Simple but urgent steps needed to end vaccine inequality involving South Africa’s elderly
If we fail to halt discrimination now it will work its way through to younger age groups. Of course, there are costs, relatively small, involved with public education, moving away from monolingualism, and getting vaccines to the people or people to the vaccines. But, these are funds that would have to be found at some point if we are to reach anything close to ‘herd immunity’.
On 26 June, acting minister of health, Mmamoloko Kubayi-Ngubane, expressed concern that “demand [for vaccination] from the 60+ age group is reducing exponentially.” She added: “we understand that this manifestation is a combination of high vaccine hesitancy in this group and difficulty accessing the technology to register, as well as the vaccination centres.”
At present, there is a huge disparity in levels of vaccination among poorer people and the middle classes, and we demonstrate that in order to raise the overall level of vaccination we must address this inequality. The challenge is principally one of delivery by the government rather than demand from the people. Evidence comes from the government’s own Electronic Vaccination Data System (EVDS), the UJ/HSRC Covid Democracy Survey and the University of Johannesburg’s (UJ’s) Rapid Community Action Research, conducted by ourselves and cited by the acting minister.
What does the EVDS show?
First, as the acting minister said, there has been a decline in the rate of vaccination of senior citizens. However, secondly, the level of vaccination has been exceedingly uneven between insured and uninsured people; that is, between those who are better-off and pay for medical aid, and those who are generally poorer. As shown in a presentation dated 21 June, the proportion of the insured population which had been vaccinated was 48% and the proportion of the uninsured population which had been vaccinated was 26%.
While the President is comfortable talking about global vaccine apartheid, we also have vaccine apartheid at home, and that is something he could fix.
According to the large UJ/HSRC survey, completed in early January 2021, about 67% of adults either definitely or probably wanted to get the vaccine (‘acceptance’) and only 18% definitely or probably did not want the vaccine (‘hesitance’). The other 15% were “don’t knows”).
A new round of the UJ/HSRC survey is currently underway, and the results will be valuable (*To complete the survey click here). However, more recent surveys show an even higher level of acceptance (though with smaller samples and slightly different questions), and drawing on experience from other countries, there is no reason to believe that an upward trend in acceptance will be reversed.
According to EVDS statistics, about 50% of the total 60+ population has been registered, so it is reasonable to assume there is some scope for improving the general level of registration.
In the survey, the level of acceptance increased with age, so the acting minister’s emphasis on high vaccine hesitancy in this particular age group is probably mistaken. We also found higher levels of vaccine acceptance among black Africans than among other ‘races’ and higher levels among those on lower incomes (less than R5,000 per month) than those on higher incomes.
Thus, while better-off people are much more likely to be vaccinated than poorer people, the pattern is reversed when it comes to data for acceptance. This underlines the extent of vaccine inequality.
According to EVDS, only about 30% of senior citizens have been vaccinated, that is, two out of five people who have registered have not been vaccinated. Thus, getting people to vaccination sites is critical.
Returning to the contrast between the insured and uninsured populations, the figures were, respectively, 65% and 45% for registrations and, as mentioned, 48% and 26% for vaccinations. So the main problem is getting uninsured people registered and then vaccinated. Insured people are much less of a challenge.
Vaccinating the uninsured assumes even greater importance when we consider their numerical preponderance. According to the 2019 General Household Survey, only 17% of the population is covered by medical aid, and that number may have declined. The vast majority of the population is uninsured.
Important questions to ask and solve
So, why have less than half the uninsured 60+ group been registered, and why have only about a quarter been vaccinated? While registration and vaccination rates are considerably higher among the insured, their level of hesitancy is also greater, so the hesitancy/acceptance issue is, at most, a minor part of the explanation.
Here we turn to qualitative data present in our community action research. With this research, the methodology involves locating problems in a particular community and then finding practical solutions, either locally or through policy initiatives. Along the way, lessons are learnt and conclusions reached.
Having undertaken work in Protea South (an informal settlement south of Johannesburg), we then moved to five villages around Lephalale (Limpopo) followed by four mixed settlements in eastern KwaZulu-Natal. These are all places where a large majority of the population is impoverished. The research involves taking a ‘deep dive’, as the acting minister put it, unlike survey research, which can provide a broad overview.
There was certainly evidence of hesitancy. Some of this can be described as ‘hard hesitancy’, which is more or less political and draws on ‘fake news’ (including some translated into isiZulu we found). Most of it, though, is ‘soft hesitancy’, expressed in the form of uncertainty, of not knowing enough about vaccines. Regrettably, the government has done far too little to counter misinformation, educate the public and explain policy. In this regard, there were complaints from sangomas in Gauteng, councillors in Limpopo and community leaders in KZN.
The problem is partly about lack of advertising, absence of content in mass media, shortage of educational materials, and dependence on social media.
