Covid-19 Vaccines, Health regulations, Monkeypox, Operations backlog; with Ministry

Meeting report

Status of COVID19 and COVID Vaccines

Dr Nicolas Crisp, DDG: National Health Insurance (NHI), Department of Health (DOH), took the Committee through the presentation providing a status update on Covid19 and vaccines. The Department continued to target 70% of the adult population vaccinated against Covid. Challenges include the limited demand for vaccines despite the coverage of just over 50% amongst adults. Low demand was due to covid fatigue, vaccine hesitancy and barriers to accessing vaccines. Strategies for improving demand:

-Providing COVID-19 vaccination through routine health services

-Supplemented by outreach services in schools, congregate settings, workplaces, and areas with low coverage with a focus on priority districts

-Ongoing demand generation with an emphasis on social mobilisation – working with local community-based organisations

-Strengthen use of data to identify areas of low coverage, and to respond appropriately.

Attempts have been made to terminate agreements with CF (Covax Facility) and J&J to avoid receipt of vaccines. Many attempts have been made to donate vaccine doses but:

-Many countries are donating so there is a glut of vaccine

-Most countries that would accept donations are unable to manage the Pfizer vaccine logistics

-Recipients of donated vaccines must also have a No-Fault Compensation scheme, but most poorer countries do not

-So AVAT, COVAX and ACDC are potential channels for donation

Vaccine safety and potency are tested regularly and so far, the vaccines are very stable in central storage conditions so extensions of expiry dates are possible. Destruction of expired vaccines is an absolute last resort.

The COVID-19 pandemic has settled for now but the virus has not gone away. People are still getting sick but not in large numbers and generally not as sick as before. Despite all the uncertainties and challenges, at least 50 % of all adults have received at least one vaccination. Vaccination (with repeated boosting doses) is still the most effective tool against COVID-19 infection. South Africa procured vaccines in a hostile global market and lives with the consequences of very one-sided contracts. Public demand for vaccination is extremely low now that the perceived threat is low so there are millions of excess doses of vaccines. Some of these vaccines are vulnerable to expiry despite increased knowledge of stability. The public is still advised to vaccinate and to get boosters every 120 days while the COVID-19 virus is still in circulation.

See presentation for further details

Update on public comments processing on health regulations

Dr Aquina Thulare, Technical Advisor on NHI, DOH, provided an update on the public comments received on the health regulations. As of the closing date on 5 August 2022, a total of 394 931 public comments have been received by the Department of Health. The finalisation of these regulations will be guided by the provisions of Section 90 (4) (a) and (b) of the National Health Act. Socio-Economic Impact Assessment Study (SEIAS) on the four sets of Regulations has been conducted and is awaiting final approval by the Department of Planning, Monitoring and Evaluation.

Monkey Pox in SA

Dr Crisp provided an update on monkeypox in SA. Since 22 June 2022 to date (21 September 2022), five unlinked laboratory-confirmed monkeypox cases have been reported in South Africa with no deaths. No new laboratory-confirmed case has been reported since the last case reported on 17 August 2022. The cases in South Africa were reported from Limpopo (n=1), Gauteng (n=2) and Western Cape (n=2). There have been no secondary cases linked to the five confirmed cases.

From 25 May to 21 September 2022, the National Institute for Communicable Diseases conducted 382 monkeypox laboratory tests (PCR) from individuals suspected of monkeypox disease within South Africa (n=268) and other African countries (n=114). This testing volume does not account for the testing conducted by private-sector laboratories. Full genetic sequencing for the first two cases reported (i.e., the first cases to be identified in Gauteng and Western Cape) was conducted. The viral genomes clustered in the B.1 lineage of the Western Africa clade with other viral genomes associated with cases of the current multi-country outbreak.

On 23 July 2022, the WHO Director-General declared this outbreak a public health emergency of international concern (PHEIC). It issued temporary recommendations for countries to stop transmission and contain the outbreak. Several actions have been undertaken to address the requirements imposed by the WHO and related to the PHEIC status of monkeypox. A national risk assessment and WHO-mediated gap analysis have been conducted, and a multi-sectoral action plan has been developed. Discussions are underway to determine the need for monkeypox vaccines and possible strategies for access to monkeypox vaccines. Steps have also been taken to improve surveillance through employing an active case finding approach in partnership with non-governmental organizations, and improved accessibility of testing aimed at the at risk population.

