Introduction The recent 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 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 in stakeholder literature pertaining to Free Trade Agreements (FTAs). Methods 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. Using the rights, regulation and redistribution (3R) framework, recommendations were categorised as Technical Mechanisms, Collaborative and Adaptive Mechanisms, or Determinants of Vaccine Equity. These were then located on a novel systems map to elucidate gaps and actions. Results 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 Determinants of Vaccine Equity and lack of policy coherence were not addressed. These findings are limited by under-representation of low- and middle-income country authorship, demonstrating deep institutional and methodological barriers to change, and reflecting imbalances in international policymaking processes. Conclusion Overall, our research shows how the current trade paradigm has produced and sustained vaccine inequity, leading a synthesis of action proposals. Transformation of FTA policy is essential and urgent, particularly since 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 serving corporate over community interests, including through TRIPS waiver on Essential Technologies.

TP is Visiting Research Fellow at the Global Health Academy University of Edinburgh and conducted this work alongside a Regenerative Economics MA at Schumacher College University of Plymouth. He is a member of Peoples Health Movement (PHM) Scotland and Universities Allied for Essential Medicine (UAEM). He is employed as a research consultant through MetaVirology. In receipt of funding from the International Treatment Preparedness Coalition (ITPC) for Access to Medicines related projects associated with the Make Medicines Affordable Campaign, not including this work. This research does not necessarily describe the views of any of the above organisations. AKM is the link between the Usher Institute, University of Edinburgh and the Association of Schools of Public Health in the European Region. She is a member of the Public Health Emergencies Task Force and Chair of the Vaccination Sub-Group. She is an ASPHER member of the World Federation of Public Health Associations NGOs for Equity. a link with their Vaccination Group and a member of the International Association of Public Health Institutes Inequalities Thematic Committee. She is a member of the SPECTRUM research consortium (Shaping Public Health Policies to Reduce Inequalities and Harm) which focuses on the Commercial Determinants of Health and Health Inequalities but is not funded by the Consortium. She is a research member of the NHS Scotland Public Benefits and Privacy Panel and National Records of Scotland NHS Central Registry Stakeholder Advisory Group. She is Co-Chair of the Faculty of Public Health Europe Special Interest Group and a member of the Faculty of Public Health Global Health Committee. Invited lectures to other academic and learned institutions over the past 3 years have been unpaid. MK is a professor at Tampere University. She is member of Physicians for Social Responsibility Finnish Association for social medicine. She is a member of the Finnish Medical Association. EUPHA. Health Action International network and other international networks promoting health policy analysis. Health in All Policies. and rational use of medicines. She has prior experience in analysis of trade agreements and health for Finnish public authorities and has provided expert views for public health-related national and international nongovernmental organisations and groups. She is currently co-director of the WHO Collaborating Centre on Health in All Policies and Social Determinants of Health in Tampere University Finland. Her work for WHO includes advice on health in all policies and social protection. She has received consulting fees through the expert advisory mechanism for providing advice to Finnish Ministry for Foreign Affairs. Some of the invited lectures to other academic and learned institutions are paid at standard rates (<500 EUR) and are part of taxed income. LG is an Assistant Principal at the University of Edinburgh with a remit for Global Health. She is professor of Global health and Development and Director of the Global Health Academy. She is a fellow of the Edinburgh Futures Institute and Deputy Dean International Royal College Physicians Edinburgh.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The work has benefited from a research project funded by the Research Council of Finland, Grant no. 357101.

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