One is often told there is a shortage of funds, with this sometimes blamed on the Digital Vibes scandal. However, even where communications would cost virtually nothing, such as keeping councillors informed about details of the roll-out, there can be bureaucratic obstacles hindering cooperation between departments. So, even hesitancy should be seen, at least in part, as a failure of government.
Moreover, the language for communication is predominantly English, whether it is ‘family meetings’, social media and even the few posters that do appear, and this has racial, class and age implications.
Difficulties of registration for over-60s
There are also fundamental difficulties with the registration system. In 2019, only 63% of households had at least one member with access to the internet, so a high proportion of old people are excluded from the benefits of digital technology. 96% of households had at least one functional cell phone of some kind, and while registration through the EVDS call centre eventually leads to a friendly, multi-lingual assistant, it is first necessary to penetrate layers of English-language jargon.
Another possibility is to register with pen and paper, perhaps with help from a community health worker, but the process is laborious and information can be misread when transferred to a computer.
The whole system lacks empathy for the large majority who do not have English as a mother tongue and may not be able to understand it all, especially in its written form. Further, there are still many complaints that people who registered have not received an appointment — a challenge that poorer and wealthier people appear to have in common.
Fortunately, there is a simple solution to closing the gap between ‘registration’ and ‘vaccination’. For the 60+ group, registration should be undertaken at vaccination sites and immediately followed by vaccination, that is, ‘walk-ins’. This approach is now backed by the government, yet we still come across people waiting for appointments. We are not arguing that advance registration should be scrapped for the under-60s, because Covid-19 infection, especially the Delta variant, could spread rapidly if sites are congested.
The rollout programme institutionalises class discrimination. Up until 24 June, 20% of doses had been delivered through the private sector (Clicks etc.). This figure is greater than the 17% of people who are insured. More significantly, while uninsured senior citizens cannot be vaccinated at private sites (unless they are 80+), those who are insured can be vaccinated at public sites, and lots have done so, possibly as many as half.
The government now wants uninsured people to have access to private sites, a welcome move, but we have yet to see this publicised.
From our research, it is likely that a substantial factor holding back vaccination, and perhaps the most important source of socio-economic inequality, is transport. For older people with a car, it has, from the beginning, been quite easy to get a vaccine (even without an appointment). One simply drives around searching for a relatively short queue at a site that accepts walk-ins. For those without a car, the reality is very different.
If walking to a site is not a possibility, the alternative is usually a taxi. For people in Protea South, this meant two taxis each way and R42 for the round trip. If a site has used its supply of vaccines for the day, there is no chance of simply driving to another site.
A choice had to be made: bread and milk for the family or a vaccination? In Protea South, the former was coming out on top. Some of the villages outside Lephalale were nearly 50km from the nearest site, and, again, old people were deciding not to vaccinate.
We should remember that most people in South Africa rely on public transport. According to the 2019 household survey, only 24% of people used their ‘own transport’ when going to the health facility they normally use, with the rest mainly dependent on walking and taxis.
Once again, poorer people are disadvantaged.
We were heartened when the acting minister followed her reference to our research by echoing our call to ‘get the vaccines to the people.’ Now we need to monitor the situation and ensure that rhetoric becomes reality.
The top priority is to make greater use of mobile teams, which can vaccinate people in community halls, churches, schools, clinics and tents in places like Protea South and Lephalale. In the UK, Canada and India, so-called ‘pop-up’ vaccination clinics, a similar concept to our mobile teams, have proved popular. In South Africa, the most successful provinces have been KZN (top for overall coverage and second for uninsured coverage) and Limpopo (second for overall coverage and top for uninsured coverage) and both have deployed mobile teams.
Second best, but still an improvement, is ‘get people to the vaccines’. In some areas, Uber has helped out. Surely the government can work with taxi associations to secure their assistance, and why not use school buses when they are not in use? It is likely that some seniors who own cars would be willing to volunteer when they have received their second shot — it just takes some coordination.
Of course, there are costs, relatively small, involved with public education, moving away from monolingualism, and getting vaccines to the people or people to the vaccines, but, these are funds that would have to be found at some point if we are to reach anything close to ‘herd immunity’. Better we fork out now and maximise the vaccination rate in the age group most susceptible to hospitalisation and death, and better to focus on people living in dense informal settlements where infection can spread more rapidly both locally and then, via work, to others in society.
If we fail to halt discrimination now it will work its way through to younger age groups. Poorer people have a right to equal access to vaccines and ‘getting vaccines to the people’ makes good sense in limiting the overall level of suffering from Covid-19.
There have been fine words from the acting minister, but can she deliver? DM/MC
The authors are grateful to the National Research Foundation and National Institute of Humanities and Social Sciences for supporting their research.
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