Review & Documentation: Coordinated donor support to the COVID-19 vaccination programme by DG Murray Trust

Review and documentation of the Coordinated Donor Support to the COVID-19 Vaccination programme (March 2021 – June 2022) Main Report Dr Andrew Hartnack, Rory Liedeman & Anthony Muteti June 2023

ABBREVIATIONS

AG auditor general

B4SA

BPESA

BUSA

CBO

Business for South Africa

Business Process Enabling South Africa

Business Unity South Africa

community-based organisation

CDS

CEO

CFO

COSATU

Coordinated Donor Support

chief executive officer

chief financial officer

Confederation of South African Trade Unions

DATT

DDG

DGMT

Demand Acceleration Task Team

deputy director general

director general

DG Murray Trust

EVDS

FBO

GBV

GCIS

Electronic Vaccination Data System

faith-based organisation

gender-based violence

Government Communication and Information System

GIZ

KfW

Deutsche Gesellschaft für Internationale Zusammenarbeit

human resources

information technology

German Development Bank

M&E

MIS

NCCC

NDoH

monitoring & evaluation

Management Information System

National Coronavirus Command Council

National Department of Health

NEDLAC

NGO

NHI

NHLS

National Economic Development & Labour Council

non-governmental organisation

National Health Insurance

National Health Laboratory Service

PFMA

PMO

POPI

RCCE

Public Finances Management Act

Project Management Office

Protection of Personal Information Act

Risk Communication and Community Engagement

SACC

SAHPRA

SANTACO

SASSA

South African Council of Churches

South African Health Products Regulatory Authority

South African National Taxi Council

South African Social Security Agency

TABLE OF CONTENTS Executive summary........................................................................................................................................ 5 1. Introduction and review background ....................................................................................................... 9 2. Terms of reference..................................................................................................................................... 11 3. Approach and methods............................................................................................................................. 13 4. Findings...................................................................................................................................................... 17 4.1 The need for, anticipated purpose and outcomes of the CDS initiative............................................ 19 4.2 Activities and outputs funded through the CDS initiative................................................................. 23 4.3 Governance and implementation structures and processes: their strengths and weaknesses .......33 4.4 The effectiveness of CDS activities, factors enabling and constraining success, and the degree to which intended outcomes were achieved......................................................................... 41 4.5 The unique value of the CDS mechanism...........................................................................................73 4.6 The CDS contribution to new precedents or platforms for national disaster management, mobilisation, collaboration, and future service delivery, and lessons towards this end.................77 4.7 Unintended consequences................................................................................................................. 83 4.8 The costs of management and support..............................................................................................87 5. Conclusions and recommendations ......................................................................................................... 91 Appendix 1: List of key informant interviews............................................................................................... 95

The CDS initiative was conceived in January 2021 when several philanthropic organisations realised that a fast and effective COVID-19 vaccination programme was crucial and that the National Department of Health (NDoH) would require comprehensive and coordinated financial, strategic and technical support in order to implement such a response.

EXECUTIVE SUMMARY This report presents the results of a detailed review of the CDS (CDS) to the South African government’s COVID-19 vaccination programme. The review was conducted in early 2023 by a team led by Dr Andrew Hartnack, gathering primary and secondary evidence from programme records and documents, 59 in-depth key informant interviews, and an electronic survey with technical support personnel. The CDS initiative was conceived in January 2021 when several philanthropic organisations realised that a fast and effective COVID-19 vaccination programme was crucial, and that the National Department of Health (NDoH) would require comprehensive and coordinated financial, strategic and technical support in order to implement such a response. The vaccination programme sought to reach 70 per cent of the population in order to achieve herd immunity, reduce COVID-19 morbidity and mortality, and allow South Africa to return to normal. Allan & Gill Gray Philanthropies; Bill & Melinda Gates Foundation; DG Murray Trust (DGMT); ELMA Foundation; and the Michael & Susan Dell Foundation therefore approached the NDoH with an offer to provide coordinated strategic and operational support to the vaccination programme for the duration of one year (March 2021–February 2022). An agreement was subsequently signed with the NDoH for an initial sum of R69 million, on condition that the Solidarity Fund match this amount, which it did. The initial amount was later increased to R82 million through further commitments from the Bill & Melinda Gates Foundation and the ELMA Foundation, giving the CDS a total value of R152 million. A grant agreement

between the Solidarity Fund and the DG Murray Trust was eventually signed on 24 May 2021, but activities commenced in February.

