UNICEF’s Eva Kadilli outlines the work that the organisation’s supply division is undertaking in the global push for a COVID-19 vaccine, the impact of the pandemic on immunisation programs for other diseases globally, and makes a call for further solidarity between stakeholders across the public sector, private industry, and civil society.
The biggest challenge for us is that while responding to the immediate crisis caused by the global pandemic, we still needed to continue and coordinate our responses to other emergencies
Eva, could you briefly introduce yourself as director of the UNICEF Supply Division and the important work that the organisation is doing?
UNICEF, or the United Nations Children’s Fund, is the UN agency responsible for providing humanitarian and development aid to children worldwide. Our mission here in UNICEF’s Supply Division is to deliver sustainable access to lifesaving supplies where they are most needed, accelerating results for the most vulnerable children.
UNICEF Supply Division is based in Copenhagen, Denmark, where we manage around USD 3.8 billion for the procurement of goods and services every year. Our supply operations support the overall program implementation of UNICEF, and our global warehouse in Copenhagen is the largest humanitarian warehouse in the world. We currently have a team of over 420 staff based here in Copenhagen and additionally nearly 1,200 supply chain staff working across 190 countries, where UNICEF delivers a multitude of programs across sectors such as health education, child protection, and sanitation.
We are the world’s largest single buyer of vaccines, purchasing around 2.4 billion doses every year. Due to the particular needs of the storage and distribution of vaccines, we work with industry to ensure that the vaccines we procure move directly from the manufacturers to the governments and end users in nearly 100 countries.
As for me, I have been with UNICEF for nearly 25 years, including assignments at different country offices in the field in Africa as well as Central and Eastern Europe. In my current role, I oversee UNICEF’s global supply chain functions, as well as manage UNICEF’s supply response to humanitarian crises. I am currently leading the Organisation’s strategic procurement and logistics emergency response to the COVID-19 pandemic and I also represent UNICEF on the UN COVID Supply Chain Task Force.
How critical has the role of vaccines historically been in UNICEF’s work with children globally?
This has been absolutely critical. In the past two decades, we have provided live-saving vaccines to over 760 million children worldwide, preventing over 13 million deaths. We are also a founding partner of Gavi, the Vaccine Alliance. There is a well-established body of literature demonstrating the highly beneficial and cost-effective impact of vaccines as a public health intervention. Through vaccines, we have been able to address diseases like cholera, measles, and polio.
In addition to the provision of vaccines, we have also had a major role in market shaping for vaccines, in coordination with our partners, including Gavi and the Bill & Melinda Gates Foundation. Market shaping means ensuring that we are able to obtain affordable, quality-assured vaccines to ultimately reach every child.
Presently, there are still around 14 million children in the world that unreached by our efforts each year; we call them the ‘zero dose children’. Major efforts will be needed to reach these children, particularly in the light of COVID-19, because the pandemic has had a major negative impact on immunisation programs globally. Countries have postponed over 100 immunisation campaigns this year. This means that many children are not receiving their vaccinations, putting them at risk for preventable diseases, and increasing the risks of outbreaks globally.
What are the typical challenges of access when it comes to these ‘zero dose children’?
It varies from vaccine to vaccine, but first and foremost, the issue could be awareness. This is why UNICEF works with local communities and community leaders, including religious leaders, as well as families directly, to communicate the life-saving impact of vaccines. We also work with and train local health workers to administer the vaccines and deliver these public health messages.
The second issue is distribution and access to hard-to-reach areas, particularly in remote or conflict-affected parts of the world. For most of these ‘zero dose children’, there are significant inequities and inequalities within the society that hinder access to vaccines, for instance, if we look at migrant or refugee populations. This is why we also have to work with governments across all levels.
The third aspect is affordability, which is why UNICEF invests in market-shaping efforts. Some vaccines are quite expensive. While lower income countries can benefit from negotiated pricing and development aid, we have seen that pricing may be prohibitive for middle- and upper-middle income countries, limiting access to these life-saving vaccines for children in these countries. Therefore, we also work with industry to try to promote a healthy market with appropriate pricing for equitable access to these life-saving tools.
The global COVID-19 pandemic is not the first public health emergency UNICEF has had to manage, though certainly the most global. What lessons has UNICEF learnt from previous crises like the Ebola outbreak that have proven useful this time around?
Certainly, given the role of UNICEF to respond to emergencies and support children at risk, COVID-19 is absolutely not the first crisis we have had to respond to. The biggest challenge for us is that while responding to the immediate crisis caused by the global pandemic, we still needed to continue and coordinate our responses to other emergencies, such as the provision of vaccines and other health supplies to children in countries facing crisis, such as Yemen, South Sudan, Venezuela, even as COVID-19 has dramatically disrupted global supply chains to an extent we have not seen before.
