest the rising human toll and economic strain from the pandemic that is exacerbating already diverging recoveries.
- Ending the pandemic is a solvable problem but one that requires further coordinated global action.
- Many organizations and initiatives have led the effort, including the Access to COVID-19 Tools (ACT) Accelerator, Coalition for Epidemic Preparedness Innovation, Gates Foundation, GAVI, Global Fund, World Bank, World Health Organization, and World Trade Organization. The proposal in this paper seeks to build on and complement these efforts.
- There is no durable end to the economic crisis without an end to the health crisis; pandemic policy is thus economic policy.
- Projections point to highly unequal health prospects well into 2022, posing severe risks for the world. “The pandemic is not over anywhere until it is over everywhere.”

### Proposal targets and rationale
- The proposal targets:
  - vaccinating at least 40 percent of the population in all countries by the end of 2021 and at least 60 percent by the first half of 2022,
  - while tracking and insuring against downside risks, and
  - ensuring widespread testing and tracing, maintaining adequate stocks of therapeutics, and enforcing public health measures in places where vaccine coverage is low.
- Building on the budgeting of the ACT Accelerator, the estimated cost of this proposal is around $50 billion.
- Estimated benefits of a faster end to the pandemic are around $9 trillion.
- Advanced economies stand to gain around $1 trillion in additional tax revenues from a faster end to the pandemic.
- Given that ending the pandemic in a timely manner is a global public good, of the $50 billion total cost there is a strong case for grant financing of at least $35 billion from public, private, and multilateral donors and the remainder by national governments potentially supported by concessional financing from multilateral agencies.

### Funding gaps and available resources
- The grant funding gap identified by the ACT Accelerator amounts to about $22 billion.
- At least $15 billion is available from COVID-19 financing facilities created by multilateral development banks.
- This leaves an estimated $13 billion in additional grant contributions needed to get to the $50 billion identified by the proposal.
- The additional $13 billion is mainly for raising COVID-19 Vaccines Global Access (COVAX) coverage to 30 percent, procuring additional COVID-19-tests, and expanding at-risk production capacity to insure against downside risks.
- The proposal requires upfront financing, upfront vaccine donations, and at-risk investment; it is essential that all necessary financing is available immediately.

### Key proposed steps (summary)
- Achieving the vaccination targets:
  1. Provide additional upfront grants to COVAX of at least $4 billion to increase their vaccine coverage goal from 20 percent to 30 percent for 91 low- and middle-income countries (LMICs): This will help finalize their orders, and activate unutilized vaccine capacity.
  2. Ensure free cross-border flows of raw materials and finished vaccines: Such restrictions are jeopardizing vaccine access for billions of people in the developing world.
  3. Donate surplus vaccines: The projection is that at least 500 million vaccines courses (equivalent to around 1 billion doses) can be donated in 2021, even if countries prioritize their own populations. Donations, including for delivery costs, should be done through COVAX so that vaccines are shared equitably and on the basis of public health principles.
- Insuring against downside risks:
  4. Make at-risk investments to diversify and increase vaccine production capacity by 1 billion doses in early 2022 to handle downside risks, including from new variants that require booster shots. [$8 billion]
  5. Scale up genomic surveillance and systemic supply chain surveillance with concrete contingency plans in place to handle mutation scenarios or shocks to the supply chain. This should be prepared with the participation of multilateral agencies, vaccine developers and manufacturers, and key national governments. [$3 billion]
- Managing the interim period when vaccine supply is limited:
  6. Ensure widespread testing, sufficient therapeutics, and adequate public health measures, and prepare for vaccine deployment. [$30 billion]

_International Monetary Fund — sdnea2021004 EXECUTIVE SUMMARY_

### 7. Urgently	evaluate	and	implement	(where	approved)	dose	stretching	strategies	to	expand	effective

### sdnea2021004 - 7. Urgently evaluate and implement (where approved) dose stretching strategies to expand effective supply.

### Executive summary and objectives
- Proposal aims to bring the pandemic under control by:
  - Vaccinating at least 40 percent of the population in all countries by the end of 2021.
  - Vaccinating at least 60 percent by the first half of 2022.
- Estimated overall cost of the proposal: $50 billion.
  - Strong case for grant financing of at least $35 billion.
  - Grant funding gap identified by the ACT Accelerator: about $22 billion.
  - At least $15 billion available from COVID-19 financing facilities created by multilateral development banks (MDBs).
  - Remaining additional grant contributions needed: $13 billion.
- Financing mix recommended: nearly-all financing for steps 4, 5, and 7 and the majority of financing for step 6 should take the form of grants to various arms of the ACT Accelerator.

