Richmond Hill, Ontario, Canada (15 October 2026) – Beginning the global COVID-19 vaccine roll-out 100 days after the virus was sequenced could have saved more than 8 million lives by the end of 2021, most of them in lower-middle-income countries, according to modelling evidence brought together in a new Policy Brief from the United Nations University Institute for Water, Environment and Health (UNU-INWEH) . The authors argue that fair vaccine-sharing rules should be established before the next pandemic, rather than negotiated during the crisis itself.
Best Practices in Global Vaccination Roll-Out to Reduce Health Inequity , written by researchers from UNU-INWEH, the University of Oxford, Imperial College London, the London School of Hygiene and Tropical Medicine, King’s College London, Nagasaki University, Japan Institute for Health Security, Public Health Foundation of India, and the Middle East Liver Disease Center argues that international commitments to vaccine equity have not yet produced the operational mechanisms needed to deliver timely access across countries. It proposes an ‘equity-by-design’ framework that links vaccine development to financing, procurement, manufacturing, allocation, delivery, uptake, safety monitoring and accountability. It presents six recommendations as practical pillars for delivering on the WHO Pandemic Agreement, adopted in May 2025, and the amended International Health Regulations, in force for most States Parties since September 2025.
The 8 million estimate comes from a modelling study reviewed in the publication, which assumes that the public health measures followed their historical course. An earlier start would have allowed high vaccine coverage to be reached before the Delta variant spread. The brief is equally clear that speed alone is not enough: parallel investment in vaccine manufacturing and health system infrastructure could have saved a further 3 million lives.
The Policy Brief, accompanied by a peer-reviewed publication in the Expert Review of Vaccines journal in September 2026, highlights that COVID-19 vaccines were introduced across countries faster and more equitably than any earlier vaccine, whereas low-income countries often waited 10 to 30 years for vaccines against Haemophilus influenzae type b (Hib) and human papillomavirus (HPV). Even so, access remained sharply unequal. By the end of 2021, high- and upper-middle-income countries had administered at least one dose per person on average, compared with one for every three people in lower-middle-income countries and one for every 25 people in low-income countries.
Studies reviewed in the publication estimate that if lower-middle- and low-income countries had matched the roll-out rates of high-income countries, as many as half of their COVID-19 deaths might have been averted by October 2021, and that sharing existing supply more equitably could have prevented 1.3 million deaths worldwide by the end of 2021. Delayed protection in lower-resource settings also prolonged transmission, raised the risk of new variants emerging and slowed economic recovery, weakening health and economic security across borders.
“Effective pandemic preparedness requires clear allocation principles to be agreed before a crisis begins. When vaccine supplies are limited, distribution should respond to epidemiological evidence, including disease burden, risk of severe outcomes and the speed of transmission, so that vaccines reach the places where they can prevent the greatest harm,” said Dr. Mahan Ghafari, Wellcome Trust Early Career Research Fellow at the University of Oxford who led the investigation. “But for millions of people in poorer countries, they still arrived too late. The science moved at record speed while the systems for financing, sharing and delivering vaccines did not. Next time, the rules on who receives vaccines, and when, have to be agreed upon before the outbreak rather than negotiated in the middle of it.”
The authors caution that regional manufacturing is not a stand-alone solution without long-term demand, predictable finance, regulatory convergence and a skilled workforce. They also argue that countries which report outbreaks and dangerous variants early should be supported rather than penalised, noting that punitive responses such as travel restrictions may have discouraged timely reporting during COVID-19.
“COVID-19 proved wrong those who claimed that the virus would treat us all equally,” said Professor Kaveh Madani , Director of UNU-INWEH and a co-author of this publication. “Once again, we saw how a shared global threat can disproportionately harm the poor and less privileged. That experience taught us that we cannot rely on the speed of science and innovation alone. Before the next global emergency strikes, we must strengthen the foundations for equity through cooperative global mechanisms that can effectively improve financing, manufacturing and delivery, ensuring that life-saving solutions reach those who need them most.”
The authors also call for sustained investment in pathogen genomic surveillance, including sequencing, analysis and workforce training across countries, to detect emerging threats and inform vaccine responses. Timely sharing of high-quality, geographically representative data should be encouraged through recognition of contributors and equitable access to benefits, including vaccines and other countermeasures, rather than punitive responses.