Another challenge we faced was the presence of counterfeit products, which is especially dangerous when it comes to medicines and personal protective equipment (PPE). It is reassuring that we have seen that our existing due diligence processes have proven strong enough to address situations like this in order to prevent sub-quality products from entering our supply chains at this critical time.
One of the learnings from our Ebola experience is the experience of implementing a Health Emergency Strategy. Back in 2014 and 2015, we worked out how to requisition PPE and other essential health supplies quickly so when COVID-19 occurred, we already had the contract processes, equipment specifications and so we needed to move fast on establishing an emergency global supply chain.
Through our experience and expertise in emergency responses, we have also been able to anticipate and prepare for potential challenges and situations that could arise as a result of COVID-19. For instance, we foresaw that access to therapeutic food (RUTF) for children with severe acute malnutrition could become compromised, so we worked quickly to diversify our global prepositioning of supply.
Ultimately, the most important aspect of our response has been the fact that we have extensive experience working in emergencies and we have boots on the ground, staff who know the local context extremely well and are able to undertake risk management. This helps our teams upstream understand the actions and initiatives they need to work on with partners such as industry manufacturers and global institutions, to support the right downstream response.
In your view, how modern is UNICEF’s current supply chain and how are you embracing new developments in digitalisation and so on to optimise your operations further?
Our global warehouse here in Copenhagen is state-of-the-art, thanks to support from the Danish government.
As highlighted, counterfeit detection is an important priority for us, and in addition to working on that aspect with technology within UNICEF itself, we also work with partners in the private sector to strengthen the supply chains of the governments for whom we work. This is very important since in many cases, the governments are the ones that ultimately distribute the supplies we procure to the people who need them. So we are working with private sector actors to try and support the strengthening of the governments’ own supply chains, so that we can guarantee that the products make it to the end users through that final leg of the journey.
Overall, I do think we are quite innovative when it comes to ways of working, both upstream and downstream, but there is always room for improvement and we look forward to opportunities to work closely with the private sector.
How is UNICEF currently involved in global efforts to deliver a COVID-19 vaccine?
As you know, a group of stakeholders have established the COVAX (COVID-19 Vaccines Global Access) facility, which is a key pillar of the global ACT-Accelerator initiative. UNICEF has been entrusted to oversee the procurement and delivery of vaccine on behalf of COVAX. Our focus here is to work with all partners to ensure equitable access to COVID-19 vaccines, once available. It is of fundamental importance that vaccines are delivered globally according to the allocation mechanism that will be put in place.
The first priority is health workers, because they are critical to the continued functioning of health systems globally. In addition, from UNICEF’s perspective, we need to protect the health of these frontline workers so we can resume and continue to advance our health programs including immunisation programs for children globally. The second priority goes to those at higher risk mortality high-risk and elderly populations.
Of course, ultimately in-country distribution decisions will be taken by the sovereign governments that have signed up to participate in the COVAX facility.
In April 2020 UNICEF, on behalf of the COVAX Facility, issued an Expression of Interest (EOI) to 28 vaccine manufacturers to map ongoing vaccine R&D efforts for COVID-19 vaccines and potential manufacturing capacity. It is truly a historical moment as we have not seen this intensity or pace of scientific research happen before. Typically, it takes at least ten years to bring a vaccine to the market but nine months into 2020, there are already over 200 vaccine candidates under exploration, with many already in human trials. We have been in close engagement with them to stay updated on their progress. We are also working with the Pan-American Health Organisation (PAHO) to prepare joint bids for vaccine doses once they are ready.
In addition to our work upstream with industry, we are also working downstream with various governments as well as regional and local partners to support in-country readiness and preparedness initiatives. For instance, this means the mapping of available resources and infrastructure in-country to receive vaccine supplies once ready and procured. We are looking at massive volumes so there needs to be capacity for that. UNICEF has been working with GAVI on cold chain optimization platforms over the past few years so that work has been serving us well here.
Many of the vaccine candidates do not currently have sufficient stability data, partly due to the speed of their development, so we might not know the precise storage condition requirements until later. It does seem that the majority of companies are working to develop vaccine candidates that only need to be stored between two to eight degrees Celsius, normal cold chain conditions, but we still lack clarity on this. It is possible that in some cases we might be looking at cold chain conditions below negative 20 degrees Celsius or even below negative 60 degrees Celsius. There is still infrastructure and capacity available globally for vaccines that need to be stored below negative 20 degrees Celsius as the polio vaccine has the same requirement. The only countries with ultra cold chain capacity for vaccines that need to be stored under negative 60 degrees Celsius would be those countries that received the Ebola vaccine.
From your vantage point, what is the key message you would like to pass to global stakeholders on the topic of vaccine supply and distribution?
The current situation is absolutely unprecedented. The only way we can overcome this global pandemic successfully is if everyone – government, private sector and civil society – come together. Solidarity is necessary, first and foremost. No one will be safe until everyone is safe.