### Key findings and projections
- Vaccine production and deployment
  - More than 1.1 billion vaccine doses had been administered globally by the end of April 2021.
  - Industry projection cited: close to 10 billion doses by the end of 2021 (IFPMA estimate).
  - Conservative business-as-usual estimate used in projections: at least 6 billion vaccine doses produced and administered worldwide by the end of 2021.
    - 6 billion doses translate to about 3.5 billion vaccine courses (accounting for single-dose shots).
    - 3.5 billion courses would be sufficient to cover about 45 percent of the world’s population by the end of 2021.
  - Global vaccination pace reached 20 million doses per day as of the end of April 2021, equivalent to 0.25 per 100 people in the world.
- Targeting high-risk groups
  - Worldwide high-risk population (older adults plus those with underlying conditions) accounts for about 22 percent of world population.
  - With vaccine prioritization, 6 billion doses would allow universal coverage for the worldwide high-risk population.
- Inequality and country groupings
  - Vaccine access is highly unequal: as of end-April 2021, less than 2 percent of Africa’s population had been vaccinated; more than 40 percent in the US and more than 20 percent in Europe had received at least one dose.
  - LMICs (excluding China and India) are split into:
    - AMC91: 91 countries requiring explicit global support, combined population about 2.5 billion.
    - The rest: 35 upper-middle-income countries with population about 1.1 billion.
  - Under the business-as-usual 6 billion doses scenario:
    - Vaccine coverage in AMC91 countries expected to remain below 30 percent by end-2021.
    - Coverage in India expected to reach under 35 percent by end-2021.
    - Other LMICs and high-income countries expected to have coverage of around 50 percent and 70 percent, respectively, by end-2021.
- Downside scenarios (all disproportionately harm LMICs)
  - Scenario 1: Persistent shortages of raw materials and export restrictions → longer delays; Serum Institute of India delays could reduce access for 4 billion people in 91 developing countries plus India relying on COVAX.
  - Scenario 2: Safety concerns in a class of vaccines (adenovirus-based) → example shock where 30 percent of global vaccine supply in 2021 is compromised, reducing supply from 3.5 billion courses to 2.5 billion courses; AMC91 and India coverage by end-2021 could decline from about 26 percent and 33 percent to 10 percent and 12 percent, respectively.
  - Scenario 3: HICs administer boosters and vaccinate children (and/or reduced efficacy vs. variants) → reallocation of about 425 million vaccine courses from AMC91 countries to high-income countries; AMC91 and India coverage may fall to around 10 percent by end-2021.

### Proposed measures and policy recommendations
- Immediate financing and procurement actions
  - Provide additional upfront cash contribution of at least $4 billion to COVAX (COVAX AMC facility) to close current financing deficit and increase AMC91 coverage goals from 20 percent to 30 percent.
  - Most high-income and upper-middle-income countries are already on track to attain the vaccination goals; countries with insufficient coverage should immediately place purchase orders for vaccines.
  - India: to reach 60 percent coverage by first half of 2022, India will need to immediately place sufficient vaccine orders of about 1 billion doses through contracts that incentivize investment in additional capacity and augmentation of the supply chain.
    - Authorities’ recently announced financing of about $600 million to the Serum Institute of India and Bharat Biotech to boost production capacity noted as a welcome step.
- Supply-chain and trade measures
  - Ensure free cross-border flow of raw materials and finished vaccines; eliminate constraints on exports of critical raw materials and finished vaccines to enable timely vaccination targets.
  - International efforts urged to eliminate export restrictions on all critical inputs; commitment by producing countries to avoid export restrictions once near-term shortages ease.
- Donations and allocation
  - Donate surplus vaccines equitably and based on public health principles; donating to COVAX is recommended.
    - Proposal calls to donate at least 500 million courses (equivalent to 1 billion doses) of surplus vaccines in 2021.
    - Scenario analysis: donation of 500 million courses (half of a 1 billion-course surplus) would result in close to 40 percent vaccine coverage in all countries by the end of 2021.
  - US case study: estimated 80 million surplus vaccine doses available to donate as of April 2021; stockpile could grow to about 350 million doses by August 2021.
  - Prioritization of donations should focus on saving the most lives; COVAX allocation rules allow special consideration for countries facing major outbreaks or national disasters.
  - Make the COVAX Exchange operational to enable intertemporal trade and faster reallocation of doses to where they are most needed.
- Manufacturing and at-risk investments
  - Make at-risk investments to expand vaccine manufacturing capacity to address downside risks and/or long-term needs of LMICs (budgeted amount example: 88 in table for total; of which grants indicated elsewhere).
  - Facilitate cross-border voluntary licensing and technology transfers to create regional manufacturing capacity.
- Research, surveillance, and regulatory
  - Conduct trials to evaluate vaccine efficacy against new strains (potentially financed by donor grants).
  - Develop booster or multivalent shots as needed to protect against possible new variants.
  - Invest in and maintain genomic surveillance for Sars-COV-2 variants.
- Interim public health measures
  - Maintain social distancing, masking, and other public health measures; encourage rapid uptake of tests, therapeutics, and PPE.
  - Procure adequate supply of tests, treatments, and PPE; expand hospital capacity for COVID-19 patients.
  - Prepare to scale up vaccine deliveries and uptake (including storage and transportation issues; prepare systems for prioritized vaccines; fight disinformation on social media; fast track emergency use authorization).

