Joint Statement on WHO proposed Global Allocation Framework for COVID-19 products

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Thank you to our French translation contributors: Farah Bentahar, Yasmine El Addouli, Vesela Ivanova, Johanna Manga, Jana Martic, Mathilde Moreau, Madeleine Bélanger Dumontier and Mira Johri

Global solidarity requires addressing the structural drivers of inequities – Response to invitation for feedback

The rapidly escalating COVID-19 pandemic is a critical risk to global health, prosperity and security. Confronted by an urgent and common threat, governments and international partners from all sectors have mobilized with unprecedented speed to support the search for effective diagnostics, therapeutics and, especially, vaccines. Because all people everywhere are vulnerable to the SARS-Cov-2 virus that causes COVID-19 disease, global demand for treatment and prevention products is anticipated to outstrip supply in the early phases. On June 18th, 2020 the WHO released a draft allocation framework to expedite control of the COVID-19 pandemic while ensuring fair and equitable allocation of COVID-19 products,[1]  using the global distribution of a hypothetical COVID-19 vaccine as an example of how it could be applied.

Yet, we are not all equally vulnerable. Around the globe, the pandemic is exposing structural fragilities – poverty, governance deficits, weak social safety nets, poorly resourced health systems, social and economic exclusion—all of which disproportionately heighten vulnerability to the pandemic and amplify its negative impacts. Responding to the socio-economic impacts of COVID-19 is a cornerstone of the UN strategy for a better recovery.[2] Canadian leaders in global health call upon the WHO and global partners to reexamine how the WHO Global Allocation Framework addresses the structural drivers of exclusion, inequalities and discrimination.

Analysis: Allocation criteria proposed in the WHO Framework

The Global Allocation Framework argues for prioritization of certain populations to achieve public health goals.[1] Taking the example of allocating a newly developed COVID-19 vaccine (or vaccines) among countries, the framework argues that strategic allocation will help to maximise health impact and prevent health systems from being overwhelmed, thereby improving overall well-being and mitigating the impacts of the pandemic on societies and economies.[1]  The Framework proposes that initial country shares of vaccines be determined by their proportions of three priority populations:

  1. Healthcare system workers (medical doctors, nurses, midwives, community health workers), estimated at 1% of the global population;
  2. Adults >65 years old, representing roughly 8% of the global population;
  3. Adults 30-70 years old, with specific comorbidities (cardiovascular disease, cancer, diabetes, obesity or chronic respiratory disease), representing approximately 15% of the global population.

Ethical justifications are offered for prioritising each of these populations. Health care workers are prioritised because of their contribution to the health and well-being of the community, and because they may serve as transmission vectors spreading the illness should they fall ill. Older adults and adults with co-morbidities are prioritised due to their higher risk of severe disease outcomes. An upper age limit is set on those with co-morbidities, to ensure that those who receive scarce vaccines are able to benefit.[1]

Although we agree that prioritisation is necessary, we are concerned that the criteria currently proposed risk compounding the disadvantages faced by the poorest. The share of healthcare workers is lower in low-and middle-income countries, and lowest in the most resource-poor settings.[5] The same pattern holds true for adults over 65 years of age, with the oldest high-income countries having proportions of adults over age 65 close to 30%, while the youngest, located overwhelmingly in sub-Saharan Africa, have shares of less than 5%.[4] Finally, the chosen comorbidities vary substantially among countries and regions and are lowest in the poorest countries.[5] Taken in the context of vast global inequities in health, the three priority areas privilege the world’s already most-resourced populations.

Selection of co-morbidities is designed to reflect who is at highest clinical risk; however due to the history of how the pandemic has evolved, our medical knowledge is nascent. The majority of research on COVID-19 disease comes from the countries that have been first or most affected, such as China, the United States, and Italy. In these countries, the risk factors leading to severe complications and mortality include diabetes, heart disease (hypertension), chronic respiratory disease, severe obesity and immune deficiency.[6-9] Severe cases and deaths are concentrated in older age groups (65 years+) and, in some countries, in men. [6, 8-10] Health conditions in many LMICs countries differ sharply from those in countries from which current COVID-19 research originates. Key unanswered questions include the possible impact of COVID-19 when pre-existing conditions such as anaemia, HIV, tuberculosis, or undernutrition are prevalent. Shaped by co-morbidities and gender norms, the gender distribution of risks and outcomes may also be substantially different in LMICs. WHO promises that the approach will be fine-tuned based on “product characteristics”.[1] We recommend that the definition of priority populations at higher risk be responsive to emerging information on co-morbidities common in LMICs.

