Anban Pillay, Deputy Director-General of South Africa’s National Department
We also don’t want to be in that position where we purchase vaccines, and our neighbours are left with nothing on the continent. So I think this pooled procurement talks to the solidarity and fairness for access to vaccines.
Moderator: Tian Johnson
Complied by: Vivienne Naidoo
Date: 21 January 2021
Dr Anban Pillay is the Deputy Director-General of South Africa’s National Department of Health. Hailing from KwaZulu Natal province, he is a former health intern. Dr Pillay was spurred into a life of public service when he witnessed the substandard care offered to communities in Chatsworth in Durban during apartheid. He later studied pharmacy at the University of KwaZulu Natal and obtained his medical degree at the same institution. He subsequently completed a PhD in health economics in Australia and is an early champion of the National Health Insurance. He works to ensure that staffing equipment and access to medication for the public sector remain on the agenda, as does the urgency to standardize health care across provinces. Dr Pliiay serves on the Ministerial Advisory Council on COVID-19.
QUESTION AND ANSWERS*This section contains a transcribed account of the Question and Answer Session*
What vaccine is coming first as part of phase one?
So the first vaccine that is coming through is a vaccine that was initially produced by AstraZeneca.AstraZeneca developed a vaccine together with the Oxford group. And after the development of the vaccine and the success of the clinical trial, AstraZeneca decided that they would like this vaccine to be available globally, without the constraint of production. So that meant that AstraZeneca would have to spread its production far more widely than it had been doing. They signed up several producers globally and then divided the global market so that producers focused on supplying particular markets. We have been given to suppliers, or producers if that is a better way of putting it for the AstraZeneca vaccine, one of which is the Serum Institute. So that is how we ended up with them because they’ve been allocated our vaccine market. The vaccine has been registered with the Medicines & Healthcare productsRegulatory Agency(MHRA) in the United Kingdom. The production of the vaccine at the Serum Institute must comply with the product quality requirements of the innovator, AstraZeneca. So AstraZeneca is monitoring the production. So even though they have in simple terms, outsourced the production, they monitor the quality of the product all the time because effectively it’s the brand in effect. In all our discussions with Serum Institute. AstraZeneca has been very much part of it to ensure that the product’s quality issues are guaranteed. And they’ve been very, very interested in making sure that that happens. So we take a lot of comfort in their interest in that. And I think that will undoubtedly help us assess the product’s quality when the product gets here; at the South Africa National Control Lab. They will test the levels to take samples and do testing to confirm the quality of the product. So in case, there were any deviations in temperature, etc., during transport, and it affects the quality the lab wilee ensure that the product is still stable and good quality before we distribute it to our facilities. I hope that that clarifies it.
What happened to the at costs and the no-profit commitments from AstraZeneca?
When we were presented with those costs, we were quite taken aback. We also saw the $3 costs, and below $3, in some cases from the leaked procurement prices that came out of Europe, which were even higher than the COVAX prices that we were given. When we inquired from both the Serum Institute and AstraZeneca, we were told that there is a tiered pricing approach and that South Africa is a higher middle-income country. And in terms of the formula, this is then the price that we would need to pay. I was informed that the lower prices in Europe didn’t add up because if we were paying this price, then why was Europe paying a lower price? I was advised that the Europeans had funded the front-end Reserach and Development(R&D). And so they were given a discounted price for conducting the R&D. We do not know how much the R&D was and what the discount was. And we were told from both parties that this is a consistent price that they would be charging all middle and upper-middle-income countries.
Was there a point where we stood up and said these are our bodies, universities, and taxpayer money? And to be fair, our contributions have been relatively minimal compared to the global funding of these trials, even in South Africa. So I think there’s hunger at the national level of understanding when did our governments stand up and fight? And of course, there’s a huge amount of work going on behind the scenes. Perhaps now you could articulate the work done, if any, to motivate for similar discounts that Europe is getting based on our local investment in R&D.
In the case of the AstraZeneca vaccine, we were left to negotiate with a party that did not do the R&D here. We were not very successful in negotiating a lower price in terms of the Serum Institute vaccine. We were told this is basically our price to upper-middle-income countries, and you can decide to take it if you want it and if you do not want it, that we’re open to selling it to somebody else. But I think the other companies have been more responsive. Pfizer has certainly been more responsive, particularly given that the trials were done here. And Johnson and Johnson have also been more responsive around that. So I think we get different responses from different companies that we have engaged with around the price issue. We didn’t want to do, is push the price debate to the extent where we don’t have access because the demand exceeds supply, and that supply is currently a supplier’s game. If I can put it like that. We do not want a situation where we simply drive price hard. And we are put at the bottom of the list for access, simply because we have the lowest price because, in the general medicines market, that’s what happens when a company has a low price and margin. They first service the markets that are the highest price and margin, and then come to the lower price countries and we didn’t want to negotiate to that extent.
