South Africa: Hits and Misses of the National Vaccine Rollout - Experts Weigh in

Government has been criticised for the slow pace of the country's vaccine rollout which started on 17 May. By 9 June about 1.1 million people had been vaccinated (including the health workers under the Sisonke research trial) and just over 2.4 million people 60 and older, had registered on the electronic vaccination registration system (EVDS). By 4 June, there were 471 active vaccination sites operating across the country.

When Spotlight and GroundUp in an opinion piece questioned the slow pace and suggested ways to speed up the process, Deputy Director-General in the Department of Health, Nicholas Crisp hit back saying "it's not that simple".

Now, Spotlight tried to cast the net a little wider and spoke to four experts about the national vaccine rollout.

Not vaccinating fast enough

A big part of the public backlash over South Africa's vaccine rollout has been around the slow pace.

According to Professor of Medicine at the University of Witwatersrand, Prof Francois Venter not nearly enough people are being vaccinated.

"At this rate, we won't vaccinate close to all the people we need to," he says. The government aims to vaccinate 40 million.

Public health specialist and President of the Public Health Association of South Africa (PHASA) Dr Harsha Somaroo echoes this.

"Even at the planning stage, I don't think we would have been able to vaccinate fast enough. Since the rollout has started as well, different bottlenecks have prevented a streamlined functioning at some of the sites," she says.

Scheduling problems

One of these bottlenecks Somaroo says, related to the manner in which appointments were scheduled when the rollout started.

"A lot of people may not actually have shown up at the appointments because they may not have been able to come on such short notice... But now that the scheduling has improved, the number of people who are actually able to attend the appointments will probably improve," she adds.

The scheduling for vaccination appointments is done through the Electronic Vaccination Data System (EVDS).

During a Daily Maverick webinar Crisp who is managing the EVDS explained that when the rollout started, vaccination site managers and administrators did not have control of their own scheduling yet. This has since changed and sites now have more control over their scheduling.

Initially, because many people missed their initial appointments because of the short notice, more vaccines were available for walk-ins, Crisp explained.

"But now... especially in some of the bigger private sites... pretty much 100% of people who get SMSes are now coming because they are getting their SMSes a couple of days ahead of time," he said. "It's not quite as good in some of the public sites so there are still walk-ins. So, we understand that."

Crisp said that the national policy is that walk-ins are still accepted, but they will have to wait and a vaccine on the day is not guaranteed.

"If people have walked in, they must wait and if you have to wait until the end of the day and you haven't been scheduled then you can't complain because you've taken a chance," he said.

He adds that those using private sector sites shouldn't be surprised if as a person on a medical aid there are no slots for you on that day if you just walk in without an appointment.

"In the public sector, the public has less access; less access to SMSes, less access to transport. So, in parts of the country there are still large numbers (of walk-ins)," Crisp says.

But South African Research Chair in Social Change at the University of Johannesburg Professor Kate Alexander says that the rollout discriminates between class and race and puts many people at a disadvantage.

"People who are insured (covered by medical aid) can get a walk-in injection at a public site, but people who are not insured cannot go to a private site unless they are over 80," she says.

She refers to the policy document, issued on 4 June by the Director-General of Health stating that vaccination site managers can accept walk-ins at their own discretion, but that people with appointments should be given priority.

It also states that the private sector sites may accept walk-ins with medical aid and that persons without medical aid should be referred to public sector sites, unless they are over the age of 80, as the National Department of Health will not pay for uninsured persons getting vaccinated at private sector sites, with the exception of those over the age of 80

No such distinction is made for public sector sites, she says.

"All people should be allowed to go to a private or public site whether or not they have received an appointment," Alexander says. She says that the cost of transport to sites has also been an issue, and stresses the need for more public sector vaccination sites. "We have found many cases where poor people cannot get to a site because of the cost of transport... it (government) must work with others to provide transport to sites for those who require this," she adds.

Alexander is also concerned about the registration process, excluding poor or non-English speaking people. "The registration system requires a phone, which many older people don't have if they are poor, and it requires knowledge of English," she says.

EVDS: 'impractical, inefficient'

Clinical pharmacist and health and medical law consultant, Shafrudeen Amod remarks about the vaccine rollout, "It's a maddeningly slow pace."

Because of the slow pace of vaccinations, Amod warns against excluding walk-ins at vaccination sites.

"Those walk-ins may never register on the EVDS," he says. "We should have had two parallel systems running. We're living in a country that is in-between a third and a first world, so we are going to have to make allowance for walk-ins," he explains.

