UNICEF- Update on key activities
IPC Meeting
Geneva, 10-11 December 2015
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Technical report providing most recent country,
regional and global estimates on child mortality
United Nations Inter-agency Group for Child
Mortality Estimation
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4th annual report
Includes more in-depth analysis on mortality
Includes coverage of interventions
Projections to 2030
UNICEF
Where under-five deaths are occurring:
The highest under-five mortality rates are in sub-Saharan Africa
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In Sub-Saharan Africa 1 in 12 die before age 5, in high income countries 1 in 147 die before
age 5; Sub-Saharan Africa and South Asia account for more than 80% global under-five deaths
Under-five mortality rate and under-five deaths by country, 2015
Source: UN Inter-agency Group for Child Mortality Estimation (UN IGME) 2015
Who is most at risk
Children from poor, rural or low-maternal-education households
are much more likely die before age five
• Mothers with no education vs secondary education: 2.8 times
• Poorest vs richest: 1.9 times as likely to die before the age of 5 as richest
• Rural vs urban: 1.7 times
Under-five mortality rate by mother's education, wealth and residence, 2005-2010
Source: UNICEF analysis based on Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other nationally
representative sources
Why and when under-five deaths occur
Most under-five deaths are still caused by diseases that
are preventable or treatable
Pneumonia, diarrhoea and malaria are main killers of children under age 5; preterm birth
and intrapartum-related complications are responsible for the majority of neonatal deaths
Global distribution of deaths among children under age 5 and among newborns, by cause,
2015
Source: WHO and maternal and Child Epidemiology Estimation Group (MCEE) provisional estimates 2015
• The world has achieved tremendous progress in
reducing child mortality
• Promisingly, progress has accelerated in recent years,
especially in some of the most challenging contexts
• However, progress is not enough to meet the MDG 4
target of a two-third reduction in the under-five
mortality rate between 1990 and 2015
• Most under-five deaths are still caused by diseases
that are readily preventable or treatable with proven,
cost-effective interventions
• The remaining burden of child mortality is not evenly
shared among or within countries
• Addressing the sources of inequity that persist in
many contexts will be key to achieve further
progress
• We know what needs to be done to address
under-five mortality. Millions of lives can be
saved if we all work together.
• As we look ahead to the SDGs, and the roll-out of
the SG’s Global Strategy 2.0, the lessons of
successes and shortcomings send a clear
message: we can shape the future we want for
the world’s children.
UNICEF Health Strategy 2015-2030
Convention on the Rights of the Child (CRC)
Convention on the Elimination of
all Forms of Discrimination
against Women (CEDAW)
Sustainable
Development
Goals
(SDGs or “global
goals”)
Every Woman
Every Child
Global Strategy
(EWEC or Global
Strategy 2.0)
2015-2030
Strategy
Approaches to be included in UNICEF program
areas
Approaches
Equity in health
outcomes
Definition
• Identifying marginalized groups in all contexts who may have below-average
outcomes by looking at disaggregated country data
• Identifying and removing bottlenecks that prevent equitable outcomes
• Enhancing Policies, Strategies, Plans, Financing and Budgets
(Focus on equity using evidence)
Health system
strengthening
• Improving Decentralized Management Capacity
including emergency
(Evidence-based planning, budgeting and monitoring)
preparedness and
resilience
• Strengthening Community Platform (Demand generation, Social Accountability,
Service delivery, Social inclusion and reduction of financing barriers)
Integrated, multisectoral policies and
programs
• Developing shared goals / targets / planning across program areas and within
program areas internally to health section, as well as with other sectors within
UNICEF
• Promoting health as a platform for delivery of multi-sector packages of interventions
and services
• Chlorhexidine: utilization expanding
 Over 28 countries in
various stages of
engagement in Africa
and Asia
 Focus on promotion of
introduction in practice
and support scale up
(formative research,
regulation, demand,
local manufacturing)
Credit: Chlorhexidine Working Group 2015
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Challenges in access of chlorhexidine
 Solution and gel available
– Markets for each formulation is evolving
 Limited sources
– But manufacturing base increasing (Nepal, India, Bangladesh, Nigeria,
Ethiopia, Kenya…)
 New products under development (sachets)
 Require appropriate messaging to mothers and other
caregivers to ensure proper product use through:
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Appropriate product labeling,
Context appropriate product
presentation
Proper messaging to mothers and other
caregivers to ensure proper product use.
