South Africa’s COVID-19 vaccine roll-out – a dream deferred?

 

A Johnson & Johnson vaccine against the COVID-19 at the Klerksdorp Hospital, as South Africa proceeds with its inoculation campaign on February 18, 2021. Photo: Phill Magakoe/AFP

On Tuesday 13 April, Health Minister Dr Zwelini Mkhize announced the suspension of the Johnson & Johnson (J&J) vaccine roll-out to healthcare workers over fears of blood clotting. The decision comes after the Food and Drug Administration (FDA) in the United States suspended its use of the vaccine and J&J’s delay in further shipments.  Over 1.5 million South Africans have been infected with COVID-19 and the variant B1.351, causing the loss of over 53 000 lives. After an incredibly difficult year for South Africans, the arrival of the COVID-19 vaccine roll-out brings new hope for life returning to some degree of normality. The pandemic has highlighted the socio-economic and healthcare inequalities found across South African communities. Effectively administering the COVID-19 vaccines will be vital in the quest to halt further socio-economic decline and give South Africans a brighter outlook for 2021.

Despite facing serious challenges in Personal Protective Equipment (PPE) and oxygen availability, and overwhelming hospital admissions, South African healthcare workers must be commended for their efforts in combatting the virus thus far. Their efforts have translated to a recovery rate of about 95% among COVID-19 patients. It is hoped that the vaccine roll-out will begin easing pressure on our healthcare system, because there are many other important healthcare crises that need our healthcare workers’ attention.

Progress for Phase 1

Source: Department of Health, 15 April 2021. *Announced on 24 March 2021

South Africa was the first country on the African continent to receive the AstraZenca COVID-19 vaccine in February. Since then, Minister Mkhize presented a three-phase plan to inoculate healthcare workers, essential workers, vulnerable groups, and the public. The first phase of the vaccine roll-out runs in conjunction with the Sisonke Study, which is a clinical trial of the single-dose J&J COVID-19 vaccine. The clinical trial allows the government to make the J&J vaccine available to healthcare workers while it processes the licensing of the vaccine. The target set for the Sisonke trail is to vaccinate 500,000 healthcare workers.

Since vaccinations began in February, about 292,623 healthcare workers have received their dose. This slow rate of inoculation has raised concerns. The daily vaccination rate is too low to meet the proposed target of 1.25 million healthcare workers by 17 May. However, at the current rate we will only vaccinate just over 500,000 healthcare workers. When President Cyril Ramaphosa addressed the nation before the Easter weekend, he indicated that the government were on track to complete healthcare worker vaccinations within three months. However, there is confusion as to whether he is referring to the Sisonke trial or the 1.25 million targets. In Minister Mkhize’s cabinet statement, he refers to 1.5 million healthcare workers, whereas on the National Institute for Communicable Diseases (NICD) website, the number is 1.2 million healthcare workers. That would leave around 650,000 healthcare workers remaining, to be carried over to Phase 2, placing an additional burden on the roll-out process. Strengthening our primary healthcare infrastructure is vital if we are to vaccinate 67% (~41 million people) of South Africa’s population.

Source: Department of Health, Government Communications 2021

Reflections from healthcare workers

In an attempt to ascertain the vaccine roll-out’s progress, we interviewed some healthcare workers – doctors, administrative staff and biokineticists. Experiences varied and were mostly positive. The electronic vaccination data system (EVDS) was complimented for its ease of use in both registering and booking their vaccine appointments. In some cases, doctors were turned away if doses had run out before the end of the day, requiring them to reschedule for another day. When queuing for their vaccination, social distancing protocols were not strictly followed, which were a concern for those we spoke to. They all described having the expected post-vaccination symptoms for 48-72 hours.

A repeated concern raised was the hesitancy among some healthcare workers to register for vaccination. There are myths and misinformation circulating amongst communities about the safety of the vaccine. If healthcare workers are hesitant, rallying citizens to register could be a challenge. The government has released a ‘myths and facts’ page addressing some of this misinformation. The government implemented mask-wearing campaign is a good example of a positive initiative adopted by the public and private sector. Continued communication from government and civil society to remote communities is equally important to build positive vaccine sentiment.

Minister Mkhize has also proposed a post market surveillance system study to ensure medical authorities closely monitor the deployment of both J&J and Pfizer.

Three phase roll-out strategy – the devil is in the detail

Phase 1 roll-out facts and challenges

The first phase of the government’s roll-out plan proposed 18 centralised sites which have now expanded to 58.  During the expansion there was confusion around certain sites being listed as open but were in fact closed and vice versa. For a venue to be utilised as a vaccination site, the South African Medical Research Council (SAMRC), the Department of Health (DoH), Desmond Tutu Health Foundation, Centre for Aids Programme of Research (CAPRISA) and Janssen Pharmaceuticals must be consulted. This makes the coordination of opening a vaccination site somewhat complex. The process of approving venues creates a bottleneck. The sites need constant updating on the EVDS where registration occurs. There is little information yet on how the government plans to overcome this process when Phase 2 begins next month, which could add to the already strained roll-out process.