Amod is also critical of the EVDS system, particularly since the over 60-year-old population needs to use it. "The EVDS system is impractical, its inefficient... for me the system must match the target population. We are putting a complex internet-based or web-based system in place for the over 60s," he says.

He explains that many people over 60 cannot access or utilise the system properly, and it would make more sense to use an existing database that already reaches people in that age group, namely the South African Social Security Agency (SASSA).

"You've got to simplify the system in order to increase the uptake... we need to find a strategy with regard to COVID that works, and a strategy that is easily adopted by the public," he adds.

Some sites cope better than others

For Somaroo, the rollout has improved since 17 May, but is vulnerable because when it started, not all the vaccination sites or plans were at "a 100% capacity". Another issue, she says, was that some vaccination sites could handle the logistics of the rollout better than others.

"It really depends on the site you're talking about. I think in some contexts they were able to plan and be more responsive to manage high numbers of scheduled patients and walk-ins and have an approach of how they were going to do that and also communicate widely so that people are aware," she explains.

Other sites are still improving as the rollout progresses. "I think a lot of them are improving as they go along, I think many may have not had the capacity, but there has been a lot of support that has been offered by the different levels of government and also by departments and different partners that support the government as well," says Somaroo.

She says it's important to be monitoring the rollout carefully and responding quickly to issues as they arise. "Monitoring of the rollout is important, we should [monitor] which of these sites is actually performing better and we should learn from approaches there to see whether these lessons could be implemented at the sites that are not performing as well," she adds.

Impact of the Johnson & Johnson vaccine delay

Another bottleneck in the vaccine rollout has been concerns that a batch of Johnson & Johnson vaccines manufactured at an Emergent BioSolutions plant in the United States, failed to meet quality control standards. The US Food and Drug Administration (FDA) is currently investigating, and depending on their findings, doses of the Johnson & Johnson vaccine allocated to South Africa may be affected.

According to Somaroo, the delay caused by the FDA's investigation can impact the rollout.

"The rollout is definitely vulnerable to delays in supplies of the vaccine. If these delays continue, it will definitely result in a delay in the rollout," she says. "Hopefully it is released soon, and the rollout continues unaffected and improving. If the doses are released, it will have a positive effect in that we can continue as planned," she adds.

For Amod the delay, regardless of whether or not the batch is cleared, will have implications for the rollout. "The delay, as justified as it is, is going to have huge implications, particularly in light of us finding ourselves in a protracted and very stunted third wave," Amod says. "The implications are that we're in the middle of a third wave, that could have been tempered a little bit, and there will an impending fourth wave now," he adds. The delay will also affect confidence in the safety of the Johnson & Johnson vaccine, Amod says, and will stall the rollout because people are skeptical of that particular batch.

The Health Ministry until now has communicated plans and progress in the vaccine rollout by stressing that all plans depend on vaccine supply. But some people have been questioning if there will be enough people at vaccination sites to ensure that vaccines are used expeditiously.

More sites, less bureaucracy

According to Venter, more sites need to be made available and more work must be done on weekends.

"We need more sites and less bureaucracy," he adds.

For Amod, the rollout needs to be revised urgently. "It's very simple, we need to go back to the drawing board, we need to revise," he says. "We need to make it a more consultative process... get more academics involved, get more academic institutions involved, get more private enterprises, and private enterprise healthcare involved," he says. "If we don't do that as a matter of urgency, we're going to fail dismally. We've got to come back with an intensified program that is strategic and targeted," he says.

But according to Somaroo, it is important to stick to the rollout plan and monitor where goals are not being met, and respond quickly to issues so sites can improve their performance and reach optimal vaccination rates.

"We just need to stick to what the plans are and make sure we are able to implement it as best we can and where there are gaps, we need to be responding very quickly," she says. "For me, that we have actually managed to plan and implement a vaccine rollout is something that should be commended. It's the largest vaccine rollout we and the rest of the world have ever planned. The fact that we've put systems in place quickly to get to the rollout is a success in itself," she adds.

Spotlight requested comment from the national Department of Health on the concerns raised but did not receive a response by time of publication.

Crisp, however, provided an update on the rollout plans during an interview on eNCA on Tuesday.

When asked why fewer vaccines were administered over weekends, Crisp explained reasons, including that the staff needs a break and that there is not an unlimited budget available for paying overtime over weekends.

He added that the current vaccine pipeline would not be able to handle it.

"We just don't have a vaccine pipeline that can sustain more vaccines than they are administering at the moment. At the moment we are pretty much operating at capacity with the vaccines moving down the supply chain at a speed that allows us to keep at least ten days' worth of vaccines in that supply chain at one time so that we don't run out along the way," he explained.

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