Backlog on elective surgery

Dr Nonhlanhla Makhanya, Acting DDG: Hospitals Tertiary, healthcare policy and planning and HRD, provided an update on the interventions regarding reducing elective surgery backlogs in hospitals in the country. Backlogs on elective surgery have been building up over the past two and a half years primarily due to the COVID-19 pandemic thus threatening quality of life for affected patients. There was a moratorium on all elective surgeries to accommodate the influx of patients due to COVID-19, which has already impacted the increased backlogs. The moratorium on elective surgeries was lifted in 2021, and a plan to accelerate backlogs was put in place and as measures to deal with emergency surgeries and electives concurrently. Disciplines presented are those that have been highly affected and have the highest numbers of backlogs. The total numbers of backlogs received from the province are for the period starting in June to August 2022. These are updated frequently to monitor the impact of all interventions.

There was a total backlog of 175 024 – see presentation for provincial breakdown and key surgical disciplines affected.

Interventions application to all provinces:

-Moratorium on elective surgery was lifted in 2021

-All emergencies are prioritised

-The hospitals have rescheduled all non-emergency operation

-Providing theatre services during the weekends and extended hours to reduce backlogs, includes increase in theatre times

-District outreach surgical teams provide services in most provinces

-Use of private hospitals theatres through a dedicated grant

-Patients are booked six months in advance according to capacity available and quality of life.

-The waiting list is constantly being reviewed and monthly monitoring of the waiting period

-Maximum utilisation of theatres with added slates on weekends

-Additional theatres utilised in some provinces

-Most provinces recruit specialists to increase output

See presentation for specific interventions per province 

Discussion
Ms A Gela (ANC) welcomed the NDOH presentation and was pleased to receive the updates. She asked about the number of vaccines due to expire in the next two months and the estimated value for these expired vaccines. On the Digital Vibes scandal, she wanted to know how many communication campaigns had been launched around the country on essential health information to curb the virus and how much had been spent on vaccine mobilisation.

Given the low demand for vaccines in the country, she asked if NDOH would still be obligated to pay and receive the outstanding J&J and Pfizer vaccines that have been ordered. On load shedding, she requested clarity on plans to curb its negative effects on essential health services. She asked NDOH to explain what actions had been taken to address the public health emergency of international concern (PHEIC) global requirements about monkeypox imposed through the World Health Organisation. She asked if they had a plan to produce or procure a vaccine for monkeypox. On the health regulations, she asked for their potential cost implications. Lastly, on the surgical backlogs, what was being done to increase the number of theatre nurses and how quickly could these positions be filled? In addition, she requested an update on the status of Charlotte Maxeke Hospital.

Ms E Wilson (DA) noted that the Committee no longer received Covid status updates regularly. She requested regular updates on current Covid cases and deaths. Citizens needed communication to be consistent because Covid was still an issue in the country as deaths from the virus were ongoing. According to NDOH, South Africa is no longer procuring vaccines, but we are paying for vaccines that we are not using and that we cannot offload to other countries because the rest of the world is not procuring as well. This was very alarming because it demonstrated the Department's lack of efficient planning. She wanted to know how it would mobilise the masses to take up the vaccine and booster shot.

On the health regulations, the Committee looked forward to reviewing the alterations. She expressed that the fact that the alterations would be published without consultation with the Committee was quite concerning. She was particularly concerned that the alterations would be in contravention of section 27 of the Constitution. On monkeypox, she asked if doctors were aware of the symptoms and if they understood how to treat the viral disease.

On surgical backlogs, she said that the situation was nothing short of horrific. The backlog was unacceptable because it compromised people’s access to healthcare, which had far-reaching implications. The situation would not only affect people’s health, but also affect people’s livelihoods and quality of life. If critical illnesses were not being treated with the immediate attention and emergency they demanded, NDOH was basically putting people through a death sentence. This was certainly in contravention of section 27 of the Constitution – the right to healthcare. South Africa has a serious shortage of surgeons, theatres badly supplied and deteriorating infrastructure in public hospitals. Surgeons from private hospitals who desire to assist in public facilities are afraid to do so because they do not want to subject themselves to medico-legal cases because of a lack of infrastructure.

Ms M Clarke (DA) requested that NDOH provide clarity on the cost of vaccines to be destroyed and the loan amount they took out to pay for the vaccines. She asked about the additional vaccine awareness programmes and if there were specific programmes targeted at the younger population. She wanted to know if local clinics were still being used as spaces to channel vaccine awareness to the wider population. She requested that the Special Investigating Unit (SIU) present a report to the Committee on the status of the individuals who defrauded the UIF of Covid-19 TERS funds.