### Budgeting notes and prioritization
- The budgeting exercise assumes zero additional cost for in-kind donations of surplus vaccines (procurement is considered sunk cost), but notes a strong case to count donations to the COVAX-AMC facility as official development assistance (ODA).
- The unutilized financing from lending facilities is based on World Bank and Asian Development Bank pandemic lending facilities.
- The proposal emphasizes grant financing because identified needs are largely on behalf of low- and lower-middle-income countries.

### Operational urgency and rationale
- Without urgent actions, many emerging and developing economies may have to wait until the end of 2022 or later to bring the pandemic under control, which is too late both for those countries and for the world.
- IMF research estimates the cumulative gain to the world from greater success on all aspects of the fight against the virus—including vaccinations, diagnostics, and therapeutics—is around 9 trillion dollars by 2025, with over 40 percent of this gain going to advanced economies.
  - This translates into a cumulative gain of $1 trillion dollars in additional tax revenue for advanced economies.
- The proposal focuses on upfront financing, upfront vaccine donations, and at-risk investment to accelerate global control of the pandemic and to insure against downside risks.

*International Monetary Fund (excerpted content from sdnea2021004).*

### 3.5	billion	vaccine	courses	by	the	end	of	2021	(as	in	the	business-as-usual	scenario)	to	about

### sdnea2021004 - 3.5	billion	vaccine	courses	by	the	end	of	2021	(as	in	the	business-as-usual	scenario)	to	about

### Excerpt
- 3.5	billion	vaccine	courses	by	the	end	of	2021	(as	in	the	business-as-usual	scenario)	to	about

*Source: sdnea2021004 (PDF chapter/section).*

### 4.25	billion	vaccine	courses—and	also	reduce	inequity	in	vaccine	access.	This	 would	 facilitate

### II. Insure against downside risks for vaccinations

### Make at-risk investments to ensure sufficient production
- Immediate objective: enter contracts to secure an additional 1 billion doses by first half of 2022 to handle downside risks or longer-term needs of LMICs.
- Cost of increasing vaccine production capacity by 1 billion doses in 2022: about $8 billion.
- Under the discussed scenario:
  - 4.25 billion vaccine courses would facilitate vaccine coverage of more than 40 percent in all countries worldwide by the end of 2021 (equivalent to about 7.5 billion vaccine doses).
  - An estimated 5.5 billion vaccine courses or more by April 2022 would facilitate a minimum vaccine coverage of 60 percent in all countries (in-line with the 60 percent target in the first half of 2022).
- Recommendations:
  - Direct a subset of additional capacity toward mRNA vaccine candidates where appropriate, ensuring equitable and public-health-driven access (COVAX as a natural candidate to execute at-risk investments).
  - Ensure at-risk investments address raw material shortages and increase capacity across all parts of the supply chain.
  - See Annex VII for design considerations of at-risk investments.

### Encourage voluntary licensing, technology transfer, and quality/yield improvements
- Scale-up manufacturing via voluntary licensing and cross-border/cross-company partnerships (examples cited: AstraZeneca deals in India, China, Brazil; U.S. efforts to get J&J and Merck to collaborate; Quad vaccine initiative in India).
- Coordinate expansion across countries through WHO, WTO, and COVAX to avoid crowding out short-term supplies.
- Enhance quality control to prevent production delays.
- Increase yield/efficiency of existing capacity (e.g., Pfizer efforts to increase yield) and allocate gains to LMIC near-term supplies.

