GroundUp: SA vaccination programme in trouble, says the man who ran it until December

First published by GroundUp.

A slew of issues face South Africa’s public sector immunisation programme including understaffing, misdirected funding and inaccurate data collection, according to the programme’s former national manager.

The Expanded Programme on Immunisation (EPI), which was created by the World Health Organisation, aims to ensure immunisations for children globally.

In a recent article in the South African Medical Journal titled Vaccines: SA’s immunisation programme debunked, the former national EPI manager Johann van den Heever spoke of his frustration with unreliable data, understaffing and an insufficient operational budget. For these reasons, he resigned in December 2015 after holding the position since 2004. His vacancy has yet to be filled. He had given notice of his resignation in October.

More work with fewer resources

Van den Heever told GroundUp that he was responsible for the total management of the programme, which included overseeing operational issues, social mobilization, surveillance and training. When other EPI staff resigned in August 2015, he was expected to take on more work with fewer resources. “It was totally impossible,” he said.

“There were all kinds of frustrations. I was knocking my head against the wall trying to get to everything,” he said.

Van den Heever is concerned that there is no accurate national system that electronically records each vaccine dosage a child is given, he said. Currently, if a child goes to a clinic to get a second dose of a vaccine at, for example, 14 weeks of age, there may not be proof that the child received the first dose. Instead, it is assumed that the child already received a first dose, and the child is only given the 14-week dose. This gives a false sense of security that a child is fully protected, he said. “We have the infrastructure, but we don’t have any vision or insight to improve those systems.”

Because data has not been collected reliably, the programme does not know which districts are doing better than others in terms of vaccination coverage, he said.

If an outbreak were to strike, government and programme staff would not have accurate enough data to know where to look for cases, Van den Heever said. The data does not show which communities would have at-risk children. “It’s a shot in the dark,” he said.

From birth to 12 years old, children are supposed to receive about 18 vaccinations in the public sector, protecting them against multiple infectious diseases including TB, measles, hepatitis B and many others (see table below).

Leading paediatrician confirms concerns

Haroon Saloojee, the head of community paediatrics at the University of Witwatersrand, said no one knows exactly what the vaccination coverage rate in South Africa is. It might be 85%, he said, but the data is too unreliable to know for certain.

Saloojee outlined three primary reasons why the rate might be low: staffing issues, problems with health workers’ skills and vaccination stock outs.

Immunisations should be offered every day. But human resource issues have made this difficult, he said. This results in long queues for children on the days immunisations are offered.

Meanwhile, stockouts occur because both the clinics themselves have poor management and international pharmaceutical companies do not prioritise South Africa, and therefore do not provide enough doses, he said.

Problems also stem from insufficient vaccine promotion throughout the country. While most parents are aware of vaccines, they do not follow through with the proper vaccination schedule because of a lack of communication and social mobilisation, he said. For children 18 months old, the dropout rate is around ten percent, he said.

These key issues are accentuated by problems with the management of the EPI at a national level, he said.

Saloojee does not think the EPI is necessarily underfunded, but instead the provided funds are not properly allocated.

Over the last few years, the EPI has introduced new vaccines, raising its cost for vaccinations from R120 million to around R1.5-billion, Saloojee said. The budget is funded entirely by the national Department of Health.

More money should be put into running the programme itself, focusing on proper refrigeration and storage, and the human resource issue, he said.

While Saloojee thinks a national immunisation coverage survey is warranted, the cost of it would be R30-million, which has made the idea look less attractive to some. However, Saloojee believes R30-million for a survey committed solely to immunisation questions is necessary when running a programme with what he said is a R1.5-billion budget.

Ministry of Health's response

Although Van den Heever was the programme manager, he never managed the budget of the unit, Van den Heever said. He never knew how much money they had, so he could never prioritise anything, he said. He said R1.4-billion was spent on vaccines when he left in December. Joe Maila, the Ministry of Health’s spokesperson, confirmed this amount.

The operational budget is completely underfunded, Van den Heever said. “As much as you need proper vaccines, you need proper people,” he said.

But Maila said that the EPI is neither understaffed nor underfunded. “The fact that one manager left does not mean the unit won’t perform its functions as required,” he wrote in a response to GroundUp.

Maila said that data surrounding the number of immunisations provided per health district is accurate. Data reports are sent through the District Health Information System, a system that gathers data monthly from public healthcare facilities. Data on how many children are in the South African population is obtained from StatsSA, Maila said.

“The country has embarked on a [Demographic and Health Survey] in 2016 which will provide data that will augment the routine data,” he said.

Maila said that the EPI’s primary weakness is the “need to strengthen demand for health services by our communities.” DM

Photo by Health-E.

Vaccine schedule

The 2015 vaccine schedule below has been provided courtesy of Amayeza Info Services. You can download it from their website as a PDF. Also see this useful spreadsheet prepared by a doctor for GroundUp. While the doctor has tried his utmost to be accurate neither he nor GroundUp can take any responsibility for any errors in it.