Supply Chains Save Lives: Unlocking access for children, their families and communities

Publication date: 2023

01Supply chains save lives: Unlocking access for children, their families and communities SUPPLY CHAINS SAVE LIVES Unlocking access for children, their families and communities 04 Contents 04 01Executive summary ��������������������������������������� 08 02The state of supply chains: Understanding their role and identifying barriers to access ������������������������������ 12 What are supply chains and why are they important? ��������������������������������������������������������������������������������������������� 14 What is access? ������������������������������������������������������������������������������������������������������������������������������������������������������� 16 Strong supply chains: The key to equitable access �������������������������������������������������������������������������������������������������� 18 Health supply chain barriers to access ��������������������������������������������������������������������������������������������������������������������20 Nutrition supply chain barriers to access �����������������������������������������������������������������������������������������������������������������30 Water, sanitation and hygiene supply chain barriers to access ��������������������������������������������������������������������������������34 Education supply chain barriers to access: UNICEF’s lessons learned from the education response to the COVID-19 crisis ��������������������������������������������������������������������������������������������������������������������������������������������������38 Transforming end-to-end supply chains ��������������������������������������������������������������������������������������������������������������������42 Buying and delivering life-saving supplies and services to all corners of the globe �������������������������������������������������44 Driving innovation at scale ���������������������������������������������������������������������������������������������������������������������������������������48 Meeting children’s humanitarian and development needs ����������������������������������������������������������������������������������������51 Delivering supplies in emergencies��������������������������������������������������������������������������������������������������������������������������52 Working with governments to strengthen public supply chains ������������������������������������������������������������������������������54 Creating long-lasting change for local economies ���������������������������������������������������������������������������������������������������56 Stimulating local RUTF production ���������������������������������������������������������������������������������������������������������������������������58 03UNICEF Supply chains in action ��������������������������� 40 04Global goods ��������������������������������������������� 60 UNICEF Supply Chain Maturity Model  ��������������������������������������������������������������������������������������������������������������������62 The effective vaccine management initiative  ����������������������������������������������������������������������������������������������������������63 05 C O N T E N T S 05 05Global supply and programme partnerships: Unlocking access for children ����������������������������� 76 06Case studies: Bridging the access gaps �������������������� 86 07Recommendations ��������������������������������������� 114 Global health partnerships ���������������������������������������������������������������������������������������������������������������������������������������� 78 Global nutrition partnerships ����������������������������������������������������������������������������������������������������������������������������������������������������� 83 Global WASH partnerships ��������������������������������������������������������������������������������������������������������������������������������������� 84 Global education partnerships ���������������������������������������������������������������������������������������������������������������������������������� 84 Accelerate access to reliable supply chain data and technology to support decision-making �������������������������������116 Promote environmental, social and economic sustainability through supply chains �����������������������������������������������118 Strengthen service delivery systems and quality of care all the way to the last mile �������������������������������������������� 120 Increase public financing for supplies and reform fiscal policies ���������������������������������������������������������������������������� 122 Support local production and manufacturing of supplies, including through market-shaping �������������������������������� 123 Enhance governance, private sector involvement and multi-partner coordination ��������������������������������������������������� 124 Invest in supply chain workforce development ������������������������������������������������������������������������������������������������������ 125 Foster and strengthen global partnerships in a post-pandemic future ������������������������������������������������������������������� 126 The Traceability and Verification System ������������������������������������������������������������������������������������������������������������������� 66 Vaccine Independence Initiative and other supply financing solutions ��������������������������������������������������������������������� 69 NutriDash ����������������������������������������������������������������������������������������������������������������������������������������������������������������� 71 People that Deliver �������������������������������������������������������������������������������������������������������������������������������������������������� 73 The life-saving power of data in Nigeria ������������������������������������������������������������������������������������������������������������������� 88 Drones: The missing link in Malawi �������������������������������������������������������������������������������������������������������������������������� 90 Beating malnutrition in Africa ����������������������������������������������������������������������������������������������������������������������������������� 93 One UN for health supply chains in Madagascar ���������������������������������������������������������������������������������������������������� 96 Rolling out vaccines in Mozambique, Nepal and Uzbekistan ���������������������������������������������������������������������������������� 98 Delivering on multiple fronts in Haiti �����������������������������������������������������������������������������������������������������������������������101 A new, cleaner normal in Pakistan ��������������������������������������������������������������������������������������������������������������������������103 Helping children to hear in Rwanda ������������������������������������������������������������������������������������������������������������������������106 Ensuring continuity of care in Lebanon ������������������������������������������������������������������������������������������������������������������108 Oxygen: Saving children’s lives in Cambodia �����������������������������������������������������������������������������������������������������������112 06 Acknowledgments This UNICEF publication was produced by the Supply Chain Strengthening Centre and is the product of a collaboration between Supply Division, Programme Group and Regional and Country Office staff working on health, nutrition, education, water, sanitation and hygiene systems and supply chain strengthening. Purpose of the report: This report provides a compendium of information and resources for UNICEF staff and partners working on supply chains� While it may be read from beginning to end, readers are encouraged to use the contents page to locate specific materials that are most applicable to their needs and access the report online to easily navigate throughout the compendium� We hope that this publication will assist readers in 1) understanding the supply chain gaps for specific programmes; 2) providing examples of tools to overcome bottlenecks; 3) demonstrating how UNICEF’s expertise in supply chain management achieves results for children; and 4) informing future supply chain development requirements and investments� Lead authors: Ken Legins, Raphael du Boispean, Jonathan Moody Technical reviewers and contributors: Suvi Rautio, Regine Weber, Aboubacar Kampo, Victor Aguayo, Gisela Henrique, Robert Jenkins, Hanne Bak Pedersen, Ephrem Tekle Lemango, Michelle Seidel, Vivian Lopez, Andrew Owen Jones, Katinka Rosenbom, Abdallah Makhlof, Kristoffer Gandrup-Marino, Elena Trajkovska, Emma Maspero, Francisco Blanco, Lama Ramzi Suleiman, Jean-Cedric Meeus, David Girling, Thomas Sorensen, Dorcas Noertoft, Saul Ignacio Guerrero Oteyza, Gian Gandhi, Sebastian John Meany, Anne Detjen, Grainne Mairead Moloney, Musonda Kasonde, Jens Grimm, Samuel Kweku Ocran, Landry Dongmo Tsague, Stephen Jones, Mounir Bouazar, Hamdana Chowdhury, Ann Thomas, Gemma Orta-Martinez, Marcia Attaran, Cynthia Kamtengeni, Aurelia Gasca, Jan Debyser, Mary Atieno Ojoo, Aadrian Sullivan, Manuel E. Lavayen, Max Kabalisa, Patrick Gaparayi, Innocent Dube, Dominique Zwinkels, Dorte Andersen Friis, Marieme Abderrahma Diallo, Olamide Folorunso, Anahitta Shirzad, Ranjit Dhiman, Michael Emerson Gnilo, Heather Moran, Marieme Diallo Toure, Ndiaga Seck, Emma Creighton, Maryline Orsini, Rudina Vojvoda, Olayinka Sanusi, Zabihullah Kamran, Fredrick Sheshe, Ryan McWhorter, Eduardo Celades Blanco, Anne Cabrera Clerget, David Muhia, Sibylle Selwan, Rabab Saffideen, Michael Zanardi, Alison Fleet, Mamadou Diallo, Adebayo Adekola, Albert Nettey, Jorge Mazuze, Claire Frijs-Madsen, Aleksandra Krukar, Dan Ilie, Mathias Thomann-Arenhorst, Louise Mwirigi, Moira Staplehurst, Elvira Kabdulova, Annette Imohe, Prakash Raj Lamsal, Asiya Ashraf Chaudhry, Postar Chikaoneka, Michael Scheibenreif, Olga Kosyak, Abolfazl Khosravi, Fady Mansour, Pieter Verhoog, Lindsay Cotton, Fulvia Bellingeri, Tautvydas Juskauskas, Philippe Morel, Amy Porrit, Leila Belaid, Ian Lacey, Jamie Gill Design: Formato Verde, Lda. 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They are one of the fundamental building blocks of the health, nutrition, education, and water, sanitation and hygiene (WASH) systems that must work to meet children’s rights so every child can meet their full potential� From product selection and strategic procurement to contracting logistics services through to last mile delivery, UNICEF and our partners are supporting governments to reach all children in need, delivering to the right place, at the right time with quality supplies and services� The COVID-19 pandemic has shown the whole world the value of resilient, equitable supply chains� Equitable access to lifesaving health, nutrition, education and WASH supplies will require us to work together to be prepared, respond to and reflect on successes and failures. This report was developed with two objectives: 1� To provide an analysis of the key health, nutrition, education and WASH supply chain barriers that limit children’s access the products, services and treatments they need� 2� To offer a compendium of resources to address the most critical barriers to strengthening supply chains� Evidence from the experiences and knowledge of partners including governments, USAID, the Global Fund, the Global Alliance for Vaccines (GAVI) the Bill & Melinda Gates Foundation, the African Centre for Disease Control, SAPICS (the professional body for supply chain management), the private sector, WHO, UNFPA and many others has informed eight recommendations that can increase access to quality, lifesaving supplies and services in a post-pandemic future. To develop strong supply chains with the aim of saving lives, we must invest in: 1� Accelerating access to reliable supply chain data and technology to support decision-making 2� Promoting environmental, social and economic sustainability 3� Strengthening service delivery systems and quality of care to the last mile 4� Increasing public financing for supplies and reforming fiscal policies 5� Supporting local production and manufacturing of supplies, including through market-shaping 11Supply chains save lives: Unlocking access for children, their families and communities 6� Enhancing governance, private sector involvement and multi-partner coordination 7� Empowering the supply chain workforce 8� Fostering and strengthening global shared-value partnerships Accelerating action requires a concerted effort to scale global goods, in conjunction with the reinforcement of existing, and establishment of new, partnerships that foster entrepreneurial and well-proven supply chain expertise. For years UNICEF has been partnering with host governments, international development agencies, civil society organizations, industry, private sector organizations and academia to produce and deploy global innovative tools and public goods to strengthen supply chains across all the aforementioned areas� These include: • The Vaccine Independence Initiative, a $234 million fund that governments can tap into to procure health and nutrition supplies and treat tens of millions of children each year� • The Traceability & Verification System, which serves to verify the authenticity of vaccines and other health products and improve patient safety� • NutriDash, which provides a common nutrition monitoring system for internal and child nutrition programming and reporting� • The Effective Vaccine Management Initiative and Maturity Model, which have both been instrumental in identifying supply chain development needs, shaping improvement plans and directing resource allocations� • People that Deliver, UNICEF’s supply chain workforce arm, which, through its coalition of public and private partners, supports countries to develop, empower and equip the supply chain workforce� These partnerships have also been pivotal to support and scale-up UNICEF’s unique supply chain management expertise for the benefit of children, their families and communities. • As the largest UN procurement agency, UNICEF provides, stores and transports critical vaccines, medicines, nutrition, education products and many other critical supplies to children across the globe – including in emergency settings. In 2021 alone, UNICEF procured a record $7.2 billion worth of supplies and services. • UNICEF leverages its purchasing power to diversify and bolster the local production of vaccines, nutrition products and other essential commodities� In 2021, UNICEF procured RUTF from 22 different suppliers, of whom 18 were located in or close to countries with high levels of child wasting. Around two-thirds of UNICEF RUTF programme demand was satisfied through local RUTF production. • UNICEF lends its technical expertise and strengthens the capacity of governments to run and manage their own health, nutrition, education and WASH supply chains. Since 2019, UNICEF has been leading 639 technical cooperation projects across 20 areas in 66 countries, from supporting domestic resource mobilization for supplies and deploying cutting-edge last mile innovation to building the skills of the supply chain workforce and improving product visibility from manufacturer to child� Accelerating the implementation of the eight recommendations will require all partners to work in collaboration and share good practices. Case studies from Malawi, Mozambique, Nepal and Pakistan testify to the added-value of strengthening supply chains to achieve programme outcomes and make a difference in children’s lives, from determining when to deploy drones to increase the availability of health commodities or steering a coordinated COVID-19 vaccine roll out, to working with the private sector to improve the supply of clean water for remote communities� Although remarkable progress in child survival has been achieved over the last three decades, more needs to be done. In 2021, five million children were still missing out on basic vaccines while 13�6 million under the age of 5 suffered from severe wasting and 698 million lacked basic sanitation services at school� As social welfare systems rebuild after the COVID-19 pandemic, UNICEF and partners have an opportunity to make supply chains more resilient, more sustainable and more efficient. This report is a call to action to leverage best practices and ensure the global development community is better positioned to achieve our mutual goals together. 12 02  THE STATE OF SUPPLY CHAINS Understanding their role and identifying barriers to access 13Supply chains save lives: Unlocking access for children, their families and communities 14 WHAT ARE SUPPLY CHAINS AND WHY ARE THEY IMPORTANT? What are supply chains? Supply chains are made up of the people, processes, operations, infrastructures, innovations and capabilities that are necessary to source, produce and deliver products, from the early stages of sourcing raw materials to reaching children, families and communities� Supply chains comprise a network of all the individuals, organizations, resources, assets and technologies that have a role in identifying the demand for essential products, understanding the factors that influence this demand, and matching needs with appropriate services. End-to-end supply chains include manufacturers and suppliers, transporters, warehouses, retailers, social workers, policymakers, digital service providers and the end user� Supply chains are dynamic and involve the constant flow of information, products and funds between different stages. The supply chain rainbow (Figure 1) illustrates the different components of the supply chain, beginning with a definition of need and ending with monitoring and evaluation. It sets out the ‘enablers’ – the core supportive capability functions that are required to effectively manage supply chains (including people and policy, data analytics, system design, financing and regulations) and shows how they come together to form an end-to-end supply chain. Definition of need People and practices Financing and domestic resource mobilization Policies and regulatory frameworks Data analytics System design Delivery & clearance Utilization by end user Monitoring & evaluation Warehousing distribution & reorderProcurement Inspection Budgeting & planning Figure 1. The UNICEF supply chain rainbow 15Supply chains save lives: Unlocking access for children, their families and communities Why do we need to strengthen supply chains? Supply chains play a fundamental role in products reaching the beneficiary – even in hard-to-reach areas – and ensuring access to life-saving vaccines, medicines and other health technologies, as well as education and water, sanitation and hygiene (WASH) supplies� Supply chain blockages can prevent products from reaching children� For children to thrive, they require timely, continuous and equitable access to health, nutrition and education products and services from the moment they are born� Resilient and agile supply chains are a fundamental building block of national health, nutrition, and education and other child-centred programmes and necessary to attain the SDGs. UNICEF and partners have made systems-strengthening a priority and joined forces to build well-functioning, environmentally sustainable, responsive, accountable and resilient systems that better support communities, children and their families. Only with fit-for-purpose supply chain systems can we guarantee access to timely, high-quality essential supplies and ensure they are used without discrimination� Developing resilient and well-functionning health systems entails strengthening each component of the supply chain� Strengthening national statistical and data systems is central to UNICEF’s work as it strives to boost education systems and build the capacities of the social service workforce to ensure that health, nutrition, WASH, education and social protection systems can deliver for children� The challenge in low- and middle-income countries There are numerous reasons why low- and middle-income countries (LMICs) often lack the capacity and resources to build and manage agile and resilient supply chains� They face upstream challenges, such as limited visibility of data, a lack of analytic insight of demand behaviour, limited fiscal space and fragmented procurement processes. They also face downstream supply chain challenges, including limited warehousing, storage and distribution capacity� They often lack an adequately staffed and skilled supply chain workforce� The challenges are often further compounded by the absence of local manufacturing capacity and an over-reliance on offshore manufacturers, active pharmaceutical ingredients (API) vendors, and suppliers� Supply chain barriers can limit the availability of health products and other supplies, and trigger service interruptions that compromise the quality of products and undermine the safety of patients� Such barriers sometimes lead to prohibitively expensive operational costs resulting in unequal distribution and coverage� UNICEF and partners have made great strides towards improving equitable access to life-saving products and services with the support of development agencies including Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the United States Agency for International Development (USAID); and the United Kingdom Foreign Commonwealth & Development Office (FCDO), the European Union, and with global, regional and local private sector companies, academia and local/regional institutions� The COVID-19 pandemic has pointed a spotlight on the structural and operational limitations of existing supply chain systems and highlighted the importance of investing in strengthening systems� At the same time, the world’s pandemic response has underscored our collective commitment and shared vision to support countries as they address immediate needs related to COVID-19 and build stronger primary health care systems, including supply chains that are resilient to shocks. 