### Scale up genomic surveillance and systemic supply chain surveillance
- Need greater global surveillance of SARS-CoV-2 variants and supply chain risks with contingency plans, regularly updated and stress-tested via scenario planning (participation: multilateral agencies, vaccine developers, key national governments).
- Develop guidelines for repurposing manufacturing capacity under scenarios (including lineages that evade immunity) while preserving equitable access.
- Initial supply-chain step: develop a global database of critical raw materials and manufacturing capacity and utilization (coordination options: WTO or World Bank).
- Establish a centrally coordinated COVID-19 database (vaccine contracts, disease surveillance: cases, deaths, testing) to enhance transparency; World Bank initiative to establish a database about vaccine orders is noted positively.
- Annex VIII presents an indicative list of data gaps for pandemic surveillance.

### III. Managing the interim period when vaccine supply is limited

### Prioritize vaccination of high-risk populations and address hesitancy
- Demographics/statistics:
  - Share of vulnerable population in LMICs typically in the range of 20-25 percent of the population.
  - Only 7 percent of vaccine coverage of the full population will be needed to cover individuals over the age of 65 in LMICs.
  - Vaccine uptake appears to slow considerably as early as 40–60 percent of population coverage.
- Policy actions:
  - Invest in vaccine delivery infrastructure (storage, transportation, logistics) to reach vulnerable groups.
  - Public health messaging to address vaccine hesitancy and fight disinformation on social media.
  - Evaluate a broad range of vaccines for fast-track emergency use authorization; expedite evaluation of non-Western vaccines to broaden global portfolio.
  - Make vaccines available free of cost to people to maximize uptake and avoid within-country inequality; fully utilize existing multilateral pandemic facilities for financing.

### Dose-stretching strategies and delivery innovations
- Urgent need to evaluate and, where approved, implement dose-stretching strategies and invest in products that ease vaccine delivery.
- Dose-stretching options:
  - First Doses First: delay the second shot to 12 weeks or more; evaluate longer delays (say 24 weeks) for a subset of highly effective vaccines to increase near-term coverage.
    - Evidence cited: Novavax has an efficacy of about 83 percent as early as 14 days after the first shot; Moderna and Pfizer/BioNTech have comparable efficacy after two weeks of the first shot; AstraZeneca appears to offer protection of 70 percent or more after the first dose.
  - Fractional Dosing: administer half-doses (or full dose followed by half-dose); used effectively in prior epidemics.
  - Single dose for previously infected: first dose plus prior infection may be as or more effective than two doses for naïve individuals; population-level antibody screening can reduce vaccine needs in high-seroprevalence countries (study: Anichini and others 2021).
- Other delivery-focused strategies:
  - Develop nasal or oral vaccine products to overcome needle hesitancy.
  - Develop mRNA vaccine formulations with improved cold-chain characteristics for LMIC suitability.
- Impact claim:
  - Dose-stretching strategies could increase the global supply of vaccines by 50 percent in 2021 relative to business-as-usual; under such a scenario all countries could reach the 60 percent vaccine coverage target by the end of 2021 (Figure 5 referenced).
- Support needed:
  - Public support for clinical trials evaluating these strategies; private sector incentives may be weak, so public funding is urgent.
  - Public support for trials and lab studies evaluating efficacy of existing vaccines against new variants and to support updating vaccines (e.g., multivalent shots).

### Diagnostics, therapeutics, and public health measures

### Opportunities
- Social distancing and public health measures work (WHO 2021b).
- Treatments can reduce mortality risk; examples include dexamethasone (Wiersinga and others 2020).
- Testing and contact tracing work (Fetzer and Graeber 2020).

### Challenges
- Difficulty and reluctance in maintaining social distancing and public health measures, especially in dense and developing country contexts; fatigue and vaccine optimism can lead to complacency.
- Testing remains low in LMICs: while daily testing rates are above 3 per 1000 in most high-income countries, most LMICs are testing far below 1 per 1000 daily.

### Proposed solutions
- Invest in testing and tracing:
  - Rapid Antigen Tests: advance purchases could lower cost to about $2-3 per test and scale production to billions.
  - LMICs need support to scale testing capabilities across AgRDTs, PCR auto/manual, genomic sequencing, self-tests for purposes including case management, test-trace-isolate, border control, health-worker protection, disease surveillance.
  - WHO accelerated approval of a broader set of tests, manufacturer volume access, procurement funding, updated guidance, and on-the-ground technical assistance are needed.
- Expand global capacity and procurement of medical supplies and treatments:
  - Increase global-level capacity and align procurement/distribution with ACT Accelerator strategy.
  - Accelerate uptake of therapeutics such as dexamethasone and oxygen in LMICs through country engagement, technical assistance, and procurement support.
  - Consider scaling up investment in PPE for healthcare workers in LMICs.
- Maintain social distancing and public health measures:
  - Prioritize measures (masking, ventilation, avoiding crowds) until the acute phase ends.
  - Step up communication from top officials, increase resources to fight misinformation, and use regional surveillance to guide targeted responses.
- Maintain and strengthen social safety nets for the vulnerable, including in-kind and cash transfers and support for viable firms while the virus is brought under control.