She asked if investigations were being done to determine if there was any validity to the claims about vaccine side effects in younger people. Also, NDOH talked about programme upgrades, what were the specific programmes to receive these upgrades, was there an indication on the rate of immunity in the country and what plans did we have to respond to another Covid surge? How was NDOH engaging about the TB and HIV backlogs? Regarding the public comments on the health regulations, the Committee had requested an audit on the number of rejections that had been reportedly erased from the system. She reiterated the question about the level of awareness medical professionals had about monkeypox symptoms.

The statistics on backlogs presented in the report were completely skewed because there were far more backlogs than indicated in the presentation. These backlogs were due to several issues such as surgeons who are unable to get their operational needs met, the severe shortage of staff in hospitals, service providers who are unable to deliver necessities to hospitals because they are not being paid, outdated infrastructure, unskilled project managers and contractors to complete renovations, lack of proper planning in place to deal with load shedding in hospitals and job vacancies that take forever to be filled. Backlogs would remain a problem unless the appropriate interventions to mitigate these were enforced.

Ms M Sukers (ACDP) appreciated the presentation. She requested more information on the R7.6 billion World Bank loan taken to curb the spread of Covid, the loan terms and when it will be paid off, reasons the World Bank loan was better, what fees had been paid to third parties to secure and structure the loan and who the third parties were. In addition, what fees or penalties are being paid to original lenders to settle our debt? Strategic procurement has been an ongoing topic since Mr Zweli Mkhize was the Minister of Health.

Monkeypox was a health crisis but it appeared that politicians in the country were not giving the crisis any special attention. Instead, doctors on the ground were the ones prioritising the issue and inciting a public outcry. As a Committee of Parliament that has oversight over NDOH, it was important to remind it to effectively manage not just a part of their responsibilities but all their responsibilities. In addition to curbing the spread of Covid, it also had to tackle impeding healthcare services severely undermining every citizen’s right to access healthcare.

She implored the Minister to address all the urgent, pertinent and critical health issues otherwise it would appear that they were waiting for the National Health Insurance (NHI) to come into effect before they adequately deal with the healthcare crisis in South Africa. In her constituency, there had been a shortage of ambulances dating back to the previous year. She was told that if anyone over the age of 70 needed an ambulance, they would be added last to the list of emergency cases. These are constitutional challenges impeding people’s ability to realise their rights to healthcare.

On strategic procurement, NDOH systems are clearly not working because there were serious miscalculations in supply and demand and understanding behavioural economics of the country which the private sector are experts on. How was there an oversupply of vaccines whereas NDOH had experts who should have been able to make better estimations on the number of vaccines needed? On the spread of monkeypox, she asked if there were strategies currently in place for the purpose of messaging. No one is talking about the severity due to a lack of a communication strategy to make citizens aware of the viral disease. How is NDOH utilising their behavioural experts recruited during Covid and extending them to other health concerns and programmes like TB and HIV?

Mr P van Staden (FF+) commented on vaccine procurement that it did not seem that government had good business sense because it did not make sense to have an outstanding amount on a Covid contract which guaranteed the country 12 million doses but we only received 1.3 million doses. On the health regulations, he asked if the Minister would bring a final report on the regulations before the regulations were published. It was part of parliamentary oversight and, in all fairness, for the Committee, the public, and other stakeholders who submitted comments to get the final report before the regulations were published. He acknowledged that NDOH was still working on these submissions, but he hoped that they would provide an indication of how many people were in favour or not in favour of the draft regulations before the publication.

The surgery backlog numbers were frightening and they indicated that the crisis was not going to be resolved quickly. What steps were to be taken to deal with the backlogs and what was the proposed timeline to eradicate the backlogs? He was very disappointed that most provinces had responded by saying they had not set a timeframe to eradicate or resolve the setbacks which are alarming. Comprehensive plans are needed immediately because this could result in a life-or-death situation for so many patients. He implored NDOH to empathise with patients and attempt to understand what they were going through. He reiterated the comments on the misleading number of backlogs. The number of backlogs in provinces does not add up. Incorrect information was being conveyed to the Committee.

Ms H Ismail (DA) asked why NDOH had not learned from the initial purchase of AstraZeneca vaccines and their expiry date. NDOH could have taken important lessons from the millions of doses that had to be destroyed in March 2022. Why do we have to go through the same expiry issues again? She asked why no contingency plans were in place prior to the expiry date of the vaccines to ensure that vaccines would not be destroyed. This was going to cost taxpayers billions. Accountability tools were necessary to ensure that nothing like this happens again. She asked NDOH what they were going to do to ensure that the millions of Pfizer vaccines would not expire after the extension date allocated by the South African Health Products Regulatory Authority (SAHPRA). She requested clarity on what exactly had led to the country’s failure in its vaccination uptake, keeping in mind that anti-vaxxers could not be solely blamed for the lack of uptake.

