Last year, in a closed process led by McKinsey & Company, a small group of organizations, including the World Bank, the Bill & Melinda Gates Foundation, and the WHO, shaped what is now one of the only pathways for many low-income countries to access COVID-19 vaccines. The COVID-19 Global Access initiative (COVAX) has been hailed as a “historic step” toward vaccine equality, facilitating the kind of global coordination necessary to avoid “catastrophic moral failure” (though 2.78 million deaths, disproportionately of poor people and minorities, might suggest that ship has sailed). It’s made necessary by the fact that 130 countries are yet to receive a single dose, while rich countries have secured enough to vaccinate their populations many times over — five times in Canada, almost four in the UK, and twice in the United States.

Wealthy countries were able to hoard vaccines by preordering doses from manufacturers before they were licensed, giving them priority access once in production. The bulk of manufacturing capacity is now committed to fulfilling these advance purchase agreements (APAs) — constituting billions of doses over the coming months and years — leaving countries without the capital to negotiate APAs unable to procure vaccines.

COVAX pools resources to preorder vaccines from a diverse portfolio of manufacturers and aims to distribute them at the same rate to its over 180 participating countries. High-income nations pay upfront for a chosen number of doses, which act as “insurance” in the event their preorders fail to produce enough viable vaccines. Vaccines for the 92 participating low- and middle-income countries are largely subsidized by aid and the private sector.