### Financing
- Total cost of the proposal: about $50 billion (Annex VI provides budgeting details).
- Strong case for grant financing of at least $35 billion to ensure AMC91 countries (mainly low- and lower-middle-income) can undertake measures without large debt burdens.
- Existing financing landscape:
  - ACT-Accelerator grant funding gap: about $22 billion.
  - At least $15 billion available from COVID-19 financing facilities created by multilateral development banks (World Bank and Asian Development Bank).
  - Estimated additional grant contributions needed to reach $50 billion: $13 billion (mainly for raising COVAX vaccine coverage to 30 percent, procuring additional COVID-19 tests, and expanding vaccine production capacity).
- Multilateral development bank facilities:
  - World Bank: $12 billion set aside for developing countries to purchase and distribute vaccines, tests, and treatments (about $2 billion utilized as of end-April 2021).
  - Asian Development Bank: $9 billion in financing available for vaccine procurement and delivery in developing Asia.
- IMF role:
  - Support countries to create fiscal space and act as a third-resort line of finance; explore options within existing toolkit and adapt as needed.
  - IMF Executive Board considering an SDR allocation of $650 billion, which would add substantial financial resources to all countries; IMF is exploring options to channel SDRs from countries with strong external positions to support global public policy goals.
- Pledge delivery: Most importantly, all pledges need to be delivered immediately.

### Caveats and uncertainties
- Data limitations:
  - Many vaccine contracts remain unavailable in the public domain; contracts with China and Russia are relatively more likely to be undercounted.
  - Vaccine pricing estimates are based on existing assumptions and actual contractual prices reported by COVAX, African Union, and others; reference price used in analysis: $12 per course (compared to base price of $10.4 used by COVAX internally).
  - Uncertainty exists around costs for vaccine delivery, diagnostics, therapeutics, and PPE; estimates rely on work by various agencies.
- Biological and behavioral uncertainties:
  - The global COVID-19 landscape includes possible unknown unknowns related to virus biology, human behavior, and supply chain complexity.
- Data transparency:
  - Need for greater data disclosure by country authorities and private sector participants to enhance global surveillance and improve policy effectiveness.
- The report hopes future work can build on this analysis as more data becomes available and uncertainty lessens.

*Source: A PROPOSAL TO END THE COVID-19 PANDEMIC — excerpts from sdnea2021004 (International Monetary Fund).*

### CONCLUSION

### CONCLUSION

### Urgency and global nature of the problem
- Ending the pandemic is a solvable problem, but "No country can return to normalcy until all countries can defeat the pandemic."
- Recent record-high global COVID-19 cases and the emergence of new variants demonstrate the risk of renewed lockdowns, continued restrictions on international travel, shipping disruptions, shortages of goods, and rising production costs.
- The social and economic costs continue to rise and "already diverging recoveries between rich and poor nations looks to worsen."
- Strong global action over the "next twelve months" can durably exit the health crisis and requires "very little in terms of financing relative to the outsized benefits."

### Vaccination coverage, scenarios, and observed patterns
- Share of population vaccinated as of End-April 2021: presented across country groups in figures (authors’ calculations; see Annex III).
- Estimated share of population fully vaccinated as of End-2021 under a Business-as-Usual Scenario: presented across country groups in figures (authors’ calculations; see Annex III).
- Downside scenarios show materially lower End-2021 vaccination coverage across country groups; figure annotations group populations as:
  - High-income countries (1.2bn people)
  - China (1.4bn people)
  - Other Low- & Middle-Income Countries (1.2bn people)
  - India (1.4bn people)
  - AMC91 Countries (2.5bn people)
- Example scenario outcomes reported in figures (End-2021 Vaccine Coverage under Different Downside Scenarios):
  - Business-as-usual: reported bar values include 72, 70, 48, 33, 26 (percent of population — see figure).
  - Other downside scenarios and mixes (e.g., Boosters for Adults, Boosters + Children, Reduced Supply of Adenovirus-Based Vaccines) produce lower effective coverage (see figure).
- Achieving the Vaccination Targets Scenario charts effective vaccine coverage for Apr-21, Dec-21, Apr-22; noted effective rate depiction: "equivalent to total doses per 100 divided by two."
- Upside scenarios and pre-purchase / surplus donation calculations are presented in figures (authors’ calculations; see Annex IV).