My understanding of healthcare workers’ definition is everybody involved with health care delivery, in terms of contact with patients. The fact that a separate party funds them does not change the risk they are presented with daily in delivering care.
Are we receiving vaccines from the African Union?
Well, we’re not receiving vaccines. We are part of the African Union (AU) vaccine procurement approach, which the President announced. As part of that, each country will receive an allocation of vaccines as part of that procurement. Our procurement will happen directly with those companies after we receive our allocation. The AU is about pooled procurement mechanism; I suppose it’s the best way to describe it. Also, not to discriminate between countries because South Africa’s buying power will certainly be higher than many other countries on the continent. So we potentially could out purchase our neighbours in terms of procurement. But that is not the right thing to do. I think while we’re complaining about what’s happening in Europe, and the US and other places where they have bought four times the vaccines that they require, we also don’t want to be now in that position where we purchase vaccine, and our neighbours are left with nothing on the continent. So I think this pooled procurement talks to the solidarity and fairness for access to vaccines.
What do you think is that comfortable space or balance that we need to reach between government being accountable to citizens while respecting the business space, and these non-disclosure agreements?
My understanding of non-disclosure agreements is that they are primarily linked to the negotiation process between the companies and us. As soon as the deal is concluded, our local legislation then or the Public Finance Management Act(PFMA) more particularly kicks in regarding accountability. And I think there are high levels of transparency in terms of that. We would certainly need to share the necessary information in terms of that. South Africa is probably one of the countries that drove the transparency around access to medicines at the WHO resolution, to create transparency around pricing and access. We are very much still there, and we would like to share that. At this stage, we just need to appreciate that we are dealing with parties that have control over the vaccines. Once we were able to procure them, we will certainly be sharing a lot more information because the negotiation process would no longer tie us down.
Would you champion the initial vaccination of political and civil servant leadership at the outset as part of phase one?
The Ministerial Advisory Committee(MAC) was debating that. There are, I suppose two views on it. The one view is very clearly the one you have articulated. I think political leaders need to come out and be vaccinated so that the public has confidence in the vaccination programme and the vaccines in terms of their safety and efficacy. The other side is that it may be seen that political leaders are getting protection before other people. So I think trying just to get that right is probably the issue. The MAC was looking at it, and I think they will likely advise the Minister on how, when and how they should be vaccinated. But I think the point is relevant. Several countries have already seen the heads of the Queen’s etc., being vaccinated. And that is probably something that needs to happen here publicly.
Are you eager to get vaccinated?
Yes, I’d like to be vaccinated. But I also appreciate the argument that other people are at higher risk than me, so I’m prepared to stand in the line and be told when my time is.
The first batch of vaccines are due in less than two weeks for phase one, are we on par with rollout, are we ready?
We are waiting for Serum Institute to tell us what day the vaccines will land in-country. They haven’t given us that exact date; they just said it would definitely be next week. I can only give you the kind of processes involved and that the vaccine will have to be stored at a local facility for the batch testing. So the South African Health Products Reulatory Authority SAHPRA, the national control authority will take random samples and test those samples and confirm that the product is still of appropriate quality, which probably takes about three days. Once they’ve got the results, they will say that the product is good to go.Meanwhile, we have been meeting with the provinces and the private health sector and have a list of health care workers that need to be vaccinated in terms of the list. So we’ve tried to bring together the independent practitioners who don’t have a formal employ as such and that Coordinating Committee will divide those doses between those two sectors. The stock will then go to provincial depots or a private depot where it will be stored. Using what is best described as a hub and spoke model, the doses will be distributed across that region. At a provincial level, the private sector will be working together with the provincial health department to ensure coordination of the vaccine delivery and the individuals who have been vaccinated. We’ve worked very closely with the medical schemes that are on this and ensure that there is very good coordination. The intention is that all the people’s information (to be vaccinated) will be uploaded onto the system before they get vaccinated. They will then effectively receive messages about the day that the vaccinator will be coming to the hospital or clinic or wherever and be ready to be vaccinated. They will receive a certificate or vaccination card to confirm that they have been vaccinated. It’s a two-dose vaccine. So they will be given a date for the second dose as well. And they will need to come back and get that.
What is the security situation in terms of these vaccines?
So the vaccines have a particular coding on them. We would know if there is a counterfeit in the system because there is a code on each one. And the vaccinate is having to upload that code onto the system. So then we know which batch etc. If there is an adverse event, amongst other things, we’re monitoring it from that perspective as well. In terms of the security, we’ve brought on board private security to manage the vaccines together with that, we’ve spoken to our military about securing the larger vaccine stocks given that we do stand the risk that vaccines will be stolen and move to other places.
What are we doing to ensure people come back for that second dose?