It was agreed at the outset that DGMT was the best placed organisation to lead the CDS initiative, with CEO Dr David Harrison being seconded to head up the core implementing team, alongside other highly skilled and experienced individuals seconded from the other donors or headhunted for their role. A project management office was quickly set up within DGMT, with this review finding that sound governance and implementation structures were quickly established. These allowed for a very flexible, efficient and rapid mobilisation of funds and technical skills to the NDoH to support every level of the programme. The CDS was a true partnership between the donors and the NDoH, with members of the core team working closely with senior government counterparts to support the planning and delivery of the programme. However, the structure of the CDS crucially allowed the funding, personnel recruitment and procurement processes to remain in the control of the CDS team, enabling the rapid establishment of a vaccination delivery platform unencumbered by the constraints of the government accounting system and bureaucracy.

One of the key early tasks of the core team was to support the development of a sound and effective strategic rollout plan, incorporating input from a wide number of stakeholders. David Harrison and the core team worked closely with the NDoH to develop an optimal vaccination strategy which focused on reaching the most vulnerable over 60-year age group first, followed by younger age groups. While the strategic plan was never officially signed off, the government adopted this effective approach, rather than attempting the much more complicated alternative approaches. Along with a strategy which could be quickly put into practice, technical support at every level had to be mobilised to enable functional area-based teams to roll out vaccination strategies at provincial and district level. Provincial facilitators were quickly recruited to work with government vaccine coordinators in capacitating these teams to run vaccination sites at sub-district level. A range of required skills were identified in collaboration with each province, and these were swiftly advertised and recruited. Identified skills were in cold-chain and logistics; vaccine management; data analysis and IT support; communications; and area-based planning. Although there were challenges in recruiting the required skills in some provinces. These individuals proved critical in assisting the districts to implement their vaccination strategies. Importantly, they were employed by the DGMT but were supervised by line managers within the DoH. This review found that most of these personnel were very well integrated into their units and teams, and that they played a fundamental role in the ability of these units to run their vaccination programme. To further support these area-based teams, the CDS also developed local area-based service delivery plans and toolkits, which were distributed widely. To address gaps in capacity, a special fund was set up to allow local NGOs to support areabased teams in a number of crucial ways. Over 100 local NGOs participated in this endeavour by April 2022. The CDS also supported the government to set up mass vaccination sites which could cater for the anticipated surge in demand in 2021, and entered into partnerships with transport providers such as Uber and the taxi industry to assist people to reach these sites easily. The CDS initiative also provided under-capacitated vaccination sites with tablet computers, barcode scanners and laptops, helping to ensure that the over 3 000 sites which were established countrywide were as effective as possible. One area which the CDS hoped to support strongly was the establishment of effective district-level information systems, using current data from the Electronic Vaccine Data System (EVDS) to inform real-time planning, resource allocation and demand creation efforts. This proved to be the biggest challenge and impediment 6

experienced by the CDS initiative as the NDoH never allowed full access to the EVDS, citing data privacy laws. The lack of access to up-to-date data meant that vaccination sites and planners were “flying blind”, and could not tailor their efforts to address the realities on the ground. The CDS also played a major role in developing and implementing a public communications strategy for the vaccination programme.

Working with private sector experts, a highly effective National Contact Centre was established in record time, with teams of trained call centre operators able to keep the public informed on a range of COVID-19-related issues from May 2021. Demand for this service was high, and within a year of its launch it had handled over three million calls. The communications team also worked closely with government counterparts to establish a sophisticated “communications dynamo” through multiple content development and communications streams. Demand creation became a critical focus in the second half of 2021, with the CDS playing a fundamental role in setting up the multi-sectoral Demand Acceleration Task Team (DATT). This team worked tirelessly to create demand in many sectors through involving influencers from organised labour, civil society, traditional leadership, youth, and religious bodies. Community radio campaigns, social media and traditional media platforms were used, along with campaigns such as the Vooma Vaccination Weekends, the Vooma Vax Champs, and the Vooma Voucher incentives, which have been shown to have contributed greatly to demand creation in later 2021. Young doctors were also brought into the initiative to reach the youth with an accessible and relatable approach, through community events, podcasts and YouTube videos.

Equity was a key concern for the CDS from the outset, a concern increased by evidence that the most vulnerable were vaccinating at far lower rates than the wealthy.

An innovative outreach campaign was therefore established to reach the millions of pensioners who spend time each month in state pension queues. Following a successful pilot and the contracting of a number of regional clinical operators, the outreach project was expanded to more pension queues, community halls, malls, taxi ranks, schools, colleges and other pop-up venues. Clinical operators liaised closely with public health facilities and private sector partners to get sufficient vaccine stocks to where they were required daily.