Allocation criteria missing from the WHO Framework

In defining who is at risk, the WHO Allocation Framework focuses on clinical markers that influence risk of severe disease. Yet, poverty and other structural drivers place some individuals and groups at much higher risk of infection and poor outcomes. The WHO defines the social determinants of health (SDH) as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”[11] These determinants are the root causes of health inequities, the differences in health status or the distribution of health resources among different populations that disproportionately advantage some groups over others.[11, 12] They are particularly important for understanding the multiple, systematic disadvantages faced by the poorest populations and countries. Even in relatively wealthy nations, epidemiologic data clearly indicate that groups already facing the greatest social and health inequities also bear the brunt of the pandemic (e.g., disproportionate cases and deaths among Black and other racialized groups).

Ability to prevent exposure to the SARS-Cov-2 virus differs sharply within and among countries. Deficient water, sanitation and hygiene infrastructure, high exposure to indoor and outdoor air pollution, crowding, poor quality or precarious housing, working conditions that promote occupational exposure, and less awareness of disease mechanisms are among the important factors that may make poorer individuals and countries more vulnerable and favour rapid disease transmission.

For those who fall ill, health system preparedness and response is also a critical concern. While the world average is 14.9 doctors, 32 nurses and midwives and 28 hospital beds per 10,000 people (and the averages for countries with high human development are respectively 30.4, 81 and 55), countries with low scores on the human development index have only 2.1 doctors, 8 nurses and midwives and 6 hospital beds per 10,000 people.[13] Compounding problems of limited access to healthcare facilities, out-of-pocket expenditures are generally higher in countries with weak health systems. Weaker health systems have lower diagnostic and treatment capacity, limited access to personal protective equipment, and a higher likelihood of nosocomial infections. As COVID-19 mitigation efforts and cases surge, weak health systems are the first to forego provision of other essential services, with devastating consequences.[14]

Finally, due to the interplay of poverty and weak social safety nets, those who are most vulnerable have little ability to rebound from stresses caused by pandemic mitigation measures or illness. The poignant struggles of migrant workers around the globe over the last months are a case in point.

As the first wave of infection peaks in North America, and as subsequent waves of infection emerge in Asia and Europe,  we are reminded that the second wave of the 1918 influenza pandemic killed more people than the first. In Africa alone where the first wave is still unfolding, by the end of 2020 up to 190,000 people could die of COVID-19, and an additional 44 million people could be infected.[15]

As the world engages in unprecedented containment, control and mitigation measures, COVID-19 will continue to hit poorer countries particularly hard, where new outbreaks expose and exacerbate inequity and vulnerability. As the pandemic and its cascade effects continue to unfold, even the best case scenarios leave the UN warning of global famines that could affect 250 million people by the end of 2020.[16] Here, those most at risk are in 10 countries affected by conflict, economic crisis and climate change, or who are in other complex humanitarian settings.[17] An ethical priority setting strategy must account for these factors.

The UN Sustainable Development Goals ask us to place equity at the heart of our actions. As we struggle to emerge from the pandemic, the design of economic and social policies such as the ACT Accelerator and the WHO Allocation Framework will play a critical role in shaping life chances.[18] By failing to address the structural drivers of health and disease, the WHO Global Allocation Framework may inadvertently exacerbate vulnerabilities. We fully agree that global UN coordination is required to ensure a fair and equitable response, but this should be grounded in a broader, more inclusive vision of health determinants and outcomes. We call upon WHO and its partners to work in solidarity to address the root causes of health inequities and ensure a better recovery for all.[2]