During her visits to clinics and hospitals, she frequently asks the healthcare staff how they are dealing with Covid and from the responses, she receives there seems to be a general attitude of apathy toward Covid as many people believe that it is no longer something we should be concerned about. We can see that there are no longer any awareness programmes on the ground. How is the country expected to use millions of vaccines if there are no awareness programmes? She wanted to know the amount of money the expired vaccines had cost the country and what some of the mitigation and consequence management plans NDOH had considered enforcing.

She commented that the healthcare system is failing the citizens of the country and many issues must be dealt with when it comes to upgrading facilities, shortage of staff and equipment, and the allocation of community service doctors who are sitting at home waiting for placement. All the money wasted on the influx of vaccines could have been budgeted to solve these challenges. She requested NDOH provide updated information on the adverse effects following immunization, how many cases were reported and what was the severity of the cases. Also, how many people applied for the Compensation Fund, how many were rejected and approved? How many claims had been finalised and paid and how many claims had been delayed? Covid had major impacts on TB testing and treatment so how was NDOH going to address the shortcomings in TB testing and treatment throughout the country?

On 13 June 2022, the World Health Bank approved 454 million Euros to assist South Africa’s Covid-19 emergency response plan. The loan came following a request by the government for assistance in financing the procurement of vaccines. Government’s response to the Covid pandemic was marked by corruption and mismanagement of funds which cost people their lives. These failures included the R18 million Digital Vibes corruption scandal which implicated the former Minister of Health and the PPE corruption. All these were a serious indictment on NDOH.

Covid-19 vaccine procurement in South Africa and other African countries was on the back foot of developed countries in the race to secure adequate vaccine supply for their populations. Given the frequency with which diseases are being reported across the globe, she asked how effectively South Africa's disease surveillance and mitigation systems identify and contain these outbreaks before they reach our local population. On monkeypox, she asked if NDOH had a plan to procure vaccines if needed and how far the country was in developing our own vaccines. Ultimately, what were the lessons learnt from how we dealt with Covid and what were the plans to improve issues such as consequence management and the updates for health regulations?

Mr M Shaik Emam (NFP) commented that whilst a lot of good work has been done by NDOH most of it was overshadowed by the serious challenges in the healthcare system in the country. He was unsure why NDOH seemed to be defending itself because if you looked at Baragwanath Hospital alone, there have been reports of almost 11 000 surgical procedures that have been delayed for a considerable period. Some of the reasons given for the backlogs include non-availability of clean linen, maintenance issues, as well as food shortages. This was a big problem. Given the state of healthcare in South Africa, how sure are we that the country is going to make a success of the NHI? More and more medical experts in this country, medical practitioners and healthcare workers are leaving the country. We already have a massive shortage, particularly in rural towns, and more people are leaving. He was not sure how NDOH planned to deal with these issues.

Time and time again, you find patients being turned away. Some of the patients die. Medico-legal claims are increasing in government hospitals – not that we are not having that in the private sector. Yes, we are. But the numbers in the public sector are worse. The wait for some patients is extremely long. Also the lack of electricity is causing the death of babies in incubators. Although the Minister did say there are generators, it does not seem like a true reflection of what is happening on the ground. There are no consequence measures for people failing these government institutions, instead they get to keep their jobs year in and year out. He insisted that the Minister be given an opportunity to improve the quality of healthcare with the assistance of the Committee and other stakeholders. Lastly, he wanted a report back from NDOH on the vaccine's side effects, how severe the cases were and what percentage of people had been affected.

Mr T Munyai (ANC) appreciated the report from NDOH. No government worked as hard to save the lives of its people during the pandemic than the ANC government led by Minister Phaahla and his team. Covid-19 had brought unprecedented consequences, but it was important to appreciate the report by the Minister and support the efforts of the Ministry in serving the interests of all South Africans. All the challenges presented to the Committee were noted and the MECs from each province would be called before the Committee to account for the interventions deployed to speed up eradicating surgical backlogs.

Ms N Chirwa (EFF) stated that there had been support across all political parties for a bouquet of vaccines to be made available to unvaccinated South Africans. However, despite the Sinopharm vaccine being approved by SAHPRA the vaccine has not been acquired and made available by NDOH to the public sector. She asked what NDOH was doing to ensure the vaccine was included in the national vaccination programme. When the vaccine had not been made available earlier, the reason given was that it had not been approved but now that the vaccine was approved, what was the reason for the hold up?