By April 2022 there were 253 active outreach sites around the country where over a million vaccines were administered to people who would not otherwise have accessed the jab. Young people also became a priority focus of outreach efforts, and a key lever to drive demand in early 2022. The CDS therefore partnered with the NDoH to launch the KeReady programme of action, which sought to reach young people in a vibrant, accessible, participatory manner, through social media, events, incentives, community radio and the inclusion of young doctors to drive the message among their peers. Independent research confirmed that this campaign resulted in 251 000 more young people being vaccinated within the first two weeks of its launch. This review highlights that the CDS initiative contributed greatly to the achievements of the vaccination programme, helping 37 million vaccines to be administered between May 2021 and June 2022, and ensuring that over a million additional people were vaccinated through innovative strategies such as outreach, demand acceleration and incentives. By the time of the handover of activities to other partners, 70 per cent of the most vulnerable 60+ age group had received at least one dose of the vaccine, 65 per cent of the 50–59 age group were vaccinated, and 50 per cent of adults had been covered. Although South Africa did not reach its target of 70 per cent of adults vaccinated, these achievements are impressive and should be understood in context.

allowing the government to access support effectively, without itself being overwhelmed. Government officials interviewed for this review were highly positive about the potential of the CDS arrangement as a model for a true partnership between the government, civil society and the private sector. This report thus makes a number of recommendations from the many lessons learnt from the CDS initiative and its application to the COVID-19 vaccination programme. They may be used to inform preparedness for future public health disasters; improve delivery of health and other services, provide models of collaborative funding and technical support, and show how costing for such endeavours might be approached. The gist of these recommendations is that the government, funders and private sector partners should ensure they continue to strengthen platforms for working together, and to remove obstacles preventing quick and effective responses to both urgent and routine needs, in order to ensure that South African citizens can live a happy, prosperous and dignified life.

The review documents a number of key enablers of the success of the CDS as a model for supporting the government in times of crisis. Among the most significant is the way in which the CDS brought together a range of civil society and private sector partners, not only to provide financial support to the government, but also to provide crucial strategic leadership and technical support. The CDS offered a rapid platform which could mobilise and deploy resources quickly to where they were most needed, without dictating to the government or operating in parallel to the NDoH.

At the same time, the CDS platform ensured sound governance structures which inspired the confidence of other funders to invest a further R500 million through DGMT to assist the NDoH with vital equipment and outreach services. The CDS platform also contributed new precedents and lessons for how the government might work together with multi-sectoral partners in times of crisis and during routine service delivery. It is a useful mechanism for pooling funds and expertise, and 7

In early March 2020, South Africa experienced its first case of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), known for short as COVID-19.

1. INTRODUCTION AND REVIEW BACKGROUND In early March 2020, South Africa experienced its first case of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), known for short as COVID-19. Reacting to the outbreak, the National Coronavirus Command Council (NCCC) was established by the government on 17 March 2020, and a hard lockdown was in place by the end of March. As South Africa battled through the first waves of COVID-19, and the associated socio-economic disaster situation, all sectors of society responded to ameliorate the effects of this pandemic, especially on the poor. Government and the business sector formed the Solidarity Fund, a vehicle through which resources could be raised to support the fight against COVID. Civil society also played a fundamental role in this response, supporting communications; social relief of distress; scholars and students; the early childhood development sector; and the health sector through a range of activities and mechanisms.1 By the second half of the year it was becoming increasingly apparent that a COVID vaccine was going to be highly necessary to save lives, prevent the health system from being overwhelmed and achieve herd immunity, so that the economy could reopen fully.

A number of clinical trials got underway across the developed world in 2020, seeking to produce a safe COVID-19 vaccination in record time. The COVAX facility was then established as an international mechanism through which countries could gain access to vaccination doses. The South African government was in talks with various potential vaccine suppliers in 2020, including Pfizer, AstraZeneca, Johnson & Johnson, Moderna, Cipla, and producers in Russia and China.2 An incremental vaccination rollout plan was put forward, based on six criteria: availability; safety, efficacy and quality as determined by the South African Health Products Regulatory Authority (SAHPRA); ease of use and number of doses required; stability during storage and distribution; supply and sustainability; and costs. The early negotiations and strategy around which vaccine and which procurement mechanism South Africa should use were not optimal. It was not until 19 January 2021 that the Interministerial Committee on Vaccines was properly established. As this review shows, the hesitation cost the country several weeks and probably thousands of lives. The initially ordered AstraZeneca doses were found to be not effective enough against transmission of the second COVID-19 variant and were therefore deemed inappropriate for administration at the time.3 This led to the urgent procurement of the single dose Johnson & Johnson vaccine, 500 000 doses being brought in in February 2021 for use in Phase 1 of the vaccination programme, the Sisonke Open Label Programme targeting the health sector.