Phase 2 roll-out plans

The government plans on increasing the number of vaccination sites to 1,750 and they will range between small, medium and large sites. Small sites will likely be community clinics or pharmacies and general practitioner offices. Medium sites include hospitals, medical centres and retail locations that may be fixed or temporary. Large sites are venues such as stadiums and conference centres.

A massive scale-up effort is needed for site approval if they are to reach this target and vaccinate up to 300,000 people a day. To reach that number per day we will need to mobilise at least 6,250 vaccinators (per day) and they’ll need to do 48 inoculations a day. If South Africa enters a third wave it could mean that some sites would have to de-escalate vaccination efforts to open facilities for COVID-19 testing, slowing down the roll-out further.

Vaccine procurement

Source: Department of Health 2021

Before the end of April, an additional one million doses of J&J are expected to arrive, after which two tranches of 900,000 doses will arrive in May and June. 31 million J&J (single dose) and 30 million Pfizer (two dose) vaccines have been secured by the DoH. Just under two million Pfizer doses are expected to arrive in May. In total South Africa is expected to have 46 million full vaccine doses, which should be sufficient to cover the necessary 40 million needed to obtain herd immunity.

The J&J vaccine will be particularly important for the roll-out in rural areas and remote communities. The J&J vaccine is easier to store, with only a single dose and can be frozen and kept for up two years (refer to the table below). Its efficacy against the B1.351 variant is 95% and is very effective in preventing severe disease or death associated with COVID-19. Unopened vials can be kept for up to three months at fridge temperatures of between 2˚C and 8˚C. If they are drawn into syringes, they will need to be administered within six hours.

Source: Department of Health, National Institute of Communicable Diseases 2021

The Pfizer vaccine on the other hand requires colder storage -20˚C for up to 14 days, and 2-8˚C up to 5 days, with two doses required and can be frozen for up to 6 months (refer to table below). The second dose should be administered between 21-42 days after the first dose.  As yet there is no substantial clinical evidence that the Pfizer vaccine protects against the B1.351 variant. A recent study concluded that the B1.351 variant was, to some degree, able to break through’s the Pfizer vaccine’s protection. The government will need to confirm veracity of this study before administering the vaccine. Coordination amongst pharmacists, vaccinators, researchers, and medical administration staff is vital to ensure jabs are not wasted, so as to avoid any impediments to the roll-out process.

Supply chain governance

Proposals for storage and distribution of the vaccine will be done on an open-tender basis. The Biologicals and Vaccines Institute of Southern Africa (Biovac) and the SAMRC have helped distribute the J&J vaccine but the government is yet to announce who will distribute the Pfizer vaccine. Minister Mkhize has said the department have identified storage capacity across the country but no further details on where these facilities are located.

When vaccines reach their destination, they will need to be signed off by a pharmacist on delivery. The World Health Organization (WHO) recommends at least one pharmacist for every 2,300 people, in South Africa we have one for every 3,837 people. The distribution of pharmacists across provinces is not equal and may pose a problem when delivery is made to areas without these specialists. Measures should be implemented to ensure the adequate placement of pharmacists across provinces is finalised so as to mitigate challenges that may arise.

Local vaccine manufacturing

The government has partnered with Biovac, Aspen and ImmunityBio to develop localised manufacturing of a COVID-19 vaccine that will offer long duration immunity against multiple variants of COVID-19. President Ramaphosa has called for the continent to use its existing skills and capacity to manufacture its own vaccines. Rwanda’s President Paul Kagame said that “vaccine equity” cannot be guaranteed by “goodwill alone” and that Africa should produce its own vaccines and pharmaceuticals products. The COVID-19 pandemic presents an opportunity for African countries to collaborate and promote continental (and local) innovation within the pharmaceutical industry.

Recommendations

  • Government to continue sharing relevant information learnt from Phase 1 to grow public trust and confidence in the vaccination roll-out process.
  • Finalise the sites and required number of healthcare workers to be placed to administer vaccines per site.
  • Formulate measures to overcome potential internet connectivity concerns for vaccine registration.
  • Finalise registration process for undocumented migrants without passports or identification documents.
  • Government to continue sharing the vaccination roll-out progress.

[1] Current population estimate for South Africa is 59.6 million according to StatsSA data from 2020.

Dr Craig Moffat is Head of Programme: Governance Delivery and Impact at Good Governance Africa.
Monique Bennett is a senior researcher at Good Governance Africa. She has a keen interest in data science, data visualisation and statistics using the R programming language. Throughout her studies, research topics such as development, democracy and the environment within the context of developing countries have been her focus areas.

The COVID-19 pandemic a year on

Lessons and the way forward

On 5 March 2021, South Africa reached an important milestone: 100 000 vaccinations were administered to healthcare workers. Exactly a year to the day after South Africa recorded its first case of the coronavirus, it is a bittersweet triumph, but in these uncertain times, a triumph nonetheless.