Secondly, she asked why two shipments of Pfizer were noted as the last contractual shipments, whereas NDOH was expecting 20 million more doses of Pfizer. The information on the procurement of more Pfizer doses was relayed by anonymous tippers within NDOH who were concerned about its bias in favour of Pfizer and the Bill Gates vaccines. The Department was about to administer the vaccines to children even though Pfizer had not reached the necessary standards for this to happen. This meant that NDOH was buying vaccines for children when Pfizer had not yet presented the required standards.

She asked why the Committee was not apprised of NDOH plans when dealing with vaccines and about the extra effort by NDOH to buy Pfizer and J&J even though there are other options available that have been approved. She questioned who would benefit if they were not receiving this information as the Committee on Health. More so, it is a norm to report even on future agreements, estimated and contracted agreements by NDOH for the procurement of vaccines. This only confirmed their suspicions that NDOH had been captured by Bill Gates.

Thirdly, she requested that NDOH provide some clarity on the reasons South Africa was still buying vaccines of this magnitude whereas the demand had decreased. She questioned if the reason they were still buying more vaccines was because of an agreement that the Committee had no idea about between government and J&J, Pfizer and Bill Gates that is forcing the government to buy vaccines that are going to expire.

On surgical backlogs, she asked what informs the stipulated waiting periods for surgeries and when would the waiting periods be reduced systemically. It is very embarrassing that NDOH has it written on paper that patients must accept that they can only get medical assistance after seven years. This was an overt admission of failure by NDOH because they cannot give people healthcare as per need. She asked the Minister what he was still doing in office if he could not provide citizens with healthcare services. What are the intervention plans for dealing with specialist shortages and surgical backlogs? Lastly, what has NDOH done to deal with corruption at Thembisa Hospital?

The Chairperson stated that he had given NDOH input on the good work they had managed to achieve particularly the high vaccination rate and low infection rate currently. The Department was focusing on ongoing demand generation specifically on strengthening the use of data for the geographic system. He asked NDOH how they intended to maintain the integrity of the information system. The strategies to mitigate the delivery of J&J vaccines and to lower the cost of vaccines were commendable and he wished NDOH success in saving the government money. He acknowledged that during the time South Africa was negotiating, it was very challenging for the whole global market and the demands placed on governments and departments to procure vaccines, so the fallout was understandable in hindsight.

Monkeypox is a clinical diagnosis made purely on the presentation of the patient. There was no way that a trained doctor would confuse chickenpox with monkeypox. On surgical backlogs, it was difficult to fathom that the plan was to address these challenges between a two-week and seven-year programme. If one looked at the type of operations required by patients, surely there must be a more urgent means to address this challenge. He proposed that the way to address this was firstly securing the patient availability and secondly, the availability of the necessary personnel who can perform the surgeries as well as the facilities required. Although the presentation mentioned that emergency cases would be considered, it did not state if a new timeframe would be considered for non-urgent cases and if they would be given extended timeframes.

On registrar posts that have been reduced to about a quarter of what they used to be, he insisted that this should be addressed immediately by the national department. They had to ensure to increase those numbers. The two-year community service by new graduate doctors was an area that needed urgent intervention by increasing the number of graduates who performed work in mainly rural areas. He supported the position taken by the Family Physician Association of South Africa to place a family physician in every hospital because this would go a long way to address the operation backlogs that specialists could perform.

On why hospitals and other medical facilities could not be exempt from load shedding, he said that City Power had announced that ten facilities in the greater Johannesburg would be exempt from load shedding which was commendable. However, it was necessary to look at all facilities not just the ten. He was aware that exemptions were also being implemented in the Western Cape regional hospitals.

Minister and Department of Health response
Minister of Health, Dr Joe Phaahla, explained that before vaccines became available, there were trials at the end of 2020 and NDOH had discussions with various manufacturers. Manufacturers wanted millions of rands to be paid upfront at a time when regulators had not even approved the vaccines in any part of the world. Some wealthier countries put down upfront payments of billions of rands before the vaccine trails were concluded and approved. When they entered into an agreement with Covax, a World Health Organisation (WHO) coordinated facility that had been pooling together all the manufacturers rather than putting a down payment to each individual manufacturer, NDOH had meetings with Pfizer, J&J, AstraZeneca and several other manufacturers.

After discussions with National Treasury, NDOH decided that the funds would be put into Covax. Also the Solidarity Fund, a public benefit organisation with a mandate to support the national health response, contributed to the country’s funds into the Covax facility. South Africa did not fit into the category of countries classified as the lowest income countries which is the reason we did not qualify for a certain kind of subsidy distributed by WHO which would have made certain vaccines free to acquire.