The Information Technology (IT) system is programmed to message the individual. For example, if Anban Pillay went in for his vaccine today, it will then calculate the date when he must come back; it will send him a message to say this is the date and then closer to that date, there will then be a reminder to say this is the date you need to come back. The plan is if an individual doesn’t respond to confirm which day, they are coming in to get the second dose vaccine at that particular facility, there will then be a follow up with that individual to say, hey, you need to come back for your second dose. What happened? Are you okay? Or is there a problem, etc.? To try to understand why the individuals are not coming back.
The IT system you have described does not have any data requirements; does it require a smartphone?
I’m not an IT expert, but from what I’ve been told, the system’s requirements from an individual user perspective are that it uses one-third of the data required that you would use on a WhatsApp call. So I am not sure how what that stands up like. I was told that it’s very low. And there is also going to be the opportunity period to register at the facility for when you would be able to come in and get your vaccine as well because everybody would not have a smartphone. We can’t just have a situation where people who only have smartphones are able to register.
We are told that health officials filed an application to SAHPRA seeking emergency approval for AstraZeneca authorization last week. Could this delay the process in the rollout for phase one?
No, there is no delay. Remember that the Serum Institute talked to SAHPRA from about December, sharing a lot of the data. And as the data became available, they were sharing that with SAHPRA, they were waiting for two things. The first that Serum needed was the approval from a stringent regulator on the product’s clinical approval. And that happened through the Medicines & Healthcare products Regulatory Agency(MHRA). The second was the Serum Institute, needed approval from its local regulator, which is the Indian equivalent of SAHPRA called Drugs Contoller General India(DCGI). And once those two were in place, Serum Institute was able to then file with SAHPRA for review. I am pretty confident by the end of this week; we will get sign off from SAHPRA to import the product.
What are the plans to address what feels like a tsunami of the stigma surrounding our health care facilities?
That’s an important issue. And it’s a problematic issue for us. You know, there are even people infected with COVID, that would say to us, I’m not going into the facility because I’m scared, we’re scared about infection, but they already have COVID. Still, they were so scared to go in, and they needed the oxygen. So you know, this fear, stigma is challenging. We were trying to put out messaging through social media and other media to explain to people that it’s more critical for you to take your chronic medication because you’re increasing your risk exponentially with poor control of those chronic conditions. So if you were to get COVID, it would be far worse if you didn’t control those conditions. So we’re hoping that those messages get through in our facilities. As our vaccine programme continues, there would be a sense of a safer environment. I would anticipate or hope that people will be coming back. Our colleagues running the different programmes are certainly engaging with the provincial colleagues around trying to encourage people to go back post this vaccination programme because I think there will be some perceptions about the safety of our facilities after that.
What is the Department of Health doing to contribute towards aggressively tackling corruption in the health system?
I think corruption in the public health system is much broader than just the health system. But the system I think is an attractive terrain for this because it has all of the elements that would allow for easy corruption. It’s more difficult to do it in a department where they don’t have the extent of the resources that we need to supply in a way. We provide food, beds, medicines, everything. So I think in that context, we certainly are trying to work with the Special Investigation Unit(SIU), a committee in place trying to identify corruption and fraud. As we identify corruption during the vaccine procurement process, we will send those through to SIU. We are doing the procurement centrally. I have been involved in procurement for over two decades now. When procurement is done centrally, we’ve never had a single case of corruption or anything, because it’s much easier to focus on a single group of people. And so the opportunity for that kind of thing is far more limited. And if it ever occurred, you could intervene more precisely because it cannot diffuse a response as such. Those are some of the solutions in the short term. In the long term, one of the big problems that we have in the health system particularly, is around the available information systems. Much of the goods, or services required to be delivered, are not captured in an information system. For example, if Anban Pillay went in for a service, and if it’s not clear what services and goods were delivered to him or her, it’s then easy for those products to find their way out of the system. If you had a system that gets into that level of detail, then there’s clear accountability. That is why in the private sector, it is more difficult to do these things, because you have to account for each patient. The information system that we were building around the National Health Insurance(NHI) is mainly going to get to that level of detail. So you would have to account for what you did with the medicine or how long you spent with the patient, etc. Because the data will talk for itself as such.
Amidst all of this, what gives you the most hope, looking forward?
I think we have been through, you know, so many crises. HIV, in particular, is the one that I think that all of us went through at some point. I remember working in hospitals where more people were dying than were living and you and you had to reflect as to what is the point of working in the healthcare sector if you’re only there to watch people die rather than having to save them. So I think that we will be able to get over this, identify the interventions that are going to be able to save lives is critical and work very hard at implementing that across the country. Particularly to those who have the least access, unable to stand up and be first in the queue often to get access to care, but instead identifying those people and making sure they get access to service. Today, if I walk into the same wards that I was working in at the time, I mean, they will have difficulty finding a single HIV patient in those wards like the way I did that, remember, over two decades ago.