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Credit: Chlorhexidine Working Group 2015 (please confirm)
• Chlorhexidine Working Group
An international collaboration of organizations committed to
advancing the use of 7.1% chlorhexidine digluconate for
umbilical cord care
– Advocacy
– Technical assistance
Supports activities in over 25 countries and coordinates
global efforts including development of evidence and
guidance to programmes and industry
Active participation of industry
More info:
www.healthynewbornnetwork.org/topic/chlorhexidine-umbilical-cord-care
Copenhagen, Denmark
23-26 November 2015
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PNEUMONIA
• Currently, ~3 in 4 childhood pneumonia cases around the world do
not receive treatment……and ~80% of this need occurs in just 10
countries
55M untreated pneumonia cases in children under five occur…
100%
27M
cases
80%
60%
99M
cases
55M cases
40%
20%
16M
cases
0%
Cases in top 50
countries
Treated cases
… in these 10 countries (in
order of untreated cases)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
India
Nigeria
Pakistan
Bangladesh
DRC
Ethiopia
Tanzania
Afghanistan
Uganda, and
Kenya
Untreated cases in top Untreated cases in
10 countries
remaining 40 countries
Source: BMGF, R4D and USAID. “The Growing Market for Amoxicillin Dispersible Tablets: Opportunity Assessment for Potential Manufacturers.”
September 2014.
Copenhagen, Denmark
23-26 November 2015
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• Use of amoxicillin DT for pneumonia is growing
Annual orders for
Amoxicillin DT through
UNICEF have grown 13x
since 2011
Need for scale-up supply of quality assured amoxicillin DT to meet demand arising from
new guidance for managing pneumonia
UNICEF started procuring amoxicillin DT in 2011.
 Activities under the work UNCLSC encouraged engagement of new manufactures and increase in
availability.
 An ERP was established in 2013: 11 Manufacturers engaged in the ERP
Need more suppliers
Copenhagen, Denmark
23-26 November 2015
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• Potential global demand is expected to continue to
grow, with up to ~4.1B amox DT needed over the next 5
years
Global annual amox DT demand could grow from ~300M tablets in 2015 to ~1.2B
in 2020
Amox DT (M)
1200
1,162
High
Medium
1000
937
800
740
718
570
600
594
425
484
400
293
200
387
303
247
0
2015
2016
2017
2018
2019
2020
Note: R4D analysis based on 50 country childhood pneumonia antibiotic forecast prepared by John Snow, Inc; includes
public and private sectors
Copenhagen, Denmark
23-26 November 2015
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• Country-level product registration is important as regulatory
conditions in key growth markets are increasingly enabling amox
DT scale-up
Source: Diarrhea and Pneumonia Working Group. “Country Update Summary.” May 2015.
Copenhagen, Denmark
23-26 November 2015
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SCALE-UP IS LINKED TO APPROPRIATE DIAGNOSIS
ARIDA (Acute Respiratory Infection
Diagnostic Aid) Project:
• Launched by UNICEF, multistakeholder project to develop a
respiratory rate measuring device for
diagnosis of pneumonia by health
workers. www.unicef.org/innovation
Pneumonia Diagnostics Project
• Malaria Consortium. Multi-country field trial of several
new diagnostic tools
Copenhagen, Denmark
26 November 2015
23-
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… AND APPROPRIATE USE
PATH and UNICEF piloting use of dispensing aids
Aimed at dispensing by community health workers (CHW)
and primary health settings.