1. World Health Organization. A global framework to ensure equitable and fair allocation of COVID-19 products: And potential implications for COVID-19 vaccines. WHO Member States briefing, 18 June 2020. Accessed 2020-06-23.
2. United Nations Sustainable Development Group. Shared responsibility, global solidarity: Responding to the socio-economic impacts of COVID-19, March 2020. Accessed 2020-06-23.
3. World Health Organization. Health Workforce – data and statistics. Accessed 2020-06-23.
4. United Nations Population Division. World Population Prospects 2019.
5. Clark A, Jit M, Warren-Gash C, Guthrie B, Wang HHX, Mercer SW, et al.. Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study. The Lancet Global Health2020;World Health Organization. Social determinants of health. Accessed 2020-06-23.
6. Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020.
7. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62.
8. Centers for Disease Control and Prevention. Groups at Higher Risk for Severe Illness 2020.
9. Task force COVID-19 del Dipartimento Malattie Infettive e Servizio di Informatica. Epidemia COVID-19, Agiornamento nazionale: 23 marzo 2020 Rome, Italy: Istituto Superiore di Sanità; 2020 [Available from:
10. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020.
11. World Health Organization. Social determinants of health. Accessed 2020-06-23.
12. Canadian Coalition for Global Health Research. (2015, November). CCGHR principles for global health research. Retrieved from: Accessed 2020-06-23.
13. Kovacevic M, Jahic A. COVID-19 and Human Development: Exploring Global Preparedness and Vulnerability United Nations Development Program – Human Development Report Office; 2020 [Available from: Accessed 2020-06-23.
14. Roberton T, Carter ED, Chou VB, Stegmuller AR, Jackson BD, Tam Y, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. The Lancet Global Health. 2020
15. WHO (2020).Up to 190 000 people could die of COVID-19 in Africa if not controlled. Accessed May 9,2020 at:
16. BBC News (2020) “Coronavirus: World risks ‘biblical’ famines due to pandemic – UN,” BBC News, Accessed 22 April 2020
17. FSIN (2020). 2020 Global Report on Food Crises. Food Security Information Network. April 20, 2020. See:
18. Oxfam International. OPEN LETTER: Uniting Behind A People’s Vaccine Against COVID-19. Accessed 2020-06-23.


Mira Johri, PhD MPH (Lead Author)
Professeure titulaire, Département de gestion, d’évaluation, et de politique de santé, École de santé publique de l’Université de Montréal (ÉSPUM)
Member, Board of Directors, Canadian Coalition for Global Health Research
Co-Chair, Policy and Advocacy Committee, Canadian Coalition for Global Health Research

James Orbinski OC, MA, MSc, MD (Contributing Author)
Director and Professor
E:, T: +1(416)736-2100 x34447
COVID-19 Global Health & Humanitarian Portal
Dahdaleh Institute for Global Health Research
Suite 2150, Dahdaleh Building, York University
88 The Pond Road, Toronto, Canada, M3J 2S5
W: | T: @DIGHR_YorkU

Dr. Katrina Plamondon PhD RN (Contributing Author)
Assistant Professor
Faculty of Health & Social Development, School of Nursing
The University of British Columbia,Okanagan Campus
Co-Chair, University Advisory Council, Canadian Coalition for Global Health Research
ART360 1147 Research Road, Kelowna BC, V1V 1V7 Canada
Phone 250 807 8681 | @KMPlamondon

CCGHR Leadership

Dr. Shafi Bhuiyan, MBBS, MPH, MBA, PhD
Asst. Profesor, Clinical Public Health, DLSPH, U of T
Co-Founder & Program Manager, ITMDs Post Graduate Bridge Training Program
The Chang School of Continuing Education, Ryerson University
Founding Scientific Board, International Committee on MCH Handbook
Chair, Board of Directors, Canadian Coalition for Global Health Research
E-mail: | Tel:+1-647 534 3946

Christina Zarowsky, PhD
Professor and Director
Dept of Social and Preventive Medicine
Ecole de santé publique de l’université de Montréal ;
Extraordinary Professor
School of Public Health
University of the Western Cape;
Vice-chair, Board of Directors, Canadian Coalition for Global Health Research

Charles P Larson, MD,CM, FRCP(C)
McGill University Global Health Program
Interim Director
National Coordinator, Canadian Coalition for Global Health Research
514 557 1243

Susan J. Elliott, PhD
Professor, Geography & Environmental Management
Fellow, Balsillie School of International Affairs
Professor, United Nations University Institute for Water, Environment and Health (Adjunct)
Co-Director, Waterloo Survey Research Centre
Co-Chair, University Advisory Council, Canadian Coalition for Global Health Research
Board Member, Canadian Society for International Health; Twitter: @Geohealthe

Canadian Society for International Health Leadership

Geneviève Dubois-Flynn, PhD
Co-Chair, Canadian Society for International Health

Chris Rosene
Co-chair, Canadian Society for International Health

Eva Slawecki
Executive Director, Canadian Society for International Health

Leaders in Global Health Research, Education, & Practice (listed alphabetically)

Jill Allison, PhD RN
Global Health Coordinator
Clincial Assistant Professor, Community Health and Humanities
Faculty of Medicine
Memorial University of Newfoundland
Faculty of Medicine Building Room | M3M115A
300 Prince Philip Drive
St. John’s, Newfoundland | A1B 3V6
T 709 864 6032

Barbara Astle, PhD, RN
Director MSN Program & Associate Professor | School of Nursing
Director | Centre of Equity & Global Engagement (CEGE)
Trinity Western University | t: 604.513.2121 (3260)
7600 Glover Rd | Langley BC Canada | V2Y 1Y1