Thus far, official figures confirm more than 1.5 million cases of COVID-19, and over 50,000 deaths. Unofficially, the number of true infections may exceed 10 million. A recent South African Medical Research Council report states a more realistic number of COVID-19 deaths may be closer to 130 000. While we may never know the true figures, citizens hope that the government will formulate and implement measures which will strengthen South Africa’s national coronavirus response.

The arrival of several lifesaving vaccines into the pandemic space has been seen as a timely miracle. Some estimates conclude that without the vaccines, the pandemic threatens to take more than 150 million lives globally. However, what has also become apparent is that expecting vaccines alone to rid us of the pandemic may be a mistake. Scientists have predicted the coronavirus may remain with us for several years to come, so finding a solution to the pandemic will require a global collective effort.

To date, more than 320 million doses of various coronavirus vaccines have been administered in over 118 countries worldwide. The latest rate was roughly 8.25 million doses a day on average. This achievement is humanity’s silver living in this dark, uncertain period brought on by the COVID-19 pandemic. Unfortunately, with most silver linings, there are grumbling dark clouds waiting to roll in and exploit any laxity. This is particularly true regarding our national-level South African coronavirus response.

To adequately address and take heed of lessons learned over the last year, it is important to take stock of where the global and national coronavirus response stands. When COVID-19 first struck, governments were caught by surprise. Now it is imperative to formulate policies that pre-emptively plan the way forward. Moving into the vaccination phase of the fight against the pandemic, certain factors must be taken into account and prioritised so as not to lose any positive momentum going forward. It is clear from the literature that we should expect to have some degree of COVID-19 in our lives in the future. The following items should therefore be considered and prioritised in policy formulation going forward, so as to reinforce our collective national response fight against the pandemic:

Current Situation and State of Affairs

  • Global Vaccination: will it be possible to vaccinate all of the almost 8 billion people on earth, or a large enough portion of that population, in time to avoid the formations of variant strains? Aside from the developed world, the majority of the developing world has yet to start its vaccination programmes. If they are not vaccinated in time, will they be hosts for new strains of the virus?
  • New viral variants: While vaccines are making the coronavirus less infectious, and are protecting people against death, the advent of new viral variants is a concern.  The South African, Brazilian (P1) and Kent (UK) strains vary in their transmissibility. Of concern is the discovery that these new strains have shown they are up to 70% more infectious than the standard strain.
  • Vaccine refusal: South Africa plans to vaccinate 67% of the population against the coronavirus before the end of 2021, a figure of roughly 40 million people. But a recent global survey highlighted that only 53% of South African respondents stated that they would agree to be vaccinated. South Africa is lagging far behind the global curve, not only in the acquisition of vaccines, but more importantly in perceptions around the effectiveness and safety of immunisations. These concerns must be alleviated if our vaccine rollout and efforts to curb the pandemic are to be successful.

Mixed Messages

At the end of February, Health Minister Zweli Mkhize stated the country aims to vaccinate around 1.1 million people against COVID-19 by the end of March.  However, earlier this week the Deputy Director General at the Department of Health, Dr Anban Pillay, stated Phase 2 of South Africa’s COVID-19 vaccine rollout could begin at the end of April or early May. Also this past week, however, Deputy Health Minister Joe Phaahla raised some concern when he alluded to the fact that there are not enough vaccines currently available to meet the demands of Phase 1.

Additionally, almost three months ago, certain government officials were lecturing South Africans to the effect that vaccines are no “silver bullet”, which was irresponsible, as South Africa must prioritise inoculating as many people as possible to curb the threat and challenges experienced over the past year.

In normal circumstances, a month or so may not make a big difference, but given the unpredictability of the fast-mutating COVID-19 strains, even a few days could cost the lives of many more South Africans. These mixed messages exacerbate the already high levels of mental stress brought on by the pandemic.

A World Health Organization (WHO) survey has found that the pandemic is creating an increasing demand for mental health services, triggered by bereavement, isolation, loss of income and fear. Measures should be implemented to ensure mixed messaging is limited, so as to not burden an already stressed healthcare system battling with growing social ills brought on by the pandemic, such as family breakdown, alcohol abuse and a rise in alcohol-related deaths.

South Africa’s COVID-19 vaccine roll-out plan. National Department of Health

Vaccine Rollout

While we should celebrate having already vaccinated over 100 000 healthcare workers, it would be remiss of me to fail to highlight concerns about the vaccination rate.  At present, the daily roll-out rate sits at about 6250 doses per day (between 17 Feb and 5 March). Meeting the initially proposed target of 1.25 million doses by the end of March is highly unlikely.  If the target is to be met, it would require averaging at least 44 230 doses of the vaccine every day over the next 26 days.

Encouragingly, during President Cyril Ramaphosa’s address on 28 February, he stated that all provinces have established vaccination sites and have put in place plans for the expansion of the programme going forward. He also stated the number of sites that will be available for vaccination will be expanded from 17 to 49. Of these 49, 32 will be located in public hospitals and 17 in private hospitals. This should provide both optimism and a sense of relief that the number of vaccines administered should increase dramatically going forward.

