In his opening speech to address the United Nations General Assembly in September 2021, Secretary General António Guterres expressed stark discontent with the highly unequal global distribution of COVID-19 vaccines: “A majority of the wealthier world is vaccinated. Over 90 percent of Africans are still waiting for their first dose. This is a moral indictment of the state of our world. It is an obscenity” (United Nations Secretary-General, 2021). At the time of writing, and a year after Guterres gave his speech, 80% of the citizens of low-income countries are still waiting for their first dose of a COVID-19 vaccine, whereas in high-income countries, almost 80% of citizens are vaccinated. While the initial sense of urgency at the onset of the pandemic may have passed, this blatant inequity in access to COVID-19 vaccines prevails, continuing also throughout the more recent booster campaigns: In the past 12 months, the total number of vaccine doses administered per 100 people amounts to almost 100 in high-income countries and to only 27 in low-income countries (Mathieu et al., 2021; Our World in Data, 2022). It therefore also seems likely that we will observe this same pattern again with the new Omicron-specific vaccine.

Achieving high COVID-19 vaccination rates globally is imperative for three reasons. From an ethical perspective, unequal access to vaccination leads to high rates of transmission, severe infections, and deaths in those parts of the world where health care capacity is the lowest. This aggravates existing health inequities between the Global South and North (Godlee, 2021; Katz et al., 2021; Krause et al., 2021; Wagner et al., 2021). In addition, achieving a more equitable vaccine distribution would have utilitarian benefits: A recent modeling study compared two hypothetical scenarios – one in which the 50 richest countries used all available vaccines and one in which vaccines were allocated to all countries proportionally to their population size – finding that the former scenario would lead to twice as many COVID-19 deaths (Herzog et al., 2021). Second, there are compelling economic arguments in favour of equitable vaccine distribution: The RAND Corporation estimates that constrained access to COVID-19 vaccines in low- and middle-income countries (LMICs) would reduce the global GDP by US$ 153 billion each year, including a loss of US$ 56 billion in the European Union and United States combined (Hafner et al., 2020). Put differently, every US dollar spent on supplying vaccines to LMICs would yield a return of US$ 4.8 (Hafner et al., 2020). Third, alleviating global asymmetries in COVID-19 vaccine coverage is warranted for virologic reasons. Unmitigated COVID-19 transmissions in some parts of the world create evolutionary reservoirs from which new SARS-CoV-2 variants arise, increasing the risk of immune escape - for both vaccine-induced and natural immunity - and of other phenotypic changes that could lead to greater virulence (Saad-Roy et al., 2021; Telenti et al., 2021; van Oosterhout et al., 2021; Wagner et al., 2021). As WHO Director General Tedros Adhanom Ghebreyesus put it: “none of us will be safe until everyone is safe” (WHO Director General, 2022).

The globally unequal distribution of COVID-19 vaccines, including the stockpiling of vaccine doses for their own citizens, is partly a consequence of widespread vaccine nationalism in high-income countries (Harman et al., 2021; Herzog et al., 2021; Wagner et al., 2021). To ensure ‘fair and equitable access’ to COVID-19 vaccines for all countries and achieve high vaccination rates everywhere, the WHO, the Vaccine Alliance (Gavi), and the Coalition for Epidemic Preparedness Innovations (CEPI) formed a multilateral initiative named ‘COVID-19 Vaccines Global Access’, COVAX (Herzog et al., 2021). However, several governments have resorted to making bilateral purchasing agreements with vaccine manufacturers outside of COVAX, which has substantially weakened the initiatives’ collective purchasing power (Kim, 2021; Wouters et al., 2021). Moreover, out of those vaccine doses that were initially announced as donations to COVAX by high-income countries, substantial proportions – 25% of announced EU doses and almost 50% of announced US doses – have in fact not yet been donated (WHO ACT-Accelerator Hub; Our World in Data, 2022; Mathieu et al., 2021). The WHO’s pledges for a more equitable COVID-19 vaccine distribution have thus still not been fulfilled.