When the vaccines were approved and presented to SAHPRA for approval that is when NDOH started negotiating the actual uptake of vaccines. At that stage, there was a lot of pressure to acquire as many vaccines as possible to have enough vaccines to reach population immunity. Population immunity was defined as 70% of the population which was 40 million. They were determined and committed to covering at least 70% of the adult population. Youth below the age of 18 would be vaccinated at a later stage. This meant that they had to make provision immediately, but this had been difficult because wealthier countries had purchased vaccines in advance so that they would be the first to receive vaccines. That resulted in South Africa being pushed to the back of the waiting list. Ultimately, NDOH had a responsibility to commit to the amount they had negotiated which is why they are currently bound by that amount.

All top specialists locally and internationally could only make projections on how the disease would progress. They had a good uptake around May, June, July and August at the height of the Delta wave when there were very high mortality rates. However, once the severity of the disease declined, uptake slowed down; this is where we have been sitting up until now. He denied the allegations that they had backhand deals with any companies, saying that it was totally unfounded. He reminded the Committee that everything they do is made public and is reported back to the Committee, to Treasury and the Auditor-General.

On the regulations, in case there were major changes, they would not avoid raising these matters with the Committee. Most submissions were put off during Covid because it was more important to put in place emergency interventions as they had been under immense pressure to control the spread of Covid. Now that the interventions had been lifted, they were working under the normal procedures for the amendment of regulations by using input from submissions, consulting experts and WHO advisories. If proposals must be considered for the final regulations, they would consider having discussions with the Committee. However, if there were no major deviations from what already existed, they may not necessarily come back to the Committee.

Dr Crisp replied that no vaccines would expire in the next two months. Of the Pfizer vaccine, they had 3.9 million vaccines set to expire on 31 December, and 4.7 million doses set to expire on 31 January. They do have an ongoing review of the stability of the vaccines and those dates may still be pushed out on a rolling three-month basis – which was not a decision taken by NDOH. It was a decision taken by SAHPRA based on the laboratory results from testing the vaccines. He assured the Committee that at the moment, nothing was going to be destroyed. On the 1 million doses destroyed earlier in the year, he clarified that none of those doses was destroyed. They were able to use all the doses. No vaccines had been destroyed centrally. The only vaccines that get destroyed are the half used or unused or damaged vials in the periphery sites.

They had not placed an order for vaccines since 21 June 2021. He reiterated the Minister's remarks explaining the problem was that they had commitments that were made long ago. They were bound by these commitments because of the nature and structure of the agreements. They had gotten out of a large part of the Covax facility because the United States government had made South Africa a donation. South Africa was given a credit for that donation against the vaccines not received from the Covax facility. The J&J agreement was a different story. They had paid for most of the vaccines and they one invoice still due for vaccines awarded a long time ago. They had not received the vaccines because they had been deferring the deliveries. These were the vaccines that they were trying to donate back to WHO or the Covax facility so that they did not have to go to waste. NDOH had not procured more vaccines because they had more than enough to manage any potential flare-up or new surge.

On notifications of cases and deaths, NDOH did put out a notice saying that they would only publish figures once a week and not daily. The reason was that the numbers were very small and keeping staff busy with daily updates when they should be focusing on other things did not seem valuable at this stage. They monitor very closely whenever anything looks slightly different. They meet as a team with the National Institute for Communicable Diseases (NICD) to deal with the matter immediately. He assured the Committee so far, there had been nothing to be too concerned about.

On whether NDOH can deal with another surge, Dr Crisp replied that they were able to reactivate everything they had in place before to deal with a potential surge. They were still using clinics to vaccinate. Some clinics cannot vaccinate because they do not have the capacity, but the majority do. Also there were still many private pharmacies that vaccinated. There is a website where one can view where vaccines are available at any time. At the moment, most of the vaccines available are Pfizer vaccines. When they bought the vaccines originally, they had bought it with the understanding that they would be vaccinating 41 million people but only 23 million people have taken up the vaccine.

On the loan, they needed to have a separate discussion with Treasury. Treasury would be the one to come back to expand on the loan because the loan was a Treasury-negotiated loan. Departments are not the ones who negotiate loans directly, especially not on foreign loans. There are very specific procedures for loan negotiation facilitated by Treasury. It is a retrospective loan, so NDOH does not get involved in the technical details. All NDOH must do is report what it is doing in the vaccination programme.