Vaccine Supply

During President Ramaphosa’s 28 February address he specified the following regarding the procurement and supply of vaccines:

  • An additional 80,000 doses of the Johnson & Johnson vaccine were scheduled to arrive in the country which will (hopefully) steadily increase the number of doses administered each day.
  • An agreement was signed with Johnson & Johnson to secure 11 million doses. Of these doses, 2.8 million doses will be delivered in the second quarter and the rest spread throughout the year.
  • 20 million doses were secured from Pfizer, which will be delivered from the second quarter.
  • 12 million doses were secured from the COVAX facility, with government finalising South Africa’s dose allocation from the African Union.

He also assured the nation: “We are in constant contact with various other vaccine manufacturers to ensure that we have the necessary quantities of vaccines when we need them.”

Potential Third Wave

 The Health Minister recently explained there was no clear model for predicting exactly when South Africa may experience a third wave of COVID-19 infections, but there are strong indications it could take place in late April or early May. Several analysts have predicted it may occur during the Easter break where there will be large numbers of the population traveling and attending events.
Some actuaries have calculated a third wave will occur if followed by super-spreader events, coupled with reinfections during the Easter period. Such a combination could increase expected deaths in South Africa to 92 500.

It is important to remember and reiterate that society’s behaviour is the key determining factor in whether policy measures for curbing the pandemic will be successful or not.

Herd Immunity

  • In the worst case, we do not actively perform physical distancing or enact other measures such as mask-wearing and hand sanitising to slow the spread of the coronavirus. The virus will continue to infect thousands more people in a matter of a few months. This will result in our hospitals being overwhelmed and lead to high death rates.
  • In the best case, we maintain current levels of infection – or even reduce these levels – until the South African vaccine rollout is accessible to all.
  • The most likely case is somewhere in the middle, where infection rates rise and fall over time; we may relax social distancing measures when numbers of infections fall, and then may need to re-implement these measures as numbers increase again. This calls for a more pre-emptive approach from government. While waiting for the vaccine to be more inclusive of the population, children could be infected before they can be vaccinated, or adults may be infected after their immunity wanes. However, the silver lining is that it is unlikely in the long term that the virus will have the explosive spread we have become accustomed to, because much of the population will be immune in the future.
  • Also, in tandem with South Africa’s COVID-19 national response, it is necessary that the neighbouring countries also attain some degree of herd immunity. If not, we may expect an influx of infections to continue streaming in from across the borders.

A Brave New Corona World

Even once vaccination targets are achieved, life as we knew it may not return to the normal we were accustomed to and took for granted.  Medical advances are seeing the tweaking of vaccines to provide a more all-encompassing protection. These tweaks may provide further protection against the arrival of new variants. In a perfect world, according to The Economist: “the best outcome would be for a combination of acquired immunity, regular booster jabs of tweaked vaccines and a menu of therapies to ensure that COVID-19 need rarely be life-threatening. But that outcome is not guaranteed.”

But as we have seen throughout our COVID-19 journey, medicine alone may not be able to prevent lethal outbreaks of the pandemic. Thus, to complement the medical advances, responsible social behaviour becomes that much more important. Individuals and communities must embrace a future that may necessitate continued mask wearing, washing of hands and sanitising as the norm for our daily existence. Other possible measures being considered by several countries is the need for vaccine passports and mandatory restrictions in crowded spaces. Vulnerable people will have to maintain great vigilance in order to avoid becoming infected.

To this end, it is apparent that the new phase of addressing the COVID-19 pandemic will require all governments to procure and administer vaccines in a timely manner to achieve some level of herd immunity. Trust deficits brought on by mixed messaging and the harsh consequences of sometimes poorly formulated lockdowns must be redressed. As argued by Professor Geo Quinot: “Thus, apart from the constitutional values of good public governance, which require high levels of transparency, such transparency in government’s vaccination programme is essential for the very success of the programme, since without transparency there cannot be public trust.” And without public trust, responsible social behaviour will wane, jeopardising our efforts for a successful national coronavirus response.

Dr Craig Moffat is Head of Programme: Governance Delivery and Impact at Good Governance Africa.

The largest immunisation drive: Is Africa ready?  

One of the largest immunisation drives in Africa’s history is about to commence and African governments must urgently ramp up their readiness, both on the front end with the administration of the vaccine as well as on the back end with supply chain and distribution logistics.  

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South African President Cyril Ramaphosa is inoculated with a COVID-19 vaccine shot at the Khayelitsha Hospital in Cape Town on February 17, 2021. Photo: Bianluigi Guercia/Pool/AFP via Getty Images

The economic impacts of COVID-19 are threatening to undo years of economic progress in Africa, with the worst recession expected in close on 25 years. Health systems in Africa are particularly overstretched, and the social measures (lockdown) to limit transmission are placing a heavy socioeconomic burden on vulnerable populations in particular. Is the vaccine the way out? Only if readiness can be rapidly and universally ramped up. 