Decision-makers in high-income countries are likely to exhibit vaccine nationalism and refrain from vaccine donations if they believe there is little public support for giving COVID-19 vaccines to poorer regions of the world (Clarke et al., 2021). Thus, governments will likely only donate vaccines or actively participate in international vaccine alliances such as COVAX if they do not expect to pay a price at the ballot box. A thorough understanding of public preferences for the global distribution of COVID-19 vaccines is therefore paramount.

Recent empirical literature has explored public preferences for the allocation of COVID-19 vaccines. A majority of these studies examined public opinion on prioritisation within high-income countries and when COVID-19 vaccine availability was still heavily constrained in those countries (Duch et al., 2021; Gollust et al., 2020; Knotz et al., 2021; Luyten et al., 2020; Persad et al., 2021; Reeskens et al., 2021; Sprengholz et al., 2021). Based on data from online surveys and survey experiments, the studies revealed substantial public support for prioritising frontline healthcare workers and clinically vulnerable groups (Duch et al., 2021; Persad et al., 2021).

To our knowledge, only four studies to date have examined individuals’ preferences on the distribution of COVID-19 vaccines across national borders (Clarke et al., 2021; Guidry et al., 2021; Klumpp et al., 2021; Vanhuysse et al., 2021). One online survey conducted in seven high-income countries found that around 50% of participants generally supported global allocation schemes that would give priority to the countries that could not afford to purchase vaccines (Clarke et al., 2021). Another survey conducted in the US found that 40% of respondents were in favour of donating at least 10% of the nationally purchased vaccines to poorer countries. Support was less pronounced among older respondents – a group that is at greater risk of severe disease progression if infected (Guidry et al., 2021).

A survey conducted in Germany asked participants to choose between different options for international agreements and alliances on the distribution of COVID-19 vaccines, which varied by (i) countries joining the agreement, (ii) distribution rules, and (iii) cost per German household. The authors found that participants displayed a strong preference for an alliance exclusively composed of EU states. More importantly, the authors found that participants were more supportive of vaccine alliances if the national cost of participation was lower and national vaccine coverage higher, suggesting that participants’ preferences were significantly shaped by self-interest (Vanhuysse et al., 2021).

In contrast, in a discrete choice experiment conducted in Germany and the US, participants in both countries expressed a strong preference for prioritising vaccine allocation to countries with a higher number of COVID-19 deaths and fewer intensive care unit beds, even when they were asked to imagine that they or a vulnerable family member were still waiting for the COVID-19 vaccine (Klumpp et al., 2021). Notably, no previous study to date has exclusively sampled participants who were still waiting for their first COVID-19 vaccine dose when participating in the survey experiment.

In this paper, we analyse new experimental evidence from six EU countries on citizens’ preferences for the distribution of COVID-19 vaccines between the Global South and North. We advance the literature in three ways. First, by covering six countries, we implement the largest survey experiment on international vaccine allocation preferences to date and are thus able to examine differences in citizens’ preferences across EU member states. Second, we conduct a discrete choice experiment among participants who are themselves not yet vaccinated, asking them to allocate a COVID-19 vaccine to either a person in their own country or to a person in a country in the Global South. This places specific salience on the notion that donating a vaccine dose to a person in the Global South might mean sacrificing one’s own dose or that of a fellow citizen, thus leveraging self-interest-based and nationalistic considerations. Third, we specifically examine heterogeneity in participants’ preferences along key sociodemographic characteristics as well as in terms of regional COVID-19 case numbers. Policymakers can use these insights to anticipate which groups will be most supportive of vaccine donations and might thus be at the heart of a supporting coalition - and to which groups political leaders, epidemiological experts, or civil society groups might still need to provide better information about the benefits for the donating country.