Dr. Megan Aston PhD RN
Associate Director of Research and International Affairs
Director of the Centre for Transformative Nursing and Health Research
School of Nursing, Dalhousie University
5869 University Ave PO Box 15000
Halifax, Nova Scotia, Canada B3H 4R2
(902) 494-6376

Malek Batal, PhD
Professeur titulaire et directeur de TRANSNUT
Centre collaborateur de l’OMS
sur la transition nutritionnelle et le développement
Professor and Director of TRANSNUT
WHO Collaborating Centre on Nutrition Changes and Development
Département de nutrition, Faculté de Médecine
Université de Montréal

Peter Berman, PhD
Professor and Director
School of Population and Public Health
University of British Columbia
2206 East Mall Room 117
Vancouver, B.C. V6R1Z3

Hélène Carabin, DMV MSc PHD
Professeure titulaire
Faculté de médecine vétérinaire – Département de pathologie et microbiologie
3190, rue Sicotte – Pavillon de santé publique vétérinaire local 2202-35
514 343-6111 #8569

Dr. Colleen Davison
Department of Public Health Sciences
Queen’s University
01-613-533-6000 x 79518;;

Jackie Denison RN, MSN
Assistant Director School of Nursing | Senior Instructor |
The University of British Columbia
Okanagan Campus | Syilx Okanagan Nation Territory
Faculty of Health and Social Development |School of Nursing
1147 Research Rd – ARTS Building 340
Kelowna, BC, V1V 1V7
Cell phone: 604-306-0640 Tel: 250-807-9822

Erica Di Ruggiero, MHSc PhD RD
Director, Centre for Global Health
Director, Collaborative Specialization in Global Health
Associate Professor, Social & Behavioural Health Sciences
Associate Professor, Institute of Health Policy, Management & Evaluation
Dalla Lana School of Public Health | University of Toronto
Health Sciences Building, 155 College Street, Suite 408 Toronto, ON M5T 3M7
Phone: +1 416 978-6066 | Fax: +1 416-978-1833
Cell: 416 524-0111

Jacques E. Girard, MD, FRCP
Directeur en santé mondiale
Vice-décanat à la responsabilité sociale
Faculté de médecine
Pavillon Ferdinand-Vandry, Bureau 4692
Université Laval
1050, avenue de la Médecine
Québec (QUEBEC) G1V 0A6

Lori Hanson, MSc, PhD
Associate Professor, Department of Community Health and Epidemiology
Director, Division of Social Accountability
College of Medicine
University of Saskatchewan 306-966-7936

Jennifer Hatfield, PhD
Jennifer Hatfield PhD
Professor, Department of Community Health Sciences.
Senior Global Health Lead,
Strategic Partnerships and Community Engagement,
Cumming School of Medicine.
Adjunct Professor, Faculty of Veterinary Medicine,
University of Calgary, Alberta, Canada

Yipeng Ge, MD BHSc
Canada’s Youth Delegate to the 73rd World Health Assembly
Incoming Public Health Resident Physician, University of Ottawa

Craig R. Janes, PhD
Professor and Director
School of Public Health and Health Systems
University of Waterloo
Waterloo, ON N2L3G1

Angela Kaida, PhD
Associate Professor and Canada Research Chair in Global Perspectives in HIV and Sexual and Reproductive Health
Faculty of Health Sciences, Simon Fraser University
co-Director, SFU Inter-disciplinary Research Centre for HIV (SIRCH)
Scientific Advisor, Women’s Health Research Institute (WHRI)
Blusson Hall Rm 10522, 8888 University Drive, Burnaby, B.C. V5A 1S6
Tel: 778-782-9068 Email: Twitter: @akaida
Web: | | |

Emily Kocsis, MSc
Student & Young Professional Network Coordinator
Canadian Coalition for Global Health Research

Alison Krentel MScPH PhD
Investigator, Bruyère Research Institute
Assistant Professor, School of Epidemiology and Public Health, University of Ottawa
85 Primrose Avenue, Room 306
Ottawa, ON K1R 6M1 Canada
Tel: +1 613-562-6262 ext 2954

Manisha Kulkarni, PhD
Associate Professor
School of Epidemiology & Public Health
University of Ottawa
600 Peter Morand Crescent
Ottawa, ON, K1G 5Z3 Canada
Tel: +1 (613) 562-5800 ext. 8713

Dr. Ronald Labonté
Professor and Distinguished Research Chair
School of Epidemiology and Public Health
University of Ottawa
600 Peter Morand Crescent
Ottawa, Ontario K1G 5Z3
ph: (613) 562-5800 ext.2288
cell: (613) 818-6579

