UNICEF Access to Global COVID-19 Tools Accelerator (ACT-A) Situation Report No. 4: 01 January to 31 December 2022

With funds from the ACT-A Humanitarian Action for Children (HAC) appeal, UNICEF achieved the following results in 2022:

Supported the administration of 2.82 billion doses of COVID-19 vaccines in low- and middle-income countries (LMIC), including in 34 priority countries of the COVID-19 vaccine delivery partnership.

Delivered 2.1 million COVID-19 diagnostics tests to countries that are responding to humanitarian situations.

Delivered 14.6 million treatment courses of molnupiravir antiviral medication to seven low- and middle-income countries.

Provided ongoing supply and technical support for increased oxygen access, including for the implementation of 123 oxygen plants in 32 countries across seven regions.

Shipped US$64.8 million worth of personal protective equipment (PPE) to 44 countries responding to the COVID-19 global health emergency.

Supported 133 low- and middle-income countries to rollout risk communication and community engagement (RCCE) and promote trust in COVID-19 tools, including the integration of COVID-19 vaccination with other routine immunization globally.

ACT-A targets for 2022 to be achieved with partners

4 billion

Vaccine doses to be delivered via ACT-A partners, including UNICEF

988 million

Diagnostic tests to be delivered via ACT-A partners, including UNICEF

120 million

Cases of COVID-19 treated with support from ACT-A partners, including UNICEF

2.7 million

Health workers protected with PPE with support from ACT-A partners, including UNICEF


The UNICEF ACT-A HAC appeal enabled UNICEF, as a lead implementation partner of the ACT-A global collaboration, to support national governments to equitably scale up access to COVID-19 vaccines, tests, treatments, and PPE. The ACT-A HAC appeal presented the agency’s most urgent needs, particularly for humanitarian contexts, and formed a significant part of UNICEF’s 2022 funding requirements as outlined in the investment case “UNICEF’s Role In Accelerating Equitable Access To COVID-19 Tools.” UNICEF revised the ACT-A HAC appeal fundraising targets in June 2022 to include the carry-over of funds in the Vaccine Pillar and realigned the pillar-specific budgets of the appeal in November 2022 to better reflect the changing context and programmatic needs.

As of 31 December 2022, UNICEF had received US$929.4 million against the 2022 ACT-A appeal. The funds available against this appeal totalled US$1,290.4 million, which included US$361.0 million received and carried forward from the 2021 ACT-A HAC appeal, in line with grant end-dates and implementation timelines. The 2022 UNICEF ACT-A HAC appeal includes grants received late in 2022 to support the roll-out of COVID-19 tools and their integration into the delivery of services, and initiatives to strengthen primary health care (PHC)systems, which have end-dates that extend beyond 2022.

UNICEF would like to thank all partners, especially those who provided flexible and timely contributions against this appeal. We acknowledge the flexible funding from the Governments of Norway and the United States, in addition to ongoing, solid support from Gavi, the Vaccine Alliance, and its underlying donors, including governments and the private sector. We also acknowledge significant flexible funding from the Government of Canada for COVID-19 vaccine roll-out in countries supported by the COVID-19 Vaccines Global Access (COVAX), along with similar, multi-year country-earmarked support for COVID-19 vaccine delivery, including PHC strengthening. We acknowledge additional contributions from the German Federal Foreign Office, building on previous substantial investments of flexible funds for COVID-19 vaccine roll-out. In addition, we thank the Government of Japan for cold chain system building support, and the Governments of Iceland and Italy for their contribution of fully flexible funds to scale up the response to COVID-19. We would like to thank all private sector partners including the Z Zurich Foundation and UNICEF National Committees for their tireless efforts in fundraising for ACT-A.


As of 1 January 2023, more than 656 million confirmed cases of COVID-19 and over 6.6 million deaths have been reported globally. However, the change in testing strategies across the world (i.e., fewer tests performed, leading to fewer cases detected) has made it difficult to assess status and monitor trends, underestimating the true burden of the pandemic.

The year began with a marked increase in COVID-19 cases. Across the Americas, Africa, the Eastern Mediterranean, South-East Asia, the Western Pacific and Europe, more than 21 million new cases of COVID-19 were reported in the last week of January 2022, representing the highest number of weekly cases recorded since the beginning of the pandemic. Between February and early March 2022, there was a consistent decreasing trend in the number of new COVID-19 cases globally, but in early summer, the rate of global COVID-19 cases and deaths began increasing steadily, peaking again in mid-July 2022. Subsequently, the number of new weekly cases and deaths started to steadily decline, and by the end of December 2022, the rate of new cases and deaths reported globally was stable, with over 3 million new cases and 10,000 deaths reported during the last week of the year.