### Core proposal elements and financing priorities
- Core operational measures (Table 1) include:
  - Maintain social distancing, masking, and other public health measures; encourage rapid uptake of tests, therapeutics, and PPE.
  - Procure tests, treatments, and PPE; expand hospital capacity for COVID-19 patients.
  - Prepare to scale up vaccine deliveries and uptake (storage and transportation, prioritized vaccine systems, fight disinformation, fast track emergency use authorization).
  - Invest in and maintain genomic surveillance for Sars-COV-2 variants.
  - Facilitate cross-border voluntary licensing and technology transfers to create regional manufacturing capacity.
  - Undertake surveillance of systemic supply chain risks; prepare contingency plans to shift production capacity between vaccine candidates.
  - Conduct trials to evaluate efficacy against new strains (potentially donor-financed); develop booster or multivalent shots if needed; evaluate dose-stretching strategies (potentially donor-financed).
  - Scale up utilization of existing pandemic lending facilities; convert grant pledges to up-front cash contributions.
  - Ensure LMIC vaccination will not be crowded out due to new HIC needs (e.g., booster doses, youth vaccination).
  - Provide upfront cash grant of $4 billion to COVAX; plus additional grant and concessional financing for vaccine procurement as needed.
  - Make at-risk investments to expand vaccine manufacturing capacity for downside risks and long-term LMIC needs.
  - Donate at least 500 million courses (equivalent to 1 billion doses) of surplus vaccines in 2021.
  - Commit to maintaining free export of vaccine supplies and final products.
- Budgeting and financing notes (Table 1 and notes):
  - The grant funding gap identified by the Access to COVID-19 Tools (ACT) Accelerator "amounts to about $22 billion."
  - The proposal treats in-kind donations of surplus vaccinations as zero additional cost in the budgeting exercise, while noting a "strong case to count donations to the COVAX-AMC facility as official development assistance (ODA)."
  - The plan calls for converting pledges into up-front cash where possible and leveraging unutilized financing from existing lending facilities (World Bank, Asian Development Bank).

### Selected concrete numbers and country/regional arrangements
- COVAX / AMC:
  - The COVAX Facility and the COVAX AMC aim to provide minimum vaccine coverage of 20 percent of the population in AMC91 countries, and about 7-9 percent coverage for India (special treatment due to size).
  - As of May 5, 2021, total donor pledges to the COVAX AMC amounted to $6.7 billion, plus nearly $1 billion in commitments for vaccine delivery and/or logistics.
  - The United States has pledged to match other donors by pledging an additional $2 billion through 2021 and 2022, "of which the first $500 million will be made available when existing donor pledges are fulfilled and initial doses are delivered to AMC countries."
  - Under the proposal, "additional grants of $4 billion for the COVAX AMC will be sufficient to raise the minimum vaccine coverage for COVAX AMC91 countries to 30 percent, and for India to about 14 percent (using existing Gavi rules for allocation)."
- African Union / AVAT / Afreximbank:
  - AVAT agreement (signed on 28 March 2021) provides access to 220 million doses of the Johnson & Johnson single-shot vaccine, with the potential to order an additional 180 million doses.
  - Afreximbank approved a $2 billion financing facility for vaccine purchase by African Union member states.
  - The AVAT transaction offers vaccine coverage of 18-32 percent to the roughly 1.25 billion people in the African Union.
- India and China specifics:
  - As of mid-May 2021, Indian authorities estimate "over 2 billion doses will be available by the end of the year" based on company-level supply projections; current pre-purchases plus COVAX AMC coverage remain around 25 percent.
  - To reach a coverage of 60 percent of the population, "India will need to order roughly 1 billion doses of additional vaccines."
  - China is administering "about 10 million doses daily (or 0.7 per 100 people)" as of mid-May, and is "on track to vaccinate its adult population by end-2021."
- Regional and bilateral manufacturing/production deals:
  - AstraZeneca deal for Latin America (Argentina and Mexico) expected to produce approximately 150 million doses in 2021 and up to 250 million doses in 2022 for Latin America and the Caribbean (manufactured in Argentina with fill-finish in Mexico).
- Existing financing facilities and utilization:
  - World Bank: Board approved an envelope of $12 billion for developing countries (purchase and distribution of vaccines, tests, treatments); as of April 20, 2021 about $2 billion of the $12 billion had been approved for 17 countries.
  - Asian Development Bank: launched a $9 billion vaccine initiative—the Asia Pacific Vaccine Access Facility (APVAX).
  - "Much of the existing pandemic lending facilities remain unutilized" and limited uptake suggests scope to scale up use of these facilities rather than create new lending instruments immediately.