16 WHAT IS ACCESS? Disease, injury, environmental hazards and the devastating effects of conflict put children around the world in harm’s way� But countless deaths can be avoided with access to vaccines, medicines and other critical health supplies�1 Access refers to the opportunity and the ability of people to obtain the supplies and services they need� While access can be measured across a multiplicity of dimensions, this report will focus specifically on three components: Physical accessibility This is understood as the availability of basic health, nutrition, WASH and education services within reasonable reach of those who need them and with opening hours, appointment systems and other aspects of service organization and delivery that allow people to obtain services when they need them� Financial affordability This is a measure of the ability of governments and individuals to pay for services without financial hardship. It considers not only the price of the services but also indirect and opportunity costs, such as the cost of transportation to and from facilities and the cost of taking time away from work� Acceptability, appropriateness and choice This captures people’s willingness to seek and make use of the supplies and services offered. Acceptability is low when populations perceive services to be ineffective or when social and cultural factors such as language or the age, sex, ethnicity or religion of the health provider discourage them from seeking services. The ability for populations to choose their products – for instance, their COVID-19 vaccines – brings stronger confidence in health and immunization services within communities� It leads to more adults, adolescents and children seeking treatment, which leads to fewer illnesses, hospitalizations and deaths� For various reasons, existing supplies do not always reach children in need. A lack of coordination, financing or data keeps some life-saving medicines and products far from the children they are meant to protect� Especially for children in remote areas, or in countries affected by crisis, ensuring that supplies reach the last mile is essential� Strong supply chains are fundamental in overcoming obstacles to access� Supply chains are the vehicles that ensure that medicines and other supplies reach children, even in the most remote areas. 1 Evans, David B et al. “Universal health coverage and universal access.” Bulletin of the World Health Organization vol. 91,8 (2013): 546-546A. doi:10.2471/BLT.13.125450. 17Supply chains save lives: Unlocking access for children, their families and communities Much of UNICEF’s work centres on technical cooperation and strengthening supply chains in countries� Adapting to global development trends and growing country demands for technical assistance, UNICEF works with governments in a number of areas, including supply forecasting, market-influencing and training of health workers� In emergencies, UNICEF is capable of delivering pre-positioned life-saving supplies within 72 hours from a network of supply hubs2 around the globe, to bring timely relief to affected populations anywhere in the world. Supply chains save lives Universal health coverage – the overarching goal of the global health system – cannot be attained unless both health services and financial risk protection systems are accessible, affordable and acceptable to patients. Universal health coverage is tied to development more broadly; improvements in education, for example, will contribute to increased average incomes, making health services more affordable and equipping people with the awareness needed to demand and obtain the health services they need�3 When it comes to education, UNICEF’s work is grounded in the notion that a child’s right to education entails the right to learn� Yet, for too many children across the globe, schooling does not lead to learning� This is why UNICEF and its partners strive for equitable access. In this context, access means quality education and skills development must be equitable and inclusive for all children and adolescents, regardless of who they are or where they live.4 A growing body of evidence reveals that inadequate sanitation, water, and washing facilities in schools limit girls’ attendance and learning performance, notably when their menstrual hygiene needs are not met�5 This illustrates how WASH and education programmes interact with health and other aspects of development to affect people’s access to the supplies and services they need. Access is fundamental to upholding the rights of children; as such, UNICEF Supply Division focuses on ensuring that supply factors are never an obstacle to access. Where supply is a barrier, these instances must be identified and overcome. The objective of this report is to identify these barriers and offer potential routes for addressing them to ensure that every child is protected, educated, healthy and well-nourished. 2 United Nations Children’s Fund, ‘Warehousing and distribution’, <www.unicef.org/supply/warehousing-and-distribution>. 3 Evans, David B et al. “Universal health coverage and universal access.” Bulletin of the World Health Organization vol. 91,8 (2013): 546-546A. doi:10.2471/BLT.13.125450 4 United Nations Children’s Fund, ‘Education’, UNICEF, <www.unicef.org/education#how>. 5 United Nations Children’s Fund, ‘Universal Access to Water, Sanitation and Hygiene – 2021 priorities’, UNICEF 2021, <www.unicef.org/media/97591/file/Universal%20Access%20to%20Water,%20Sanitation%20and%20Hygiene.pdf>. http://www.unicef.org/supply/warehousing-and-distribution http://www.unicef.org/education#how http://www.unicef.org/media/97591/file/Universal%20Access%20to%20Water,%20Sanitation%20and%20Hygiene.pdf 18 STRONG SUPPLY CHAINS: THE KEY TO EQUITABLE ACCESS A discussion with Aboubacar Kampo, UNICEF Director of Health Programmes According to Aboubacar Kampo, UNICEF Director of Health Programmes, “Strong supply chains help ensure that essential vaccines, medicines and health products make it from the point of inception all the way to the most vulnerable children; every link of the supply chain counts.” Working alongside governments UNICEF is the leading agency for the procurement and delivery of primary health care products for children and their families, including vaccines, essential medicines, sanitation and hygiene products and cold chain equipment� The world made remarkable progress in child survival in the past three decades, and millions of children have better survival chances than in 1990—1 in 27 children died before reaching age five in 2020, compared to 1 in 11 in 1990. This is only possible owing to functioning supply chains: “We need to make sure that health supply chains are responsive and resilient, and this means making sure they are capable of adapting to shifting demands for routine products, including during emergency situations like Ebola outbreaks.” For this reason, Kampo explains, UNICEF does not only deploy life-saving products to countries during emergency situations, but it also works with governments to strengthen health systems. “A lot of our work centres on technical cooperation and strengthening health supply chains in countries� Adapting to global development trends and growing country demands for technical assistance, we work with governments in a number of areas, including forecasting, market-influencing and training of health workers, for instance.” Strong and sustainable supply chains mean that patients receive the health commodities they need, of the right quality, in the right quantities, at the right time� At the same time, strong and sustainable supply chains help governments reduce costs, stock-outs and waste. “Part of our job is to support governments throughout their supply chain strengthening journey and help them find long-lasting solutions to bridge the gaps in access to quality child health, nutrition, education and other public services,” he says. Bringing the private sector, donors and civil society organizations together Creating synergies with civil society and development stakeholders, and leveraging the competencies, technological assets and innovation capacity of the private sector, says Kampo, has been pivotal to providing a coordinated response to national needs, developing quality medicines and vaccines, keeping prices affordable and making sure we reach patients at the last mile� “For example,” says Kampo, “we are always working with suppliers and the private sector to secure affordable prices and the best value for money. In addition to supplying UNICEF programmes, we provide procurement services to national governments and other partner organizations with common goals.” 19Supply chains save lives: Unlocking access for children, their families and communities UNICEF in numbers 335.9 MILLION CHILDREN 105.5 MILLION CHILDREN 2.8 MILLION GIRLS 1.9 BILLION DOSES With its partners UNICEF supplies vaccines to reach 46 per cent of the world’s children under 5. 2.8 million girls in target countries received their final dose of the human papillomavirus (HPV) vaccine in 2021� UNICEF and partners supported the vaccination of 105.5 million children with three doses of the diphtheria, tetanus toxoid and pertussis (DTP) vaccine in 2021. 335.9 million children were reached with services to prevent stunting and other forms of malnutrition and 5�4 million children received treatment for life-threatening wasting in 2021. As of February 2023, COVAX and UNICEF had delivered more than 1.9 billion doses of COVID-19 vaccines to 146 countries� 46% “By collaborating with the private sector to develop quality medicines and keep prices affordable, we bolster the sustainability of supply chains to help expand access to life-saving vaccines and medicines for every child at the district and community levels.” All in the name of access Kampo is adamant that strong health supply chains are a fundamental element to ensuring patients’ access to the health, nutrition and education products they require� “Put very simply, supply chains are responsible for vaccines reaching children in Nigeria, hygiene supplies reaching children in Haiti and nutritional supplements reaching children in Afghanistan.” “We work hard to make sure communities at the last mile have access to life-saving products� This sometimes requires a lot of work with communities to address concerns, and at the same time, monitoring to see if products make it to patients and have the desired effect.” “When you follow a product throughout the whole supply chain, from development and procurement all the way to the child, you then realize not only how complex health supply chains are, but also how the health of the planet depends on them.” “This is why we’re calling for greater investments, resources and collaboration to sustainability strengthen public supply chains.” WHAT IS WHAT 20 HEALTH SUPPLY CHAIN BARRIERS TO ACCESS Strong supply chains adaptable to the changing needs of health programmes are critical to bridging the gap in access to vaccines, diagnostics and essential medicines. Many commodity-related obstacles are linked to financial and social barriers and rooted in broader health system challenges – such as poor governance, inadequate human resources, ineffective local supply chains and insufficient information systems�6 Such obstacles are part of the reason why some children cannot access critical health supplies� Globally, infectious diseases, including pneumonia, diarrhoea and malaria, remain the leading causes of death in children under 5. Of the nearly 6 million children who do not live beyond the age of 5, nearly 30 per cent die from malaria, pneumonia or diarrhoea�7 More than half of these early child deaths are due to conditions that could be prevented or treated with access to simple, affordable interventions.8 According to 2022 WHO and UNICEF estimates of national immunization coverage, 25 million children missed out on basic vaccines in 2021 – the highest number since 2006� Further, 18 million children missed out on any vaccination (zero-dose children) – a number not seen since 2008. In addition, an increasing number of measles and polio outbreaks have been reported, with first dose measles coverage dropping to 81 per cent in 2021, the lowest level since 2008� According to an in-depth analysis conducted by UNICEF, an increasing proportion of under-immunized children are clustered in the following three types of communities: • Remote rural communities, which face challenges related to access and infrastructure; • Urban slums, where challenges are more often related to trust, social distance and legality; and • Conflict-affected and insecure settings where there may be an interruption or breakdown in services, as well as constrained access�9 UNICEF strives to ensure gender equitable immunization programmes� Immunization is widely perceived as gender-neutral; however, in many countries, gender barriers and underlying power dynamics at household and community level can make it challenging for mothers and caregivers to access immunization services for their children. Gender barriers vary by context and can influence resource allocation, constrain women’s decision-making and limit their mobility. The unequal division of labour means that women often shoulder the majority of household and caregiving tasks, presenting important time challenges and limiting their ability to bring their children to health centres. Lack of trained 6 Every Woman, Every Child, ‘UN Commission on Life-saving Commodities for Women and Children – Commissioners’ Report’, September 2021, <www.unfpa.org/sites/default/files/pub-pdf/Final%20UN%20Commission%20Report_14sept2012.pdf>. 7 United Nations Children’s Fund, ‘Under-five mortality’, UNICEF, <https://data.unicef.org/topic/child-survival/under-five- mortality/#>. 8 World Health Organization, Regional Office for Africa, ‘Child health fact sheet: Pneumonia’, WHO, <www.afro.who.int/ health-topics/child-health>. 9 United Nations Children’s Fund, ‘UNICEF Immunization Roadmap 2018–2030’, UNICEF, September 2018, <www.unicef. org/sites/default/files/2019-01/UNICEF_Immunization_Roadmap_2018.pdf>. http://www.unfpa.org/sites/default/files/pub-pdf/Final%20UN%20Commission%20Report_14sept2012.pdf https://data.unicef.org/topic/child-survival/under-five-mortality/# https://data.unicef.org/topic/child-survival/under-five-mortality/# https://data.unicef.org/topic/child-survival/under-five-mortality/# https://data.unicef.org/topic/child-survival/under-five-mortality/# http://www.unicef.org/sites/default/files/2019-01/UNICEF_Immunization_Roadmap_2018.pdf http://www.unicef.org/sites/default/files/2019-01/UNICEF_Immunization_Roadmap_2018.pdf 21Supply chains save lives: Unlocking access for children, their families and communities female vaccinators can also have an indirect impact on immunization services and coverage, reducing the chances of both boys and girls being vaccinated�10 Key health supply chain barriers 1. Governments lack appropriate data and information systems to make supply chain management decisions Data analytics is the collection, exploitation, harnessing and management of data to transform it into actionable evidence� This transformation enables governments to make informed decisions that will affect policy, strategy and tactical-level endeavours that enable children to access health supplies and services� Forty per cent of global health resources are lost owing to preventable strategic and operational inefficiencies,11 which are often linked to countries’ limited capacity to generate and act on evidence� Currently 86 per cent of reported supply chain data are not used to inform decision-making or monitor performance.12 These unused data must be harnessed to shape well-performing supply chains that are driven by needs, and are resilient and cost-efficient. Supply chains with these features can increase access to all required health products and services for children in need� Inadequate planning, distribution, temperature monitoring, human resources and data management, coupled with limited product visibility, availability and use of electronic logistics management information systems (eLMIS) at national and subnational levels, are all among the key causes of supply stock outs� Sub-optimal stock management creates distrust in the health system� Stock outs not only increase the operational and opportunity costs but can also play a significant role in broadening inequities and stagnating demand, specifically affecting under-served, urban poor, insecure and hard-to-reach populations. Analysis from UNICEF and WHO13 indicates that 50 per cent of LMICs suffered stock-outs of at least one routine immunization vaccine at the national level, in 2021� Additionally, there are few mechanisms in place to monitor 10 United Nations Children’s Fund, ‘Immunization and Gender – A practical guide to integrate a gender lens into immunization programmes’, UNICEF Regional Office for South Asia, July 2019, <www.unicef.org/rosa/media/12346/file>. 11 World Health Organization, ‘The World Health Report: Health systems financing - The path to universal coverage’, WHO, 2010, <https://apps.who.int/iris/handle/10665/44371>. 12 Data collected by UNICEF experts in the field, 2020 13 Joint Reporting Form, 2021 14 UNICEF digital mapping exercise, 2022 15 UNICEF digital mapping exercise, 2022 16 Infectious Diseases Data Observatory, ‘Medical Product Quality Report – COVID-19 vaccines’, IDDO, <www.iddo.org/mq/research/medical-product-quality-report-covid-19-vaccines>. 17 World Health Organization, ‘A Study on the Public Health and Socioeconomic Impact of Substandard and Falsified Medical Products’, WHO, 2017. stocks at subnational level. Over the last ten years, at least one-third of countries have experienced one or more vaccine stock-outs lasting for one month or more. In addition, LMICs have seen the number of stock-outs increase from 30 per cent in 2010 to around 50 per cent in 2021. Almost half of these countries experienced service interruptions owing to stock-outs in 2020, representing a 30 per cent increase from 2014. 2. Supply chain management systems do not sufficiently embrace modern technology Many countries lack strong health supply chain information systems to inform the development of social protection and welfare policies� Two systems are particularly important: (i) national information systems identify the number of beneficiaries that require access to health services and the associated financial needs; (ii) product traceability systems enable the tracking and tracing of products; improve controls against falsified labelling and substandard, diverted and counterfeit medicines; and protect patient safety� On average, LMICs have reported using as many as 34 different supply chain related information systems simultaneously�14 They tend to be poorly connected or harmonized, making it hard to make informed decisions� This lack of insight contributes directly to wastage in health spending and high numbers of supply stock-outs in LMICs. Verification of product quality and the ability to track and trace a product in a supply chain are also crucial to inform planning and ensure the right supplies are delivered at the right time, particularly in the national supply chains of LMICs, where governance structures, tools and technical capacity for active monitoring for falsification are limited and traceability systems are either non-existent or in the early stages of development�15 The COVID-19 pandemic highlighted this critical gap, as there was an upsurge in the production and distribution of falsified and substandard vaccines and related COVID-19 supplies�16 However, the need for product quality verification and traceability extends beyond COVID-19 vaccines to all health products�17 http://www.unicef.org/rosa/media/12346/file https://apps.who.int/iris/handle/10665/44371 http://www.iddo.org/mq/research/medical-product-quality-report-covid-19-vaccines 22 Product integrity and ethical distribution are vital to ensuring trust in vaccines and pharmaceuticals and applying Global Standard 118 is one of the tools to address this important building block in reducing the risk of falsified and substandard vaccines and pharmaceuticals in health supply chains� 3. The supply chain workforce lacks the required skills and capacity The supply chain workforce often lacks the technical and managerial competencies to perform optimally or lacks the empowerment to affect supply decisions and policies.19 Many LMICs have insufficient numbers of adequately trained staff – particularly logistics staff – to manage health supply chains� This hinders planning and limits managers in mobilizing their limited resources, including the workforce� The technical capacity and knowledge of existing health supply chain staff are constrained by a lack of experience or formal training, either through supply chain and logistics degree programmes or in-service training for staff. Meanwhile, salaries are inequitable, staff lack job descriptions, the available tools and working conditions 18 See: GS1, <https://www.gs1.org/>. 19 World Health Organization, ‘WHO Roadmap for Access to Medicines, Vaccines and Health Products 2019-2023’, 2019, <https://apps.who.int/iris/handle/10665/330145>. 20 Liu, J.X., Goryakin, Y., Maeda, A. et al., ‘Global Health Workforce Labor Market Projections for 2030’, Human Resources for Health, vol. 15, issue 11, 2017, <https://doi.org/10.1186/s12960-017-0187-2>. 21 McKinnon, Alan; Flöthmann, Christoph; Hoberg, Kai; Busch, Christina, ‘Logistics Competencies, Skills, and Training: A Global Overview’, Washington, DC: World Bank, 2017, <https://openknowledge.worldbank.org/handle/10986/27723>. 22 IQVIA, 2019 are inadequate, and there is often no career plan, regular performance review or recognition� Furthermore, there may be duplication in roles and in the chain of command, making it challenging to attract and retain capable and motivated staff. Many LMICs lack a professionalized supply chain occupational category, formed through formal education or the civil service structure, with clear roles and responsibilities� This means that a desirable career path often does not exist for supply chain professionals. Primary health care professionals are essential to manage public health emergencies, such as the COVID-19 pandemic and Ebola and outbreaks and other health emergencies. Shortages of qualified staff are endemic in LMICs. In some of these countries, the lack of educators, infrastructure and equipment, and clinical training sites, prevents children from accessing supplies and receiving quality treatment� In humanitarian settings, where needs are escalating and children’s survival is at greater risk, the situation is even more challenging� Why is it important to invest in the supply chain workforce? 80 million health workers will be required by 2030 to ensure the world’s population has equitable access to medicines�20 40 per cent of logistics professionals in emerging economies lack logistics skills at operative, administrative and supervisory levels�21 The workload for the supply chain workforce will continue to increase owing to changing disease profiles and accelerated efforts to achieve universal access to health� Spending on medicines in emerging economies, including in LMICs, is expected to increase by 22 to 57 percent by 2023�22 40% 57% https://www.gs1.org/ https://apps.who.int/iris/handle/10665/330145 https://doi.org/10.1186/s12960-017-0187-2 https://openknowledge.worldbank.org/handle/10986/27723 23Supply chains save lives: Unlocking access for children, their families and communities 24 4. Supply chains are large emitters of greenhouse gases Up to 90 per cent of an organization’s environmental impact lies in the supply chain, either upstream (suppliers, manufacturing phase) or downstream (consumers, product use phase)�23 This impact is exacerbated during climate related events and other emergency contexts where the amount of greenhouse gases produced by supply chains can be considerably higher and places a greater burden on the environment and natural resources� 5. Last-mile delivery systems and sustainable health care infrastructures are underdeveloped Health supplies do not always reach their intended clients in primary health care centres or through community-based services delivered by community health workers� In some cases, this is because of poor transportation systems or road infrastructure, inadequate involvement of local private sector partners or shortages of products as a result of limited planning and/or decision-making capacity or leakage between national and district warehouses and the last mile� Health supplies may also fail to reach their intended beneficiaries due to shortages in trained and dedicated personnel with knowledge of the local area� 23 Shaw, K.; Shankar, R.; Yadav, S.S.; Thakur, L.S. Supplier selection using fuzzy AHP and fuzzy multi-objective linear programming for developing low carbon supply chain. Expert Syst. Appl. 2012, 39, 8182–8192 . 