On the social behaviour specialist, he clarified that the Ministerial Advisory Committee members were not paid. Most of the meetings were done virtually. It is only recently that NDOH has had a few face-to-face meetings. NDOH did not pay for the Ministerial Advisory Committee during Covid. The social behaviour specialists involved in that, the Human Sciences Research Council, the University of Johannesburg, the UCT network and others who were generating the social listening reports are still working with NDOH. The private sector, both through the Solidarity Fund and through independent companies and other donors, contributed tremendously financially.

NDOH cannot ensure that vaccines do not expire. They will ultimately expire. There is repeated testing of samples whether they come into the country, are manufactured here, or are bottled here, or we want to change an expiry date. They all get into the National Control Laboratory and there is a sample mechanism that complies with the WHO standards, where they then come back to NDOH and confirm or deny expiry dates. Ultimately, all medicines and biologicals expire if you do not use them. They would like to see more uptake, so they are doing targeted interventions. They do not have the resources or the capability for mass national campaigns, but the targeted campaigns are effective.

On the adverse effects of immunisation, NDOH had reported on this before, they could still report on it at a separate meeting. The figures are published on the SAHPRA website because SAHPRA has the statutory responsibility for monitoring all adverse effects, not only for vaccines but for all pharmaceuticals, and they report globally.

South Africa’s surveillance is amongst the best in the world. NICD and the network of the various universities and other research associations associated with universities have been lauded during Covid. The reason for this is the immense effort and expense that has gone into setting up capabilities for HIV. So South Africa has far greater capabilities than most countries and we use them very effectively. It does not mean there are no plans to improve and strengthen the integration of all data used.

On the development of vaccines, there is a process led by the Department of Science and Innovation along with several other participants. There is a WHO programme that NDOH is part of, a hub in Southern Africa and there are advanced initiatives for technology development in South Africa. South Africa does have the capabilities for the fill and finish of vaccines. It has been set up so that it is not just for Covid vaccines but for all manner of vaccines that we would want to use in South Africa, both the existing types of vaccines, plus others.

On vaccinating children, SAHPRA has registered the vaccine for use in small children aged five to eleven but the Vaccine Vaccines Ministerial Advisory Committee (VMAC) has been looking at the international literature and advised that there is no benefit in doing mass campaigns for children of that age. The only children of that age who should be vaccinated with one third of the adult dose, ten micrograms instead of 30 micrograms, would be children with immuno-compromised conditions. There is a very specific set of those that will be controlled by paediatricians and general practitioners and other health practitioners who look after those children specifically. Although the manufacturer would not like South Africa to use fractionate doses, in other words, taking more doses out of the same vial, it is done in other countries, and South Africa is going to use that process for vaccinating this small number of children who are at high risk.

On monkeypox, he explained that it looks different from chickenpox. He cautioned that this was the season for chickenpox in South Africa with the change of the seasons around August / September every year. Paediatricians see chickenpox in children. This is a very different mode of spread compared with monkeypox and looks different clinically. As far as awareness of monkeypox, the targeted audience interventions NDOH uses include webinars where they try and get health practitioners as well as interest groups and public groups to attend. There are guidance documents on the National Institute for Communicable Diseases (NICD) website on monkeypox. It is viable in South Africa, and it was added to Table 1, where interested groups get the most urgent information.

There are risk groups for monkeypox transmission. The bulk are people who live in very close contact with one another, particularly men who have sex with men. WHO does not recommend mass vaccination for monkeypox. It recommends targeted strategies where there are concentrations of cases. In South Africa, we have had only five unrelated cases, so we do not meet the criteria for vaccination in South Africa. There are vaccines available in the world. We do not manufacture those vaccines in South Africa. We are not likely to use them given the current spread and the fact that our cases are very well contained. The vaccines have not been registered by SAHPRA so NDOH would have to bring the vaccine into South Africa in batches for very specific cases. We have very good laboratory surveillance for monkeypox, and we do this laboratory surveillance for several other African countries.

Dr Thulare explained that when regulations are passed, NDOH looks at implementation costs, compliance costs, infrastructure costs, and communication strategy costs to popularise and mainstream the regulations. In terms of the implementation costs, port health officers may have to be increased to oversee the implementation of the regulations on notifiable medical conditions. They did not anticipate implementation costs in this area.

Funeral undertakers manage mortal remains. Those costs are not going to be directly related to government or the regulator, but they are going to be related to those regulated such as funeral undertakers who must ensure that their infrastructure meets the standards required for funeral parlours. With the current dispensation of regulations, like those published in 2017, the certificate of competency or compliance is issued free. So there are no costs. All this information will be captured in the final revised socioeconomic impact assessment study (SEIAS).

