9/5/2013

UNICEF: the equity agenda
and vaccines
Rockville
5 September 2013
Planning for Adult Vaccination in Middle and L...
9/5/2013

Deaths among children under 5 globally;
19,000 die every day from preventable causes

18%
1%
2%
2%

35%
5%
7%

1...
9/5/2013

Multiple causes of deprivation (inequity)
E.g. Wealth, education, geographic location, and gender inequity in Ni...
9/5/2013

Shifting the curve: Hib vaccine introduction

Acting upon the data collected –
Three strategies to shift the cur...
9/5/2013

Shifting the curve: new products, policies and knowledge
Vaccines are essential to equity and child survival
Opp...
9/5/2013

UNICEF annual vaccine procurement has increased significantly since
2000 supporting UNICEF Programmes and on beh...
9/5/2013

UNICEF’s procurement strategies seek Vaccine Security:
sustained, uninterrupted supply of affordable vaccines, o...
9/5/2013

Pentavalent vaccine supply has been impacted by a number of supply
interruptions, impacting supply availability ...
9/5/2013

Forecasts are at the foundation - translating need into funded
demand that will motivate production

New Challen...
9/5/2013

Although large in absolute terms, CC equip/OH costs will be
increasingly small as compared to the value of vacci...
9/5/2013

Some points for the discussion
• Hib vaccine: importance of pro-equity introduction policies,
strategies, financ...
9/5/2013

Extra Slides

The Under-five mortality dashboard
www.apromiserenewed.org

Insert: Countries procuring
vaccines t...
9/5/2013

Procurement context: Global vs. National Buyer
UNICEF supply strategy is focused on Vaccine Security – the unint...
9/5/2013

Ensuring focus on the whole supply chain

Transparency as a principle and a means of helping markets
be efficien...
9/5/2013

Innovative Finance

Increase use of innovative financing and contracting tools
to positively influence the vacci...
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Unicef o'connell equity and vaccine supply 5_sep13

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Unicef o'connell equity and vaccine supply 5_sep13

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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