In our DCE conducted online in six EU countries, we found widespread global solidarity and support for a more equitable distribution of COVID-19 vaccines between the Global North and South. Our results suggest that vaccine allocation preferences are largely driven by the assessed vulnerability of possible recipients, irrespective of whether the recipient lives in the respondents’ own country or in the Global South. Our respondents – who are themselves not yet vaccinated against COVID-19 but do favour vaccination – appear to rely upon the same solidarity considerations when deciding how vaccines should be distributed within a country and between countries. For example, they prioritise the candidate with the higher mortality risk but a foreign nationality over the candidate with a lower mortality risk but with the same nationality.

Interestingly, we found that respondents apply similar vulnerability considerations with regards to a candidate’s employment status. Specifically, employed candidates who endured income losses due to the pandemic were significantly more likely to be chosen to receive the vaccine compared to candidates not employed. Thus, respondents seem to prioritise vaccine receipt according to the extent at which a candidate’s employment status – and income generation – is affected by the pandemic situation. This is a finding, which, to the best of our knowledge, has not yet been identified explicitly by any of the other studies examining vaccine distribution preferences.

Importantly, we find that in a situation of vaccine scarcity and all else being equal, respondents from Spain, Italy, France and Sweden would prefer to allocate the vaccine to a person living in a country in the Global South with a worse health care system, as opposed to a person living in their own country of residence. We thus confirm the findings of the studies of citizens’ distributional preferences that – in the context of previous pandemics – revealed largely positive attitudes towards vaccine donations to poorer countries (Kumar et al., 2012; Ritvo et al., 2013) and showed in experimental games that individuals (i) follow egalitarian motives in their own decisions (Dawes et al., 2007) and (ii) are even willing to punish third parties for inegalitarian behaviour (Fehr and Gächter, 2002). Yet, we go beyond previous studies by showing that such support for allocating vaccines to low-income countries with low healthcare system capacity holds across European countries from Spain to Sweden, even among respondents who had themselves not yet gotten vaccinated, and in the context of a pandemic with truly global reach, which by the time when we conducted our experiments had lasted for well more than a year.

At the same time, our DCE findings were inconclusive for the Polish and diverged for the German respondents: German survey participants were significantly less willing to allocate the COVID-19 vaccine to a person living in the Global South than to a person living in their own country, thus revealing preferences consistent with vaccine nationalism.

There are several possible explanations for the strikingly contrasting findings in Germany. First, studies have repeatedly found in-group bias (or here: national bias) in distributional preferences (Bernhard et al., 2006; Reese et al., 2012; Yudkin et al., 2016). Such in-group bias might explain why German respondents prioritise, within their own country, candidates who are more vulnerable, for example due to facing higher COVID-19 risks, but not to candidates who are more vulnerable due to living in the Global South, if German participants had more nationalistic preferences, lower altruism, or less pro-social attitudes than participants from the other five European countries. We lack the data to test this possible explanation directly, but it seems unlikely: several cross-country analyses investigating nationalism, patriotism, and xenophobia have found German citizens to be among the least nationalistic in Europe (Coenders et al., 2021; Lubbers and Coenders, 2017). German citizens also do not generally appear to be outliers among their European peers in terms of altruism or similar pro-sociality variables (Fehr et al., 2021).

Second, respondents might have been influenced by heterogeneities in the pandemic situation across countries. In Germany, our experiment was implemented as the third pandemic wave peaked, whereas in the other countries, our DCEs were launched two months later, during a phase of relatively low daily case numbers. German respondents might therefore have felt a greater urgency about having faster access to vaccination. The evidence for this explanation is mixed, as our data does not show evidence of a substantially higher reported COVID-19 threat perception among German respondents (see Supplementary file 1l and Figure 1—figure supplement 1). Nevertheless, results from our subnational heterogeneity analysis provide some support for this explanation by suggesting that respondents residing in regions with a higher COVID-19 incidence rate during the time of data collection showed on average relatively less support for distributing the vaccine to a candidate from the Global South. Interestingly, this heterogeneity partly exhibits a quadratic functional form: respondents’ support for distributing vaccine doses to the Global South slightly increases with COVID-19 case numbers in the lower parts of its distribution (<100 cases/100,000 people), but then more strongly decreases in the upper distribution, leading to an overall small, though highly statistically significant, negative interaction effect, which points to a decline in vaccine solidarity with low-income countries.