24 Lee et al, 2015 “Landscaping the structures of GAVI country vaccine supply chains and testing the effects of radical redesign”, Vaccine, Volume 33, Issue 36, 2015, pp. 4451-4458. 25 Ouma et al., ‘Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: A geocoded inventory and spatial analysis’, Lancet Glob Health, 2018, Mar;6(3):e342-e350. 26 Global Effective Vaccine Management Analysis (2009-2020), based on 93 countries assessed. Why is it crucial to invest in last-mile delivery systems? 72 per cent of countries could reduce their supply chain operating costs through simplified structures and operations24 29 per cent of the population of sub-Saharan Africa live more than two hours from the nearest public hospital25 70 per cent of subnational health facilities and 50 per cent of national health facilities assessed by UNICEF were unable to provide the right number of supplies to public health care facilities in 202126 29% 72% 70% 25Supply chains save lives: Unlocking access for children, their families and communities Cold chain investments are vital for essential heat-sensitive vaccines and medicines delivery and to ensure the quality of supplies and treatment. Delivering vaccines, insulin and other medicines to all corners of the world is complex and involves a chain of precisely coordinated events in temperature- controlled environments to store, manage and transport these life-saving products. Although cold chain equipment to store heat-sensitive health care products has existed for decades, the equipment standards in countries often do not match the pace of vaccine development and demand� Primary health care centres at the last mile must improve waste management and seek ways to improve their electricity usage in ways that do not increase their carbon footprint� The lack of health care waste management at primary health care centres poses a serious risk to the lives and well-being of children. Small-scale facilities require a sound health care waste management system, comprising adequate financial resources and suitable management and monitoring capacity to minimize the potential health and environmental impacts� At least 5�2 million people, including 4 million children, die each year from diseases originating from unmanaged medical waste. More than two-thirds of health facilities in low- and middle-income economies do not practice safe and environmentally sustainable health care waste management practices� This is primarily because of a lack of resources and the non-prioritization of resource allocations – financial and technical – to acquire and employ the best available techniques and technologies�27 27 United Nations Department of Economic and Social Affairs, Division for Sustainable Development, ‘Core publications – Agenda 21’, United Nations, <www.un.org/esa/dsd/agenda21/res_agenda21_21.shtml>. http://www.un.org/esa/dsd/agenda21/res_agenda21_21.shtml 26 More than 1 billion people in the world lack access to electricity, particularly in LMICs where this has serious consequences for health care delivery.28 A 2018 survey of 78 countries found that only 41 per cent of health care facilities in LMICs have reliable electricity. In sub-Saharan Africa, one in four health facilities lacks a source of electricity and three out of four facilities lack reliable power�29 This leaves many health care facilities with inadequate power for both basic and emergency services� Moreover, an estimated 70 per cent of medical devices in the least developed countries (LDCs) regularly fail or are unavailable, with poor power quality being a major contributing factor.30 The COVID-19 pandemic further increased pressure on the health care system in LMICs and highlighted the importance of energy access in delivering reliable primary health care services to the last mile. Reliable access to electricity will drastically improve the quality of services provided at health facilities, including life-saving interventions related to maternal and newborn care, as well as the storage and distribution of vaccines, essential medicines, and the uninterrupted functioning of critical equipment such as oxygen concentrators� Many necessary components of a health facility, such as lights and imaging equipment, become effective and usable, especially in times of urgent medical need� 28 Africa Energy Portal, ‘Lasting impact: Sustainable off-grid solar delivery models to power health and education’, AEP, 29 April 2019, <https://africa-energy-portal.org/reports/lasting-impactsustainable-grid-solar-delivery-models-power-health-and-education>. 29 World Health Organization and World Bank, ‘Access to Modern Energy Services for Health Facilities in Resource- Constrained Settings: A Review of Status, Significance, Challenges and Measurement’, WHO, reprinted in 2015, <https:// apps.who.int/iris/handle/10665/156847>. 30 Sustainable energy for All Powering health care� 2020 31 United Nations Development Programme, 2020 Global Multidimensional Poverty Index (MPI): Charting pathways out of multidimensional poverty: Achieving the SDGs’, New York, 2020, <https://hdr.undp.org/content/2020-global- multidimensional-poverty-index-mpi>. 32 United Nations Children’s Fund, ‘Key asks for 2020 – SDG Voluntary National Reviews: SDG 7’, <www.unicef.org/ documents/sdg-issue-brief-7>. 33 Ibid� More than 186 million students are in primary schools with no access to electricity�31 Why is it crucial to invest in sustainable energy? Children living in households with electricity spent an average of 274 more days at school than children living in households without electricity�32 600,000 children under age 5 die each year from respiratory infections due to indoor and outdoor air pollution and second-hand smoke resulting from unsustainable energy practices�33 https://africa-energy-portal.org/reports/lasting-impactsustainable-grid-solar-delivery-models-power-health-and-education https://apps.who.int/iris/handle/10665/156847 https://apps.who.int/iris/handle/10665/156847 https://hdr.undp.org/content/2020-global-multidimensional-poverty-index-mpi https://hdr.undp.org/content/2020-global-multidimensional-poverty-index-mpi http://www.unicef.org/documents/sdg-issue-brief-7 http://www.unicef.org/documents/sdg-issue-brief-7 27 6. Insufficient and inequitable primary health care financing restricts access to supplies Financial resources for the health sector – and particularly for primary health care – remain insufficient in many countries. Annual government spending on primary health care ($3 per capita in low-income countries and $16 per capita in LMICs) falls far short of standard benchmarks for the minimum spending needed to ensure universal health coverage (between $65 to $95 per capita)34� This means that household out-of-pocket expenditures on health supplies and services are unacceptably high for families and can have catastrophic and impoverishing consequences. In 2019, in countries where children and families were already lacking the resources to meet their daily needs, 60–79 per cent of health costs came directly out of their pockets rather than from insurance or government spending� These included low-income countries such as Afghanistan, African Republic, Guinea-Bissau and the Central, Sudan, Togo�35 Against this backdrop, the reallocation of regular government health funding to respond to COVID-19 has been particularly damaging, further straining the already poorly resourced health sector� Public finance management36 obstacles often impact governments’ ability to mobilize the required resources and/or maximize investments for children. These challenges take many forms, including:37 • low budget priority owing to a lack of awareness among financial decision- makers of the need to invest in children; • insufficient budget allocation to implement child-related programmes; • inefficient expenditure due to delayed disbursements, leakages and procurement issues; • ineffective expenditure by funding high-cost, low-impact interventions, or fragmented spending where multisectoral interventions are required; • inequitable allocations resulting in lower investment and poorer services for disadvantaged areas or populations; and • limited financial accountability, compounded by limited budget transparency or citizen participation� The decisions governments make about how to fund social services are critical to children and to equitable development� In some countries, these challenges are compounded by shifts in external financing trends, such as a reduction in official development assistance, which further raises the importance of domestic public resources for social policies and services� 34 The Global Health Observatory, ‘Out-of-pocket expenditure as percentage of current health expenditure’, World Health Organization, <www.who.int/data/gho/indicator-metadata-registry/imr-details/4965>. 35 Figures from WHO, Global Health Expenditure Database, <https://apps.who.int/nha/database/ViewData/Indicators/en>, accessed 26 April 2022. 36 Public financial management refers to the way (budget process) governments manage public resources (revenue and expenditure) and the impact of such resources on the economy or society. 37 United Nations Children’s Fund, ‘UNICEF’s Engagements in Influencing Domestic Public Financing for Children’, UNICEF, December 2017, <www.unicef.org/sites/default/files/2019-12/UNICEF_Public_Finance_for_Children.pdf>. http://www.who.int/data/gho/indicator-metadata-registry/imr-details/4965 https://apps.who.int/nha/database/ViewData/Indicators/en http://www.unicef.org/sites/default/files/2019-12/UNICEF_Public_Finance_for_Children.pdf 28 7. Poor governance of primary health care hinders access to supplies Government policy and strategy choices affect all children. Countries with poor governance have weak or limited policies, programmes and accountability mechanisms that protect children’s rights and meet the needs of children, their families and communities. Decision-making may be influenced by political or private interests. In these settings, the most vulnerable are often the least able to exercise their rights and contribute to the decisions that affect them. This is especially pronounced for local governments and health administrations struggling with limited staff and budgets without the mechanisms to engage with communities, civil society and the private sector� A supply chain can be defined as an ecosystem of organizations, people, technology, activities, information and resources that have to come together to ensure the delivery of the product from the point where it is manufactured to the final customer in a cost-effective way.38 In this regard, a national public health supply chain should operate within a defined policy and regulatory framework to ensure the highest levels of patient safety or be supported by private sector regulations to improve equitable access to life-saving supplies. Governments are responsible for ensuring the quality and safety of essential supplies for children and for designing and implementing quality assurance policies and mechanisms that ensure that safe and effective products reach their intended end user. Absent or weak regulations are a major cause of illicit and poor-quality drugs in both legitimate and informal supply chains (internet, unregistered pharmacies) posing a serious threat to public health, especially where there is no stringent national medicine regulatory authority� It is estimated that 1 in 10 medicines in LMICs is falsified or substandard, causing serious risks of illness or even death�39 Since 2013, antimalarials and antibiotics have been the products most commonly reported to be substandard or falsified, according to the WHO. The WHO African Region was the most affected (42 per cent), followed by the Americas and the European Region (21 per cent each)�40 8. National immunization supply chain activities and investments lack coordination and inter-operability with primary health care National immunization programmes in developing countries face several challenges in ensuring equitable access to vaccines against preventable diseases through the Expanded Programme on Immunization (EPI). Safely storing and transporting large volumes of vaccines and other immunization commodities to immunization service points has become increasingly difficult, especially in remote and hard-to-reach areas. Critical barriers include lack of inventory, inadequate cold chain capacity, insufficient funding, insufficient coordination of interventions, and low interest in immunization supply chain and logistics policies�41 38 Prashant Yadav, ‘Health Product Supply Chains in Developing Countries: Diagnosis of the Root Causes of Underperformance and an Agenda for Reform’, Health Systems & Reform, 2015, vol. 1, issue 2, pp.142-154, DOI: 10.4161/23288604.2014.968005. 39 World Health Organization, ‘1 in 10 medical products in developing countries is substandard or falsified’, WHO, 28 November 2017, <www.who.int/news/item/28-11-2017-1-in-10-medical-products-in-developing-countries-is-substandard-or-falsified> 40 Ibid� 41 TechNet21, ‘NLWGs’, June 2018, <https://technet-21.com/fr/chapter-4-antibody-detection-methods-for-laboratory- confirmation-of-measles-rubella-and-crs/itemlist/category/258-nlwg&format=feed&Itemid=3683&type=atom>. http://www.who.int/news/item/28-11-2017-1-in-10-medical-products-in-developing-countries-is-substandard-or-falsified https://technet-21.com/fr/chapter-4-antibody-detection-methods-for-laboratory-confirmation-of-measles-rubella-and-crs/itemlist/category/258-nlwg&format=feed&Itemid=3683&type=atom https://technet-21.com/fr/chapter-4-antibody-detection-methods-for-laboratory-confirmation-of-measles-rubella-and-crs/itemlist/category/258-nlwg&format=feed&Itemid=3683&type=atom 29Supply chains save lives: Unlocking access for children, their families and communities National logistics working groups (NLWGs), comprising representatives from the EPI, UNICEF, WHO, ministry of health departments responsible for pharmaceuticals, can address impediments to accessing life-saving vaccines by uniting national stakeholders and decision- makers to rally behind a shared vision for the country’s immunization supply chain� The key challenges facing such coordinating groups include low levels of engagement among logistics managers and lack of understanding of the roles and values of NLWGs. Other barriers include the lack of specialized human resources and capacity at the national level, the lack of a systematic and clear modes of functioning, the size and complexity of countries and the few numbers of partners�42 Immunization services are integral to primary health care and can be used as an entry-point to strengthen service delivery where access barriers exist. Integrated and more people-centred care has been shown to improve health outcomes and the attainment of universal health coverage. Efficiency gains can be derived from reducing the duplication of resourcing through use of common infrastructure, human resources, and financing, service delivery and information platforms� Equity gains can be derived from reducing missed opportunities for immunization through increased interaction with the health care system, including through the private sector�43 9. Restricted access to supplies negatively impacts the quality of primary health care When primary health care is implemented as an ad hoc set of minimal and under-resourced services, or by a workforce with limited training and competence, it will fail to deliver the expected results and can undermine public confidence.44 This can happen owing to multiple challenges, including low capacity of health care providers, lack of water and sanitation, and fragmented health systems� As a result, health facilities and community 42 Ibid� 43 United Nations Children’s Fund, ‘Primary Health Care and Universal Health Coverage’, UNICEF Regional Office for South Asia, 2019, <www.immunizationagenda2030.org/images/documents/BLS20116_IA_Global_strategy_document_SP_1_003.pdf>. 44 Bitton, A. et al., ‘Primary health care as a foundation for strengthening health systems in low- and middle-income countries’, J Gen Intern Med, 2017, vol. 32, no.5, pp. 566-571. 45 United Nations Children’s Fund, ‘Quality of care’, <https://www.unicef.org/health/quality-care>, accessed 20 May 2022. 46 World Health Organization and UNICEF, ‘A vision for primary health care in the 21st century: Towards universal health coverage and the Sustainable Development Goals, WHO, Geneva, 2018�� 47 World Health Organization, 2019. 48 Fadhiru Kamba, P., ‘Compliance of private pharmacies in Uganda with controlled prescription drugs regulations: A mixed-methods study’, BMC, vol.15, no. 5, 2020, <https:// substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-020-00261-x>. health workers often struggle to provide the care needed to treat newborns, children and women, and manage acute but easily treatable conditions, including maternal complications during delivery or acute childhood illness� Without such care, many at-risk infants will not survive their first month of life.45 Quality health care delivery across the full range of primary health care services is compromised if care is not safe, people-centred, timely, equitable and efficient; when it is not effectively supervised, mentored and supported and when it lacks a good referral system�46 Having all the building blocks of primary health care in place is essential to ensuring access to life-saving supplies. The private sector provides more than 40 per cent of health services globally and more than 80 per cent in South Asia�47 However, the potential for better performance is restricted due to little state and civil society oversight in applying regulations and quality control� In many cases, legal and regulatory frameworks for primary health care are not applied in private health care settings. Data from private primary health care providers may not be incorporated in national health information systems, thus skewing the information available about health conditions and coverage of care� Prescription drug abuse is a growing global health challenge in sub-Saharan Africa. Effective supply chain regulations on dispensing and stock control are important for controlling this epidemic� Since compliance with these regulations in resource-limited countries is poor, there is a need to understand its predictors in order to reduce the risk�48 In Uganda, the pharmacy business became a regulated professional business in 2018 under the National Drug Policy and Authority Act to address this issue and advance the national health strategy� http://www.immunizationagenda2030.org/images/documents/BLS20116_IA_Global_strategy_document_SP_1_003.pdf https://www.unicef.org/health/quality-care https://substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-020-00261-x https://substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-020-00261-x https://www.sciencedirect.com/science/article/abs/pii/S0955395921001560 https://www.sciencedirect.com/science/article/abs/pii/S0955395921001560 30 NUTRITION SUPPLY CHAIN BARRIERS TO ACCESS The case of ready-to-use therapeutic food According to the 2022 Global Report on Food Crises, there are currently 193 million people living in severely food insecure contexts in 42 countries, with children under five accounting for at least 27 million. These children are particularly vulnerable to wasting – the most life-threatening form of undernutrition in early childhood, which increases children’s risk of death by up to 12 times� Before the global food and nutrition crisis in 2022, there were an estimated 47 million children suffering from wasting globally, 13.6 million of whom suffered from severe wasting. In 2022, the number of children suffering from severe wasting in the 15 worst affected countries increased at an unprecedented speed – one additional child with severe wasting every minute. Only 1 in 3 children with severe wasting receives treatment.  In the last two decades, significant progress in national policies, strategies, and programmes to prevent malnutrition in children resulted in the reduction in the global prevalence of child stunting by one third (55 million children)� This achievement demonstrates that positive change for nutrition is possible and is happening at scale, across countries and regions49� However, in the countries most severely affected by the current global food and nutrition crisis, programmes and interventions are not addressing the determinants and drivers of the more life-threatening forms of child wasting. Many of the current global efforts focus on food assistance with little or no attention to the direct, underlying and enabling interventions for the early prevention, detection and treatment of child wasting, which are: nutritious and safe foods for children, essential nutrition services, positive nutrition and care practices, and financial resources in the hands of women to prevent malnutrition in children, particularly among the most vulnerable� The coverage and impact of early detection and treatment services for the most severe forms of child wasting remain hampered by a lack of predictable, commensurate and sustainable access to funding for programme scale up and life-saving nutrition commodities, particularly ready- to-use therapeutic food (RUTF). 