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Equitable roll-out of Covid-19 vaccines is critical to programme’s success

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Bongiwe Ndondo is Executive Director of the Hlanganisa Institute for Development in Southern Africa.

Every country has unique challenges when it comes to ensuring that Covid-19 vaccines achieve maximum effect, and South Africa is no different. We have our own challenges that need to be faced to achieve vaccine equity.

The conclusion of the deal that will see South Africa secure its share of the Covid-19 vaccine on the global market is a significant step forward in efforts to protect South Africans from the pandemic. 

But as South Africa prepares to roll out its vaccination programme, much remains unclear about how it will reach the populace. The government has prioritised healthcare workers and other frontline staff, consistent with approaches adopted by other countries. But how will a wider roll-out work in practice?

In South Africa, the epidemic has been severe (543 deaths per million compared with neighbours Namibia, 96; Lesotho, 35; Zimbabwe, 30; Eswatini, 233; Mozambique, six; and Botswana, 20). 

Bedeviled by inequality, a broken health system and rampant corruption, there is much to think about now in order to deliver the vaccination programme in a fair, just and efficient manner. In setting about this, we should learn from our past experience as well as the experiences of other countries.

There are four critical principles that should guide our approach:

Equitable access

The vaccine should be made available to all who need it, based on an equitable process. This will be no easy task. The gross inequality in our society has meant that access to public health and education has largely been determined and shaped by socioeconomic status.

The public healthcare system is weak and inadequate, often to the detriment of those who rely on it. Those who can afford to do so will obtain these services through the private healthcare system – in this instance, through medical insurances and service provider networks at costs prohibitive to many South Africans. 

If the government does not address this, the resultant health disparities will continue to impact mortality rates along the lines of class and, unfortunately, race.

Communication drive to build citizen trust

Many myths and conspiracies are circulating about the virus, the vaccine and the intent. This has resulted in widespread skepticism among citizens: an obstacle to their embracing the vaccine as the lifesaving measure it is meant to be.

In most regions, vaccination programmes have been widely accepted as safe, well intended and offering beneficial medical outcomes. However, in a December 2020 poll conducted in 15 countries by market research firm Ipsos, only 53% of South African respondents said they would be willing to take the vaccine. This, compared with 80% in China, 78% in Brazil and 69% in the US, which arguably has one of the more sceptical administrations. 

Despite this, we have not seen much effort on the part of government to ensure that citizens receive accurate information in a manner which addresses their concerns and builds trust.

Preservation of the healthcare system

The vaccination programme must be administered without collapsing the healthcare system. Now, more than ever, we need a strong and robust healthcare system as we mitigate the impact of the second wave of the pandemic. 

In South Africa, it is estimated that there are only 1.3 nurses per 1,000 people. South Africa must be innovative about how it reaches the masses who are dependent on the public healthcare system if it is to avoid putting strain on other health programmes such as maternal and child health, HIV, tuberculosis and a rising epidemic of chronic diseases.

What is needed? The first step is to consider what other community resources and infrastructure can be leveraged to achieve this mammoth task. 

At the height of its Covid-19 outbreak, China set up street booths and cubicles to increase testing coverage, enabling it to test and isolate 9 million people over two weeks. In the 1980s, countries like Zimbabwe achieved over 85% child immunisation coverage (higher than most countries in the subregion) through a combination of primary healthcare facilities and village health workers. During the Ebola crisis in central and west Africa, community- and faith-based organisations, as well as humanitarian agencies such as the Red Cross, were instrumental in delivering and coordinating the ring vaccination approach that had been adopted. 

Could these approaches be appropriate for our vaccination programme?

Accountability and resourcing

Although the cost of a Covid-19 vaccine dose has been estimated at between $4 and $33, studies have shown that the non-vaccine costs of vaccination programmes are in the region of 50% of the total costs. Non-vaccine costs include training staff, social mobilisation, transport and other overheads.

The two urgent questions arising for us are whether National Treasury will allocate these funds timeously and whether the authorities will ensure the money is not plundered by public officials, as happened with earlier Covid-19 relief funds. 

Fortunately, the approved vaccine does not require complex refrigeration protocols. However, the logistical challenges of getting the vaccine to remote areas could still hinder access.

For some time now, countries like Rwanda have used drones to deliver critical medical supplies. In South Africa, schools have been used as an entry point for the human papillomavirus vaccination programme targeting young girls – with greater efficiency and effectiveness. 

What lesson can we draw from these approaches? 

In conclusion, South Africa needs to think innovatively about what entry points are available in communities, and whether these can be used for the vaccination programme. 

We must consider, for instance, what role business and workplaces could play in the vaccination of employees. 

A study conducted in Cape Town found that outsourcing vaccine logistics to the private sector reduced delivery and inventory costs, improved adherence to temperature threshold and other handling practices, and reduced delays. What role could the private sector play in the vaccine roll-out?

At Hlanganisa Institute for Development in Southern Africa, we work with community-based organisations operating across the country. Community organisations could arguably be part of the roll-out plan.

In addition, we need to consider which healthcare staff could be assigned this urgent task. The HIV epidemic saw extensive task-sharing between clinicians and allied health staff, including community health workers, with overwhelming success. 

With an acute shortage of nurses, who traditionally administer vaccines, and the urgent need to reach more than 40 million people (based on the WHO estimate of 70% coverage to obtain herd immunity), there is an urgent need to consider what approach South Africa will take to ensure that having made huge investments in obtaining the vaccine, we do not end up with a failed vaccination programme. DM

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