Countries that detect and report a dangerous new variant early are doing the whole world a service, the research team believe. Vaccine equity requires more than statements of intent. This policy brief offers an equity-by-design framework that translates the principle into practical action across financing, procurement, allocation, surveillance, data sharing and delivery, so these mechanisms can be established before the next health emergency rather than improvised during it.
Key Facts
Starting the global vaccine roll-out 100 days after the virus was sequenced could have saved more than 8 million lives by the end of 2021, with the life-years saved valued at US$14 trillion.
Parallel investment in manufacturing capacity and health systems could have saved a further 3 million lives and corresponded to a monetary saving of US$5 trillion.
By the end of 2021, high- and upper-middle-income countries had administered at least one dose per person, against one dose for every 25 people in low-income countries.
Had lower-middle- and low-income countries matched high-income roll-out rates, as many as half of their COVID-19 deaths might have been averted by 1 October 2021.
Sharing existing vaccine supply more equitably could have prevented 1.3 million deaths worldwide by the end of 2021.
Vaccination averted far fewer deaths per capita in low-income countries, particularly in the Eastern Mediterranean and African regions, than in high-income countries.
Earlier vaccines, such as those against Hib and HPV, often reached low-income countries 10 to 30 years after high-income countries.
Six steps to equity by design
The brief sets out six policy recommendations for national governments, international organisations, vaccine manufacturers and the trusted voices who shape confidence in vaccination:
Prepare before the next health emergency. Design pooled procurement mechanisms, fund research and development, and link pathogen surveillance to vaccine research, scalable manufacturing, supply chains and regional stockpiles before a crisis begins.
Allocate vaccines equitably between nations. Build on the pooled demand and needs-based allocation of COVAX, adding earlier and predictable finance, enforceable access commitments, pre-defined dose-sharing triggers and public tracking of roll-out timelines.
Secure timely and equitable vaccine procurement. Use advance purchase agreements that require transparent prices, flexible delivery and automatic dose-sharing under triggers agreed before an emergency, and diversify vaccine portfolios to reduce supply risks.
Promote transparent data sharing and effective communication. Report cases, hospital admissions, deaths, vaccine adverse events and vaccination by age, sex, geography and risk group in standard, machine-readable formats, and plan community engagement and misinformation monitoring before a crisis.
Insulate vaccine decisions from political distortion. Strengthen international regulatory standards, establish independent national advisory committees, and support rather than penalise countries that report outbreaks and variants early.
Strengthen delivery systems and regional capacity. Invest in health facilities, trained health workers, cold chains and real-time stock and temperature monitoring, alongside regional manufacturing and products suited to low-resource and conflict-affected settings.
Cross-cutting priority: within countries, target vaccines to vulnerable and high-risk groups using models that capture health and socio-economic vulnerability, with independent national oversight.
Publicationn Information
Ghafari, M., Watson, O.J., Dascalu, S., Hsu Hnin Mon, S., Abeler-Dörner, L., Rezaee-Zavareh, M.S., Pley, C., Kordasti, S., Abbas, K., Panovska-Griffiths, J. and Madani, K. (2026). Best Practices in Global Vaccination Roll-Out to Reduce Health Inequity. United Nations University Institute for Water, Environment and Health (UNU-INWEH), Richmond Hill, Ontario, Canada. doi: 10.53328/INP26MAG001
Support Paper: Ghafari, M. et al. (2026). Global vaccine readiness: equity-by-design in pandemic preparedness and response. Expert Review of Vaccines. doi: 10.1080/14760584.2026.2732508
Available for Interview: Interview requests should be submitted to media.inweh@unu.edu
About UNU-INWEH
The United Nations University Institute for Water, Environment and Health (UNU-INWEH) is one of 13 institutions that make up the United Nations University (UNU), the academic arm of the United Nations. UNU-INWEH addresses critical water, environmental, and health challenges around the world. Through research, training, capacity development, and knowledge dissemination, the institute contributes to solving pressing global sustainability and human security issues of concern to the UN and its Member States. Headquartered in Richmond Hill, Ontario, UNU-INWEH has been hosted and supported by the Government of Canada since 1996 and has Hubs in Calgary, Hamburg, New York, Lund, and Pretoria.
Best Practices in Global Vaccination Roll-Out to Reduce Health Inequity
20-Oct-2026