49 UNICEF, UNICEF Nutrition Strategy 2020 -2030, https://www.unicef.org/reports/nutrition-strategy-2020-2030 https://www.wfp.org/publications/global-report-food-crises-2022 https://www.unicef.org/reports/nutrition-strategy-2020-2030 31Supply chains save lives: Unlocking access for children, their families and communities The financing landscape for maternal and child nutrition further makes the implementation of an appropriate response even more challenging� Resources for the implementation of a comprehensive package of actions for the early prevention of child wasting in the countries most vulnerable to the food and nutrition crisis are severely lacking, putting increasing numbers of young children at high risk of severe wasting and death� To make matters worse, the cost of treatment is increasing as a result of the global crisis: recent data shows that the price of RUTF – the primary nutrition commodity for the successful treatment of child wasting – increased by 16 per cent in 2022 resulting in a potential 660,000 fewer children treated globally with available resources�50 At a global level, the conditions are ideal for mounting a concerted effort to support the most vulnerable children. In 2020, the United Nations Secretary-General launched the Global Action Plan (GAP) on Child Wasting – the first-ever global plan to achieve the SDG targets for the prevention of child wasting and to scale up timely treatment for children with the more severe forms of wasting� In 2021, UNICEF launched Nutrition, for Every Child: UNICEF Nutrition Strategy 2030, setting forth UNICEF’s strategic intent to support national governments and partners in upholding children’s right to nutrition and ending child malnutrition in all its forms� The Strategy lays out UNICEF’s vision of a world where all children realize their right to nutrition, a vision guided by the Convention on the Rights of the Child, which recognizes the right of every child to adequate nutrition� As elaborated in the UNICEF Nutrition Strategy 2030, prevention of all forms of malnutrition should be the priority in all contexts. UNICEF nutrition programmes aim to prevent child malnutrition in all its forms across the life cycle, however, if prevention fails, treatment is a must. When efforts to prevent malnutrition fall short, our programmes aim to ensure the early detection and treatment of children suffering from life-threatening malnutrition, both in development and humanitarian contexts. Guided by the strategy, No Time to Waste, our approach is based on scaling up prevention, early detection, and the treatment of wasting for the most vulnerable children� 50 UNICEF Supply Division, ‘Ready-To-Use Therapeutic Food (RUTF) Supply Alert June 2022 and outlooks’, https://www.unicef.org/supply/reports/ready-use-therapeutic-food-rutf- supply-alert-june-2022-and-outlooks 51 United Nations Children’s Fund, ‘UNICEF Child Alert: Severe Wasting: An Overlooked Child Survival Emergency’, UNICEF, May 2022, <www.unicef.org/media/121891/file/English.pdf>. 52 United Nations Children’s Fund, ‘Market Outlook: Ready-To-Use Therapeutic Food’, UNICEF, March 2021, <https:// www.unicef.org/supply/media/7256/file/RUTF-Supply-Update- March-2021.pdf>. 53 Kakietech, S. et al., ‘Investing in Nutrition, The Foundation for Development: An Investment Framework to Reach The Global Nutrition Targets’, World Bank, 2016, <https://documents1.worldbank.org/curated/en/963161467989517289/pdf/104865-REVISED-Investing-in-Nutrition-FINAL.pdf>. The Strategy recognizes the importance of protecting children from wasting and offers concrete actions and commitments to do so in a way that is commensurate to the scale and urgency of their needs� Effective supply chains play a key role in our approach to ensure access to the key life-saving treatment of RUTF for all children in need, in the right place at the right time� Supply chains are a key pillar of UNICEF’s plan to accelerate the delivery of proven essential actions for the treatment of child wasting� Key RUTF supply chain barriers 1. The global production capacity of therapeutic foods does not meet demand In 2020, nearly 10 million children who needed RUTF for the treatment of severe wasting were unable to access it�51 UNICEF procures an estimated 75 to 80 per cent of the global demand for RUTF, averaging 49,000 metric tons (MT) per year over the last four years – enough to treat 3.5 million children. Despite the high volumes of RUTF procured through UNICEF, this still only covers 25 per cent of the global estimated number of children suffering from severe wasting� RUTF procured by governments, non-governmental organizations (NGOs) and other United Nations agencies cover an additional 5 to 10 per cent� As such, approximately 65 to 70 per cent of children suffering from severe wasting globally do not have access to treatment. Most of these children live in non-humanitarian contexts, which receive less attention.52 2. There are inconsistent investments for effective and responsive RUTF supply chains The continued reliance on humanitarian funding to address child wasting has fuelled a cycle of weak systems, inefficiencies and unnecessarily high costs. According to a World Bank analysis53, it will cost $7 billion per year over the next 10 years to fully scale up treatment for children with severe wasting� However, countries with a high burden of wasting currently spend less than 1 per cent of their public health budgets on nutrition services� The question of how services should be financed as part of health systems strengthening, and what role global funds and domestic resource mobilization should play, remain critically important� https://www.unicef.org/media/96991/file/Global-Action-Plan-on-Child-Wasting.pdf https://www.unicef.org/media/92031/file/UNICEF%20Nutrition%20Strategy%202020-2030.pdf https://www.unicef.org/media/92031/file/UNICEF%20Nutrition%20Strategy%202020-2030.pdf https://www.unicef.org/supply/reports/ready-use-therapeutic-food-rutf-supply-alert-june-2022-and-outlooks https://www.unicef.org/supply/reports/ready-use-therapeutic-food-rutf-supply-alert-june-2022-and-outlooks https://www.unicef.org/supply/reports/ready-use-therapeutic-food-rutf-supply-alert-june-2022-and-outlooks http://www.unicef.org/media/121891/file/English.pdf https:// www.unicef.org/supply/media/7256/file/RUTF-Supply-Update-March-2021.pdf https:// www.unicef.org/supply/media/7256/file/RUTF-Supply-Update-March-2021.pdf https://documents1.worldbank.org/curated/en/963161467989517289/pdf/104865-REVISED-Investing-in-Nutrition-FINAL.pdf 32 This lack of predictable and sustained investment in treatment has limited opportunities to drive down costs – especially those associated with the supply of RUTF to treat children with wasting� However, there is room for optimism with the development of the recently created catalytic Nutrition Match Instrument (NMI), which incentivizes the investment of domestic resources to scale up wasting prevention and treatment services, including the supply of ready-to-use therapeutic food (RUTF). The NMI is supported by supported by the United Kingdom’s Foreign Commonwealth and Development Office (FCDO), the Bill & Melinda Gates Foundation and the Children’s Investment Fund Foundation 3. Therapeutic nutrition products are not integrated into health system supply chains Unlike vaccines, many countries do not include RUTF and other life-saving supplies on their essential medicines and commodities lists� As such, these countries do not routinely budget for or procure nutrition therapeutic supplies and cannot plan or manage their delivery within national supply chains� The integration of treatment for child wasting within national health services is key to improving treatment efficiency and effectiveness. In emergency-prone countries, there is often a lack of coordination between health and nutrition partners who duplicate activities and costs� Services are often delivered through the same facilities using different funding streams, which involve two sets of operating costs, two reporting lines and two sets of staff. It also means that opportunities are missed to maximize treatment coverage and streamline supply chains for health and nutrition commodities� Consequently, ongoing efforts to integrate the treatment of severe wasting into routine services need to continue for sustainable programmes� 4. Therapeutic nutrition products are subject to price hikes Owing to the ongoing global food and nutrition crisis, UNICEF has indicated that the average price of lifesaving RUTF may increase by up to 16 per cent in the second half of 202254, which risks reducing access to RUTF and placing more children’s lives at risk. More immediate and flexible funding is essential to ensure a continuous pipeline of RUTF supplies to save children’s lives� In addition, support to suppliers across the global south to access financing for the purchase of quality raw ingredients is required to ensure their ability to scale up and meet the increasing demands. In addition, alternative cost-effective RUTF products are another key strategy to reduce cost, a number of which are being tested in a variety of settings across the globe. These new formulas explore the use of cheaper, locally available ingredients for longer-term benefits in both locally produced� UNICEF aims to build evidence on the acceptability, palatability, and effectiveness of RUTF formulations and support the roll-out and uptake of these formulations across the world� 54 United Nations Children’s Fund, ‘Ready-To-Use Therapeutic Food: A Supply Alert’, UNICEF, June 2022, <www. unicef.org/supply/media/12591/file/ready-to-use-therapeutic-food-supply-alert-June-2022.pdf>. http://www.unicef.org/supply/media/12591/file/ready-to-use-therapeutic-food-supply-alert-June-2022.pdf http://www.unicef.org/supply/media/12591/file/ready-to-use-therapeutic-food-supply-alert-June-2022.pdf 33Supply chains save lives: Unlocking access for children, their families and communities 5. Supply chain distribution networks are inefficient and storage facilities are insufficient RUTF stock-outs are frequent: inefficient distribution systems between the national stores and health districts, and between the district level and other health facilities, mean that often RUTF does not make it to the last mile� This is caused, in part, by a lack of infrastructure and storage at the district level� RUTF is a bulky product and requires more transport and storage space than pharmaceuticals; this increases the costs of management at the peripheral level and causes stock shortages if it is not replenished proactively� To compound this problem, inoperative logistics information systems do not allow for the visibility of the product at the district levels and the last-mile distribution points. There can often be a lack of storage capacity at subnational levels especially for RUTF� This can create delays in delivery given orders can take longer to process, which can be exacerbated by local or regional suppliers who often also do not have adequate room to store RUTF at their premises� Life-saving nutrition supplies for every child in need Ready-to-use therapeutic food – or RUTF – has been specifically designed to treat severe wasting, also known as severe acute malnutrition� RUTF is a portable, shelf-stable, single-serving food. RUTF is a simple, effective, affordable solution for treating children under the age of five with severe wasting. 34 SDG 6 calls for the global community to achieve access to hygiene for all by 2030� Good hygiene is critical to preventing the spread of infectious diseases and helping children lead healthy lives� Access to WASH at home and in schools also prevents them from missing school and contributes to better learning outcomes� Proper hand hygiene has been proven to reduce deaths from respiratory and diarrhoeal diseases in children under 5 by 21 per cent and 30 per cent respectively. Yet in 2021, an estimated 2�3 billion people globally did not have access to soap and water at home� While 51 per cent of health facilities globally have basic hygiene services, this drops to 32 per cent in lesser-developed countries.55 More than 1 million deaths each year are associated with unclean births, while infections account for 26 per cent of neonatal deaths and 11 per cent of maternal mortality� An estimated 15 per cent of patients in LMICs develop one or more infections during a hospital stay, which are often preventable by improved hand hygiene practices� Similarly, almost half (43 per cent) of schools lack basic hygiene services, leaving 802 million children without soap and/or water to wash their hands while at school. Of these students, 480 million had no hygiene services at all� Of the 73 countries that had not achieved universal access to basic hygiene services by 2020, only six are on track to achieve universal coverage (defined as over 99 per cent coverage) 55 United Nations Children’s Fund and World Health Organization, ‘State of the World’s Hand Hygiene. A global call to action to make hand hygiene a priority in policy and practice’, UNICEF and WHO, 2021, <www.unicef.org/media/108356/file/State%20of%20the%20World%E2%80%99s%20Hand%20Hygiene.pdf>. 56 United Nations Children’s Fund, ‘State of the World’s Sanitation� An urgent call to transform sanitation for better health, environments, economies and societies’, UNICEF and WHO, 2020, <www.unicef.org/media/86836/file/State-of-the-world%E2%80%99s-sanitation-2020.pdf>. by 2030. At the current rate of progress, 1.9 billion people will still lack facilities to wash their hands at home by 2030, the SDG target for reaching universal hand hygiene. The COVID-19 pandemic drew public focus to the life- saving benefits of hand hygiene practice and created new demand for hand hygiene products such as soap and hand sanitizer and services� This increased demand, coupled with national hand hygiene measures to control the virus, and resulted in great strains on the markets and systems to meet demand� Sanitation is a human right� Everyone is entitled to sanitation services that provide privacy, ensure dignity and safety, and are physically accessible and affordable. Sanitation is also a public good, providing benefits across society in improved health as well as economic and social development� The lack of safe sanitation leads to illness and disease that disproportionately affect children, including diarrhoea, worm infections and stunting.56 Progress towards universal sanitation is alarmingly off track and coverage is uneven, resulting in inequalities and the further marginalization of the most vulnerable� The rate of progress in improving sanitation will need to quadruple to achieve SDG 6.2, access to adequate and equitable sanitation and hygiene for all, by 2030� WATER, SANITATION AND HYGIENE SUPPLY CHAIN BARRIERS TO ACCESS http://www.unicef.org/media/108356/file/State%20of%20the%20World%E2%80%99s%20Hand%20Hygiene.pdf http://www.unicef.org/media/86836/file/State-of-the-world%E2%80%99s-sanitation-2020.pdf 35Supply chains save lives: Unlocking access for children, their families and communities Between 2000 and 2017, the number of people practicing open defecation was cut in half, from 1�3 billion to 673 million� However much of the progress in eliminating open defecation is being driven by gains in a few high population countries. Despite progress, 2 billion people still lack even a basic level of sanitation service, while nearly 698 million school-age children lacked basic sanitation services at their school�57 An estimated 367 million children, meanwhile, attend a school in which there is no sanitation facility at all. Over half of these children live in two regions: sub-Saharan Africa (213 million children) and Central and Southern Asia (200 million children)� Globally, less than two-thirds of schools have basic sanitation and 4�2 billion people use sanitation services that leave human waste untreated, threatening human and environmental health.58 The COVID-19 pandemic has exacerbated many sanitation challenges�59 People have been isolated at home, where they may have unsafe sanitation facilities or are forced by their lack of sanitation facilities into unsafe, communal areas, such as poorly managed public latrines or open defecation areas� WASH programmes and services require strong national policies, supply chain management, financial systems, and monitoring mechanisms to be sustainable, resilient and accountable. To provide quality care, health care facilities need to have a safe and accessible water supply; clean and safe sanitation facilities; hand hygiene facilities at points of care and at toilets; and appropriate waste disposal systems� Health care facilities in resource limited settings lack essential WASH and health care waste services Infrastructure that supports WASH and health care waste management practices helps prevent the spread of diseases within the health care facility and to the surrounding community. According to the Centers for Disease Control and Prevention, 50 per cent of health care facilities lack access to piped water; 33 per cent lack improved sanitation; 39 per cent lack soap for handwashing and 39 per cent lack adequate infectious waste disposal�60 57 Ibid� 58 Ibid� 59 United Nations Children’s Fund, ‘Returning to school safe and healthy’, UNICEF, October 2021, <https://www.unicef.org/afghanistan/stories/returning-school-safe-and-heathy>, accessed 18 October 2022. 60 Centers for Disease Control and Prevention, ‘Water, Sanitation and Hygiene in Healthcare Facilities’, CDC, <https://www.cdc.gov/healthywater/global/healthcare-facilities/overview.html#>. 61 United Nations Children’s Fund, ‘State of the World’s Sanitation� An urgent call to transform sanitation for better health, environments, economies and societies’, UNICEF and WHO, 2020, <www.unicef.org/media/86836/file/State-of-the-world%E2%80%99s-sanitation-2020.pdf>. Key WASH supply chain barriers 1. There is a lack of data to inform decisions and track progress In many countries, WASH services are planned without timely or accurate data, which affects their supply forecasting, budgeting, product selection and other supply planning dimensions� This in turn adversely impacts equitable access to WASH supplies by children and communities� In LMICs, the availability of hygiene-related data has steadily improved over the last few years, with large increases at the regional level as populous countries collected data for the first time. However, some countries do not collect data on basic hygiene and only four regions had enough data to allow the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene to produce regional estimates for basic hygiene in 2020� Data availability for monitoring progress towards the SDG targets on sanitation also remains limited in many countries� Fewer than half of countries have estimates for coverage of safely-managed sanitation services. Estimates for open defecation and access to basic services can be disaggregated by rural and urban settings, subnational region and wealth quintile, but very few countries have the disaggregated data needed to identify and address inequalities in safely-managed sanitation services. The limited availability of time-series data makes it difficult to determine rates of progress. An estimated 60 to 70 per cent of forcibly displaced persons live outside of camps and settlements61. Very few countries have disaggregated sanitation data for displaced populations, which makes it difficult to track whether they are being left behind the rest of the population� https://www.unicef.org/afghanistan/stories/returning-school-safe-and-heathy https://www.cdc.gov/healthywater/global/healthcare-facilities/overview.html# http://www.unicef.org/media/86836/file/State-of-the-world%E2%80%99s-sanitation-2020.pdf 36 2. The lack of domestic and international investments is holding back progress Government budgets for financing WASH, especially WASH infrastructure, and for expanding services to those in need remain low� Private sector investment is also insufficient, given the lack of legal frameworks, associated risks, and low returns in the water and sanitation business� As a result, one of the greatest barriers to achieving WASH-related targets is the large spending gap.62 In August 2021, UNICEF and WHO published a study63 that estimated the cost of hand hygiene for all in household settings in 46 of the least developed countries of the world� In these countries it was estimated that achieving universal hand hygiene by 2030 in all domestic settings would cost $11 billion, averaging just over $1 billion a year. This estimate assumes that governments would contribute 27 per cent of the cost of achieving universal hand hygiene at home, and more than two and a half times this amount would be invested by households, comprising the remaining 73 per cent�64 The cost of implementing hand hygiene strategies in health care facilities is low – estimated between $0.90 and $2�50 per capita per year, depending on the country�65 Donors tend to prioritize water over sanitation and hygiene� In fact, aid disbursements for sanitation were half that of drinking water between 2010 and 2018�66 The total investment in sanitation from governments and donors is not enough to provide the sustainable, resilient, safely-managed services that will bring about substantive benefits to health, the economy and the environment.67 Most countries report insufficient resources to meet their national sanitation targets�68 Eighty per cent of countries that responded the UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water 62 United Nations Children’s Fund, ‘Universal access to water, sanitation and hygiene’, UNICEF, <www.unicef.org/documents/universal-access-water-sanitation-and-hygiene>. 63 United Nations Children’s Fund and World Health Organization, State of the World’s Hand Hygiene: A global call to action to make hand hygiene a priority in policy and practice, UNICEF, New York, 2021� 64 Ibid� 65 World Health Organization and United Nations Children’s Fund, ‘Hand hygiene for all’, UNICEF, New York, 2020. 66 United Nations Children’s Fund, ‘State of the World’s Sanitation� An urgent call to transform sanitation for better health, environments, economies and societies’, UNICEF and WHO, 2020, <www.unicef.org/media/86836/file/State-of-the-world%E2%80%99s-sanitation-2020.pdf>. 67 Ibid� 68 Ibid� 69 World Health Organization and UN-Water, ‘National Systems to Support Drinking-water, Sanitation and Hygiene: Global Status Report 2019’ (GLAAS 2019 Report), WHO, Geneva, 2019. 70 United Nations Children’s Fund, ‘State of the World’s Sanitation� An urgent call to transform sanitation for better health, environments, economies and societies’, UNICEF and WHO, 2020, <www.unicef.org/media/86836/file/State-of-the-world%E2%80%99s-sanitation-2020.pdf>. 