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The Health Justice Initiative (HJI) has raised the issue of access to a safe, effective and affordable vaccine/s for both the public and private sector in our country and the Global South, calling also for an equitable allocation of a vaccine in our country, for several months.

This is because, by about mid-2020, reports indicated that there would be a shortage of vaccines in the Global South, in part due to limited supplies and global “scarcity” fuelled by the stockpiling by wealthier nations and the invocation and applicability of intellectual property (and patent) rules in a pandemic. 

We encouraged the government and the private health sector to adopt a single access and equitable allocation plan, to ensure that, in this pandemic, everyone, everywhere who needs a vaccine can access it. Where access is not based on wealth or medical insurance benefits. This is important for social solidarity and is in line with calls from health advocates in other parts of the Global South. It will lend itself to achieving herd immunity hopefully in our country and region. Public health principles also require that herd immunity can be achieved only by widespread access to vaccines. We are all protected when everyone is protected and non-infective.

In November 2020, because we were concerned about the lack of communication from those entrusted with and responsible for this function by law, we formally began correspondence with the Disaster Management Centre (DMC), Cogta and the Minister of Health, copying in various officials including the MAC Vaccine Advisory Committee Chairperson. 

Since then, we have sent three letters requesting a detailed response to several questions. We indicated that we were worried about the government’s readiness in relation to the access and allocation of Covid-19 vaccines. Our concerns were predicated on:

1. South Africa’s ability to access vaccines — once developed — in light of the predicted pricing, global shortage and high demand which may even require rationing. 
2. The determination of an equitable allocation of such vaccines within South Africa in light of the dual nature of our unequal health system and the vast disparities in access to the right to healthcare. 
3. An incomplete medicine pricing and patent framework where local laws that could benefit vaccine access, affordable pricing and equitable allocation, have not yet been passed.

We drew their attention to the fact that the DMC is accordingly the body mandated by statute to ensure South Africa has a coordinated and effective strategy to respond to a disaster. The affordable, equitable and transparent access to vaccines within the context of Covid-19 falls squarely within this mandate. Accordingly, the National Centre (DMC) and all relevant institutional role players responsible for managing this disaster are responsible for the development of disaster management plans and strategies for the affordability and allocation of vaccines.

To date, only the DMC has replied, indicating (incorrectly, in our view) that the function of the national vaccine strategy is located solely in the NDoH. We are yet to receive a formal response from the NDoH and Cogta, despite being promised one from the NDoH (Office of the DG) several times in late 2020. 

This unprecedented crisis also requires (by law) all relevant ministries and departments and especially the National Treasury, Department of Science and Innovation and Department of Trade Industry and Competition to work with all stakeholders. 

Nevertheless, on 3 January 2021, finally, the government broke its silence and indicated to the nation the status of various vaccine negotiations and its attempt/s to access limited supplies in a global pandemic, including through Covax. 

The Minister acknowledged that the nation is anxious and in need of information given the devastating impact Covid-19 is having on our country and especially on our health system. He should prioritise weekly briefings so that we and the media do not have to piece together time-sensitive information in this pandemic. Regular communication is necessary so that all sectors can play a part in meaningfully addressing this pandemic. This will help in part to address mistrust and vaccine hesitancy too, that is worryingly growing in our country. 

We welcome the commitment to implement a single access and equitable allocation plan for both the public and private health sectors in our country. This type of social solidarity, which involves all medical schemes and the business and private health sectors, is unprecedented and should be recognised as such. In our view, it is appropriate and rational for a pandemic and a crisis such as the one we are facing.

This will also ensure that those with medical insurance do not needlessly and without good cause get to the front of the queue, and that the vaccine is allocated on a proper, evidence and clinical need basis, an underlying equity principle which is universally endorsed. Medical schemes also include lower-income and public sector workers through schemes set up for state healthcare workers, state teachers, and the police, as well as other public servants — GEMS and Polmed, respectively. Members of Parliament (MPs) are also covered by Parmed, for example. 

Following the presentation, the previously unshared “MAC Advisories on Vaccines” was uploaded on the NDoH website. By 17 September 2020 the MAC on Vaccines stated: “…wealthy countries have secured over $2-billion doses in deals… South Africa has also been approached by vaccine manufacturers to consider bilateral purchasing agreements. The risk of this agreement is that price negotiations are confidential, upfront payments may be lost should the vaccine not prove safe and efficacious, and South Africa will be limited to only a few vaccines through this mechanism and run the risk of not having a vaccine if these few candidates are not successfully licensed.” 

Many rich nations, including our trade partners, and Brazil (a BRICS partner) as well as the global pharmaceutical industry, are opposing the waiver request and refusing to share vaccine know-how, inexplicably still not regarded as a global public good. 

The MAC further advised that Covax was only likely to cover about 3% of (presumably Global South/poorer) countries’ populations (including SA) due to limited supplies; but that Covax could potentially give SA access to nine possible vaccine candidates (through the “option 1” agreement); and that the possible forfeit of South Africa’s down payment could be up to 20% if a vaccine candidate did not come to market; and that Covax would charge about $10.55 — $22.10 (ex-factory), excluding delivery and logistical costs for Covax-accessed vaccines. 

