As summer arrives, the COVID-19 pandemic appears to have turned a corner — in the U.S., at least, with all 50 states seeing the number of cases decline. As vaccinations have increased and supply starts to outstrip demand, life appears to be returning to some semblance of normalcy.

That’s far from the case in most countries around the world, where the pandemic is raging unabated. At the heart of the issue is a lack of vaccine access: Many low-income countries standing in line for doses may not be able to distribute them and inoculate their populations until 2023.

The Serum Institute of India, a significant player in a plan to get vaccines to low-income countries through Covax, said earlier this week it wouldn’t be able to supply doses outside India until the end of the year. That puts a dent in Covax’s goal to provide two billion vaccine doses to the world’s poorest populations. So far, the partnership has delivered a little over 68 million doses, representing a mere 3.4% of its goal.

This has left wealthier countries like the U.S. under mounting pressure to help address the problem. But experts say it’s a long and complex road ahead.

“There’s no public health strategy from the U.S. government on how to address the problem,” said Josh Michaud, associate director of global health policy at Kaiser Family Foundation. “The government says it’s working on one, and we may see one soon, but it’s not publicly available. We don’t know stage one, stage two or stage three of their plan to ramp up global vaccines.”

While nearly half of people in the U.S. have received at least one shot of the vaccine, that percentage dwarfs the percentage in countries like Honduras or Somalia, where around 1% or less of the population has received their first dose.

So far, the Biden administration has pledged to donate some 80 million doses abroad, though it hasn’t specified which countries will receive them. This week, the White House announced it would send some 20 million COVID-19 vaccine doses abroad by the end of June. It marks the first time the U.S. will be sending its homegrown vaccines (Pfizer, Moderna and Johnson & Johnson) to other countries.

“We’ll share these vaccines in the service of ending the pandemic everywhere, and we will not use our vaccines to secure favors from other countries,” President Biden said.

That pledge, alongside the Biden administration’s support for a vaccine patent waiver, represents the first step in a vaccine diplomacy effort that has so far lagged. That’s largely due to an “America first” plan to get people vaccinated domestically before donating vaccines to the rest of the world.

Some have criticized the U.S. for hoarding vaccines, and falling behind Russia and China’s efforts in donating doses to countries that need them. In a report from the Duke-Margolis Center for Health Policy, public health experts called for more action from the U.S.

“The virus will continue to circulate in these countries and new variants will emerge, threatening the U.S. and the world and slowing global economic recovery,” the authors of the paper wrote. “In short, the pandemic will not end anywhere until it ends everywhere. It is in the U.S. interest to proactively and urgently address COVID-19 vaccine equity.”

Loren Becker, associate principal of vaccine policy and market access at healthcare consultancy company Avalere, said she expects the U.S. to catch up once it deems its own domestic vaccination effort complete. She pointed out two main ways the U.S. can assist the global vaccine equity effort: By donating its leftover doses and by helping to expand manufacturing capacity around the world.

“There are doses we have access to right now that we potentially don’t need in the U.S., whether that’s the dose commitments we had from the AstraZeneca deal, or a surplus of the Moderna and Pfizer vaccines currently approved in the U.S.,” she explained.

From the manufacturing-capacity side, the need goes beyond a patent waiver, Becker argued.

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“It’s more than a patent, more than the information of what the product is,” she continued. “What are the right partnerships and the right ways to train people? It also involves access to all of those raw materials, many of which are also protected by patents.”

The main way major vaccine makers have been contributing to the global capacity effort has been through partnerships and voluntary licensing agreements with facilities in other countries. Becker noted that a lot can be accomplished through such agreements.

“What we’ve heard from these companies is they have been making these licensing deals as quickly as they could, but they obviously have a strong interest in doing some extreme vetting in controlling who the licenses go to,” she said. “We’re trying to build the plane at the same time we’re flying it, in terms of manufacturing capacity. It exposes a lot of holes that, for now, we are having to fill as we go. It’s a challenging environment.”

Some vaccine makers have turned down offers from companies in Canada, Bangladesh and Israel to help partner with them to boost production. Part of that has to do with a bottleneck of the supply of raw materials, especially for mRNA vaccines, as well as safety and quality concerns, Michaud said.

“So far, pharma companies have been a little hesitant to work with partners that they’re not already familiar with. They’re saying they’re worried about safety or they’re unsure of the practices, or that it would take too long, or that it would be too expensive to start up manufacturing lines with these other countries,” he explained. “From the outside, it’s hard to know how true that is.”

The federal government could boost partnerships by incentivizing companies to reach some of the “untapped capacity” out there, Michaud said. The government has already stepped in to help broker the one between Merck and Johnson & Johnson, but its approach to date might fairly be characterized as hands-off.

“Biden has said he sees the U.S. as a potential engine for vaccination of the world,” Becker said. “Incentivizing that is valuable.”

She added that a longer-term solution that speaks to a post-pandemic world is to invest in manufacturing capacity globally, particularly in low- and middle-income countries.

Michaud agreed that equity issues around COVID-19 vaccines have exposed shortcomings and massive disparities in the global public health system. Less wealthy countries have taken note: Michaud pointed to a handful of countries in Africa, which have set their sights on increasing manufacturing capacity so they won’t experience a similar problem in the future.

“There’s every reason to believe that unless things change going forward, with a much more distributed capacity, we’re going to see a repeat of this process again and again with each new pandemic or health threat,” Michaud said. “This has been a jolt to the international system – but whether it means there will be significant change in the way the system is set up to address pandemics remains to be seen. There’s definitely going to be incentives for self-sufficiency, which will hopefully lead to more resiliency in the future.”