### LMIC universe, coverage accounting, and residual needs
- Population grouping for coverage calculations (Annex II):
  - AMC91 countries (group of 91 LMICs that are eligible to access COVAX AMC; excludes India in AMC91 labeling); population assignments used in figures and analysis.
  - India (population 1.4bn) has special treatment within COVAX (included in AMC92 but excluded from AMC91 due to size).
  - China (population 1.4bn).
  - Other upper middle-income countries (pop. 1.1bn in distribution table).
  - Total population of LMICs is about 6.5 billion.
- Post-proposal coverage expectations:
  - After accounting for African Union and COVAX AMC coverage under the proposal, "most AMC91 countries end up with a coverage over 60 percent."
  - Some remaining AMC91 countries will still need additional pre-purchases totaling "about 100 million courses" based on publicly available contract details.
  - The authors conservatively allocate about $1 billion in grant funding to cover residual needs for AMC91 countries.
- Other upper middle-income countries:
  - Many have vaccine coverage greater than 60 percent due to bilateral or other contracts; public data suggest they need about "100 million additional courses" to reach a minimum 60 percent coverage per country, but this does not account for deals such as the AstraZeneca–Latin America arrangement.

*Source: CONCLUSION, sdnea2021004 (A Proposal to End the COVID-19 Pandemic), International Monetary Fund*

### ANNEX	III:	CALCULATIONS	FOR	END-2021	VACCINATION	COVERAGE	UNDER	BAU

### ANNEX III: CALCULATIONS FOR END-2021 VACCINATION COVERAGE UNDER BAU

### Allocation assumptions and eligibility
- Countries classified as achieving high coverage under BAU if they meet any of:
  - Have already vaccinated over 20 percent of their population as of end-April 2021;
  - Have reached daily vaccination rates of 0.3 percent of the population as of end-April 2021;
  - Are high income countries.
- For those countries, assumed coverage: 85 percent of their eligible population.
  - The 85 percent coverage threshold accounts for the 15 percent of surveyed adults who are currently unwilling to be vaccinated in select high income countries.
- Eligible population for each country: the 15+ population.
- Variation in coverage among these countries arises solely from demographic differences (some countries have a greater share of older eligible individuals), producing different coverage as a share of the total population.

### AMC91 and other country-group assumptions
- AMC91 (group of 91 low- and middle-income countries, excl. India) assumption:
  - Assumed to receive and administer 60 percent of the sum total of doses they are eligible to receive from either the COVAX AMC facility, African Union, or direct pre-purchases from vaccine developers.
  - The 60 percent number is estimated based on current projected delays in vaccine deliveries.
  - Note: 46 of the 55 African Union members are part of the AMC91 countries.
- Remaining groups:
  - Low-income countries not eligible for the COVAX AMC: assumed coverage of 25 percent of their eligible population.
  - Middle-income countries: assumed coverage of 55 percent of their eligible population.
  - The 25 and 55 percent numbers are calibrated based on the expected coverage for COVAX AMC countries (for the remaining low-income countries) and the relative speed of current vaccination in middle-income countries compared to high-income countries.

### Definition of vaccine course and consistency checks
- A two-dose vaccine equals one course; a one-dose vaccine also equals one course.
- Bottom-up projection result: about 3.5 billion vaccine courses would have been administered by end-2021.
- Top-down consistency check using observed and projected daily doses:
  - As of end-April 2021: about 1.1 billion vaccine doses had been administered.
  - Daily vaccination rate had reached 20 million per day.
  - Conservative projection: total vaccines administered by end-2021 could reach about 6 billion doses, computed as:
    - 1.1 billion doses + 245 days * 20 million daily doses = 6 billion doses.
  - Using the J&J estimate of producing 1 billion doses in 2021, this implies 3.5 billion vaccine courses administered by end-2021, identical to the bottom-up estimate.

### Key numeric outcomes and calibrations
- Assumed high-coverage countries: 85 percent of eligible (15+) population.
- AMC91 administration rate assumption: 60 percent of eligible delivered doses.
- Low-income (not AMC) assumed coverage: 25 percent of eligible population.
- Middle-income assumed coverage: 55 percent of eligible population.
- Bottom-up projection: about 3.5 billion vaccine courses administered by end-2021.
- Top-down dose projection: about 6 billion doses by end-2021 (1.1 billion + 245 days * 20 million).
- J&J production assumption used in conversion: 1 billion doses in 2021.