71 Ibid� 72 Ibid� (GLAAS) ‘Support drinking water, sanitation and hygiene’ (2019 report) reported insufficient funding to meet their national sanitation targets� Even where policies are in place, few countries have adequate human and financial resources to support them. While more than two-thirds of countries reported they had policies in place to achieve SDG 6, only one-quarter identified their means of funding these policies.69 Sanitation is a public good in need of public funding� While government WASH budgets are increasing at an average rate of 11�1 per cent per year,70 detailed data on government sanitation budgets over time is very limited� Only nine countries reported comparable sanitation- specific government budget data in the last two GLAAS surveys� Five of those nine reported decreased sanitation budgets between surveys, with an average decrease of 1.2 per cent per year. Investments from external sources, such as donor grants and funds from NGOs and foundations, amounted to only 1 per cent of the total investment in sanitation� However, they contribute, on average, 42 per cent of non-household expenditures in the 11 low-income countries that reported sanitation expenditure data. 3. Weak governance is limiting the demand for sanitation and hygiene services Many countries have significant WASH policy gaps. For instance, in countries where open defecation is still practiced, about one-quarter lack specific policies and plans to address it�71 Similarly, the critical issue of faecal sludge management is not addressed in one-quarter of urban sanitation policies and plans� While 77 per cent of countries have a formal national standard for wastewater treatment, only 36 per cent of countries have a standard for the safe use of wastewater and sludge for agriculture and other productive purposes�72 http://www.unicef.org/documents/universal-access-water-sanitation-and-hygiene http://www.unicef.org/media/86836/file/State-of-the-world%E2%80%99s-sanitation-2020.pdf http://www.unicef.org/media/86836/file/State-of-the-world%E2%80%99s-sanitation-2020.pdf 37 The institutions tasked with oversight of sanitation standards are stretched, lacking sufficient funds and sufficient human resources to undertake the necessary surveillance and enforcement. Only 32 per cent of countries reported having sanitation/ wastewater regulatory authorities that fully take corrective action in urban areas and only 23 per cent in rural areas�73 Two-thirds of countries reported that they have less than 50 per cent of the human resources they need for wastewater surveillance in urban areas� While more than two-thirds of countries report they have policy measures to reach poor populations with sanitation, only one-quarter have ways of financing them.74 In 2020, UNICEF and WHO came together with a number of global partners to launch the global Hand Hygiene for All Initiative, with the aim of supporting country governments to bridge the national COVID-19 response plans with long-term national development plans, strengthening governance measures to drive progress, strengthen markets, hold institutions and stakeholders accountable, and build data and information around hand hygiene across settings� Since the Hand Hygiene for All call to action, almost 60 countries have committed and taken action to strengthen hand hygiene policies and action plans� In South Africa, where a handwashing policy was developed in 2015, institutional arrangements were clearly spelled out, so that when the COVID-19 pandemic hit, roles and responsibilities for hand hygiene were known and followed� These strong lines optimized performance in ensuring that hand hygiene services and supplies were available during the height of the pandemic�75 73 Ibid� 74 United Nations Children’s Fund, ‘State of the World’s Sanitation� An urgent call to transform sanitation for better health, environments, economies and societies’, UNICEF and WHO, 2020, <www.unicef.org/media/86836/file/ State-of-the-world%E2%80%99s-sanitation-2020.pdf>. Ibid� 75 Ibid� http://www.unicef.org/media/86836/file/State-of-the-world%E2%80%99s-sanitation-2020.pdf http://www.unicef.org/media/86836/file/State-of-the-world%E2%80%99s-sanitation-2020.pdf 38 EDUCATION SUPPLY CHAIN BARRIERS TO ACCESS UNICEF’s lessons learned from the education response to the COVID-19 crisis About 244 million children and adolescents between the ages of 6 and 18 are out of school in 2022, according to UNESCO.76 More than 75 million children aged 3 to 18 are in urgent need of educational support in 35 crisis-affected countries, and children in conflict-affected countries are 30 per cent less likely to complete primary school and half as likely to complete lower-secondary school.77 For the past two years, the COVID-19 pandemic has been disrupting education systems around the world, particularly affecting the most vulnerable learners. At its peak at the end of April 2020, schools sent home nearly 1�6 billion students: 94 per cent of those enrolled worldwide and up to 99 per cent of the student population in low- and lower-middle- income countries. Although this latter figure had fallen to 17.9 per cent by the end of November 2020, more than half of countries surveyed in October 2020 reported combining remote learning and in-person education as schools reopened. Some of the key challenges brought on and revealed by the pandemic included: • limited access of the most vulnerable children to online learning platforms; • lack of online national curricula and lack of content adapted to children and adolescents with disabilities, indigenous children, migrants and refugees; • limited knowledge and capacity of teachers to use online platforms and distance learning resources; • limited offline initiatives to respond to the educational needs of the most vulnerable children without internet access; • lack of educational materials that are culturally sensitive and adapted to all languages spoken; and • lack of tools to monitor and evaluate progress of learning outcomes� 76 United Nations Educational, Scientific and Cultural Organization, ‘244M children won’t start the new school year’, UNESCO, 9 September 2022, <https://www.unesco.org/en/articles/244m-children-wont-start-new-school-year-unesco>. 77 United Nations Children’s Fund, ‘Every Child Learns: UNICEF Education Strategy 2019–2030’, UNICEF, 2019 78 UNICEF’s lessons learned from the education response to the COVID-19 crisis and reflections on the implications for education policy Sciencedirect.com/science/article/pii/S0738059321000821 79 Ibid� The closure of schools also interrupted access to other important basic services provided by schools such as school feeding, recreational programmes, extracurricular activities, pedagogical and psychosocial support, as well as those related to health, water, sanitation and hygiene� Monitoring children’s learning needs UNICEF’s initial data and analysis from the pandemic have focused largely on the question of access� This has been useful, particularly in identifying the gaps; 463 million schoolchildren, for example, were not reached with digital and broadcast remote learning,78 sparking a push towards expanding partnerships, particularly with technology and telecommunications companies to find solutions. Modernizing how data is collected, analyzed and shared The pandemic underlined the need to close existing data gaps on pre-primary education, technical and vocational education, non-formal education, learners with disabilities or learners in crisis-affected settings, as well as we as anticipate emerging needs such as how to track students in blended-learning scenarios. The COVID-19 crisis also provided an impetus to modernize how data is collected, analyzed and shared, catalyzing the transition to faster systems and investments in institutional capacity so that data is not just collected but acted upon in a timely manner to make a real difference to children’s education.79 COVID-19 triggered mass innovation to develop flexible learning methods that can be built upon to make education systems more resilient� These tools must be paired with investments in the people that use them and investments to strengthen data systems� To ensure plans are rooted in ever-pressurized budgets, education ministers will increasingly need to turn to economic analyses� https://www.unesco.org/en/articles/244m-children-wont-start-new-school-year-unesco http://Sciencedirect.com/science/article/pii/S0738059321000821 39Supply chains save lives: Unlocking access for children, their families and communities The expansion of partnerships – such those between public and private organizations – will be necessary to secure greater and more innovative forms of finance and affordable digital learning solutions� If these opportunities are seized, they can equalize opportunities and accelerate progress�80 Transportation restrictions and price hikes The pandemic had a global impact on UNICEF’s freight operations, particularly sea shipments� Many countries, regions and territories imposed strong restrictions on international transport, which affected air freight, sea freight and logistics services, and had an adverse impact on international supply chains, including those UNICEF use to deliver education supplies� UNICEF has been receiving unprecedented requests from suppliers of educational materials for price increases owing to compounded challenges in supplying countries� Sporadic power supply is a barrier to timely production and also has financial implications for suppliers who, in some cases, are struggling to meet supply demand. The conflict in Ukraine has further increased demand to meet competing emergencies, and this has led to price increases� Such price increases come at very short notice owing to unpredictable market challenges� Product price increases also emanate from long shipment delays; these force suppliers to store their goods for four to ten months beyond normal delivery times� 80 Ibid� UNICEF: Providing education supplies In emergency and development contexts UNICEF strives to develop accessible schools and to enable children – especially girls and children with disabilities – to learn. UNICEF provides education supplies and services which include the procurement of stationery and furniture as well as the construction and rehabilitation of schools. In emergency contexts UNICEF’s objective is to minimize the disruption caused by school closures or forcible displacement� In emergencies, children can continue to learn in durable, high-performance tents that serve as safe spaces and temporary classrooms. Pre-selected, inclusive items packed in kits, such UNICEF’s school-in-a-box, early childhood development (ECD) kits, and recreation kits, help ensure that children can continue to learn and play� 40 03 UNICEF SUPPLY CHAINS IN ACTION What we do best 41Supply chains save lives: Unlocking access for children, their families and communities Transforming end to end supply chains REACHING CHILDREN UNICEF stimulates markets to better serve children. This includes encouraging demand for products and services, ushering new suppliers into the market and innovating to meet demand. In 2019 UNICEF supported the Malaria Vaccine Implementation Programme in three pilot countries: Ghana, Kenya and Malawi. By 2021, 1 million children had received the malaria vaccinees, reducing deaths by almost a third. Market shaping Product innovation at UNICEF is about turning ideas into tangible and scalable solutions. It involves the identification, development and production of fit-for-purpose and value-for-money products that respond to the needs of children. Innovations can change the lives of children. Some of our innovations include the High Performance Tents, disability-friendly latrines and non-pneumatic anti-shock garment. Product innovation UNICEF works with suppliers and the private sector to secure the best value for money and strengthen governments’ procurement capacity. In 2021 UNICEF procured 7.181 billion worth of goods and services across health, nutrition, WASH and education programmes (read more on page 44). Procurement UNICEF quantifies needs so that adequate vaccine and health products stocks are available to achieve national immunization goals. This helps children in countries, and donors and industry partners plan for the future. In 2021 UNICEF procured 2.299 billion doses of vaccines that protect children against diarrhoea, measles, pneumonia, polio, tetanus, tuberculosis and other preventable diseases. Forecasting UNICEF’s global hub in Copenhagen is the world’s largest humanitarian warehouse and is complemented by hubs in Accra, Brindisi, Dubai, Guangzhou and Panama. These are strategically located to dispatch supplies swiftly in emergencies. The global hubs combined contain sufficient emergency supplies to meet the needs of 250,000 people for three months. Warehousing & distribution UNICEF arranges shipments directly from suppliers to destination countries by air, sea and land. In 2021 UNICEF spent $226.3 million on international freight services representing 12,968 shipments. Global transport To put supplies in the hands of children, we contract local road cargo transporters, aircraft charters, and customs and warehousing services. In 2021 UNICEF injected $91.4 million into the local economies by partnering with in-country logistics and warehousing services companies. In-country logistics UNICEF SUPPLY CHAIN OPERATIONS UNICEF SUPPORT TO GOVERNMENT SYSTEMS Through community-focused surveys, UNICEF monitors whether health, nutrition and education services and products are reaching the last mile, administered adequately and aiding children’s recovery. UNICEF’s flagship end-user monitoring assessment has been rolled out in 20 countries and helped to address supply chain management bottlenecks and increase product availability. Monitoring & evaluation UNICEF supports governments to become sustainable and to self-finance essential supplies. The Vaccine Independent Initiative is a $234 million fund that governments can tap into and benefits tens of millions of children each year. Finance UNICEF lends its technical expertise to build a qualified, educated health supply chain workforce across the public and private sectors within the health system. UNICEF’s workforce development arm, People that Deliver, brings together 27 organizations in a coalition that strives to empower the health supply chain workforce. Supply chain workforce development UNICEF trains and equips frontline workers with essential knowledge and skills to address local drivers of inequity and increase demand for vaccines and other health products. Through the essential contribution of frontline health workers and community outreach, the number of children paralyzed by polio has fallen by over 99% since 1988. Frontline health workers and community outreach UNICEF supports countries to use national information systems to help improve the capacity of decision makers and track products from manufacturer to child. In 2022, UNICEF and partners launched the Traceability & Verification System, which serves to verify the authenticity of vaccines and other health products. Supply chain digitalization UNICEF strengthens cold chain infrastructure to safely store and transport vaccines, including the delivery and installation of ultra-cold chain units. Since 2017, UNICEF has procured and delivered more than 150,000 refrigerators to programme countries securing vaccine cold chain equipment benefitting close to one billion people. Cold chain management UNICEF strengthens energy sustainability along the cold chain by supporting the replacement of fridges with solar technology and making use of environmentally-friendly products. In 2020-2021, UNICEF’s Global Solar Water Pumping Programme — active in 51 countries — installed nearly 3,000 solar-powered water systems in schools, healthcare facilities and communities. Solarization & waste management Transforming end-to-end supply chains UNICEF uses its global reach and local knowledge to deliver supplies to children in more than 160 countries and territories, including in situations of conflict and disaster. We work closely with partners and governments to ensure we reach children, their families and communities at the right time, in the right place, with the right supplies at the right price. To achieve this, we rely on a unique set of skills, described below. 42 Transforming end to end supply chains REACHING CHILDREN UNICEF stimulates markets to better serve children. This includes encouraging demand for products and services, ushering new suppliers into the market and innovating to meet demand. In 2019 UNICEF supported the Malaria Vaccine Implementation Programme in three pilot countries: Ghana, Kenya and Malawi. By 2021, 1 million children had received the malaria vaccinees, reducing deaths by almost a third. Market shaping Product innovation at UNICEF is about turning ideas into tangible and scalable solutions. It involves the identification, development and production of fit-for-purpose and value-for-money products that respond to the needs of children. Innovations can change the lives of children. Some of our innovations include the High Performance Tents, disability-friendly latrines and non-pneumatic anti-shock garment. Product innovation UNICEF works with suppliers and the private sector to secure the best value for money and strengthen governments’ procurement capacity. In 2021 UNICEF procured 7.181 billion worth of goods and services across health, nutrition, WASH and education programmes (read more on page 44). Procurement UNICEF quantifies needs so that adequate vaccine and health products stocks are available to achieve national immunization goals. This helps children in countries, and donors and industry partners plan for the future. In 2021 UNICEF procured 2.299 billion doses of vaccines that protect children against diarrhoea, measles, pneumonia, polio, tetanus, tuberculosis and other preventable diseases. Forecasting UNICEF’s global hub in Copenhagen is the world’s largest humanitarian warehouse and is complemented by hubs in Accra, Brindisi, Dubai, Guangzhou and Panama. These are strategically located to dispatch supplies swiftly in emergencies. The global hubs combined contain sufficient emergency supplies to meet the needs of 250,000 people for three months. Warehousing & distribution UNICEF arranges shipments directly from suppliers to destination countries by air, sea and land. In 2021 UNICEF spent $226.3 million on international freight services representing 12,968 shipments. Global transport To put supplies in the hands of children, we contract local road cargo transporters, aircraft charters, and customs and warehousing services. In 2021 UNICEF injected $91.4 million into the local economies by partnering with in-country logistics and warehousing services companies. In-country logistics UNICEF SUPPLY CHAIN OPERATIONS UNICEF SUPPORT TO GOVERNMENT SYSTEMS Through community-focused surveys, UNICEF monitors whether health, nutrition and education services and products are reaching the last mile, administered adequately and aiding children’s recovery. UNICEF’s flagship end-user monitoring assessment has been rolled out in 20 countries and helped to address supply chain management bottlenecks and increase product availability. Monitoring & evaluation UNICEF supports governments to become sustainable and to self-finance essential supplies. The Vaccine Independent Initiative is a $234 million fund that governments can tap into and benefits tens of millions of children each year. Finance UNICEF lends its technical expertise to build a qualified, educated health supply chain workforce across the public and private sectors within the health system. UNICEF’s workforce development arm, People that Deliver, brings together 27 organizations in a coalition that strives to empower the health supply chain workforce. Supply chain workforce development UNICEF trains and equips frontline workers with essential knowledge and skills to address local drivers of inequity and increase demand for vaccines and other health products. Through the essential contribution of frontline health workers and community outreach, the number of children paralyzed by polio has fallen by over 99% since 1988. Frontline health workers and community outreach UNICEF supports countries to use national information systems to help improve the capacity of decision makers and track products from manufacturer to child. In 2022, UNICEF and partners launched the Traceability & Verification System, which serves to verify the authenticity of vaccines and other health products. Supply chain digitalization UNICEF strengthens cold chain infrastructure to safely store and transport vaccines, including the delivery and installation of ultra-cold chain units. Since 2017, UNICEF has procured and delivered more than 150,000 refrigerators to programme countries securing vaccine cold chain equipment benefitting close to one billion people. Cold chain management UNICEF strengthens energy sustainability along the cold chain by supporting the replacement of fridges with solar technology and making use of environmentally-friendly products. In 2020-2021, UNICEF’s Global Solar Water Pumping Programme — active in 51 countries — installed nearly 3,000 solar-powered water systems in schools, healthcare facilities and communities. Solarization & waste management 43Supply chains save lives: Unlocking access for children, their families and communities Buying and delivering life-saving supplies and services to all corners of the globe UNICEF procured $7.181 billion worth of goods ($5.657 billion) and services ($1.524 billion) in 2021. The largest commodity groups, and examples of supplies procured or delivered, are highlighted below. $4.121 billion Vaccines/biologicals UNICEF procured 2.299 billion doses of paediatric vaccines for 109 countries to reach 46 per cent of the world’s children under 5 years old� 48�5 per cent of these vaccines went to routine immunization programmes� The remainder supported supplementary immunization activities, outbreak response, and humanitarian situations� In 2021, COVAX delivered more than 957.7 million doses of COVID-19 vaccine to 144 countries. UNICEF managed the delivery of more than 884.2 million COVID-19 vaccine doses to 110 countries. $397.5 million Medical supplies and equipment 2 billion syringes for immunization, including 1.9 billion auto-disable syringes: • 82.4 million re-use prevention syringes delivered • $72.8 million worth of safe injection equipment (SIE) delivered to 111 countries • 18.4 million safety boxes delivered • 4.6 million malaria rapid diagnostic tests delivered to 18 countries • 1.8 million HIV rapid diagnostic tests delivered to 26 countries, including 0.7 million HIV/syphilis combination diagnostic tests to 13 countries and 58,250 HIV self-tests to 5 countries • 40,748 medical kits delivered from UNICEF global supply hubs for 18 countries $204.9 million Cold chain equipment • $73.2 million in solar-powered systems procured for 63 countries $175.6 million Nutrition supplies 67 per cent of ready-to-use therapeutic food (RUTF) was sourced from programme countries� • 44,554 metric tons of RUTF delivered to 59 countries. An additional 7,206 metric tons was delivered to 12 countries as contributions in kind (CIK) • 433.2 million vitamin A capsules, including 383�8 million capsules as CIK to 68 countries • 119.3 million deworming tablets delivered to 44 countries • 665 million sachets of multiple micronutrient powder delivered to 38 countries • 566 million iron and folic acid tablets delivered to 28 countries $155.3 million Education supplies UNICEF procured education supplies for 105 countries in 2021, including laptops for a large digital education project in El Salvador. 