More than 105,000 SARS-CoV-2 sequences were shared between 2 December 2022 and 2 January 2023, through the Global Initiative on Sharing Avian Influenza Data. The Omicron variant of concern accounted for 98.4 per cent of sequences reported globally in December 2022. There continues to be increased diversity within Omicron and its descendent lineages, with a number under monitoring. As of 16 January 2023, BA.5 continued to be dominant, followed by BA.2 and BA.4 descendent lineages.

Vaccines: Globally, 13.12 billion doses of COVID-19 vaccines were administered (cumulatively) by the end of 2022. Overall, the total share of doses administered in low-income and lower-middle-income countries has increased compared to 2021. Specifically, low-income countries (LICs) showed a modest increase in their share of administered COVID-19 doses, from 1 per cent at the beginning of the year to 2 per cent by the end of 2022. This positive trend was also observed in the 30 countries with HRPs, where the share of doses administered increased from 5.9 per cent at the start of the year to 9 per cent by the end of 2022.

Similarly, of the 34 countries targeted for concerted support by the COVID-19 Vaccine Delivery Partnership (CoVDP), 27 managed to cross the 10 per cent vaccination coverage threshold by the end of 2022, including 18 countries with coverage higher than 20 per cent and nine countries with coverage higher than 30 per cent. Globally, the CoVDP received an increasing number of urgent funding requests from priority countries, from 10 at the end of the first quarter to 55 by the fourth quarter of 2022.

Supply constraints experienced in 2021 were removed in 2022 and many countries ramped up efforts to implement vaccine delivery scale-up and other initiatives to mitigate the impact of low-risk perception and decreased population demand for COVID-19 vaccines.

Despite these achievements, vaccination rates declined across the 133 low- and middle-income countries by the end of 2022 compared to the first quarter, with exceptions in some LICs and CoVDP priority groups. Specifically, several countries, including Afghanistan, Ethiopia, Malawi, Sierra Leone, the Sudan, South Sudan and Somalia reported vaccination rates at the end of the year that were comparable to the beginning of 2022. It is worth noting that these countries implemented extensive vaccination campaigns during the year to increase the number of COVID-19 vaccine doses administered and combat the decrease in population demand.

Declining vaccination is a multi-faceted issue, which can be explained partly by the population’s decreased perception of risk vis-a-vis new COVID-19 variants,such as Omicron, contributing to lower demand for COVID-19 vaccines. In some countries, especially where significant efforts and investments were made during 2021 and where high vaccine coverage levels were achieved at the beginning of 2022, this decline naturally followed a period of high vaccination during which the majority of the population had received their primary COVID-19 dose. In addition, countries experiencing humanitarian emergencies remain among those with the lowest vaccination coverage. Populations needing humanitarian assistance face greater obstacles in getting vaccinated, including challenging programmatic contexts (including lack of security), lack of access to services and assistance, bureaucratic or administrative issues, language barriers, a lack of vaccine information, and competing priorities.

During 2022, many countries shifted from a ‘pull-system’ of reaching un-vaccinated and under-vaccinated target populations to a ‘push system’ with a focus on campaigns and other community-based delivery approaches rather than relying on facility-based delivery. To increase coverage, many countries expanded vaccine eligibility criteria and adopted vaccination delivery strategies that targeted youth and adolescents aged 12 and above. There was also a renewed focus during the year on equitable vaccine coverage within countries, with an emphasis on the most vulnerable and hard-to-reach populations (e.g., the elderly, immunocompromised/those with comorbidities, and populations in humanitarian settings,such as internally displaced persons, migrants and conflict-affected populations).

The stark reality of routine vaccination backsliding across many countries due to the impact of COVID-19 has led to an urgent need to better integrate COVID-19 vaccine delivery with other essential immunization and health services, ensuring the delivery of vaccines in an integrated approach. By the third quarter of 2022, there was a notable uptick in requests from countries to strengthen health systems in the areas of cold chain, waste management, health facility solarization, public financial management, and digital health.