*Source: sdnea2021004 - ANNEX III: CALCULATIONS FOR END-2021 VACCINATION COVERAGE UNDER BAU*

### ANNEX	VII:	DESIGNING	THE	AT-RISK	INVESTMENT	IN	VACCINE	MANUFACTURING	CAPACITY

### ANNEX VII: DESIGNING THE AT-RISK INVESTMENT IN VACCINE MANUFACTURING CAPACITY

### Equity and target population
- Objective: preserve capacity for the group of 91 low and lower-middle-income countries (AMC91).
- AMC91 population: 2.5 billion.
- Rationale: global manufacturing capacity is expected to increase significantly in 2022 but risks of continued inequity in access remain (supplies may be prioritized to high-income or upper-middle-income countries).

### Aggregate capacity and company targets
- Projected manufacturing capacity in 2022 (current approved vaccines): over 16 billion doses.
- Pfizer production targets (reported in early May): 3 billion in 2021 (up from previous target of 2.5 billion doses), and 4 billion in 2022 (up from the previous target of 3 billion doses).
- Additional global capacity expected as more vaccine candidates gain approval or authorization.

### Proposed at-risk investment size and coverage
- Proposed initial at-risk investment: 1 billion vaccine doses (for AMC91 in 2022).
- Coverage impact: this capacity will provide an additional 40 percent coverage to the AMC91 population (compared to the vaccination target of 60 percent by first half of 2022 under the baseline).
- Booster dose implication: the 1 billion doses would be able to provide nearly double the quantity of booster doses needed for vulnerable or elderly populations in AMC91 countries, if such need arises.
- Complementarity: the at-risk investment is intended to complement other efforts to increase country-level investments in vaccine manufacturing capacity.

### Insurance against aggregate risk and longer-term needs
- Guiding considerations: size of aggregate shocks to global vaccine supplies in downside scenarios and potential longer-term needs (e.g., boosters to address new variants or durability of immunity).
- Uncertainty noted: it remains unclear if and when booster doses will be needed (example: the U.K. is assessing a possible third dose for vulnerable and elderly populations later in the Fall).
- Trade-off: balance between seeking grant financing for at-risk investment and securing adequate insurance against downside risks and longer-term needs.

### Portfolio diversification and vaccine selection
- Current reliance: the developing world is heavily relying on adenovirus-based vaccines, with a dominant share expected from three developers: AstraZeneca, J&J, or Sputnik V.
- Platform risk: all three adenovirus-based vaccines share the same platform technology and are thus exposed to similar risks; safety concerns in this class could significantly impact rollout and exacerbate cross-country inequality.
- Evidence on efficacy: preliminary evidence suggests mRNA vaccines (Pfizer/BioNTech and Moderna) and Novavax have high efficacy against several variants of concern.
- Portfolio allocation: 50 percent of the at-risk investment budget allocated for relatively higher-priced mRNA vaccines.
- Pricing assumptions:
  - $6 per dose for half of the total capacity relying on vaccines such as Novavax (in line with current pricing for COVAX AMC).
  - $10 per dose for mRNA vaccines (in line with their indicative lowest-tier pricing for LMICs).
- Financing modality: 100 percent of this cost allocated to be financed by grants by the donor community.
- Social value estimate cited: Castillo et. al (2020) estimate that increasing total supply of vaccine capacity by 1 billion doses per year could generate nearly $1 trillion in social value.

### Speed and timing
- Timing requirement: additional supplies under at-risk investments should be available in the first half of 2022.
- Estimated lag: up to 9 months to bring additional capacity online (as suggested by public statements by Moderna).
- Examples of repurposing/scale-up: joint venture announced on May 8, 2021 between BioNTech and Fosun Pharma to produce 1 billion doses of mRNA vaccines.
- Feasibility: with immediate contracting and provisions for rapid scale-up/repurposing, 1 billion additional doses for AMC91 could be brought online before the end of the first half of 2022.

### Supply chain fragility and contracting approach
- Costing approach: reliance on an all-in cost estimate for expanding capacity by 1 billion doses in the first half of 2022 (preferred over option contracts to buy doses later).
- Rationale for all-in contracts:
  - Simplicity of approach.
  - Potential increased reluctance of companies to accept option contracts as new global capacity comes online in 2022.
- Comparison: the chosen costing is greater than the $3 per dose assumed by Ahuja and others. (2021).
- Contract provisions recommended:
  - Require vaccine manufacturers to demonstrate additional large-scale manufacturing capacity and augmentation of the supply chain ahead of time.
  - Aim to prevent delays due to manufacturing problems, supply chain bottlenecks, or raw material shortages.

*Source: ANNEX VII: DESIGNING THE AT-RISK INVESTMENT IN VACCINE MANUFACTURING CAPACITY (sdnea2021004)*

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_Source: https://www.imf.org/-/media/files/publications/sdn/2021/english/sdnea2021004.pdf_