1. 9/5/2013
UNICEF: the equity agenda
and vaccines
Rockville
5 September 2013
Planning for Adult Vaccination in Middle and Low Income Countries,
HIV, TB, and Malaria Workshop
Thomas O’Connell, UNICEF NY
Significant progress toward
MDG 4, but we’re fast
approaching 2015: opportunity to
accelerate progress towards MDG
4 and sustain the momentum
beyond 2015
Despite significant progress,
challenges remain – variable
progress across regions,
populations, and specific causes of
mortality requires targeted, highimpact interventions
New data insights, effective
technologies, and country
innovations enable a sharper,
more strategic focus on the
countries, diseases, and populations
with the highest burden of under-five
mortality
1

2. 9/5/2013
Deaths among children under 5 globally;
19,000 die every day from preventable causes
18%
1%
2%
2%
35%
5%
7%
11%
Annual U5 deaths
18%
2000
2010
•12.4 M
7.6 M
Specifying mortality impacts of inequity...
and hence key interventions for scale up
Under Five Mortality Rate (per 1000 Live Births) in Nigeria
250
200
21.6
4.9
36.7
150
Others
6.6
Injuries
AIDS
56.3
Pneumonia
100
8.8
50
50
13.9
Measles
Malaria
22.1
11
40.7
Diarrhea
26.9
Neonatal
0
Poorest wealth quintile
Nigeria: Nigeria Q1
Nigeria: Nigeria Q5 (richest)
Richest wealth quintile
2

3. 9/5/2013
Multiple causes of deprivation (inequity)
E.g. Wealth, education, geographic location, and gender inequity in Nigeria
14
Ukraine
Average number of years of schooling
12
10 years
Rural
Cuba
10
9.7 years
Richest 20%
Bolivia
Indonesia
8
Urban
10.3 years
Rich, rural boys
Rich, urban boys
Rich, rural girls
Boys
Girls
Honduras
Nigeria
6.7 years
6
Urban
6.4 years
Cameroon
Bangladesh
Poor, urban boys
4
Education poverty
Poorest 20%
3.5 years
Chad
Rural
3.3 years
2
Poor, rural girls
2.6 years
Extreme education poverty
C. A. R.
0
Source: SOWC 2012
Rural Hausa
0.5 years
Poor, rural Hausa girls
0.3 years
Identifying where deprived populations live
Using district level coverage and outcome “tracers” to identify key districts
Childhood immunization and nutritional status (%), Uganda
100
90
88
79
80
79
73
69
70
68
60
56
50
40
34
30
20
% Full Immunization Coverage
(12-23 months)
54
50
25
20
13
16
11
24
16
% Underweight Children
(6-59 months)
11
10
0
District
3

4. 9/5/2013
Shifting the curve: Hib vaccine introduction
Acting upon the data collected –
Three strategies to shift the curve, and narrow equity gaps
Reorienting towards pro-equity
delivery and demand
Narrowing the equity gaps
3. Legislation &
Policy changes
2. Demand
Empowerment
1. Delivery
system
Source: The Lancet 2012; 380:1341-1351 (DOI:10.1016/S01406736(12)61378-6)
8
4

5. 9/5/2013
Shifting the curve: new products, policies and knowledge
Vaccines are essential to equity and child survival
Opportunity
Unprecedented global support to introduce additional vaccines that target the
greatest killers, which are increasingly concentrated in the poorest, most
marginalised groups
Mobilised vaccine industry
Strong partnership forums , in particular GAVI Alliance Partners
Challenges
Countries face increased financial burden: higher priced vaccines & increased GAVI
Alliance co-financing requirements
Delivery and logistical challenges as fragile infrastructures are further challenged
by more vaccines
Fragile vaccine industry and constrained supply for most vaccines
Competition from other priorities for limited funding
UNICEF has a key role in vaccine procurement, procuring immunization
supplies on behalf of around 100 countries annually
Vaccines Supplies: US$ 1, 053 million
2012
1.895
billion doses
1,946
shipments
Source UNICEF Supply Division
Immunization Supplies
Vaccines
BCG , DTP, TT/Td/DT, Measles
containing, OPV, HepB, YF,
DTP-HepB, DTP-HepB/Hib,
DTP/Hib, Hib, MR, Meningitis,
MMR, PCV, RV IPV, etc.
Safe Injection equipment
Cold Chain Equipment
Countries UNICEF procures
on behalf of
Full schedule
Partial schedule
Source: 2012 country forecasts received by UNIICEF
5