86,780 education kits were delivered from UNICEF global supply hubs for 64 countries, including: • 42,968 standard classroom kits • 20,820 early childhood development kits • 18,781 recreation kits • 4,211 country-specific classroom kits 44 Source: UNICEF supply annual report 2021 https://www.unicef.org/supply/supply-annual-report-2021 $145.4 million Water and sanitation supplies • 468.8 million water purification tablets and chlorination/flocculation sachets, which could treat 10�6 billion litres of water delivered to support 45 countries • 2.6 million hygiene kits delivered to 55 countries $81.5 million Bed nets/insecticides • 18.6 million long-lasting insecticidal nets (LLINs) were delivered to 21 countries $99.1 million Pharmaceuticals • 350.8 million amoxicillin pneumonia treatments for children under 5 years old, reaching 54 countries • 1.6 million packs of antiretroviral medicine to treat 54,333 adults and 21,601 children with first-line therapy for one year delivered to 37 countries • 20.6 million artemisinin-based combination therapy (ACT) malaria treatments delivered to 29 countries • 52.5 million cotrimoxazole tablets to treat bacterial infections, including pneumonia and bronchitis, delivered to 16 countries • 34.6 million sachets of oral rehydration salts (ORS), including 5.9 million co-packaged ORS/ zinc, delivered to 43 countries • 93 million zinc tablets, including 26 million co-packaged ORS/zinc, delivered to 42 countries • 7.5 million treatments for seasonal malaria chemoprevention delivered to protect 1.9 million children • 15.2 million courses of sulfadoxine-pyrimethamine chemoprevention delivered to protect 5�1 million pregnant women $352.2 million COVID-19 non-immunization supplies reached 130 countries 434 million items of personal protective equipment (PPE) delivered to 115 countries 6.7 million COVID-19 antigen rapid diagnostic tests delivered 5.4 million molecular diagnostics delivered 299,775 COVID-19 rapid tests delivered 28,916 oxygen concentrators procured 45Supply chains save lives: Unlocking access for children, their families and communities $257.1 million Construction services Most construction services were procured in the Middle East and North Africa region ($106�7 million), the West and Central Africa region ($64�6 million), and the Eastern and Southern Africa region ($64�1 million), and included support for: • water supply and water and sanitation facilities in schools for WASH programmes • construction and rehabilitation of schools and learning facilities • construction related to health facilities $226.3 million International freight services This figure is the highest ever reported. It is a 71�6 per cent increase from 2020, and represents 12,968 international shipments in 2021. $184.1 million Local technical workforce Human resources required for programme support included working in countries to: • share expertise with partner governments • implement social mobilization campaigns • provide temporary labour for programme $173.0 million Cash and voucher assistance Includes programmes in which cash transfers or vouchers are directly provided to beneficiaries and can be used for goods or services� $118.5 million Research, surveys, monitoring and evaluation services Includes programmatic research and surveys, market and supply chain analysis, and research and monitoring and evaluation of programme implementation� $91.4 million In-country logistics and warehousing services Support to programmes includes road cargo transport, storage, local aircraft charters, and customs brokerage and clearance services, as well as warehousing services� $ The six largest categories account for 69 per cent of the total value of contracting for services. Source: UNICEF supply annual report 2021 46 Reaching the last mile Through long term agreements, UNICEF has built a large network of local transport, handling and storage service providers, which has proven instrumental to planning and managing the efficient flow of supplies from ports of entry to the final destination, prepositioning commodities in strategic locations ahead of potential crisis, coordinating agile responses to (high-scale) emergencies, and ensuring regular immunisation, health, nutrition, education and WASH programmes globally� The competencies and technological assets of our in-country logistics partners and sub-contractors have been key supply chain strengthening components and have enabled UNICEF to track warehouse inventory, shipments and deliveries, keep vaccines safe through the last mile of the journey using solar powered cold storage equipment and dispatch supplies to isolated communities including in hard-to-reach areas. https://www.unicef.org/supply/supply-annual-report-2021 47Supply chains save lives: Unlocking access for children, their families and communities 48 DRIVING INNOVATION AT SCALE Disability-friendly squatting plate add-on in emergencies  There are nearly 240 million children with disabilities worldwide, and for many of them, humanitarian crises make daily tasks even more challenging� During a humanitarian response, sanitation facilities in displacement and refugee camps typically involve squat latrines� Unfortunately, these are not suitable for children with mobility or vision impairments and have difficulty squatting or balancing.   After consulting with field partners and beneficiaries to understand their needs, UNICEF began working with industry in 2016 to develop the first ever disability-inclusive latrine� Prototypes were initially tested in Angola, Bangladesh and Mozambique, and organizations of persons with disabilities were involved in every phase of the design, development and testing.   The role of UNICEF was to understand unmet needs from the field, communicate them to industry and then drive the development of products, testing and refinement with industry partners before working to scale up their use.  Two products are now available: The first is a device that screws onto the squatting plate with a supportive frame. The second is a similar device that fits over the squatting plate with a supportive frame, in addition to a transfer point to move onto the seat. Both products were developed to offer simplicity in terms of transportation and assembly so that implementation during emergencies is quick and seamless.  The products were piloted in refugee camps in Bangladesh in 2019, directly supporting 33 per cent of those with disabilities in Cox’s Bazar. Additionally, people with chronic illnesses, older people and pregnant women have also benefited from the squatting plates. Feedback during monthly community engagement meetings was positive; caregivers noted that the innovative squatting plate enabled many children with disabilities to use a latrine independently� Innovations to uphold the rights of children with disabilities UNICEF’s work is guided by the social model and human rights-based approach to disability. We work to ensure that children with disabilities and their families have access to all the services and support they need in their communities� UNICEF advocates disability-inclusive policies and legislation, along with adequate investments to put them into practice. In 2022 UNICEF introduced 24 new assistive products, plus accessories, to its Supply Catalogue to support children with disabilities, including child-sized active wheelchairs and hearing aids� UNICEF works with industry to devise tailor-made solutions to improve the lives of children  Innovative solutions, tailored to context, are often required to improve children’s well-being and overcome barriers to accessing health care, sanitation services, shelter and education. UNICEF works with partners and experts to understand unmet product needs from the field and communicate these needs to businesses and academia� It then helps to guide industry to develop products that meet those needs and are suitable for the challenging contexts in which UNICEF works.   Through a competitive co-creation process, interested industry suppliers work to create suitable products that can make a difference in the lives of children. UNICEF’s influence – which spans innovation and its purchasing and procurement power – helps drive the development of these new products and ensures they reach scale.   This section explores three examples of innovative UNICEF products that have made a difference to the lives of children.  https://supply.unicef.org/ 49Supply chains save lives: Unlocking access for children, their families and communities Providing children with disabilities a chance to live independently and with dignity is at the core of UNICEF’s work. UNICEF aims to include the new add-on component to 10 per cent of all squatting plates dispatched in emergencies, which equates to approximately 2,500 disability-friendly latrines each year, reaching thousands of children with disabilities worldwide.  High Performance Tent  For years, UNICEF has delivered tents that have been used in emergencies as health clinics, nutrition facilities, distribution points and schools child-friendly spaces. On occasion, there have been challenges in transportation and installation, collapsing of the tents due to strong winds and rain, and a poor internal climate that is not suitable in extremely hot or cold environments.  With no solutions available on the market, in 2016, UNICEF decided to drive product development through an innovation process. First, UNICEF communicated its needs to industry through consultations and the launch of a target product profile and interested manufactures engaged with UNICEF to create a more durable and more appropriate emergency tent.  Through a trial-and-error approach, prototypes were developed by selected manufacturers and tested in labs and the field to assess them in emergency contexts in different climates: Uganda for hot and dry, the Philippines for wet and humid, and Afghanistan for cold.  Following $3 million of industry investment and $526,000 from UNICEF, the final product – UNICEF’s High Performance Tent – includes a series of innovations: it can withstand winds of up to 80km/h and is compact for easier transportation to hard-to-reach locations. In addition, there are a number of add-ons to suit various programmatic needs and climatic conditions, including hard flooring, electrical and solar kits, and a winter liner.  He can hold the handles on the sides when he sits so I don’t have to hold him. I just watch and make sure he’s okay.   Monira, Hashim’s mother “ Hashim, 14, who is cognitively impaired and cannot speak, is assisted by his mother, Monira, as he uses a newly built disability-friendly latrine next to his home in the Cox’s Bazar refugee camp, Bangladesh.  50 The new tents provide safe environments for children coming from devastating situations, such as conflict, earthquakes or extreme weather events like cyclones and heatwaves. The High Performance Tent is now being dispatched in emergencies in response to conflict and disasters. In 2021, more than 4,500 tents were ordered, including in Afghanistan, Fiji, Uganda and Yemen.   Oxygen Plant-in-a-Box  Access to oxygen can mean the difference between life and death for patients with severe COVID-19. It is also a critical treatment for children with pneumonia, which remains the leading infectious killer of children under 5 years of age, claiming an estimated 700,000 lives every year.  Since the start of the COVID-19 outbreak, UNICEF has shipped more than 59,926 oxygen concentrators in support of 111 countries as they respond to the pandemic (December 2022). Although these devices are critical in treating COVID-19, they are limited in the number of patients they can reach at one time. Large-scale oxygen sources are needed to serve health facilities with hundreds of patients at a time. As such, UNICEF worked with industry to rapidly develop an innovative emergency solution: the Oxygen Plant-in-a-Box.  The Oxygen Plant-in-a-Box is a fully functional pressure swing absorption oxygen plant; the package includes everything needed to produce large volumes of medical-grade oxygen. Easily procured and rapidly deployed, plants can be operational within days of arriving at a facility� The plants are designed for health facilities in low-resource settings and those faced with a sudden emergency, such as rising COVID-19 cases.  UNICEF also trains workers – including  biomedical engineers and technicians – to use and maintain newly installed oxygen plants. It has also signed agreements with three private sector providers to provide support to health facilities globally on maintenance and the correct use of oxygen plants.   UNICEF’s Plant-in-a-Box will also help countries build back better after the pandemic; each plant can support up to 50 COVID-19 patients or 100 children with pneumonia at a time.  Reaching remote communities with life-saving oxygen care To help indigenous communities cope during the COVID-19 pandemic, UNICEF delivered 40 oxygen concentrators to Peru’s Ministry of Health for distribution to local health centres in Amazonas, Loreto and Ucayali regions. The equipment not only provides life-saving oxygen therapy, but also enables patients to receive treatment closer to home.  51Supply chains save lives: Unlocking access for children, their families and communities Meeting children’s humanitarian and development needs With our dual mandate UNICEF works all over the world to help children survive and thrive� We work for children’s rights, the fulfilment of their basic needs and to improve their prospects� We deliver a vast variety and amount of supplies within hours when needed, and by working with local industry partners and governments to strengthen country capacity we are able to share our skills and expertise to improve the lives of children� Supply and logistics staff around the world support the planning, procurement and delivery of essential products for children’s health, education and protection� More than 1,200 staff based in 119 countries representing 147 nationalities are coordinating the procurement and delivery of supplies every day to equip children and families for a healthier, safer and more hopeful future� Our national supply chain strengthening investments are critical for countries to create sustainable supply chains that are resilient to shocks and agile enough to handle changes in demand and sudden crises� By transferring our know-know, empowering national responders and fostering partnerships with local private sector partners in post-emergency, recovery and development contexts, we work towards greater government supply chain preparedness and response planning capacity� With recent studies demonstrating81 that an average of 73 percent of humanitarian costs are supply chain related, UNICEF’s system strengthening work is central to bridge the humanitarian-development divide and reduce need, risk and vulnerability. 81 Logistics Cluster preparedness, https://logcluster.org/preparedness Our classroom is no longer hot under the sun. I am now very happy.  Rasid, 12, who was displaced from his home by typhoons in the Philippines. The newly designed tents keep classrooms cool so children can focus on learning.   “ Legend: Commodity groups $7.8 million 139 countries and areas $687.4 million Total procurement $2.0 million $0.9 million $0.8 million Medical supplies and equipment Vaccines/biologicals $399 million Total procurement $54.4 million Pharmaceuticals $45.1 million Water and sanitation supplies $57.9 million Nutrition supplies Education supplies Water and sanitation supplies Pharmaceuticals Medical supplies and equipment Vaccines/ biologicals Level-2 emergency response: The affected UNICEF country office (CO) needs additional support from UNICEF headquarters, the relevant regional office (RO) and other COs to scale up and respond to the crisis. The Regional Director provides leadership and RO support is enhanced. Level-3 emergency response: UNICEF’s Executive Director declares that organization-wide mobilisation is needed to scale up and respond, and appoints a Global Emergency Coordinator. RO support to the CO is enhanced. * $34.5 million Total procurement $26.2 million Total procurement $6.0 million $5.1 million $14.3 million Total procurement $3.7 million $7.5 million $6.5 million $4.4 million $21.8 million Total procurement $7.7 million $3.0 million $104.3 million Total procurement $28.2 million $20.4 million $17.6 million $8.1 million $2.9 million $1.0 million $18.2 million Total procurement $14.0 million $1.7 million $0.8 million $7.6 million $25.7 million Total procurement $19.6 million $2.0 million $1.8 million $7.2 million Total procurement $21.2 million Total procurement $3.7 million $2.4 million $0.3 million $17.2 million $1.8 million $1.0 million Haiti The Syrian Arab Republic AfghanistanCentral Sahel (Burkina Faso, Mali, Niger) The Democratic Republic of the Congo Myanmar Yemen Northern Ethiopia Southern MadagascarMozambique Delivering supplies in emergencies In 2021, UNICEF procured $687.4 million in emergency supplies for 139 countries and areas. The four largest commodity groups account for 80 per cent of the total value of emergency supplies procured. In 2021, UNICEF determined that 13 countries (see map) faced crises that required a Level 2 or Level 3 emergency response*. A Level 2 or Level 3 emergency response is activated in urgent large-scale situations when the UNICEF country office requires additional support. For each of these affected countries or areas, the map indicates the total procurement value of emergency supplies, and the largest commodity groups. 52 Legend: Commodity groups $7.8 million 139 countries and areas $687.4 million Total procurement $2.0 million $0.9 million $0.8 million Medical supplies and equipment Vaccines/biologicals $399 million Total procurement $54.4 million Pharmaceuticals $45.1 million Water and sanitation supplies $57.9 million Nutrition supplies Education supplies Water and sanitation supplies Pharmaceuticals Medical supplies and equipment Vaccines/ biologicals Level-2 emergency response: The affected UNICEF country office (CO) needs additional support from UNICEF headquarters, the relevant regional office (RO) and other COs to scale up and respond to the crisis. The Regional Director provides leadership and RO support is enhanced. Level-3 emergency response: UNICEF’s Executive Director declares that organization-wide mobilisation is needed to scale up and respond, and appoints a Global Emergency Coordinator. RO support to the CO is enhanced. * $34.5 million Total procurement $26.2 million Total procurement $6.0 million $5.1 million $14.3 million Total procurement $3.7 million $7.5 million $6.5 million $4.4 million $21.8 million Total procurement $7.7 million $3.0 million $104.3 million Total procurement $28.2 million $20.4 million $17.6 million $8.1 million $2.9 million $1.0 million $18.2 million Total procurement $14.0 million $1.7 million $0.8 million $7.6 million $25.7 million Total procurement $19.6 million $2.0 million $1.8 million $7.2 million Total procurement $21.2 million Total procurement $3.7 million $2.4 million $0.3 million $17.2 million $1.8 million $1.0 million Haiti The Syrian Arab Republic AfghanistanCentral Sahel (Burkina Faso, Mali, Niger) The Democratic Republic of the Congo Myanmar Yemen Northern Ethiopia Southern MadagascarMozambique 53Supply chains save lives: Unlocking access for children, their families and communities Disclaimer: the boundaries and names shown, and the designations used on the maps do not imply official endorsement or acceptance by UNICEF. Number of systems strengthening projects UNICEF's areas of technical expertise 0 - 15 projects 16 - 30 projects 31 - 45 projects 46 - 60 projects Policy and regulatory frameworks Inspection Leadership training Customs clearance Human resources for health Warehousing and distribution Vaccine management Utilization by end user Supply chain workforce development Finance and domestic resource mobilization 1 1 1 Data analytics Programme management Health information systems Budgeting and planning Needs assessments Monitoring and evaluation Network optimization Service delivery Demand promotion Procurement Nicaragua Burkina Faso 7 5 4 Cambodia 8 4 2 2 2 2 1 1 1 Mozambique 13 4 2 1 1 1 1 1 Democratic Republic of Congo 2 2 1 1 1 1 Kazakhstan19 10 5 2 2 3 2 3 1 2 2 3 1 4 Nigeria 9 4 3 3 3 2 2 2 2 2 1 1 1 Mauritania 4 4 3 3 3 2 2 2 2 2 2 1 1 1 Working with governments to strengthen public supply chains Complementing our operational supply chain management efforts to reach every child in need, UNICEF lends its technical expertise and strengthens the capacity of governments to run and manage their own supply chains. In particular, we help them to: assess performance gaps and identify priority investment areas; support domestic resource mobilization for supplies; deploy cutting-edge last mile innovation; improve product visibility from manufacturer to child; digitalize supply chains; and shape capacity building mechanisms to ensure long-term ownership and sustainability. Since 2019, UNICEF has been leading 639 technical cooperation projects across 20 areas in 66 countries including Cambodia, Kazakhstan, Nicaragua and Nigeria. 