unicef o'connell equity and vaccine supply 5_sep13

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  • 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 OConnell, UNICEF NY Significant progress toward MDG 4, but were 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 NGOs 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 UNICEFs 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. UNIC

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