According to a World Health Organization (WHO) analysis, Africa is not ready for COVID-19 vaccine distribution as indicated by the Vaccine Readiness Assessment Tool received by all 47 countries in the WHO African Region.  

The development of a safe and effective vaccine is merely the first step in a successful rollout. According to the COVAX facility, only 49 percent of African countries studied have identified the priority populations for vaccination and have plans in place to reach them44 percent have coordination structures in place24 percent have adequate plans for resources and funding; with little data collection and monitoring tools in place and insufficient plans for effective communication in order to build trust within the communities. 

Historically, Africa has largely been a passive recipient of vaccines developed and tested elsewhere. However with the emergence of the COVID-19 pandemic, African researchers and experts have played an active role in the study of the virus and in clinical trials of the approved vaccines. The major motivation for COVID-19 vaccines being evaluated at an early stage in South Africa was to generate evidence in the African context for how well these vaccines work 

Efficacy and side effects 

Normally, vaccines require many years of design, testing and additional time to produce to scale. Vaccine development begins with basic laboratory studies on the virus and its interaction with body cells. The results inform pre-clinical studies in which the vaccine is tested on animals and its safety recorded. Reaction of the animal’s body cells are documented and inform the four phases of clinical trials in humans. The South African COVID-19 vaccine trials commenced in June 2020, ranging from 4 sites to 31 sites, primarily with a four phased approach. Some of the trials revealed the following notable findings 

On the one hand, the Novavax Vaccine appeared to work well on the COVID-19 virus, however was not as effective on the B.1.351 variant against which the vaccine’s efficacy was evaluated in South AfricaAn early analysis in Britain found that the twodose vaccine had an efficacy rate of nearly 90 percent. But in a small South African trial, the efficacy rate dropped to 49.4 percentearly signs therefore indicate that the vaccine is not as effective against the fast-spreading South African variant as it is against the ordinary strain. 

On the other hand, the Pfizer-BioNTech and Moderna vaccines use advanced technology based on RNA and require storage at -70 and -20 degrees Celsius respectively. That makes their distribution and storage a logistical challengeespecially in countries without the requisite storage facilities. The Pfizer-BioNTech vaccine is not particularly suited to African contexts, as infrastructure problems make it impossible to store the vaccine at the required temperatures 

Over and above the vaccine’s efficacy, close attention needs to be channelled to the side effects of the vaccine, particularly for individuals with comorbiditiesTypical vaccination reactions have been reported after administration of the BioNTech-Pfizer, Moderna, AstraZeneca and the Sputnik V vaccines. During the Novavax trial in South Africa, which found the vaccine to have a 49.4 percent efficacy overall, the company reported that about 6 percent of the trial’s participants were positive for HIV, and for those who were not HIV positive, the vaccine had a 60 percent efficacy. 

Herd immunity 

Vaccination can help achieve herd immunity if a critical mass of people are vaccinated (and maintain immunity)According to estimates, herd immunity for COVID-19 will be achieved when more than 60% of the population is vaccinatedTo achieve the goal of vaccinating at least 60% of the population, Africa will need approximately 1.5 billion vaccine doses which at current estimates could cost between US$ 8 billion and US$ 16 billion – excluding the additional 15 to 20 percent cost for injection materials and the delivery of vaccines. In South Africa, the target is to vaccinate 67% of the population by the end of the year (as many as 40 million people) to achieve herd immunity. South Africa has recently acquired only one million of the approximately 80 million doses needed to achieve the set target of herd immunity (for the vaccine requiring two shots for optimal effectiveness) 

Getting adequate vaccine supplies is not the only challenge governments face. Anti-vaccine sentiment is a problem in several Western countries that have started the roll-out. In Norway, for example, it was reported that 33 deaths of frail and elderly were related to the of administration of the Pfizer and BioNTech vaccineAn Ipsos poll published in November 2020 found that 46 percent of French adults said they would refuse to receive a COVID-19 vaccine. In some African countries, this appears to be much less of a problem. A survey by CDC Africa and the London School of Hygiene and Tropical Medicine found that 79 percent of people in 15 African countries would be vaccinated if the jab was found to be safe and effective. 

Some middle-income countries and most low-income countries face the risk of being left behind in the immunisation drive. The Economist Intelligence Unit has predicted that while rich countries will have access to proven vaccines by mid-March 2021, poorer countries may only achieve meaningful vaccine coverage by 2023. This inequality has negative implications for economic recovery in poorer countries, exacerbating the risk of economic regression.  

Improving Africa’s preparedness  

To maintain goodwill towards vaccination and ensure its efficacy, it is essential not only that all African countries be involved in vaccine trials, but that African governments address their existing challenges. Critical issues that could impede African countries’ preparedness for equitable delivery of the highly anticipated vaccines include funding gaps, weak health systems, poor supply chain infrastructure and undefined eligibility and prioritisation criteria to ensure that the most vulnerable populations receive access as soon as possible. 