54 Disclaimer: the boundaries and names shown, and the designations used on the maps do not imply official endorsement or acceptance by UNICEF. Number of systems strengthening projects UNICEF's areas of technical expertise 0 - 15 projects 16 - 30 projects 31 - 45 projects 46 - 60 projects Policy and regulatory frameworks Inspection Leadership training Customs clearance Human resources for health Warehousing and distribution Vaccine management Utilization by end user Supply chain workforce development Finance and domestic resource mobilization 1 1 1 Data analytics Programme management Health information systems Budgeting and planning Needs assessments Monitoring and evaluation Network optimization Service delivery Demand promotion Procurement Nicaragua Burkina Faso 7 5 4 Cambodia 8 4 2 2 2 2 1 1 1 Mozambique 13 4 2 1 1 1 1 1 Democratic Republic of Congo 2 2 1 1 1 1 Kazakhstan19 10 5 2 2 3 2 3 1 2 2 3 1 4 Nigeria 9 4 3 3 3 2 2 2 2 2 1 1 1 Mauritania 4 4 3 3 3 2 2 2 2 2 2 1 1 1 Our publication “Leveraging the Power of Public Supply Chains to Drive Change for Children” provides more detailed information on UNICEF’s unique value proposition in supply chain strengthening� To discover where UNICEF deploys its technical assistance, scan this QR code. 55Supply chains save lives: Unlocking access for children, their families and communities https://www.unicef.org/supply/reports/leveraging-power-public-supply-chains-drive-change-children-every-day https://www.unicef.org/supply/reports/leveraging-power-public-supply-chains-drive-change-children-every-day 56 CREATING LONG-LASTING CHANGE FOR LOCAL ECONOMIES UNICEF contracts a wide array of local actors, from soap manufacturers to haulage companies UNICEF has a wide network of global, regional and local warehouses, distribution centres and civil society and third-party logistics partners, all of whom are instrumental to the planning and management, and efficient flow and storage of supplies from ports of entry to the final destination. They are also essential to coordinating agile responses to emergencies, including the COVID-19 pandemic, and to ensuring the functioning of regular immunization, health, nutrition, WASH and education programmes globally� In all contexts, UNICEF procures a variety of services from local businesses, including transporters, construction companies and water and sanitation suppliers� Working with local partners has other sustainable benefits, such as: • Boosting local employment Working with local companies provides steady employment for local personnel and their families� • Stimulating the local economy UNICEF’s purchasing power and resultant procurement activities guarantee revenue for local economies, helping businesses, regions and communities grow and develop� This kind of security enables local businesses to invest in their operations� • Strengthening sustainable supply chains UNICEF has an opportunity to share its expertise with local organizations, and these organizations can in turn impart their knowledge of the local context. • Overcoming economic barriers to access Through targeted catalytic interventions tailored to the local market context, UNICEF seeks to reduce market barriers and foster local healthy markets� By encouraging businesses to engage more actively in the 57Supply chains save lives: Unlocking access for children, their families and communities market, including smallholder and woman-owned companies, UNICEF can influence the access, production, storage and delivery of products for the benefit of the children who need them. • Shorter transport lead times Stimulating local production and pre-positioning of supplies in strategic locations means that products arrive in distribution centres – and therefore to children – more quickly. Increasing access to soap in Burundi During the COVID-19 pandemic, UNICEF entered into a partnership with the largest soap manufacturer in Burundi to rapidly increase people’s access to soap� This allowed UNICEF to leverage the manufacturer’s production capacity and distribution network to reach vulnerable households with low purchasing power, especially in rural areas� UNICEF supported the manufacturer to switch one of its production lines to produce generic soap in compliance with UNICEF requirements. Branded Blue Soap, the soap was subsidized by UNICEF, USAID, the United Nations Office for the Coordination of Humanitarian Affairs, and the World Bank, and had a standardized price engraved on its surface to discourage bulk buying and price grouping. Through this partnership, 43 million soap bars at half the price of non-subsidized soap were produced between June and October 2020. All soap bars were distributed and made available at retailers across the country within that same period� Diversifying RUTF production Until 2009, ready-to-use therapeutic food (RUTF) was produced by one sole supplier� Recognising the need to diversify, that same year UNICEF took steps to diversify production and has since shifted towards a local sourcing model, expanding the production of RUTF both in terms of volumes and geographic diversification of production. This has enabled faster responses to malnutrition, reduced shipping lead times and complexity, and significantly reduced fossil fuel emissions� UNICEF now procures RUTF from 22 different suppliers, of whom 18 are located in or close to countries with high levels of child wasting. Around two-thirds of UNICEF RUTF programme demand is now satisfied through local RUTF production. Given its bulky size, shipping options for RUTF are often limited to sea freight with long lead times. Local RUTF production contributes to shorter lead times, a lower weighted total loaded cost, reduced storage and transportation costs, and shorter, more resilient and sustainable supply chains� Throughout the COVID-19 pandemic, and despite complex global freight disruptions, established RUTF suppliers that were nearer to the point of demand ensured uninterrupted access to RUTF for many countries. Diversifying the RUTF supplier base is an example of how UNICEF is working to influence its supplier base to increase regional and local procurement and production to ensure equitable and inclusive access to essential supplies� In 2022, due to an unprecedented increase in RUTF demand owing to the prevailing global food and nutrition crisis, UNICEF increased its RUTF supply to 85,000 MT� Over 30,000 MT was procured from African suppliers, representing a 300 per cent increase in a decade� According to the 2022 Global Report on Food Crises, 42 countries are experiencing high levels of food and nutrition insecurity; 15 of these countries account for 8 million children with severe wasting and 27 million children living in severe food insecurity: Afghanistan, Burkina Faso, Chad, DR-Congo, Ethiopia, Haiti, Kenya, Madagascar, Mali, Niger, Nigeria, Somalia, South Sudan, Sudan and Yemen� This is why UNICEF has developed the No Time to Waste acceleration plan, which is based on scaling up prevention, early detection and the treatment of wasting for the most vulnerable children in these countries� See pages 58-59 and 93-95 on how UNICEF is stimulating RUTF production in Africa and LMICs at large. https://www.unicef.org/reports/no-time-waste https://www.unicef.org/reports/no-time-waste Sudan Ethiopia Pakistan India Madagascar Kenya Malawi Nigeria Haiti South Africa Burkina Faso SUPPORTING PRODUC- TION OF RUTF IN DE- VELOPING COUNTRIES 10000 To n s 8000 6000 4000 2000 2016 2017 2018 2019 2020 2021 0 56.89% 64.85% 68.88% 71.37% 67.24% 54.77% UNICEF's RUTF supplier base in LMICs Volumes of commodities procured Burkina Faso Ethiopia Haiti India Kenya Madagascar Malawi Niger Nigeria Pakistan Sierra Leone South Africa Sudan Share of RUTF sourced from LMICs in volume terms Stimulating local RUTF production For the last four years, UNICEF has been procuring almost 80 per cent of the world’s RUTF, a life-saving essential supply that treats severe wasting in children under five years old. More than two in three products were sourced from low- and middle-income countries (LMICs). 58 1 dot represents 1 RUTF supplier (2021) Sudan Ethiopia Pakistan India Madagascar Kenya Malawi Nigeria Haiti South Africa Burkina Faso SUPPORTING PRODUC- TION OF RUTF IN DE- VELOPING COUNTRIES 10000 To n s 8000 6000 4000 2000 2016 2017 2018 2019 2020 2021 0 56.89% 64.85% 68.88% 71.37% 67.24% 54.77% UNICEF's RUTF supplier base in LMICs Volumes of commodities procured Burkina Faso Ethiopia Haiti India Kenya Madagascar Malawi Niger Nigeria Pakistan Sierra Leone South Africa Sudan Share of RUTF sourced from LMICs in volume terms UNICEF procurement of RUTF in LMICs increased from 6 to 67 per cent between 2006 and 2021 with the average price decreasing by more than 20 per cent. 59Supply chains save lives: Unlocking access for children, their families and communities Disclaimer: the boundaries and names shown, and the designations used on the maps do not imply official endorsement or acceptance by UNICEF. 60 04 GLOBAL GOODS Shaping the future of public supply chains 61Supply chains save lives: Unlocking access for children, their families and communities 62 UNICEF SUPPLY CHAIN MATURITY MODEL  A tool to measure the performance of countries’ supply chains and shape improvement plans Launched in 2019, the UNICEF Supply Chain Maturity Model is a participatory and government-led assessment tool that allows countries to determine whether supply chain management is a barrier to access across health, immunization and nutrition programmes� The tool enables government to review the performance of 13 critical operational and technical supply chain functions� Performance is ranked between 1 (minimum development) and 5 (best practice in supply chain management)� The Maturity Model serves three main purposes:  1. Assess and quantify the strengths, gaps and priorities for improvement across all areas of the public supply chains� This information helps to develop evidence-driven supply chain strengthening plans that will ensure children have greater access to products and services; 2. Provide a common framework to help governments and partners coordinate their activities and measure impact, avoid duplication and maximize the strengths of each partner;   3. Identify gaps in funding and technical expertise and link government supply chain development needs with private sector resources and expertise where appropriate� Since 2019, the UNICEF Supply Chain Maturity Model has been used by 35 governments to identify their investment and technical needs and execute appropriate responses. Knowing the areas where they are lacking and then acting to address these gaps helps countries ensure that children enjoy higher levels of access to products and services across various public programmes (health, nutrition, education and WASH).  82 Read the full story here: https://www.unicef.org/supply/stories/strengthening-malawi-health-supply-chain-improve-access-health-care-children The Maturity Model in Malawi82  With funding and technical support from UNICEF, Malawi’s Ministry of Health used the Maturity Model to evaluate progress, highlight gaps and provide recommendations to improve the efficiency of the supply chain in bringing essential medicines and health commodities to districts and communities across the country� The results helped determine Malawi’s readiness level and management capacity for the deployment of COVID-19 tests, treatments and vaccines, and helped the Ministry of Health develop a National Supply Chain Transformational Master Plan (2021–2026). Through clear and measurable targets, the plan will assist the government as it strives to achieve better health outcomes� The Government of Malawi praised the UNICEF Maturity Model for facilitating collecting evidence to drive improvement plans, leveraging partner resources and technical cooperation, and bridging the gap in access to health care� “ The Maturity Model assessment was a timely exercise that has assisted the country in highlighting key bottlenecks in the supply chain and to prioritize areas of improvement. We will continue to use the tool to evaluate progress made towards reaching our goal of ensuring the availability of essential medicines at all times in Malawi.  Godfrey Kadewele, Director of Health Technical Support Services, Malawi Ministry of Health https://www.unicef.org/supply/unicef-supply-chain-maturity-model https://www.unicef.org/supply/unicef-supply-chain-maturity-model https://www.unicef.org/supply/stories/strengthening-malawi-health-supply-chain-improve-access-health-care-children 63Supply chains save lives: Unlocking access for children, their families and communities THE EFFECTIVE VACCINE MANAGEMENT INITIATIVE  Robust vaccine supply chains save lives “ The EVM identifies which areas require attention, allowing donor organizations, development agencies and governments to target their investments and shape national continuous improvement plans. Michelle Seidel, Senior Advisor on Immunization, UNICEF Programme Group Vaccines save millions of lives each year by protecting vulnerable populations against serious and preventable diseases� Each successful vaccination requires a strong immunization supply chain (iSC) to ensure that the right vaccine is administered at the right time, place and cost� But how do countries ensure their iSCs are fit for purpose? Complementing the Maturity Model assessment, the Effective Vaccine Management (EVM) initiative goes a long way to strengthening iSCs by pointing to areas that require strengthening� What is EVM? Co-developed by WHO and UNICEF, EVM is a tool and process that assesses each component of the iSC, to identify strengths and weaknesses� Understanding these strengths and weaknesses allows countries to develop plans and allocate resources to implement improvements where they are needed most� EVM brings together immunization professionals with the common goal of increasing immunization coverage� What makes EVM unique is that it analyses 19 critical supply chain functions, such as vaccine arrival, storage and management, and identifies those that are underperforming� Armed with information about which areas require attention, donor organizations, development agencies and governments are then able to target their investments and shape national continuous improvement plans� https://www.who.int/teams/immunization-vaccines-and-biologicals/essential-programme-on-immunization/supply-chain/effective-vaccine-management-(evm) 64 More than two decades of adoption and scale Since it was first launched in 2010, UNICEF and WHO have deployed the EVM in up to 95 countries to assess their iSCs; 66 countries have conducted two assessments and another 22 countries have conducted three� It is important that countries conduct multiple assessments to allow decision-makers to review the performance of their interventions over time� Over this time, the average global EVM composite scores have improved, from 64 (2012) to 67 (2015) and to 71 in 2020� An area of vaccine management is considered ‘Effective’ if its criterion score is greater than or equal to 80 per cent. The number of countries with a national EVM composite score greater than 80 per cent has increased from four in 2011, to ten in 2013, to 18 in 2017, to 21 in 2020, demonstrating steady improvements in vaccine supply chain performance. With the new web-based EVM 2.0, countries benefit from a more robust and automated dataset, which they can use to assess a wide range of supply chain functions and conduct dedicated supply chain function or level assessments to monitor progress at both national and subnational levels� Around 25 countries have conducted EVM assessments since the launch of EVM 2.0 in 2019, enabling countries to conduct targeted EVM assessments in specific parts of the country or in specific supply chain functions. Regular assessments (ideally every three to five years) help to monitor supply chain performance, in addition to developing and implementing dynamic continuous improvement plans� EVM Assessment + Continuous Improvement Plans A SS ES S PLAN IMP LE M EN TM O N ITOR Collect and review evidence to identify iSC strengths, weaknesses, opportunities, and bottlenecks Monitor implementation, measure progress toward outcomes Creative vision, strategy and operational plan for iSC improvement Disseminate plan, ensure funding and put plan into operation COMMIT TO CONTINUOUS IM PRO V EM EN T Figure 2. Components of an EVM assessment https://extranet.who.int/evm2/web/Public 65Supply chains save lives: Unlocking access for children, their families and communities The results On average, EVM scores have improved significantly for the countries that conducted EVM analyses before and after 2015� Improvements have been seen in every area, with particularly impressive strides made in vaccine management, distribution, storage and transport capacities. In tandem, global DTP3 coverage jumped from 72 per cent in 2000 to 86 per cent in 2019.98 With un understanding of the areas that needed improvement, UNICEF, WHO, donor agencies (including Gavi and the Bill & Melinda Gates Foundation) and other partners (such as the Clinton Health Access Initiative, JSI, PATH and VillageReach) have been able to provide targeted technical assistance� 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% E. 1 - Arrival procedures E. 2 - Temperature monitoring E. 3 - Storage & transport capacities E. 4 - Buildings, equipment & transport E. 5 - maintenance E. 6 - Stock management E. 7 - Distribution E. 8 - Vaccine management KAP E. 9 - Information management & supportive functions Overall composite score Until 2015 2015-2020 72% 72% 65% 70% 72% 81% 73% 78% 61% 67% 61% 68% 57% 66% 71% 84% 63% 64% 65% 61% EVM average per criterion, for 44 countries with EVMs pre 2015 & post 2015 Figure 3. EVM average per criterion, for 44 countries with EVMs pre-2015 and post-2015 In Bangladesh, since the country’s first EVM assessment in 2011, when it scored 72 per cent, its overall score has improved substantially. In its most- recent assessment in 2021 it scored 84 per cent – above the minimum requirement (80 per cent) across eight of nine EVM criteria. Meanwhile, Bangladesh’s DTP3 immunization coverage among one-year-olds increased from 82 per cent in 2000 to 98 per cent in 2021.99 83 https://data.unicef.org/topic/child-health/immunization/ 84 https://www.who.int/data/gho/data/indicators/indicator-details/GHO/diphtheria-tetanus-toxoid-and-pertussis-(dtp3)-immunization-coverage-among-1-year-olds-(-) Following this most-recent EVM assessment, Bangladesh developed a national continuous supply chain improvement plan and a strategic vision for the following five years. In addition to planning activities to sustain progress in key areas, improvement activities have also been planned for vaccine arrivals, waste management and the storage of vaccines and dry goods. https://data.unicef.org/topic/child-health/immunization/ https://www.who.int/data/gho/data/indicators/indicator-details/GHO/diphtheria-tetanus-toxoid-and-pertussis-(dtp3)-immunization-coverage-among-1-year-olds-(-) 66 THE TRACEABILITY AND VERIFICATION SYSTEM Protecting patients from counterfeit medicines What is the problem? As the distribution of the COVID-19 vaccine ramped up worldwide, so did the production and distribution of falsified and sub-standard vaccines and COVID-19 supplies. Even before the pandemic, one in 10 medical products in LMICs was already substandard or falsified.85 Falsified vaccines and medicines alone cost LMICs $30 billion each year and over $200 billion globally.86 Counterfeit medicines are estimated to have caused up to 169,000 deaths of children under 5 suffering from pneumonia and up to 116,000 deaths from falsified medicines to treat malaria.87 Not only do substandard and falsified medical products cause harm to patients and fail to treat the diseases for which they were intended, but they also lead to a loss of confidence in medicines, health care providers and health systems.88 What’s more, falsified medicines can promote drug resistance. National supply chains in LMICs are at highest risk – those in which the governance structures, tools and technical capacity to actively monitor falsified products are limited or traceability systems are either non-existent or in the early stages of development� And the need to trace products and verify their quality extends beyond COVID-19 vaccines to all health products. What is the solution? The Traceability & Verification System, or TRVST, is the fruit of a multi- stakeholder consortium comprising national regulatory authorities in LMICs, vaccine manufacturers, private businesses and development partners, including WHO, the World Bank, the Global Fund, GAVI, USAID and the Bill & Melinda Gates Foundation. 85 World Health Organization, ‘Substandard and falsified medical products’, WHO, January 2018, <www.who. int/news-room/fact-sheets/detail/substandard-and-falsified-medical-products>. 86 World Health Organization, ‘A Study on the Public Health and Socioeconomic Impact of Substandard and Falsified Medical Products’, WHO, Geneva, 2017. 87 World Health Organization, ‘The WHO Member State Mechanism on Substandard and Falsified Medical Products’, WHO, Geneva, 24 June 2020, <https://www.who.int/publications/i/item/WHO-MVP-EMP- SAV-2019.04>. 88 World Health Organization, ‘Substandard and falsified medical products’, WHO, January 2018, <www.who. int/news-room/fact-sheets/detail/substandard-and-falsified-medical-products>. http://www.who.int/news-room/fact-sheets/detail/substandard-and-falsified-medical-products http://www.who.int/news-room/fact-sheets/detail/substandard-and-falsified-medical-products https://www.who.int/publications/i/item/WHO-MVP-EMP-SAV-2019.04 https://www.who.int/publications/i/item/WHO-MVP-EMP-SAV-2019.04 http://www.who.int/news-room/fact-sheets/detail/substandard-and-falsified-medical-products http://www.who.int/news-room/fact-sheets/detail/substandard-and-falsified-medical-products 67Supply chains save lives: Unlocking access for children, their families and communities The initiative, which is the first GS1-enabled verification and traceability system to be used in Africa, offers a repository to store traceability and verification data. First and foremost, the TRVST verifies the authenticity of vaccines and other health products on the market� The system allows users, such as health care workers, regulatory authorities and customs agents to use a smart phone app to scan medical product barcodes and verify their authenticity in real time. Any verification failure or suspect activities trigger an alert that is sent to respective manufacturers and regulatory authorities. Using the existing GS1 barcoding technology, which is already being deployed in high-income countries, the TRVST has been implemented since July 2022 in Nigeria and Rwanda. GS1-enabled vaccines are being scanned to confirm if they are authentic, thereby ensuring patient safety while improving supply chain efficiency. The path towards digitalizing health product supply chain systems This initiative complements other global efforts led by UNICEF and partners to digitalize public health supply chain systems in LMICs and strengthen countries’ supply planning and demand capacity to ensure higher levels of equitable access to health products and treatments� Initially the global repository has been loaded with COVID-19 vaccine data from manufacturers to address the urgent risk of falsified or diverted COVID-19 vaccines. Its successful implementation is the first step towards a fully-fledged end-to-end traceability system for all health products, including vaccines, medicines for HIV, tuberculosis and malaria, and supports country efforts to achieve universal health coverage� Five basic elements of the TRVST 1. An interface that allows manufacturers to upload product master data using an application programming interface (API) or via a global data synchronization network� 2. The TRVST repository, which securely holds all the product and event data (verification and traceability). 