First published by GroundUp.

Geffen is GroundUp’s editor. Low is Spotlight’s editor. Both used to direct policy at the Treatment Action Campaign. 

Starting now, hundreds of thousands of Covid-19 vaccines will be arriving in South Africa weekly. Rather than spending energy and resources policing who gets them, we should be focusing on getting the vaccines as fast as possible into willing arms.

Yes, those most in need should be vaccinated soonest: elderly people, health workers treating Covid patients (who by now should all have been vaccinated), people with diabetes, asthma, cancer, HIV or hypertension. But let’s not be strict with that.

If a healthy 25-year-old takes the initiative to get vaccinated, let’s describe her as vaccine-keen, not a queue-jumper. (She may have elderly parents or be a party-goer; let’s help her not to spread the virus.)

For months, the Sisonke trial — government’s backdoor route to vaccinate health workers while waiting for the bureaucracy for vaccine registration to be done, and for vaccines to arrive — stuttered along. Then, in the final week of the programme, those running the trial cleverly and boldly widened the definition of health worker.

It was just the shot in the arm the programme needed, with long, eager queues and much excitement. Even so, on the best day of the final week, between 25,000-30,000 vaccines were administered. At that rate, it would take more than two years to vaccinate 20 million people. We have to do many more daily than this.

Here’s what we think needs to happen:

Don’t try to control it

The health department must resist the urge to micromanage the programme. It should not seek to control who gets vaccinated when, nor insist on too many prerequisites, like unnecessary training, or on too much patient information.

Instead, the health authorities ought to do the opposite: let go. Here, the incentive of each rational adult precisely matches the public goal: get vaccinated as quickly as possible once (for the Johnson & Johnson one) or twice (for the Pfizer one). There are no perverse incentives. So let’s not create any.

This means allowing GPs, rural clinics and pharmacies to get as many vaccines as they ask for, to allow them to distribute as they see fit. They’re good at this. They do it every year for flu. They’ll figure out how to do it for Covid, and they’ll reach large parts of the country that the health department won’t.

And the fear that this will favour those who have private medical insurance (about 16-18% of the population) or the better-resourced, is misplaced, for health facilities in rural and less-resourced urban settings should get unbarred access too.

We should make sure every care home and every homeless shelter can readily get vaccines (plus an appropriately qualified health worker or two to administer them).

We should let public and private clinics run their vaccine programmes as they see fit — just make sure they get the vaccines.

We should set up vaccine desks at the front of the queue for those collecting old-age and disability grants (though care should be taken for those who have to travel far because some people do experience rough side-effects for a day or so).

In townships, we should send health department vans door-to-door to offer vaccines to all adults.

We should set up vaccine desks at taxi ranks, even shopping malls.

In a few days, prisons could probably vaccinate about 180,000 people (including prisoners and staff); give them vaccines now.

Logistically, the Johnson & Johnson single-shot vaccine is a lot easier. We should try to ensure that institutions with less capacity or more vulnerable patients get them.

The two-shot, cold-chain sensitive Pfizer vaccine should be prioritised for tertiary hospitals, private hospitals, big pharmacy groups, and GPs who manage well-to-do patients. For them, it will be easier to get the second shot.

It’s not even essential to record the details of people who get vaccinated (unless as part of a study). Every bit of unnecessary bureaucracy delays the rollout.

Let’s not make it difficult for the vaccine-keen. Don’t insist on IDs; they’re useful for data purposes, but never deny a vaccine to someone who doesn’t have identification.

Also, patients should get a short pamphlet warning of side effects. And, with the Pfizer vaccine, the pamphlet should urge them to return for their booster shot. (The patient information sheet used in the Sisonke trial is fine. Crib it.)

Most emphatically, don’t ask about resident or cross-border status — as with our antiretroviral programme for those with HIV, the virus truly doesn’t care.

Don’t fret if the person at the front of the queue is a 25-year-old, perfectly healthy marathon runner instead of a 95-year-old with advanced diabetes — though of course, some sites should have reserved or priority queues for older people. It may also be a good idea for some sites to serve older people and people with comorbidities for most of the day and then open their queues to any adult in the late afternoon.

Let’s get rid of the voucher system; it’s no longer needed.

Those distributing vaccines should also be careful not to turn their sites into settings for super-spreader events. This will be tricky in winter — outdoor spaces are hard in cold weather. But it remains vital to insist on physical distancing and masks. The vaccines all need weeks to fully kick in. People should not be exposed to Covid when they’re trying to protect themselves.

Don’t commodify the vaccine

A great danger for South Africa is that we will create an illicit market for stolen or fake vaccines. The health department can avoid this by not turning vaccines into saleable market items.

If money must be exchanged for vaccines to ease the state’s financial problems, it must be only between the big players.

At facility/pharmacy/care home/GP level the vaccines must be free. (The vaccine rollout is not an opportunity for “empowerment” deals, bogus or real.)

Perhaps, so that there’s an incentive for pharmacies to rollout, a small administration or labour fee can be charged.

Expect problems

We must expect teething problems. Sites will run out of vaccines, or not receive them. Physical distancing measures may teeter. Occasionally, a blood clot death may be reported.

Let’s not panic. Let’s fix the problems and ignore the noise.

Let the vaccine rollout begin! Viva the vaccine-keen! DM