On how many people are opposed to the regulations, at this stage, they are looking at all the comments which are just under 400 000. They are not able to report to Parliament just yet. NDOH had not deleted submissions from the public. What had happened was that when the initial set of regulations was published, the email addresses of NDOH officials were provided to receive the comments. NDOH subsequently created a system to accommodate all the comments because the number of comments was clogging the system and preventing officials from doing their day-to-day activities. They transferred the individual comments in the emails to a link. It might have appeared that there was deletion once the transfer had taken place, but they were moved into the big pool used to assess all submissions.

Dr Makhanya replied on the data accuracy for surgical backlogs. The report reflected the data provided by provinces during the period of June - August 2022. This list of backlogs is updated so the number provided in the reports differs from the number provided previously. Looking at the weekend drives that provinces are doing, NDOH has not received updates since August. Provinces had not given them an indication of a timeframe to eradicate backlogs. They would be making a follow up as they continue to get more information on managing backlogs.

Most provinces have centralised information systems that force the provinces to monitor progress in managing backlogs. The work on backlogs is being done concurrently. There is a slate of new emergencies, including plans assigning dedicated theatres and staff to deal with the new emergencies. Elective surgeries are being booked as an intervention method for backlogs. New emergencies and elective surgeries are not compromised or competing with the backlogs.

On the increase of theatre nurses, all provinces, in the face of budget cuts, have reprioritised their budgets for compensation of employees (COE). The new prioritisation is based on the demand for service delivery and for areas where critical or specialised care is required. There is a pipeline of about 500 nurses who are qualified and they get into the system with an obligation to serve the system back. Within NDOH, there are dedicated grants that target health professional development. The grant prioritises the appointment of clinical specialists, be it doctors or nurses working in highly specialised areas.

Linked to theatre equipment, again there are dedicated grants to make sure high-end equipment required to deal with the backlog is prioritised. This grant complements resources that provinces have of their own. There is also a ten-year maintenance plan in NDOH that is aligned with the needs of the provinces. On the community service initiative, NDOH had deliberately made sure that when they were appointing contract workers to manage Covid they made sure to prioritise them for any posts that became available.

Dr Sandile Buthelezi, NDOH Director-General, stated they were equally concerned about the surgical backlogs. What they had decided to do was to pick up some best practices. He made an example of the Northern Cape that had managed to come up with some innovations that helped them cut the waiting list for oncology to almost seven days. NDOH planned on rolling out the innovation to other provinces.

Secondly, he mentioned the weekend blitz done mainly in Limpopo and KwaZulu Natal, where they can do almost a hundred cataracts over the weekend and more than 30 surgeries. NDOH wanted to replicate this in other provinces. They worked hard to ensure that they pool together staff so that hospitals function properly. On TB and HIV recovery plans that have been launched, the plans are moving forward very well. Lastly, he said that he had just received a call to meet with the Eskom generation the following day with all the provincial managers and the HODs to ensure that what had been currently happening in Gauteng would be happening in other provinces.

Dr Sibongiseni Dhlomo, Deputy Minister of Health, replied about what could be done collectively to support NDOH. He spoke about the shortage of specialists – none of their specialists are trained outside public hospitals. When they were running short of oncologists in KwaZulu Natal, there were sixty oncologists in the private sector and some of them would give their time to public hospitals. He encouraged them and health professionals to give their time and expertise in this way to the very institutions that had trained them.

The Minister stated that the NHI did not have to be disregarded while NDOH improved the quality of healthcare services in South Africa. He assured the Committee that they were not waiting on legislation to bring better services to South Africans. They believed that the healthcare system in South Africa was fundamentally flawed. Even the most advanced countries had come to terms with the fact that healthcare should not be a commodity; it had to be a public good that all could access. Until health became a public good in the country, it would not be able to totally solve all its issues.

Ms Clarke asked the Minister if he could have a look into the situation in the Eastern Cape where a 15-year-old girl was gang raped and taken to a Motherwell clinic. She was referred away from that clinic and died at the local police station. She noted the gravity of the situation and insisted that the Minister attend to the matter.

Closing Remarks
The Chairperson was certain that the Minister had taken note of the issue Ms Clarke had raised. South Africa was still in a very bad position concerning gender-based violence and abuse of younger women. It was something that they were all very concerned about. Everyone should support any initiative which would bring this to an end. He thanked Ms Clarke for bringing the issue forward.

He thanked NDOH for their presentation and agreed with the Minister’s sentiments about every citizen having a right to access quality healthcare regardless of their ability to afford healthcare. The Committee looked forward to seeing more improvements and engaging further with NDOH.