Diagnostics: During 2022, equitable access to COVID-19 testing remained a challenge. The testing target set by WHO is one test per 1,000 people per day. High-income countries remained at high levels of testing throughout the year, increasing from a daily average testing rate of 0.6 in Q1 of 2022 – 6 tests per 1,000 people per day – to 1.84 by the end of the year. Unfortunately, the scale of diagnostic testing declined in middle-income countries, with an average daily testing rate of 0.84 and 0.70 in lower- and upper-middle-income countries, respectively, at the beginning 2022; this fell to 0.07 and 0.15, respectively, by the end of the year. The situation was worst in LICs, where the average testing rate decreased from 0.08 at the beginning of 2022 to 0.02 – 0.2 tests per 1,000 people per day – by the end of the year. Africa remained the region with the lowest level of testing among all regions.

While the beginning of 2022 saw some deterioration in supply lead times for antigen detection, rapid diagnostic tests (Ag RDTs), the situation stabilized by March. For the remainder of 2022, reverse transcription polymerase chain reaction (RT-PCR) and Ag RDTs were both available without constraint and with agile supply lead times.

In 2022, prices for rapid tests under UNICEF procurement ranged from US$1.95 to US$2.40 per test. UNICEF’s Free Carrier-based weighted average price for these tests were further reduced to US$2.15 per test by the end of the year.

In 2022, demand for COVID-19 diagnostics concentrated on Ag RDTs, with some manufacturers of manual PCR tests projecting plans to phase out COVID-19 products due to the lack of demand. However, such individual product departures were not seen as a market risk, as the number of qualified suppliers and products in this category remained high. Notably, in the 4th quarter of 2022, following the WHO listing for emergency use, UNICEF established supply arrangements for the first quality-assured Ag-RDT for COVID-19 self-testing with the manufacturer, enabling increased access to COVID-19 diagnostics.

Though the pandemic continued to evolve, there was a growing sense of COVID-19 fatigue during 2022. The exhaustion of health workers and the public, coupled with competing national and local priorities, further reduced the already suppressed demand for COVID-19 diagnostics. Testing rates followed a continued downward trajectory, having declined from a high of 470 million per day in January 2022 to 32 million per day in December 2022. As a result, generating demand for testing and ensuring that affordable tests were accessible remained an integral part of ensuring equitable access to life-saving drugs as supplies became available throughout 2022 (see below).

Therapeutics: In 2022, infection with COVID-19 and related illness continued to be a global threat. While treatment of mild-to-moderate cases of COVID-19 has now become more accessible to vulnerable people who need it most, inequities persist in many low- and middle-income countries.

Since March 2022, WHO treatment guidelines have included recommendations for novel oral antivirals for patients with non-severe COVID-19 and who are at the highest risk of hospitalization, in addition to other medicines and oxygen, which are often required for patients with severe or critical COVID-19. When administered early, these medicines can reduce the risk of hospitalization, allow time to resolve symptoms, and reduce mortality.

In 2022, UNICEF established several supply agreements for the procurement of up to 4 million treatment courses of nirmatrelvir/ritonavir, covering 137 countries to date and expanding access to life-saving medicine. With increased availability of novel therapeutics, many low- and middle-income countries focused on stockpiling small quantities of therapeutics to quickly respond if there was a spike in the number of COVID-19 cases while, at the same time, piloting targeted test and treat approaches for high-risk populations.

Scaling up oxygen systems is a key part of increasing access to essential treatment for patients suffering from severe or critical COVID-19. Despite significant investments, including by UNICEF, there remained an underlying gap in oxygen as well as a limited capacity to manage and maintain these systems in many countries during 2022. There were fewer requests for rapid emergency procurement through the year, thus shifting the approach to larger-scale and longerterm solutions, such as market shaping efforts for liquid medical oxygen and the installation of oxygen-generating plants.

The significant influx of oxygen equipment since the onset of the COVID-19 pandemic raised concerns about sustainability. There continues to be a need for ongoing investment, national ownership, and coordination covering both basic and surge needs, with equitable access to all patients requiring oxygen. This includes strategic and costed plans for oxygen scale-up in relevant national and subnational budgets, a greater number of trained engineers and technicians to maintain and repair oxygen and other biomedical equipment, and the integration of oxygen in patient care protocols.

Towards the end of 2022, there was a gradual shift in the pandemic response from an emergency approach to a longerterm COVID-19 management strategy. Oxygen is an essential treatment for many conditions beyond COVID-19 and the ACT-A HAC investments have helped to close at least part of a pre-existing gap, which will impact the quality of health services and allow a faster response in future outbreaks.

Source: UN Children’s Fund

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