MBB Case: COVID-19 Vaccine

A great solution starts with great questions. Examples of relevant questions:

- Objective: does the WHO have a specific target in terms of the number of vaccine doses?

- Scope: is the scope global, or has the WHO already decided to focus on specific countries? Has a specific manufacturer/pharma company been selected, or is there scope to choose from multiple manufacturers?

- Constraints: does the WHO have a pre-defined budget to purchase and distribute the vaccines?

An excellent answer would cover the supply and demand drivers, including a governance model bringing together different stakeholders and enabling key decisions:

Supply analysis:

• Procure enough doses of safe and effective vaccines from vaccine manufacturers and allocate them fairly to the high-risk groups globally
• Distribute vaccines efficiently in the right conditions (i.e. cold storage) to avoid losses. Link different forms of transportation (e.g. plane, train, truck) to reach remote and rural communities
• Stop corrupt practices (i.e. stolen and counterfeit vaccines)
• Guarantee financial resources: subsidize vaccines for developing countries with the help of richer countries; offer incentives (e.g. tax credits) for vaccine manufacturers to reduce their profit margins, establish financing systems for low-income countries (e.g. payment in installments) and co-participation (population pays for part of the vaccine costs)
• Streamline the regulatory approval process: faster approval without compromising safety and efficacy

Demand analysis:

• Estimate the size of the target population: total number of people in high-risk groups globally
• Increase compliance rates: ensure the population is well informed about vaccine benefits and risks; fears and concerns are addressed
• Set-up tracking systems: integrated systems to track who has taken the vaccine

Governance structure:

• Develop a governance model bringing together the relevant stakeholders ensuring key decisions (e.g. vaccine selection, allocation, financial planning, and resource sharing) are made effectively

Answers need to be specific to the client (e.g. the WHO). The candidate may be tempted to do a full cost analysis of vaccine development (e.g. R&D, facilities, raw materials, labor, distribution, etc), which would have been relevant if the client was a vaccine manufacturer. The WHO would be most interested in the cost/dose of vaccines (purchased directly from the manufacturers), and distribution costs. Although distribution costs could in reality be shared between manufacturers and the WHO, we will assume the WHO will cover them.

Top strategy firms love hypothesis-driven thinking. As the candidate explains the framework, expect a few strong hypotheses for the key drivers. Hypotheses must be specific to the problem and connected to the client's goal. Some examples:

• Vaccine demand: it is important to shape public perception to increase compliance rates as vaccination campaigns only work if a high percentage of the total population takes the vaccine
• Financing: it is likely that many poorer countries cannot afford the vaccine, so richer countries may need to contribute with a bigger share
• Vaccine supply: collaboration between multiple vaccine manufacturers (or choosing multiple vaccines if possible) may be needed given the urgency to produce and distribute a large number of doses on a global scale in a short period of time
• Governance: to achieve its objectives, the model needs to bring the right stakeholders to give the right input at the right time, with enough oversight to ensure decisions are aligned towards a common goal

After the structure, verbally communicate the information below, followed by Exhibit 1.

The WHO has assembled a task force called COVAX, which brings together governments, global health organizations, vaccine manufacturers, universities, the private sector, and civil society. The COVAX has four objectives:

• Map demand from high-risk groups globally
• Select the best vaccines taking into account clinical data, manufacturing capacity, and costs
• Plan vaccine distribution to ensure fair allocation across different countries
• Define financing schemes, pooling funds from wealthier nations to support poorer ones

In order to achieve its goals, COVAX has established the governance model shown in Exhibit 1. After analyzing the model, please answer the following question: what are the strengths and weaknesses of the COVAX governance model?

An excellent answer should highlight the high complexity of the governance model, and some of its pros and cons:

Pros:

• Fairly comprehensive and relevant in terms of roles and functions, including input from technical experts
• Broad oversight provided by a dedicated Office and board
• Stakeholders from different sectors

Cons:

• High complexity. Relies on the interconnection between different groups working really well. Operational bodies have to work efficiently to ensure the different groups provide the right input to each other and actions are aligned towards a common goal
• Task duplication. (e.g. operations are overseen by multiple bodies; vaccine portfolio decisions are made both by the COVAX office and the technical advisory body). The Technical advisory body and the Allocation governance could be merged into one as they deal with very interconnected decisions (i.e. vaccine selection and allocation). Task duplication may result in members not completing tasks as they may think another group will complete them instead
• Vaccine compliance is not considered as part of the selection and allocation process
• Low or no representation from low-income countries

An effective communication strategy should:

• Consider the background level of scientific literacy when explaining terms such as efficacy, safety, and the importance of population-wide coverage
• Avoid suggestions of enforcement
• Choose channels (e.g. TV, radio, social media) according to local preferences
• Ensure social media companies are held accountable for spreading misleading information
• Address community-specific concerns (e.g. elderly people may be afraid to go to public places so could administer vaccines at their homes instead)
• Involve leaders of civic, religious, and fraternal organizations
• Leverage impartial and well-regarded NGOs such as the Red Cross and Doctors without Borders
• Be sensitive to religious or philosophical beliefs

Alternatives to make the 2.1 billion doses

At this point, the candidate should have concluded that no single vaccine meets the safety and efficacy criteria AND is capable of producing all the required 2.1 billion doses.