The MAC also recommended that government exercise due diligence in confirming any arrangements with Covax (the Covax contract was received on 15 September 2020 and the MAC stated that SA and other countries would have little decision-making power with Covax); that the NDoH should negotiate funding from medical schemes, National Treasury and the Solidarity Fund and that “bilateral discussions should continue”. 

On 15 December 2020 it issued three advisories. These refer to the status of global vaccine research and research gaps, especially for people with comorbidities and pregnant women. Annexure A sets out the “Framework for Rational Allocation” according to the MAC, for limited supplies contexts, relying on WHO SAGE principles. It also indicates that standard operating procedures “are being drafted for the rollout programme and highlights the urgent need to put in place a multisectoral communications strategy”. The last page of Annexure A includes the proposed allocation and distribution percentages per priority group for South Africa. 

Apart from serious gender inclusion shortcomings in the composition of some of the task teams such as the SA Vaccine Acquisition Task Team, it is unclear if representatives/members of Polmed and GEMS will also be included, where the contribution of medical schemes itself is being addressed and finalised. It is imperative that healthcare workers and those on the frontline have a seat at the table and on these teams, especially for the proposed national vaccination rollout phases. Efforts have to be made to consult more broadly and urgently with healthcare workers and those in the frontline at hospitals and clinics. 

There is little to no meaningful inclusion and involvement of community organisations, faith groups, social movements, worker formations and civil society organisations in these discussions and/or task teams nor, it seems, on the proposed National Vaccine Coordinating Committee. This must be remedied as a matter of urgency as the vaccination rollout programme, once it starts, will require all sectors to contribute to its expansion and success.

Our greatest concern now lies in the fact that our country has actually secured very little access to vaccine supplies (so far, 1.5 million dosages for healthcare workers). This is in part due to inexplicably delayed planning on the part of the government and also due to self-created scarcity leading to ongoing global shortages fuelled by intellectual property and patent protections of pharmaceutical companies and hoarding or stockpiling by richer nations. 

We do not believe that pharmaceutical companies are justified in enforcing non-disclosure agreements in a pandemic; they serve no public or constitutional interest. They are also contributing to distrust and a lack of transparency. Several companies are releasing press statements and the like regarding often unverified “offers” for South Africa, meaning that they themselves are going outside of and possibly breaching any non-disclosure agreement that they may have demanded in these discussions. 

We were also surprised that the briefing and presentation did not mention ours and the Indian government’s TRIPS Waiver Request and ongoing adversarial negotiations at the WTO in Geneva, led by the DTIC. The proposed TRIPS waiver is for some poorer countries, and potentially for us too, the only hope for quicker access to a vaccine and other interventions to manage and treat Covid-19 — because it seeks a temporary waiver of certain intellectual property rules for products and technologies related to Covid-19. It could also enable greater manufacturing capacity in the global south and especially in Africa. It is important that the government shares details about these negotiations because it goes to the heart of limited global supplies, the power of richer nations and that of pharmaceutical companies in this pandemic. We cannot offer support on this important proposal in the absence of any or timely information. 

Many rich nations, including our trade partners, and Brazil (a BRICS partner) as well as the global pharmaceutical industry, are opposing the waiver request and refusing to share vaccine know-how, inexplicably still not regarded as a global public good. 

Thus, both Covax and bilateral negotiations will not speedily guarantee us sufficient supplies. Yet despite this, the government is not, to our knowledge, seeking state-use licensing while it pursues the waiver request. We are unsure why not. 

If the South African public is expected to foot the balance of the bill for Covax, for limited supplies in the next few months, as things stand, we have no recourse against the secrecy underpinning Covax and its supplier agreements. We note from the presentation and subsequent reports that the NDoH and the MAC have been and are in ongoing discussions with potential vaccine suppliers… government needs to advise the public how it will ensure that a low profit or no profit “offer” is verified to be such, and confirm that the offer is indefinite, not conditional for just a “few months” or to “end 2021” and has reference to international benchmarking, pricing/offer transparency and even domestic price regulation.

We also remain concerned that the global scarcity of vaccine supplies may lead to price-gouging or excessive pricing — we therefore urge the Competition Commission to evaluate and assess all vaccine pricing claims to ensure price transparency in this pandemic, proactively and pre-emptively.

The HJI will provide further commentary on the proposed vaccination rollout programme for South Africa as details emerge, but the criteria for vulnerable populations or prioritised populations requires urgent consensus and engagement with the public, and key health and other experts. 

We are in a pandemic. This is no time for quiet diplomacy and long or drawn-out negotiations — our people are getting sick and dying, our health system is under strain and pharmaceutical companies are refusing to share vaccine know-how and technology, even though some vaccines were researched here, and several vaccine candidates benefited from global public investment and philanthropic and institutional research support, running into billions of US dollars.

We therefore need decisive state action, and proper planning and plans so that we can have a genuine People’s Vaccine (a call that our president has led and endorsed). 

We also strongly recommend that government urgently revamps the MAC Vaccine Advisory Committee/s, appoints additional expert committees and members that prioritise the voice of all communities and especially frontline workers, and brings on several multisectoral advisers and negotiators, as a matter of urgency.

Distrust is not going to help us move forward. DM/MC

The Health Justice Initiative is a public health and law initiative focusing on Covid-19, drawing on the expertise of multi-disciplinary researchers in law, economics and public health, as well as universities and experts in and outside South Africa.