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COLLABORATION WITH WHO ON ANTIHELMINTICS
Changes in target for albendazole and mebendazole
WHO: Donation programme with GSK and J&J for LF and deworming in school age children
UNICEF and INGO: Procurement for deworming in pre-school age children
 Coverage for school age children to increase from 250M (40%) in 2013 to 550M (75%) in
2020
 Coverage for pre-school age children (PSAC) expected to increase from 130M children (49%)
in 2013 to 270M children (75%) n 2020
Copenhagen, Denmark
23-26 November 2015
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Preventive chemoprophylaxis of soil-transmitted
helminthiasis : Challenges
 Many products in the market and varied standards of
quality
 Included in the WHO prequalification programme under the
EOI for Neglected Tropical Diseases
Single ingredient medicines to treat lymphatic filariasis, soil-transmitted helminthiasis (STH), and
schistosomiasis
- Diethylcarbamazine citrate 100mg tablet (scored)
- Mebendazole 500mg tablet (chewable*)
- Albendazole 400mg tablet (chewable*, preferably scored)
- Praziquantel 600mg tablet (scored)
- Ivermectin 3mg tablet (unscored)
 Limited number of dossiers submitted for PQ
– Expert Review Process established to provide interim assessment of
quality.
* can be chewed or swallowed whole
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Preventive chemoprophylaxis of soil-transmitted
helminthiasis: Progress
 In 2015, WHO and UNICEF reaffirmed commitment to procure
quality products and called on manufacturers to submit dossiers
for ERP and international buyers to use results for qualification:
– Albendazole- 11 manufacturers engaged
– Mebendazole- 2 manufacturers engaged
 Significant efforts from manufacturers to complete requirements
for dossier evaluation
 Concurrent review of Pharmacopoeia Monographs
– Albendazole: revised monograph in IP 5th Edition (2015) to include dissolution
criteria and labelling
– Mebendazole: under review
Copenhagen, Denmark
23-26 November 2015
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Supply Constrains Case Study – IPV
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Ambitious agenda to introduce IPV
in 126 OPV-using countries within
1.5 years in time for the global OPV2
withdrawal
At time of IPV planning, about 68
high and middle-income countries
were using IPV
2014 UNICEF issued a tender for
stand-alone IPV in line with
Endgame Strategy
Procurement objective to ensure
sufficient supply for 1 dose of IPV at
an affordable price to meet demand
2 manufacturers awarded, 1 pipeline
Awarded quantities and near term
bulk and filled product
manufacturing capacity anticipated
to be sufficient to meet planned and
some unplanned demand
• Demand for India and 20 L/MICs included
Case Study – IPV (2)
• Expected scale up of IPV unprecedented compared to other new
vaccine introduction programs
• Since awards major changes in supply availability
• 2014-2015 supply reduced from 129 mds to 63 mds
• 2016 supply reduced from awarded 121 mds to expected 77 mds
• At same time, significant increases in demand
• India requiring 28 million doses for 12 month catalytic support
from GPEI
• Catalytic support to 25 countries as approved by Polio Oversight
Board (POB)
• Increased demand for routine immunization (to date 1.2 million
doses – more required?)
• SIA requirements of 8.7 million doses of IPV delivered, global
stocks of 1.2 million doses set aside for SIAs - more required for
post switch outbreak response
Case Study – IPV (3) Mitigation actions
• Consultations to establish criteria for allocation of constrained supply
• No other suppliers in pipeline in near term, therefore, mitigating actions
focused on managing supply that was available in line with programmatic
priorities
• Close and ongoing coordination with WHO and GPEI partners to establish
supply prioritization criteria
• Depending on prioritization of country, a number of countries required to
delay introductions
• Effort by WHO and PQT to approve MDVP to IPV to increase doses
available
• Tight management of supply including delivery of buffer stocks, daily
monitoring of stock levels and preparation of supply and demand
scenarios
Supply Constrains- Other products?
AQ+SP for Seasonal Malaria Chemoprophylaxis
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Plans in 2015 disrupted due to quality issues
Plans for 2016 total so far around 60M treatments.