6. 9/5/2013
UNICEF annual vaccine procurement has increased significantly since
2000 supporting UNICEF Programmes and on behalf of Partners,
Global Programmes, Governments and NGO’s
Recent increases in value driven by new
vaccine introduction
PCV
2010: de
Decrease due to price reductions and India selfself-procurement (OPV), supply shortfalls
OPV
Campaign Activities (Polio, Mea), New
vaccine introduction (GAVI) Price
increases, Boosting routine activities
Penta
The arrows indicate the main programme drivers for the increased procurement value.
Source UNICEF Supply Division
Vaccine Production:
highly regulated and complex, with inherent risks
Product/ Production Profile
Impact
Biological products
Significant risks of production failures; require
multiple suppliers
Quality is the OVER-RIDING criterion
Only WHO pre-qualified vaccines procured;
requiring significant investment and
continuous oversight. Limits the supply base
Highly regulated production
environment
New regulatory requirements can cause
interruptions
Dependency on well functioning NRA Outside of the control of the manufacture –
risk; requires a diverse supplier base
Limited shelf life
Quantity and Timing of Forecasts is key
Temperature controlled storage
requirements
Requires to be maintained through to delivery
to the child.
6

7. 9/5/2013
UNICEF’s procurement strategies seek Vaccine Security:
sustained, uninterrupted supply of affordable vaccines, of
assured quality.
Number of
qualified
suppliers
Supply
interruptions
Price
Major
Dependencies
Pipeline
Availability vs
Demand
UNICEF SD develops strategies to achieve healthy market
objectives within each diversified market situation
•
Increasing complexity within procurement as new products become
available
•
Competition with high-income markets for production allocation
•
Demand reacting to changes and developments in immunization
programmes, vaccine development and funding speculation
•
Country preferences on presentation and formulation
•
Requires balancing with financial sustainability
•
Need for increased flexibility on tendering strategies, maintaining long
time horizons and providing for market flexibility
7

8. 9/5/2013
Pentavalent vaccine supply has been impacted by a number of supply
interruptions, impacting supply availability and resulting in multiple
low volume shipments to maintain supply across all countries
Forecast
Supply start
De-listing
Suspension
Each instance requiring: Work with WHO QSS, close follow up with manufacturer, work with countries affected or planned ot be supplied from the
interruptions, contingency modeling and planning; internally, with countries and with partners. Communication to market and organization, prepare
press responses etc.
Continued fragile market; since 2010, 2 manufactures with pentavalent vaccines have had their vaccines delisted and 2 new manufactures have
entered with new pre-qualified vaccines. Good response from other suppliers to meet the gaps
Has taken a toll on countries – changes in vaccines, shipment-plans, depleting country stocks
Important: while disruptive, voluntary suspensions of shipments are evidence of functioning QAC and action by manufacturers
Examples of diverse vaccine markets
8

9. 9/5/2013
Forecasts are at the foundation - translating need into funded
demand that will motivate production
New Challenges on the Horizon…
The introduction of new vaccines and increased coverage targets have increased demands on the system in a way that puts
business as usual at risk.
Diseases vaccinated against
2.5x
Vaccine doses per child (#)
~3x
[assuming receives vaccine listed above]
Vaccine volume per fully
immunized child (cm3)
Immunization cost
per child ($) (including delivery cost)
50
200
2010+
$30+
2008
$17
1980
$5
Age groups targeted
for immunization
4x
~6x
Across
life
course
4x increase
in fridges
between 2001 and 2020,
A small but one of the vital
investments in
strengthening the supply
chain from end to end
1980s Realities
2010+ Realities
Slide: adapted from McKinsey for BMFG – August 2012
9

10. 9/5/2013
Although large in absolute terms, CC equip/OH costs will be
increasingly small as compared to the value of vaccines they support
$M
3,000
2,846
Cost of CC in GAVI Countries
Procurement cost of Vaccines in GAVI Countries
2,415
2,500
2,162
2,000
1,740
1,500
1,000
500
293
267
234
205
0
2012
CC costs
as a % of
vaccine costs
2013
2014
2015
12%
11%
11%
10%
CC equip/running costs need to be supplemented with HR/transport costs
to complete picture of CC support for Vx
Source: CCL – Country Preparedness: Supply Chain and Logistics Costs in Low and Lower Middle Income Countries, P. Lydon (WHO) (Based on Decade of Vaccines costing work), Feb 2012
Never to early to plan for introduction:
Typhoid conjugate vaccine
Typhoid morbidity and mortality
relative to other vaccine preventable diseases
of long lasting protection; One dose schedule
Morbidity (1'000's)
Mortality (1'000's)
600
500
400
300
200
100
-
NOTE: this is not a WHO pre-qualified vaccine. UNICEF SD
only procures vaccines with WHO p-q status.
•
•
Typhoid
Rotavirus
Hib
HepB
Meningitis
HPV
Dengue
JE
Typhoid
Rotavirus
Hib
HepB
Meningitis
HPV
Dengue
JE
30,000
25,000
20,000
15,000
10,000
5,000
-
August 2013 Bharat Biotech Launches a typhoid
conjugate vaccine for ages from infants 6
months & older to adults . High levels (90+%)
•
How will need be forecasted?
What will be tools and instruments to
measure coverage, & its equity,?
How will resources (vaccines, funds for
training and advocacy, SC management &
capacity strengthening, etc.)
10

