Transforming trade for vaccine equity: Policy gaps and barriers.

The ongoing Pandemic Agreement negotiations illustrate significant gaps in action required to respond effectively to the lessons of the COVID-19 pandemic and make progress towards public health goals, including Sustainable Development Goals (SDGs). The pandemic revealed vaccine equity as a unifying health need, and international trade as a Commercial Determinant of Health. We explored where policy action could reshape trade relationships, identifying recommendations for vaccine equity within stakeholder literature pertaining to Free Trade Agreements (FTAs). We searched online libraries for stakeholder documents that focused on the interface between FTAs, vaccination, and vaccine equity published between 01/01/2010-31/03/2022. Our analytic framework drew from the rights, regulation, and redistribution (3R) framework, combined with systems analysis, using leverage pointsto categorise recommendations as Technical Mechanisms, Collaborative and Adaptive Mechanisms, or Determinants of Vaccine Equity (DVE). These were then located on a novel systems map to elucidate gaps and actions.No cohesive strategies for change were identified. Technical proposals were reactive, repetitive, and lacked enforcement mechanisms or incentives. There were significant gaps in the articulation of alternative Collaborative Mechanisms to democratise FTA policymaking processes. The underlying DVE and lack of policy coherence were not addressed. These findings are limited by under-representation of low- and middle-income country authorship in the studies, including in ours, reflecting imbalances in international research and policymaking processes. Overall, our research shows how the current trade paradigm has produced and sustained vaccine inequity. We propose potential pathways for action but highlight the importance and urgency of more fundamental change in negotiation and implementation of FTAs. New technologies will be crucial for the global response to emerging, neglected, and non-communicable diseases that are vaccine-preventable or -modifiable. Multilateral organisations must, therefore, prioritise the right to health above FTAs, including through TRIPS waivers on Essential Technologies.