Kelley Lee, DPhil, FFPH, CAHS
Professor and Canada Research Chair in Global Health Governance
Faculty of Health Sciences
Simon Fraser University
Hall Rm 10522, 8888 University Drive, Burnaby, B.C. V5A 1S6

Dr. Shree Mulay
Community Health and Humanities
Faculty of Medicine
Memorial University of Newfoundland

Dr. Zubia Mumtaz, MBBS, MPH, PhD
Professor of Global Health
Program Director, Global Health
School of Public Health, University of Alberta
3-309 Edmonton Clinic Health Academy
11405-87 Ave, Edmonton, Canada

Dr. Maisam Najafizada
Assistant Professor
Community of Health and Humanities
Faculty of Medicine
Memorial University of Newfoundland

Dr. Vic Neufeld
Associate Fellow
Centre for Global Studies, University of Victoria
Professor Emeritus, School of Medicine
McMaster University

Elysée Nouvet, PhD
Assistant Professor, School of Health Studies
Western UniversitySHSB 339
London, Ontario, Canada N6A 5B9
WHO GOARN COVID-19 Social Sciences Research working group member
Mobile/WhatsApp: +1 905 512 2620dies /

Shawna O’Hearn, PhD (ABD), MA, MSc (OT)
Director, Global Health, Dalhousie University
PhD Candidate, University of Waterloo
Lecturer, Community Health and Epidemiology, Dalhousie University
Adjunct Professor, International Development Studies, Saint Mary’s University
Past Chair, Canadian Society for International Health
902-220-6639 (cell) 902-494-1517 (office)

Alexandra Otis, MSc RD
Project Officer
Canadian Coalition for Global Health Research

Ana Sanchez, PhD
Professor (Parasitology and Global Health)
Department of Health Sciences
Brock University | Faculty of Applied Health Sciences
Niagara Region | 1812 Sir Isaac Brock Way | St. Catharines, ON L2S 3A1 | Phone 905-688-5550 Office x 4388.

Johanne Saint-Charles
Professeure – Département de communication sociale et publique
Directrice – Institut Santé et société
Codirectrice – Groupe-Réseaux
Directrice – Centre collaborateur OMS/OPS pour la santé au travail et en environnement (Cinbiose)
(514) 987-3000 poste 2081

Carlyn Séguin
Global Health Manager, College of Medicine
& Division of Social Accountability, School of Medicine, University of Sask
HSB E Wing Office 4104 – 104 Clinic Place
Saskatoon, SK S7N 5E5
Tel: 306-966-7993

Catherine Smith, RN, MSc, Doctoral Student
Assistant Professor
Faculty of Health Studies| University of the Fraser Valley
45190 Caen Avenue| Chilliwack, BC| V2R 0N3
T: 604 792 0025 EXT 2258

Julia Smith, PhD
University Research Associate | Faculty of Health Sciences
Simon Fraser University | Blusson Hall
8888 University Dr., Burnaby, B.C. V5A 1S6
T: 604 837 4285 | E:
Twitter: @juliaheather

Jerry M. Spiegel MA MSc PhD
Co-Director, Global Health Research Program,
Professor, School of Population & Public Health, Faculty of Medicine
University of British Columbia
430-2206 East Mall, Vancouver, BC V6T 1Z3 CANADA
Phone: (604) 822-1398 Fax: (604) 822-9210

Malcolm Steinberg
Director Public Health Programs | Faculty of Health Sciences
Simon Fraser University | Blusson Hall, Rm 11018
8888 University Dr., Burnaby, B.C. V5A 1S6, Canada
T: +1 778 782 8554 | M: +1 778 938 9118 |

Kate Tairyan, MD, MPH
Senior Lecturer and Adjunct Professor, Faculty of Health Sciences, Simon Fraser University
Director of Public Health,
Office: 778 782 9064 Fax: 778 782 5927 Cell: 604 671 2919
Email: ;

Jeanette Vinek BScN, MHScN, RN
Senior Instructor
Co-Chair Global Health Committee
School of Nursing | Office: Arts 178 | Tel: 250-807-8854
Faculty of Health and Social Development
University of British Columbia | Okanagan Campus |Syilx Okanagan Nation Territory
3333 University Avenue | Kelowna BC | V1V 1V7

Mary E. Wiktorowicz, MSc PhD
Professor, Health Policy and Management
Faculty of Health
York University, 4700 Keele Street
Toronto, Ontario M3J 1P3
Phone: 416 736-2100 x 22124