Capacity can only fulfill by August- too late for campaigns
Need to monitor availability and coordinate delivery with
countries through Malaria Consortium, CAMEG (WB),
UNICEF, USAID, GF and MSF.
A role for WHO GMP?
Work in Emergencies
Participation in WHO-WFP Global Supply Chain
For Pandemic Preparedness & Response project
UNICEF is including Health Emergencies in its programme:
• Define disease specific contingency items, stock quantities and procurement
approach
• Update ESL/CCCs/SSOPs
• Support Country office preparedness
• Incorporate health emergency/IPC expertise in surge rosters
• Develop communication materials for effective knowledge management
• Financing mechanisms for Supply component of response
IEHK update of Malaria and PEP modules- Consultancy to develop
guidance on selection and procurement of supplies for sexual assault (PEP
kit, additional modules)
Financing
A look back…
4 – 5 years ago, we began a body of work in financing, initially focusing on transactional activities:
- Delayed funds which prevented supply transactions moving forward
- Financial backing for special contracts to generate exceptional savings
But it’s organically grown to adjacent activities and has become quite robust. Here are some highlights:
2010
• Inaugural formalized pre-financing transactions
• Sierra Leone $6.7m LLINs thru 7% set-aside fund: Zambia: $4.4m LLINs (delayed WB loan) thru LoC;
2011
• Novartis OPV Firm Contract – Kept a supplier in a constrained market for 2 extra years
• Rotavirus special contracting with partners $650m of savings over 5 years
2012
• First U.S. Fund’s Bridge Fund transactions ($500k RUTF Burkina Faso)
• First ‘partial firm’ transaction (Sanofi OPV); high returns / efficient capital
2013
• $54m worth of pre-financings for COs and Countries, including polio transactions for Nigeria and Pakistan
• Special contracting to secure IPV supply via VII; special contracting for penta via GAVI/BMGF
2014
• ~$30m of pre-financings for COs and Countries, including Ebola-related; VII transition to SD
• UNICEF-led penta special contracting, novel option + commercial financing design  $57m in savings
2015
• VII Expansion ExB Approval; ~$50m worth of pre-financings YTD; Nigeria RI credit line
• Launch of domestic supplier base expansion / financing activities
Current Scope: 2014-2017
To respond to these needs, we‘ve conducted activities through 4 workstreams:
Impact on Countries
Pre-Financing
Delayed Grants
and MoH Budgets
• ~$50m worth of transactions pre-financed in
2015YTD
• VII Expansion & USF’s Bridge Fund related to PS
• Nigeria $21m credit line for Routine Immunization
Increasing Gov’t
Fiscal Space
• Support country-owned budgeting and
sustainability initiatives
• Facilitate implementation of local public-private
trust funds; access to commercial markets
Country
Financing
Special Contracting
• Penta Special Contracting  $57m+ savings over 2
years (MICs-GAVI price parity)
• Additional models to achieve “firm” contracts
including multiple partial-firm models, optionbased models
Local Supplier Base
Development
• Support access of new suppliers in programme
countries to financing via leveraging UNICEF’s
network, convening ability and credit profile
Supply
Financing
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Addressing cash
flow timing gaps
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Increasing
availability of
funds / budgets
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Lower prices,
secured quantities,
etc.
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Lower prices +
domestic
economic
development
Current Trends in Supply Financing
Pre-financing need for delayed grants and government disbursements
• $100m annual supply pre-financing requests (all commodities); $225m+ by 2020
 Expanding pre-financing activities –2015YTD (July) ~$50M worth of pre-financings (~½ through
VII) / Worth noting that since its inception the US Fund’s Bridge Fund in 2012 has supported
$100M of pre-financings and government related PS activities.
Vaccine Independence Initiative– expanding scope and capital base per Executive Board approval
in 2015
• Active: Kenya, Chad, Niger, Capo Verde, PICs, Nigeria: Soon active: Lao PDR, Cameroon, Ghana
• By end 2015, capital fund’s effective base will increase from $10M to $30M (including most
recently $5m from GAVI). Target is $100M by 2020.