No single vaccine simultaneously meets safety and efficacy criteria and is capable of producing all 2.1 billion doses. As a result, we could explore two options:

Option 1: Source from more than one vaccine manufacturer (e.g. vaccines E and B):

• Vaccine E: the preferred choice as it meets clinical goals, is cheapest, and can produce the highest number of doses (1.8 billion) out of the clinically acceptable vaccines
• Vaccine B: clinically equivalent to E and the second cheapest.
• Ideally, the WHO would purchase 1.8 billion doses of vaccine E and the remaining (0.3 billion) of vaccine B. In reality, producing a vaccine involves very high fixed costs (e.g. R&D, facilities, equipment) so the manufacturers of vaccine B would probably require the WHO to commit to a larger quantity to make it financially viable

Option 2: Increase production of vaccine E:

• Further investment (e.g. new facilities). Vaccine E may deploy resources to increase capacity and may ask the WHO to take some of the shares. As a result, we need to analyze the trade-off between the cost of new investments and savings from using Vaccine E (the cheapest on a per-dose basis). It is likely that the incremental savings from the 0.3 billion doses do not offset new investments. However, this could change if Vaccine E is rolled out beyond high-risk groups (e.g. to healthy people) so more units would be needed
• Tech transfer: other manufacturers transfer technology royalty-free/for humanitarian reasons to make Vaccine E’s production faster. Governments could offer incentives (e.g. tax credits) for companies to tech transfer

What are the strengths and weaknesses of the scoring system? Would you add or remove any parameters?

The candidate needs to do a weighted average taking into account the weight and the scores for each parameter:

Therefore country B should take priority.

Interpretation of the scoring system:

Strengths:

• Most parameters (Rt, healthcare system infrastructure and occupancy and % of high-risk groups) are relevant

Weaknesses:

• Although it is important to capture a country's development (e.g. people living in crowded conditions are more likely to spread the infection), the Hemisphere location is not the best measure (e.g. New Zealand is in the southern hemisphere but is very developed). Can be replaced with indicators such as GDP per capita, Human Development Index (HDI), etc
• Could introduce an indicator to measure the level of comorbidities (i.e. underlying health complications that lead to worse outcomes from COVID-19) in the population.

An excellent candidate would start with a small recap of the objective:

"In order to meet its goal to provide enough doses of safe and effective COVID-19 vaccines to high-risk groups globally in the next six months, the WHO should..."

A great candidate would provide an answer-first approach to the question, highlighting three main actions:

In order to deliver 2.1 billion doses of COVID-19 vaccines, the WHO should work on three fronts: improve compliance rates, streamline its governance model, and choose the best combination of vaccines:

1. Improve compliance through public campaigns that target global and local drivers of resistance and misconception around vaccines

2. Streamline its governance model through a simpler and more inclusive model to make decision making more effective and ensure fair allocation of doses

3. Choose the right combination of vaccines by undertaking a full cost and capacity analysis to determine whether to combine Vaccines E and B, or to increase the capacity of Vaccine E, working closely with vaccine manufacturers throughout the process

Supply:

• Vaccine manufacturers do not deliver on their production targets, and/or different manufacturers do not share best practices to ramp up production
• Distribution: high losses; distribution in remote areas is challenging; poor infrastructure to deliver the vaccines
• Funding: issues in getting the funds needed, especially if richer countries decide not to take a share of the poorer ones

Demand:

• Poor compliance: public opinion can shift dramatically towards resistance to vaccination
• Challenges in tracking populations, especially in developing countries, as a significant proportion of the population lack formal IDs

Governance:

• Vaccine nationalism: poor cooperation; countries sign unilateral agreements with vaccine suppliers to secure their own supplies, leaving poor nations to miss out

Final remarks

Thank you for completing my case! I hope you enjoyed it and learned as much as I did putting it together :)

Do you have any feedback or questions on the case or on your preparation? Feel free to reach out!

Wish you all the very best in your preparation,

Bernard