Third, the findings could be a function of the differences in the timing of the surveys relative to the progress of national vaccination campaigns. A recent survey experiment found that individuals with a higher perceived rank in the global income distribution feel stronger pressure to donate (Fehr et al., 2021). Extrapolating this dynamic to the context of our study, we might expect to see a higher individual inclination for vaccine donations in countries where the (perceived) vaccination rate is high by international standards. When the survey was fielded in Italy, France, Spain, Poland, and Sweden, the vaccination rate in those countries exceeded 50% (30%) for first (second) doses, whereas in Germany it was only at 25% (8%) (see Supplementary file 1l). This difference in domestic conditions may have affected the perceived scarcity of the COVID-19 vaccines between countries and the normative assessment thereof. In addition, the differential vaccination roll-out was likely also the reason for having been able to include a much higher proportion of older as well as high-medical-risk respondents in the German sample. Our separate heterogeneity analysis for Germany shows that especially the larger proportion of older respondents and high-risk respondents (the former more so than the latter), in combination with the German sample having a higher proportion of lower educated respondents, may have resulted in the lower global vaccine solidarity among German respondents (see Figure 2 and Supplementary file 1d).

In view of the above, the differential findings for Germany are most likely driven by a combination of (i) higher infection and (ii) lower vaccination rates at the time of the German data collection and (iii) a higher proportion of older, high-risk and lower educated respondents in the German sample. While we are able to provide empirical support in favor of (i) and (iii), our analysis did not allow for any in-depth investigation of (ii), not least due to a lack of publicly available data on subnational vaccination rates for some of the countries.

A number of limitations are worth noting. First, in addition to the cross-country differences in COVID-19 infection and vaccination rates discussed above, participants’ preferences may partly also be driven by cross-country variation in the pandemic trajectory over time. Given that our study utilises only cross-sectional survey data, we are not able to empirically examine any changes in public perceptions regarding the pandemic over time. Yet, the pronounced temporal nature of the pandemic needs to be kept in mind when reflecting on our findings. This includes, for instance, (i) notions of scarcity in the early phases of the vaccination campaigns, which may have affected perceptions about their value, (ii) a potential erosion of public trust during the suspension of the AstraZeneca/Johnson&Johnson vaccines, and (iii) increases in conspiracy beliefs related to vaccination through increasing spread of misinformation via social media channels (Steinert et al., 2022). More generally, however, citizens’ overall assessment of the pandemic situation likely varies strongly with the various stages of the pandemic, which we are at least partly able to capture by exploiting the different timing of our survey launches and thus some country (and regional) differences in infection rates at the time of data collection. Second, on an individual level, there may be additional characteristics that explain approval or rejection of COVID-19 vaccine donations but were not captured in all six countries, including (1) nationalistic attitudes, (2) altruistic preferences, or (3) migration background. Third, our analysis points to a number of predictors of variation. However, they are not susceptible to experimental manipulation and should therefore not be interpreted as causal. Fourth, at the country level (except in Germany), we were not able to achieve our initial target sample sizes due to budget constraints; sample sizes therefore also varied across countries. We surely have adequate statistical power in the pooled analysis, but with the exception of Germany might have insufficient statistical power in the country-specific heterogeneity analyses. Findings indicating, for some countries, a lack of statistical significance at conventional levels should therefore be interpreted with caution. That said, since we find statistically significant effects of the main attributes in all countries except from Poland, lack of statistical power might have been less of a concern in the main-effects analysis. Finally, as a consequence of the two eligibility criteria of (1) not yet having been vaccinated against COVID-19 and (2) being willing to get vaccinated, our samples are not nationally representative of the population profile of each country (compare Table 1 with the census data in Supplementary file 1a). However, since we initially sampled participants based on quotas that were matched to the census population of each target country in terms of gender, age, education, and geographic location, our samples should be representative of each country’s unvaccinated and willing-to-get-vaccinated population at the time of the data collection regarding these quotas. In view of this, our suggested estimates of citizens’ support for global solidarity in distributing the COVID-19 vaccines are most likely lower bound estimates – assuming that already vaccinated citizens and those less interested in getting vaccinated would be even more willing to donate vaccine doses to the Global South.