Special contracting to achieve improved pricing for countries
• MICs-GAVI penta pricing parity + $57m savings
• Improved pricing  increased fiscal space for other interventions
 Cost-effective / less capital-intensive special contracting mechanisms
Sourcing of supplies from programme countries
• Domestic suppliers’ poor access to affordable financing
• RMNCAH-commodities to be locally sourced by Countries
 Support domestic supplier growth while respecting FRRs and public procurement principles
The HUB
“Strengthening in-county
immunization supply chains
for all”
Three strategic pillars
New cEVM
Expanding the EVM to a fully revamped
process and comprehensive toolkit for
countries to diagnose, prioritize, plan and
implement change for their immunization
supply chain improvements, aligned with
priorities from GAVI Strategy
iSCL focus
topics
Take the lead on developing new
evidence, tools and guidance on a
selected number of high-priority iSCL
topics – starting with cold chain
management as the first priority topic
Community of
practitioners
Strengthen coordination and build a
community of skilled practitioners at the
global, regional and country level
Center of excellence
for iSCL
iSCL
Hub
Coordinator of technical
assistance to countries
Immunization: Data for Management Toolkit
• Guidance on Dashboards for Immunization Supply Chain (DISC)
– Advocacy piece: describes dashboards and benefits
– Planning and using dashboards: suggests steps in planning &
implementation, suggests continuous improvement activities
• Standardized primary key indicators: detailed reference sheets
including visualization and action examples
• Case studies around use of dashboards:
– Nigeria
– Mozambique
– India
• Material to support country-level policy advocacy
• ViVa
GF-UNICEF Coorperation: Country
level implementation
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Country dialogue led by GFATM Fund Portfolio Managers (FPMs) and Country Co-ordinating
Mechanisms (CCMs)
19 concept notes have been submitted where RMNCH has been integrated to varying degrees,
and these countries are now moving into the grant making phase
iCCM/Malaria(Child Health)
MNCH/HIV (Maternal Health)
Burkina Faso (Malaria and HSS)
Nigeria
Chad
Comoros
Rwanda
DRC
Cote d’ivoire
South Sudan
Tanzania
DRC
Uganda (Malaria)
Uganda
Ethiopia
Zambia
Zambia
Ghana
Senegal
Mozambique
Sudan
Concept note phase
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Quantification of both GF and
non GF commodities
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Gap analysis to identify
funding gaps for iCCM
commodities
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High level SC activities
Grant making phase
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Supply planning
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SC capacity assessment
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SC implementation mapping
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Supply chain (PSM) plan
At each point there a requirement for joint planning for all the commodities – responsibilities and accountabilities for
implementation and monitoring need to be agreed at country level
Nutrition supply chain strengthening
HERA report
Food for Peace
Supporting governments
in optimization and/or
integration of the RUTF
into national Supply Chain
Management.
• End-to-end nSC health checks /
assessments to identify performance
gaps/bottlenecks.
• Development of supply chain improvement
plans and support in implementing those
plans.
• Development of guidelines and tools for
nutrition supply chain performance monitoring
for governments.
• Development and dissemination of simple
nutrition commodities quality guidelines along
the supply chain.
Technical Assistance to governments in
strengthening nutrition supply chains, end to end
(planning, forecasting, pipeline management,
warehousing, distribution, end use monitoring and
visibility)
UNICEF Strategic Framework on Environmental Sustainability for
Children 2016 - 2017
Priority 1. Strengthen UNICEF policy and guidance on environmental
sustainability as a cross-cutting issue.
Priority 2. Strengthen the inclusion of environmental sustainability in
UNICEF programmes.
Priority 3. Advocate for full recognition and inclusion of children in the
policy discourse on environmental sustainability.
Priority 4. Strengthen opportunities for children’s development and wellbeing to benefit from environmental sustainability related public and private
finance.
Priority 5. Incorporating environmental sustainability management (ESM) in
the organization