11. 9/5/2013
Some points for the discussion
• Hib vaccine: importance of pro-equity introduction policies,
strategies, financing, etc.
• Pentavalent: it takes time to determine suppliers, presentations,
end-to-end SCM issues, always in flux
• CC: remember to plan early for this modest investment,
essential to protecting large investment in vaccines.
• Innovative Finance: Vaccines are produced in standardized
settings, but used in markedly diverse ones.
Financing can help inter-country equity of access
• Typhoid: Plan implementation strategies early on:
Takes a long time to build SCM capacity, generate demand,
assure end to end quality; determine M&E indicators/tools
Thanks to : Ann Ottosen , Katinka Rosenbom of SD, & Gian Gandhi Dmitri Davydov UNICEF HQ
Thank you!
11

12. 9/5/2013
Extra Slides
The Under-five mortality dashboard
www.apromiserenewed.org
Insert: Countries procuring
vaccines through UNICEF
Full programme
Partial programme
Source: 2012 Country forecasts
12

13. 9/5/2013
Procurement context: Global vs. National Buyer
UNICEF supply strategy is focused on Vaccine Security – the uninterrupted,
sustainable supply of affordable, quality vaccines – with a global
responsibility, acknowledging there is a Vaccine Security Premium.
UNICEF procurement and tender strategies are developed in support of
the above. Our role in the global market, the characteristics of the
demand market and of the supply market help inform our specific
objectives and strategies.
While objectives and strategies at a global and national level may vary, we
are dealing with the same vaccine market
UNICEF Vaccines Procurement values on behalf of governments
and partners are increasing
GAVI falls under procurement services but is highlighted separately to show the overall portion of GAVI funded procurement
Source UNICEF Supply Division
13

14. 9/5/2013
Ensuring focus on the whole supply chain
Transparency as a principle and a means of helping markets
be efficient
• Public posting of bid plans and industry consultation
presentations
• Public posting of awards > $100,000
• Posting of prices for product markets where UNICEF has
strategic influence: vaccines, RUTF, medicines, syringes, etc.
• Information notes (eg, Why a 20d BCG vial?, PCV Market
update)
Unicef.org/supply
V3P Project Focus: to broaden the knowledge and
information sharing around vaccine products,
presentation and pricing
14

15. 9/5/2013
Innovative Finance
Increase use of innovative financing and contracting tools
to positively influence the vaccine markets
• Volume Guarantees provide increased (long-term) visibility
to manufacturers and the certainty of a contractual
obligation to purchase
• Prepayments have been exceptionally made in return for
very attractive pricing from manufacturers
• Made possible through partner support
Innovative Finance Achieving Results
Tools Used
Transaction Examples
Goal
Volume
Guarantee &
Prepayment
Rotavirus Vaccine:
• Volume guarantee provided for a portion of the quantities with some
volumes paid for in advance
• Contract duration of 5-years covering 132M doses
• New vaccine launched and sustained at lower price
• Financing provided by GAVI, with strategic and technical support from
the Gates Foundation (“BMGF”)
• $15 per course €3.76 per course
• >$400M in savings over 5 years
• Prepayment understood to facilitate
expected expansion of manufacturing
capacity
• Accelerated introduction of Rotavirus
vaccine made possible through certainty
provided by commitment in new markets
Volume
Guarantee
Oral Polio Vaccine (OPV):
• Firm contract signed for 2011-2012 with large bulk and fill-finish
manufacturer who at the time was considering exit of market
• Duration of 2-years originally covering 270M doses per year (540M
doses total)
• Financing provided by BMGF
• Decrease in price offered to <$0.118 per
dose generated significant savings versus
current WAP of >$0.13
• Delayed exit of manufacturer by >2 years
• Increased visibility for manufacturer and
certainty of UNICEF procurement during
fragile OPV market
Volume
Guarantee &
Prepayment
Pentavalent Vaccine (lyophilised):
• Contract signed with new entrant to Pentavalent market with volume
paid for in advance
• Duration for <1 year covering 10M doses
• Financing provided by GAVI
• New entrant to market secured volume
and able to offer extremely attractive
price of $1.80 per dose,
• Expanded vaccine security with expanded
manufacturing capacity in a fragile
market
Volume
Guarantee
PCV
• Volume guarantees for 20/10/5% of quantities or years 1/2/3 of 10 year
contract
• Financing provided by GAVI and WB
• Part of overall AMC structure to achieve
tail price of max. $3.50 and sufficient
production quantities to meet demand
15