Policymakers and global health scholars have condemned the unequitable distribution of COVID-19 vaccines between high- and low-income countries as ‘vaccine apartheid’ (Gonsalves and Yamey, 2021; Harman et al., 2021). Still, the World Health Organisation’s call for a moratorium on COVID-19 booster vaccinations in high-income countries in favour of prioritising first dose vaccinations in low-income countries went unheeded, at least in part out of a sense that donating vaccines to countries in the Global South lacks popular support and might even subject the government to electoral punishment (Krause et al., 2021). The emergence of the Omicron and its various subvariants throughout 2022, as well as ongoing concerns about potential future variants, emphasise once again the transboundary nature of the COVID-19 pandemic. Acknowledging this characteristic of pandemics, governments in high-income countries should discard mitigation strategies that are guided by the premise of vaccine nationalism (Vanhuysse et al., 2021). Findings from our study suggest that governments of European countries can rely on solid public approval for a more equitable vaccine distribution – especially among female, younger and more educated citizens. Public support for vaccine donations to the Global South may be even more pronounced at the time of writing, since COVID-19 risk groups have now already received their first (or even second) booster vaccination. Moreover, our finding regarding prioritising candidates according to employment status, and particularly potential income losses, may also indirectly point to a pronounced public support for vaccine donations to the Global South: Employment security is much lower in low- and middle-income countries, especially in view of the high share of workers in the informal sector, where substantial income losses are more likely to occur during a lockdown or pandemic-induced economic downturns. More effective international policy initiatives to ensure efficient, adequate, and timely COVID-19 vaccine transfers to low-income countries are therefore urgently needed. They likely remain highly relevant and timely in view of the ongoing development of new, variant-specific vaccine updates such as those for the Omicron variant.

All data generated or analysed during this study are made publicly available via the Open Science Framework under the following link: https://osf.io/72jrq/.

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Author details

1. Janina I Steinert

   Hochschule für Politik/Munich School of Politics and Public Policy, TUM School of Social Sciences & Technology and TUM School of Medicine, Technical University of Munich, Munich, Germany

   Contribution

   Conceptualization, Data curation, Supervision, Funding acquisition, Validation, Investigation, Visualization, Methodology, Writing – original draft, Writing – review and editing

   Contributed equally with

   Henrike Sternberg

   For correspondence

   janina.steinert@tum.de

   Competing interests

   No competing interests declared

   "This ORCID iD identifies the author of this article:" 0000-0001-7120-0075

2. Henrike Sternberg

   TUM School of Social Sciences & Technology, Technical University of Munich, Munich, Germany

   Contribution

   Conceptualization, Data curation, Formal analysis, Validation, Visualization, Methodology, Writing – original draft, Project administration, Writing – review and editing

   Contributed equally with

   Janina I Steinert

   Competing interests

   No competing interests declared

   "This ORCID iD identifies the author of this article:" 0000-0001-8539-6478

3. Giuseppe A Veltri

   Department of Sociology and Social Research, University of Trento, Trento, Italy

   Contribution

   Conceptualization, Funding acquisition, Investigation, Methodology, Writing – review and editing

   Competing interests

   No competing interests declared

   "This ORCID iD identifies the author of this article:" 0000-0002-9472-2236

4. Tim Büthe

   Hochschule für Politik/Munich School of Politics and Public Policy and TUM School of Social Sciences & Technology, Munich, Germany

   Contribution

   Conceptualization, Supervision, Funding acquisition, Methodology, Writing – review and editing

   Competing interests

   No competing interests declared

   "This ORCID iD identifies the author of this article:" 0000-0002-4724-5000

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