Individual country level efforts should be focused on both the front end and back end preparedness for the COVID-19 vaccine. This includes the determination of eligibility criteria; administration of the vaccine by skilled and trained healthcare workers; the development of robust supply chain and distribution logistics; tracking of immunisation results and documenting of side effects and finally the availability and sustainability of the vaccine in the long run. 

Africa must continue its concerted efforts to jointly respond to the pandemic – including development, production and distribution of a COVID-19 vaccine. African governments are encouraged to be more efficient in the allocation of resources during this time, not only focusing and channelling resources to vaccine supply and distribution but also ensuring that minimal socioeconomic disruption occurs in order to avoid future poverty-related impacts of potentially ill-informed or arbitrarily imposed lockdowns. For example, non-pharmaceutical interventions (in the form of lockdowns) should be subjected to the same kind of rigour as pharmaceutical interventions (vaccines) 

African governments would be well advised to reassess some COVID-19 intervention policies like policing lockdowns that require large amounts of state resources. Allocating a portion of these resources towards resuscitating the strained socioeconomic environment may provide more optimal results. Moreover, addressing the backlog of HIV and TB testing, and building a concerted effort to reduce non-communicable diseases, may prove more effective in the long-run than lockdowns in reducing excess deaths from COVID-19. While the vaccine may be the resolution to the global health crises, the food security crises that have been exacerbated by the pandemic still needs to be addressed, particularly in developing countries. 

It is apparent that the vaccine ‘alone’ is not the way out for Africa. Rather, a combination of good governance of resources and proactive COVID-19 intervention policies enabling the recovery of the socioeconomic environment are also crucial factors for Africa’s way out of the crisis.  

Christine Dube is the Lead Researcher of our Governance Insights and Analytics programme. She completed her Bachelor of Social Sciences degree in Industrial, Organisational and Labour Studies in 2011, her Honours in Commerce in 2012, and her Master of Commerce at the University of KwaZulu-Natal in 2013. Her experience includes risk analysis, finance, administration as well as marketing and sales. Her interests include monitoring economic and social developments.

SADC COVID-19 Pandemic – An Opportunity to Strengthen Governance

To many in the research community, Africa remains an anomaly, as it has experienced less of the coronavirus burden than many other regions in the world. According to the Africa Centre for Disease Control (AU CDC), as of 27 January 2021, at least 40 countries are experiencing a second wave of the pandemic, including all countries in the SADC region. As of 2 February 2021, the confirmed number of Covid-19 cases from 55 African countries reached 3,582,328.

On the continent, South Africa is the outlier, with the highest percentage of recorded active cases of the coronavirus. Based on the available data, South Africa is the epicentre of the pandemic on the continent, and as such the South African Development Community (SADC) finds itself, by extension, in the same situation. SADC member states have experienced a spike in infection numbers attributed to the ‘second wave’ and secondly, to the more recently discovered new variant of the virus known as 501Y.V2. Up until now, more than 50% of all new daily infections of COVID-19 on the continent have been reported in the SADC region.

Factory workers check personal protective equipment for COVID-19 frontline health
workers at a factory commissioned by the government in Accra, Ghana, April 2020.
Photo: Nipah Dennis/AFP

South Africa’s discovery of the new variant has corresponded with a new surge in infection numbers. Researchers have claimed the new variant is around 50% more contagious, based on the much faster rate of COVID-19 transmission, as it appears the new variant structure enables easier attachment to and infection of human cells.

The alarming increase in new infections in the SADC in the first two weeks of January 2021 saw the total number of new confirmed COVID-19 cases surge to 346 010, accounting for about 22% of the total number of cases registered since the beginning of the pandemic in the region. Concerns are mounting that the higher percentage of regional infections are being driven in part by the new variant which, according to the AU CDC, has so far been reported in three SADC countries. With the faster rate of transmission, it is only a matter of time before other SADC countries record infections related to the new virus variant.

While the COVID-19 pandemic has hampered both social and economic activities in SADC countries to varying degrees, it has also had a detrimental impact on the governance capacity in the region. Since the end of 2020 and the start of 2021, SADC member states have lost ten cabinet Ministers from four countries who succumbed to the coronavirus:

Zimbabwe – Transport Minister Joel Matiza, Foreign Affairs Minister Sibusiso Moyo, State for Manicaland Provincial Affairs, Ellen Gwaradzimba and Minister of Lands, Agriculture and Rural Resettlement Perrance Shiri

Malawi – Transport Minister Sidik Mia and Local Government Minister Lingson Berekanyama

Eswatini – Prime Minister Ambrose Dlamini, Minister of Labour and Social Security Makhosi Vilakati and Minister of Public Service Christian Ntshangase

