Southeast Asia needs a revolving fund for vaccines

COVID-19 vaccination programmes have been relatively successful in the Association of Southeast Asian Nations (ASEAN), blunting the worst of the pandemic and increasing overall public understanding of and support for vaccination programmes. To build on these gains, we propose an ASEAN Vaccines Revolving Fund (AVRF) to strengthen long-term vaccine procurement in the ASEAN, starting with COVID-19 vaccines and expanding to other vaccine-preventable diseases. The Revolving Fund1Pan American Health OrganizationPAHO revolving fund.https://www.paho.org/en/revolvingfundDate accessed: June 23, 2022Google Scholar of the Pan-American Health Organization (PAHO) can be a useful reference for an AVRF. Founded in 1977, the Revolving Fund pools the resources of 41 PAHO countries.2Pan American Health OrganizationPAHO revolving fund for access to vaccines.https://www.paho.org/en/documents/paho-revolving-fund-brochure-2022Date: May 10, 2021Date accessed: June 15, 2022Google Scholar Today, it has a working capital of more than US$120 million, purchasing $1·1 billion worth of 47 different vaccines and 29 vaccine-related supplies for 15 million people annually.2Pan American Health OrganizationPAHO revolving fund for access to vaccines.https://www.paho.org/en/documents/paho-revolving-fund-brochure-2022Date: May 10, 2021Date accessed: June 15, 2022Google Scholar The Revolving Fund has helped double PAHO vaccination rates from approximately 25% in 1978, to more than 80% in 1993.3Pan American Health Organization25 years of being polio-free in the Americas.https://www3.paho.org/hq/index.php?option=com_content&view=article&id=15525:25-years-of-being-polio-free-in-the-americas&Itemid=1926&lang=enDate accessed: July 9, 2022Google Scholar As a result, the PAHO was the first of six WHO regions to be certified polio free in 1994,3Pan American Health Organization25 years of being polio-free in the Americas.https://www3.paho.org/hq/index.php?option=com_content&view=article&id=15525:25-years-of-being-polio-free-in-the-americas&Itemid=1926&lang=enDate accessed: July 9, 2022Google Scholar eliminated measles in 2016,4Pan American Health OrganizationRegion of the Americas is declared free of measles.https://www3.paho.org/hq/index.php?option=com_content&view=article&id=12528:region-americas-declared-free-measles&Itemid=1926&lang=enDate: Sept 27, 2016Date accessed: July 9, 2022Google Scholar and eliminated rubella in 2015.5Pan American Health OrganizationAmericas region is declared the world's first to eliminate rubella.https://www3.paho.org/hq/index.php?option=com_content&view=article&id=10798:2015-americas-free-of-rubella&Itemid=1926&lang=enDate: April 29, 2015Date accessed: July 9, 2022Google Scholar The Revolving Fund trajectory can be replicated in southeast Asia through an AVRF, which should have three objectives: to coordinate pooled procurement of vaccines in southeast Asian countries; to support country-level delivery; and to build capacity for national-level public procurement of other goods and services. A successful AVRF can increase vaccine supplies, reduce the price for new vaccines, accelerate access to new vaccines, and increase vaccination rates and health equity. An AVRF can resolve four structural challenges for vaccine procurement in southeast Asia. One, an AVRF can provide a strong negotiating position with vaccine manufacturers through a representation of 650 million people in southeast Asia. Two, an AVRF can modernise southeast Asian procurement through innovative tools such as value-based purchasing, health technology assessments, demand forecasting, and new types of reimbursement contracts with manufacturers in the short term,6Morgan S Daw J Thomson P International best practices for negotiating ‘reimbursement contracts’ with price rebates from pharmaceutical companies.https://www.healthaffairs.org/doi/10.1377/hlthaff.2012.1268Date: 2013Date accessed: June 23, 2022Google Scholar while building country-level capacity and harmonising regional standards in the long term. Three, an AVRF can strengthen local vaccine manufacturing and create incentives for local manufacturers to expand vaccine production, including partnering with foreign producers. And four, an AVRF can support member countries to amortise capital spending on expensive infrastructure such as cold chains and data systems. There are also strategic advantages of an AVRF. The vastly increased purchasing powers will assure access to vaccines that cost less, are reliably supplied, and can progressively cover more vaccine-preventable diseases over time. Moreover, consistent access to vaccines helps prevent disease while minimising the administrative and financial burdens of disease in southeast Asian countries. An AVRF can also help institutionalise modern practices and reduce corruption risks with transparent governance and standards. Ultimately, an AVRF could mitigate the tiered pricing strategy7Moon S Jambert E Childs M von Schoen-Angerer T A win–win solution? A critical analysis of tiered pricing to improve access to medicines in developing countries.Global Health. 2011; 7: 39Crossref PubMed Scopus (86) Google Scholar of vaccine manufacturers, who differentiate prices based on country-level market share and income levels. When an AVRF has achieved sufficient size, stature, and results, it can be a focal point for international aid because the AVRF governance structure meets international standards and there is a single point of contact. This strong governance creates an opportunity for impact investors and impact bonds,8Asian Development BankPromoting social bonds for impact investments in Asia.https://www.adb.org/publications/social-bonds-impact-investments-asiaDate: 2021Date accessed: June 23, 2022Google Scholar both crucial considering the decline of the aid landscape in southeast Asia. An AVRF will require a multiyear journey. Its first step would be a coalition that can be anchored by the ASEAN Secretariat or a relevant organisation such as the International Vaccine Institute in South Korea or the National Vaccines Institute in Thailand. The coalition should also partner with a geopolitically important country or region, such as China, Europe, or the USA. Having three to five founding ASEAN countries will be adequate to achieve crucial mass in population, diplomatic, financial, and technical terms, and other ASEAN countries can join in the subsequent phases. This AVRF strategy would create a pathway to fast adoption of new vaccines that are now being developed, especially those using mRNA technology. Seed funding can be obtained from participating countries and development banks such as the Asian Development Bank or the World Bank. Foundations such as The Bill & Melinda Gates Foundation or the Rockefeller Foundation are long-standing supporters of vaccination programmes9Youde J The Rockefeller and Gates Foundations in global health governance.Glob Soc. 2013; 27: 139-158Crossref Scopus (36) Google Scholar and could also play a substantial role. The ASEAN has done well in vaccinations, with high coverage rates for most vaccine-preventable diseases. However, new vaccine procurement strategies are needed as populations increase, expensive new vaccines emerge, and ASEAN countries struggle to fund post-pandemic health and social care. An AVRF can help assure stable, predictable, cost-effective, and early access to new vaccines. The PAHO example is instructive, and an AVRF can be launched in the ASEAN through a combination of political will and skill. Vaccines have been called public health's best buys, and an AVRF can make these best buys even better. We declare no competing interests.