3. Verification smart phone app and API: Users are able to verify products by scanning a barcode on the packaging using a phone application, which is available on both Android and iOS platforms. The TRVST comes with a global phone application, but national versions may be made available at the request of national authorities� 4. TRVST API interface linking with national systems: Countries’ national traceability systems – and the data in these systems – can be connected to the TRVST, providing supply chain visibility to donor organizations� 5. The TRVST dashboard allows users to view verification and traceability data� GS1: The gold standard for tracking The global repository adopts the GS1 supply chain standards, a set of global data standards that provide a harmonized framework for supply chain visibility� GS1 standards refer to a barcode system that allows supply chain professionals to track products throughout the whole supply chain and across the continuum of care, identify the root causes of supply chain issues or adverse events and, when necessary, recall products� Since 2015, UNICEF has recommended the use of GS1 standards outer box (secondary packaging) of vaccines and since 31 December 2021, UNICEF vaccine tenders backed by Gavi financing have been required to include GS1 barcoding on secondary packaging� 68 TRVST is supported by the Verification and Traceability Initiative, a multi-stakeholder consortium led by UNICEF, the World Bank, USAID, the Global Fund, GAVI, Bill & Melinda Gates Foundation and Vital Wave. Ken Legins, Chief, Supply Chain Strengthening Centre, UNICEF Supply Division “ Participation & partnerships: The key to success TRVST is expected to be scaled up and expanded to vaccines for routine immunization programmes and health products to treat HIV and tuberculosis, as well as to reproductive health supplies, anti-malarial items and other essential medicines� The success, scalability and sustainability of the TRVST are contingent upon participation and partnerships� UNICEF is calling on additional governments to join the initiative, donors to provide resources to support country-level implementation, and manufacturers to serialize their products in emerging markets and register them in the global repository� 69Supply chains save lives: Unlocking access for children, their families and communities VACCINE INDEPENDENCE INITIATIVE AND OTHER SUPPLY FINANCING SOLUTIONS Unblocking supply financing obstacles to children’s vaccines Over the past decade, routine immunization services for children have expanded significantly, especially in Africa and South-East Asia. However, the COVID-19 pandemic, subsequent national lockdowns and worldwide supply chain disruptions have strained health systems, contributing to a global drop in the coverage of routine childhood immunizations, from 86 per cent in 2019 to 81 per cent in 2021�89 Currently, there are more than 25 million unvaccinated or under-vaccinated children in the world.90 One reason is disrupted supplies. LMICs often face obstacles to quickly and sufficiently mobilizing funds to buy vaccines and other essential commodities when they are needed the most� The Vaccine Independence Initiative (VII) Launched in 1991, UNICEF’s main tool for supply pre-financing is the Vaccine Independence Initiative Revolving Fund, which accelerates access to life-saving supplies, including vaccines and other non-immunization commodities, while providing a platform for ensuring a systematic and sustainable supply for country partners facing temporary budget shortfalls� Helping countries procure vaccines and other life-saving supplies Bridging funding gaps is crucial so that children are not put at greater risk of preventable diseases� In parallel, the underlying causes of insufficient budget allocation, and delays in budget disbursements, must also be addressed to improve a country’s long-term, self-financing capacity. Through the VII platform, technical support is provided to country partners in areas of supply budgeting and 89 United Nations Children’s Fund, ‘Immunization country profile’, UNICEF, <www.unicef.org/supply/immunization-country-profile> 90 <https://www.who.int/news-room/fact-sheets/detail/immunization-coverage>. 91 The percentage of children aged 12-59 months who have received three doses of the combined diphtheria pertussis tetanus vaccine (DPT3) is a widely used indicator of the performance of countries’ routine immunization service� financing, with the objective of supporting longer-term, sustainable self-financing of these supplies. Originally focused on vaccines, the VII has evolved to support the procurement of other non-immunization commodities, such as medicines, bed nets, nutrition products and cold chain equipment� Tens of millions of children benefit from VII support to countries each year. Between 2015 and 2021, the VII facilitated the on-time delivery of more than 1 billion doses of vaccines, almost 500,000 cartons of RUTF, nearly 400,000 packs of antiretroviral drugs, as well as COVID-19 supplies such as personal protective equipment (PPE), diagnostic tests and oxygen therapy equipment during the pandemic� Increased access to vaccines in the Democratic Republic of the Congo In 2019, $3 million in pre-financing allowed for the procurement of 15 million doses of vaccines and syringes in the Democratic Republic of the Congo (DRC). This helped the country boost coverage of DPT391 from 69 per cent in 2017 to over 79 per cent by the end of 2019. In 2020, the late availability of donor funding created a $5�8 million funding gap to procure and deliver 10 million doses of childhood vaccines� A shortfall of $6�1 for 13 million doses had to be covered for 2021. This pre-financing was initiated to bridge the gap until an existing World Bank loan was disbursed; it helped avoid stock-outs and played a part in increasing vaccine coverage in the country from 35 per cent in 2018 to 53 per cent in 2020� https://www.unicef.org/supply/stories/strengthening-domestic-resources-deliver-life-saving-commodities http://www.unicef.org/supply/immunization-country-profile https://www.who.int/news-room/fact-sheets/detail/immunization-coverage 70 A growing need To date more than 30 countries have subscribed to the VII, with some successfully graduating (no longer needing access to the facility)� More than 100 countries have used VII for ad hoc pre-financing. However, the COVID-19 pandemic has strained health budgets and many countries are struggling to mobilize sufficient domestic funding to fund their traditional vaccines and the co-financing portion of their Gavi-funded vaccines. UNICEF continues to receive an increasing amount of pre-financing requests from countries driven by COVID-19-related needs during 2021, and more recently, during 2022, in the context of the food and nutrition crisis. During the transition from Gavi and become self-financing, countries are required to raise their own domestic resources to fund vaccine programmes. In these contexts, VII can help countries with their vaccine financing. The Nutrition Match Instrument Launched in 2020 to support governments in mobilizing domestic resources for nutrition, the Nutrition Match Instrument (NMI) was established and is managed by UNICEF� The NMI supplements government spending on RUTF and other essential nutrition supplies� To qualify for the NMI, governments must: (1) include overall RUTF needs and costs, which are already approved or estimated; (2) cover a portion of those total costs with domestically mobilized resources; and (3) ensure that the domestic allocation to RUTF does not negatively impact life-saving nutrition or health interventions. Complementary to NMI support, countries can access VII and technical assistance to enable a sustainable introduction of budget lines for nutrition� Read more about the NMI on page 93. Mauritania: Self-financing to prevent malnutrition In April 2022, UNICEF and partners delivered more than 36,300 boxes of RUTF to Mauritania to treat more than 35,000 children suffering from severe wasting. Half of the total RUTF consignment was paid for by the Government of Mauritania, and the remainder was covered by the NMI� These nutrition supplies were part of a consignment of 155,000 cartons ordered in October 2021. “The NMI increases collaboration between UNICEF and Ministries of Health and Finance on budgeting and financing health supplies and also extends partnerships with private sector supply chain services,” said UNICEF Chief of Nutrition in Mauritania, Christian Tendeng� “The NMI increases opportunities for national governments to access innovative financing for nutrition commodities to achieve an optimized, efficient, and timely humanitarian response and provides comparative advantages in product sourcing”, he added. 71Supply chains save lives: Unlocking access for children, their families and communities NUTRIDASH Improving coverage and equity of nutrition supplies and treatment NutriDash is UNICEF’s global nutrition monitoring system for maternal and child nutrition programming� With its interactive data and reporting platform, NutriDash provides an avenue for both UNICEF and partners at all levels to collect data that allows them to collaborate in identifying gaps, opportunities and resources for strengthening evidence-based national nutrition responses. The platform not only collects and stores data from more than 120 countries, but it also analyses and visualizes these data to inform decision-making. Data means the ability to forecast The data stored in NutriDash relates to programme coverage and performance, governance knowledge and nutrition supply needs. Data are mainly used to monitor progress against defined targets, allowing decision makers – including donors – to prioritize actions. NutriDash is a key tool to strengthen routine monitoring and reporting at country level� Importantly, the data that NutriDash collects on nutrition supply requirements support the global planning and procurement of nutrition supplies� These supply data have many uses, including initiating dialogue between governments, donors and development partners, such as UNICEF, to commit to and invest in key nutrition interventions� Through NutriDash, UNICEF collects data for vitamin A capsules from about 58 countries each year. Owing to this information, about 500 million vitamin A capsules are sent to eligible countries each year from the vitamin A in-kind donation programme (see Box). Through this process, UNICEF works with countries to project future needs and strengthen national demand planning capacity� What is the added value of NutriDash? By collecting all maternal and child nutrition data in one place, governments and partners, including UNICEF, are given a snapshot of the state of nutrition globally, which helps: • Inform decision making by monitoring progress against targets and identifying bottlenecks • Strengthen reporting capacity by tracking country progress towards global and national nutrition targets and making global-, regional- and country-level data accessible to all stakeholders • Identify key programme and supply trends by generating reports on key indicators • Strengthen nutrition information response by supporting countries to routinely track nutrition data • Build political will using evidence-based advocacy to spark dialogue with governments Improved demand planning data for life-saving vitamin A supplementation Every year, vitamin A capsules are provided to eligible countries through the in-kind donation programme, implemented in partnership between UNICEF and Nutrition International, with support from the Government of Canada� Using the data collected by countries, NutriDash allows donors and development partners to better understand programme coverage gaps and therefore estimate countries’ additional vitamin A requirements and funding needs. For example, Nigeria has received over 1 billion vitamin A capsules since 2005. Over the last five years, the country’s needs for vitamin A have increased with the growth in its population. Despite this population increase, however, the quantity of new supplies needed by Nigeria declined because NutriDash, as a central repository platform uniting data across districts, regions and states, had allowed decision makers to holistically analyse programme needs, and plan accordingly� Since 2017, more than 110 million capsules remained unused in Nigeria during the year they were provided, and were therefore saved to be used the following year to fulfil needs. The enhanced monitoring of programme data provided by NutriDash has translated into around $2�2 million in savings and improved donor value for money. 72 73Supply chains save lives: Unlocking access for children, their families and communities PEOPLE THAT DELIVER Standing up for the health supply chain workforce People that Deliver (PtD) is UNICEF’s supply chain workforce arm: a 27-member strong coalition of governments, donors, development partners, academic institutions, professional associations and private sector companies that works to ensure that the supply chain workforce is competent, professionally skilled and adequately staffed. Through PtD, UNICEF has developed dozens of tools over the last decade, all of which are freely accessible to support countries’ supply chain workforce in becoming empowered, skilled and properly equipped to improve the delivery of health commodities. The supply chain workforce is integral to functioning health supply chains: through which health commodities – such as vaccines, essential medicines and nutrition products – reach children. Given that strong and efficient supply chains give children access to these products, it is critical to support the human resources running them� Building human resources for supply chain management: Theory of Change In LMICs, often the supply chain workforce lacks the technical and managerial competencies to perform optimally or is not empowered to positively influence supply decisions and policies. Further, insufficient numbers of competent staff can cause breakdowns in supply chain systems and lead to poor system performance. The PtD’s Theory of Change (ToC) is an tool to help enable health supply chain organizations reach their human resources potential� PtD’s ToC analyses the conditions needed to ensure that workers at every level in a supply chain perform optimally. It centres on four pathways: staffing, skills, working conditions and motivation� Addressing these is necessary to make commodities available in the most cost-effective way to improve health outcomes. People that Deliver in action in Ethiopia People that Deliver implemented the ToC in Ethiopia’s pharmaceutical supply chain in 2019 to identify human resources and competency gaps. This led to the development of a competency framework and a training plan by the Ethiopian Pharmaceuticals Supply Agency (EPSA)� In the months that followed, measurable supply chain efficiencies were gained: EPSA’s procurement lead time decreased by 25 per cent, contract signing lead time decreased by 35 per cent, and tender lead time decreased by 5.5 per cent between 2018 and 2020.   https://www.peoplethatdeliver.org/ https://www.peoplethatdeliver.org/ 74 Through PtD, EPSA developed a work culture transformation strategy using the diagnostic results� For example, a code of conduct was developed, a gender audit was conducted, and as a result, EPSA produced a manual on gender mainstreaming and women’s empowerment manual, as well as a five-year strategic plan for EPSA’s women, youth, children and people with disabilities� The professionalisation framework centres on the library of competencies and designations – a detailed framework that defines the knowledge, skills and attributes needed for people working in health supply chain management to fulfil their roles. PtD is the central coordinating hub of a group of partners that work collaboratively to promote health supply chain professionalization� The hub is a platform for partners to network, exchange information and engage practitioners working on or interested in supply chain professionalisation� Health supply chain professionalism in action in Rwanda The Rwanda Medical Supply Limited, owned by the Government of Rwanda and the University of Rwanda, alongside PtD and USAID’s Global Health Supply Chain Program, Procurement and Supply Management (GHSC-PSM) project, began implementing the supply chain management professionalization framework in Rwanda in 2021. The project is currently at phase three of five: the development of a mapping tool� This tool will be used to highlight competency gaps in the Rwandan workforce� The results of this exercise will influence educational course offerings and help map out a career path for the public sector health supply chain management workforce in the country� “ It was in Ethiopia’s pharmaceutical supply chain that we implemented the ToC. The tool was extremely useful. We were able to identify gaps in human resources management and competency, and conducted training needs analyses in order to provide targeted solutions in each of the pathways, particularly the skills pathway. This comprehensive approach led to great results, starting with leadership awareness of the importance of human resources for supply chain management and the need for them to be skilled, adequate in number and provided with an enabling environment. Pamela Steele, founder & CEO, Pamela Steele and Associates, implementer of PtD’s Theory of Change in Ethiopia The professionalisation framework Developed in 2020, PtD’s professionalisation framework is a set of global standards that align career path, education and professional growth in health supply chain management� It is a tool that can help to transform supply chain management into a recognized profession of the highest integrity� 75Supply chains save lives: Unlocking access for children, their families and communities 76 05 GLOBAL SUPPLY AND PROGRAMME PARTNERSHIPS Unlocking access for children 77Supply chains save lives: Unlocking access for children, their families and communities 78 UNICEF uses its global reach, supply hubs, expertise and local knowledge to deliver supplies to children in more than 160 countries and territories, including in situations of conflict and disaster. This is achieved by leveraging a wide range of partnerships, which enable UNICEF to save lives by providing those in need with the right supplies, at the right time and in the right place� Partnerships also allow UNICEF to strengthen countries’ supply chain management, preparedness and response capacity, with a view to shaping sustainable transitions from emergency response to programme delivery for children� GLOBAL HEALTH PARTNERSHIPS UNICEF is the leading agency for comprehensive primary health care procurement and delivery for children, their families and communities. UNICEF operates global end-to-end supply chains (see page 42), from the point of procurement – where we secure affordable prices and achieve the best value for money – to the last mile, where we reach local communities. Operating and supporting end-to-end supply chains gives us an understanding of the weakest links – and where technical and financial investments are needed to save lives. UNICEF strengthens primary health care systems by taking a holistic approach, addressing both upstream (product selection, forecasting, procurement, market-shaping, international transport and customs clearance) and downstream (transport, warehousing and end-user monitoring) supply chain management functions to improve quality and equitable access to health care services. Strengthening primary health care through supply chain management In 2021 through its global health partnerships, UNICEF procured a record $6�3 billion worth of supplies, including 2.7 billion doses of COVID-19 vaccines and vaccines against diarrhea, measles, pneumonia, polio, tetanus and tuberculosis. Other key primary health care commodities included oral rehydration solution, zinc, antibiotics, antiretroviral drugs, long-lasting insecticidal nets, RUTF, point-of-care diagnostics, sanitation and hygiene products, and cold chain equipment� This was complemented by another $317 million invested in transportation, including $226 million on international freight service and $91 million on in-country logistics and warehousing services� As the world’s biggest buyer and supplier of children’s vaccines, UNICEF has a pivotal role in implementing immunization programmes in Gavi-supported countries and beyond. In 2021, UNICEF procured 2.299 billion doses of paediatric vaccines for 109 countries to reach 46 per cent of the world’s children under 5 years of age� Of these vaccines, 48.5 per cent supported routine immunization programmes, while the remainder supported supplementary immunization activities, outbreak responses and humanitarian situations� Complementing its procurement function, UNICEF serves as one of 28 members of the Gavi Board, providing technical leadership to shape Gavi’s strategies, priorities and investments, resulting in policies centred on meeting the goals of the immunization agenda to reach ‘zero-dose children’. The Gavi Secretariat, UNICEF and WHO lead a multi-partner technical committee tasked with implementing strategies, developing global goods to address identified obstacles and supporting governments in their systems-strengthening journey by leveraging Gavi’s resources. With financial support from Gavi, UNICEF provides technical assistance to all 54 Gavi-eligible countries, working with manufacturers to ensure a reliable supply of quality and affordable vaccines, and with governments to identify and address potential barriers to equitable access for all� This is done in collaboration with Gavi’s Immunization Supply Chain Steering Committee members, co-chaired by UNICEF and the Gavi Secretariat and comprising the Bill & Melinda Gates Foundation, VillageReach, Path, JSI and the Clinton Health Access Initiative� The Immunization Supply Chain Steering Committee Alliance, co-chaired by UNICEF and WHO, was established in 2015 as a cross-partner mechanism to provide a coordinated response to supply chain gaps in countries� This integrated approach, which supports the alignment of partners’ resources, investments and expertise, has yielded positive results as evidenced by the increase of EVM overall composite scores for 44 countries between 2015 and 2020� UNICEF, in partnership with Gavi, the Global Fund, USAID and other partners works to improve the efficiency, performance and maturity of immunization supply chains in countries� Areas of technical cooperation and assistance include the strengthening of supply chain management decision making and product visibility as part of wider national digital health transformation efforts. This work is undertaken in partnership with the Digital Health Centre of Excellence, which serves as a multi-agency consortium co-led by UNICEF and WHO with membership from the World Bank, Gavi, the Global Fund and the Bill & Melinda Gates Foundation� Established in 2021, the Centre of Excellence works to improve donor coordination, ensure alignment with digital investment principles, guide http://www.unicef.org/ https://www.gavi.org/our-alliance/strategy/phase-5-2021-2025 https://www.gavi.org/our-alliance/strategy/phase-5-2021-2025 79Supply chains save lives: Unlocking access for children, their families and communities investments in digital public goods and global goods, and provide targeted technical assistance and quality assurance to countries� The Centre of Excellence works within existing UNICEF and WHO regional and country structures, bolstering their capacity to identify, develop and scale digital solutions in support of national health priorities� Its goal is to make health services, such as vaccines, maternal and child health, and nutrition, more equitable and attainable through a data-driven approach and by harnessing the power of sustainable and scalable digital health solutions. Partnerships with the African Union and Africa Centres for Disease Control and Prevention UNICEF’s partnership with the African Union is based on the development and accelerated implementation of child-responsive policies and programmes to achieve the goals of the Agenda 2063: The Africa We Want and Africa’s Agenda for Children 2040: Fostering an Africa Fit for Children� UNICEF is working with the African Union and the Africa Centre for Disease Control and Prevention (Africa CDC) to advance local procurement, market intelligence to inform local manufacturing and market-shaping, traceability and verification of health products, and supply chain systems strengthening� UNICEF is a significant procurement and supply chain partner in the Africa CDC’s COVID-19 response. UNICEF supported the procurement and delivery of close to 1 billion doses of COVID-19 vaccines to Member States through the COVAX Facility and directly, in addition to providing $800 million worth of vaccines, ancillary supplies, cold chain equipment and personal protective equipment� UNICEF and Africa CDC have also recently expanded their cooperation through a partnership framework (2022–2024), which centres on public health emergency preparedness and response a

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