South Africa – Minister in the Presidency Jackson Mthembu

Unfortunately, unless there is a drastic change in the rate of transmission, it is anticipated the above list will grow as the variant takes hold in all SADC member states. As states remain the chief bearers of the responsibility to govern, there is an inherent expectation of them to provide and implement political, social and economic measures to service the expectations of their citizens. The onset of the COVID-19 pandemic has heightened this responsibility of the state apparatus, as the normal livelihoods of the citizens may have been disturbed. Thus, citizens have found themselves in a position where they must rely more on the state to formulate policies and provide means to mitigate the devastating effects of the pandemic on their livelihoods. Without a doubt, there is an expectation of the states to formulate and implement adequate policy interventions to address the negative impact of the pandemic, while still providing effective service delivery and maintaining good state-society relations. With a view to attaining these goals, more so in times of crisis, states should continue upholding the rule of law, respecting fundamental human rights and freedoms, be accountable and ensure inclusive and participatory democratic governance.

With the death of several SADC political leaders from Ministries that were tasked with dealing directly with providing goods and services to the society at large, it adds only to the already heavy burden of the state to provide for even the most basic needs of their citizens.

However, as the adage goes: ‘in crisis lies opportunity’. This may be the opportunity for SADC member states whose primary responsibility remains to govern, to reflect on lessons that have emerged from the COVID-19 pandemic. These lessons may require SADC leaders to be open to having deeper, difficult deliberations around the possibility of re-energising the role of the state in good governance practices in the region in particular, and the continent in general. The COVID-19 pandemic has exposed the limitations states have in adequately addressing emerging challenges such as a pandemic. States have to be more resourceful in developing sophisticated means to address the scourge of inadequate service delivery, which was heightened and on display during the course of the pandemic. If this threat is left to fester, it may increase instability which in turn impacts negatively on governance, peace and security on the continent.

An alarming underlying feature which emerged during the pandemic was the high occurrence and degree of lack of accountability and corruption in both the public and private sectors in the procurement of personal protective equipment (PPE) to curb and manage the threat posed by the pandemic, while undermining effective good governance practices. In the case of South Africa, it is unlawful for public servants to do business with the state, but there have been several high profile public servants accused of abusing their positions or proximity to power to exploit the emergency procurement regulations. This enabled some government officials and their families to rake in the millions through alleged corrupt deals with opportunistic companies that emerged suddenly and diversified into the PPE market. According to Tedros Ghebreyesus, the Director-General of the World Health Organization: “Any type of corruption is unacceptable. However, corruption related to PPE… for me it’s actually murder. Because if health workers work without PPE, we’re risking their lives. And that also risks the lives of the people they serve. So it’s criminal and it’s murder and it has to stop.”

Moving forward, there should be a change in approach in which the SADC as a region seeks to remedy the prevailing trust deficit. Regional leaders should endeavour to uphold the social contract through inclusive and participatory governance with the aim of positively delivering to the citizens. The COVID-19 pandemic demonstrated how the most vulnerable of the population, including women, children, youth and persons with disabilities carried more of the pandemic’s burden. The SADC member states should therefore seize this opportunity in this time of crisis to strengthen their capacity for achieving adequate service delivery, continued respect for human rights, upholding the rule of law, constitutionalism and transparency.

In a recent statement, President Filipe Jacinto Nyusi of Mozambique, in his position as the current SADC Chairperson, strongly encouraged the region to “build on the knowledge and experience achieved in mitigating this pandemic and continue to adopt common and harmonised policies, guidelines, strategies and measures in response to the pandemic.” Let us hope that he is true to his call and the SADC will not miss this opportunity to strengthen its good governance principles. It is imperative going forward that best practices and lessons learnt during the COVID-19 pandemic are formulated into policies and implemented to benefit the citizens of the region.

This article also appeared in the Cape ARGUS.

Craig Moffat, PhD is the Head of Programme: Governance Delivery and Impact for Good Governance Africa’s National Security Programme. He has more than 17 years of practical experience working for government institutions and multilateral organisations. He was previously employed by the South African Foreign Service, where he worked extensively at identifying and analysing security threats towards South Africa as well as the southern Africa region. Previously, he was the political advisor for the Pretoria Regional Delegation of the International Committee of the Red Cross. He holds a PhD in Political Science from Stellenbosch University.

The impact of South Africa’s governance response to COVID-19

City of Tshwane Health officials are seen during a testing drive for COVID-19 at the Bloed Street Mall in Pretoria Central Business District, on June 11, 2020. Photo: Phill Magakoe/AFP

When COVID-19 first struck, South African policymakers reacted promptly and implemented one of the world’s strictest lockdowns for five consecutive weeks. Despite that, and slow release of the restrictions thereafter, the curve of infection rates has taken shape independently of economic lockdown interventions. By all accounts, those interventions have produced extensive opportunity costs and unintended negative consequences. But with infection rates on the rise, policymakers are confronted with having to make difficult decisions yet again 

The initial decision in March 2020 to impose a hard lockdown was relatively well received, but the subsequent formulation and implementation of regulations under the National Disaster Act has been haphazard at best. Perhaps the most stark manifestation of the economic impact is reflected in a R300bn shortfall in expected tax revenue. This amounts to nearly 30 percent of South Africa’s annual budget of over R1 trillion.    

Key questions pertaining to COVID-19 governance responses also remain unanswered: Were the regulations pertaining to lockdown levels consistently implementedor were they arbitrary and disproportionately unfair to the poor? Was lockdown warranted? Until these questions are addressed, policymakers may continue to devise and implement strategies with high opportunity costs and unintended negative consequences. For instance, HIV and TB testing rates have decreased during the last few months, raising the risk of more immune-compromised citizens dying than would otherwise have been the case, even as COVID-19 continues to spread.

Malnutrition has increased in the wake of deepening poverty, further compromising immune system health. In addition, thousands of children have missed their vaccinations as parents face increasingly stark choices between earning daily bread and taking their children to a local clinic. A resultant measles outbreak would result in far higher excess deaths than what COVID-19 has inflicted.    

A critical dimension of these questions is how much freedom (and future health) citizens should be expected to sacrifice for the greater good, in the context of a pandemic. Logical criteria have to be formulated by which trade-offs are made to produce the least-worst long-run outcome. Only once these are established is public adherence to regulations likely to occur in good faith. Consistent, transparent and equitable interventions establish trust; autocratic and arbitrary impositions break trust, rendering interventions invariably counter-productive.   

In this respect, it is important to think of COVID-19 not as a single global pandemic, but as a simultaneous outbreak of innumerable local epidemics, each one slightly different. Context-specific understanding of local dynamics really matters. Infectious disease outbreaks unfold differently in different communities, according to social conditions that only local people understand. A densely populated township has a different infection rate trajectory to a middle-class suburba villagea refugee camp or community of nomadic people. Therefore, it is particularly important for local communities to be fully involved in planning and implementing epidemic control measures.  

Asia, Europe and North America all adopted much of the same epidemic control policy – some form of ‘lockdown’. African governments followed suite, but it is not clear that lockdowns were appropriate for our contextsIn South Africa, for instance, our deep societal inequalities – a function of our apartheid past – seem to not have been sufficiently considered. Social distancing is impractical for people sharing communal water and sanitation facilities, or living in high-density townships. Moreover, these are the same citizens whose livelihoods are made even more precarious by economic restrictions.

For most black communities, with people living from hand to mouth and reliant on earning cash in the market to buy food, a few days of lockdown can be the difference between survival and starvation. The measures taken to prevent the spread of the coronavirus exposed a wide range of systemic problems right across the continent, from water shortages to overcrowding to a lack of sanitation. 

The largest impact of the pandemic was and still is felt by informal workers, through lockdown measures that limited or prevented them from working. The problem for informal traders starts with their means of travel to and from their working stations, as they rely heavily on public transport. The first people to experience police brutality from the lockdown imposition were informal workers. Enforcing these restrictions presents a significant challenge for the police: ethically, should they have rigidly enforced social distancing and other measures, or should they have been more cognisant and considerate of the local context? 

The impact of lockdown regulations on the informal sector is just one example that raises the more significantbroader question of whether the government sufficiently considered the foreseeable economic and social consequences of its lockdown decisions. On a macro level, South Africa started the year with the economy in a technical recession, after the fourth quarter of 2019 saw a 1.8% quarterly decline on the back of a preceding 0.8% quarterly decline. GDP dropped by a massive 16.4% between the first and second quarter of 2020, and 5.2 million workers exited the workforce.  

During an economic crisis, small businesses are the most vulnerable to collapse, as they have fewer resources with which to adapt to a changing context. The ITC COVID-19 Business Impact Surveyconducted from 21 April to 2 June 2020revealed that in Africa two out of three businesses were negatively affected by COVID-1975% of respondents reported reduced sales and 54% had difficulty accessing inputs. While some service companies (i.e. software and internet based) have managed to thrive during the course of the pandemic, others have been hard hit. In hospitality and food services, 76% of surveyed firms said partial and full lockdown strongly affected their business operations.  

In relation to the key questions pertaining to COVID-19 governance, the jury is still out on whether lockdown slowed the spread of the virus, while evidence is clear that it had a disproportionately detrimental economic impact on the poor and marginalised, who have no reserve cash flows to sustain themselves.  

Ultimately, South Africa needs further fundamental reforms to achieve more robust and inclusive growth. Policies need to support marginalised communities through improved quality of education, health, transportation and an enabling business environmentIn short, this requires improved governance at every level, something which the COVID-19 lockdown appears to have simply eroded  

This article was first published in Business Day here

Sixolile Ngqwala is Data Analyst in GGA’s Governance Insights and Analysis department and holds a Masters of Commerce (MCom) in economics from the University of Fort Hare, where he was involved with the National Income Dynamics Study (NIDS) in econometric research (econometric modelling, data coding, data mining, data analysis and interpretation). He has a BCom Hon in economics, and an undergraduate degree in Business Management and Industrial Psychology.
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