1 See Harrison, D. 2020. Harnessing the thunder: civil society’s care and creativity in South Africa’s COVID storm. Johannesburg: Porcupine Press. 2 See Soodyall, H., Ataguba, J., Botes, M., Dhansay, M.A., du Plessis, E., Gray, G., Kleyn, L., Reddy, P., Rumbold, K. and Thaldar, D. 2021. “Chapter 3.1. Legal and regulatory responses”. South Africa COVID-19 Country Report [First Edition]. DPME (Department of Planning, Monitoring and Evaluation), GTAC (Government Technical Advisory Centre) & NRF (National Research Foundation), Pretoria, June. (Pg: 98). ³ In retrospect, once it became clearer that the main value of COVID-19 vaccines was to reduce the severity of disease and not prevent transmission, it could be argued that the AstraZeneca vaccine would still have been effective. 9

As will be outlined in this report, several donors which had been integrally involved with the COVID-19 response in 2020 saw that supporting the government on the vaccination programme would be the next frontier. This group of funders, consisting of the Allan & Gill Gray Philanthropies; Bill & Melinda Gates Foundation; DG Murray Trust (DGMT); ELMA Foundation; and the Michael and Susan Dell Foundation, approached the Director General of the NDoH with an offer of coordinated donor support to provide strategic and operational support to the vaccination programme for one year (March 2021–February 2022). An agreement was subsequently signed with the NDoH for an initial sum of R69 million, on condition that the Director - General approach the Solidarity Fund to match this amount. The initial amount was later increased to R82 million through further commitments from the Bill & Melinda Gates Foundation and ELMA Foundation. A grant agreement between the Solidarity Fund and the DG Murray Trust was eventually signed on 24 May 2021.

The total amount of funding raised through these funders over the process of implementation was over R151 million, which was bolstered by interest earnings on the capital. Further funding for specific ring-fenced projects was later contributed by a range of funders. The CDS initiative evolved over time, eventually being extended to June 2022. With leftover funding, it was decided that a review of the process of CDS implementation and outcomes, as well as a documentation of the model, and lessons arising from it, should be commissioned. In the second half of 2022 DGMT thus sought a suitable service provider to conduct this review, which had the aim of recording the experience of support and learning from it to strengthen current funding practices and approaches to public health, as well as future responses to public health disasters.

Dr Andrew Hartnack, a social anthropologist with 20 years' experience of research, implementation and evaluation in the development sector in southern Africa, was commissioned to conduct this review in January 2023. This report provides the detailed results of this review and documentation of the CDS to the South African COVID-19 vaccination programme.

2. TERMS OF REFERENCE The core task of the review was to study documentation and interview a wide range of representatives from different sectors who were involved in different capacities in the project in order to describe and analyse the following: •

•

The governance and implementation structures put in place to govern and drive the CDS, identifying the strengths and weaknesses of the process; The activities funded through the CDS and, to the extent possible, assess their effectiveness. This includes support for supply and demand side interventions (technical support for management, service delivery, mobile services, communications, public interfaces, analytics, etc.); The placement processes of technical and other support (at national, provincial and district level) aimed at ensuring integration with government structures; The user experience of interventions spearheaded through the CDS mechanism (as captured in digital records specific to the interventions and augmented by user perspectives from social listening and national and sub-national surveys); The degree to which the intended purpose and outcomes, as anticipated by both donors and the South African government, were achieved as a result of the CDS (differentiating between outcomes within and outside of the direct control of the secretariat);

•

• •

•

The main factors facilitating and constraining the success of the CDS both in supporting the NDoH and in contributing to the momentum of the vaccination programme; The unique value that the CDS mechanism was able to contribute, clarifying its qualitative enablers of success; The degree to which this process contributed to new precedents or platforms for national disaster management, mobilisation, collaboration and future service delivery; Any unintended consequences (negative or positive) that should be documented as a learning from this experience; and The costs of management and support.

Arising from these findings, the review was asked to make recommendations that will help: • • • •

Inform preparedness for future public health disasters; Improve the delivery of health and other services, based on the emergent lessons from this experience; Inform models of collaborative funding and technical support; and Provide an example of actual costs of implementation to inform future interventions.

This review took a multi-method approach aimed at obtaining as rich a perspective of the CDS implementation process and outcomes as possible.

3. APPROACH AND METHODS This review took a multi-method approach aimed at obtaining as rich a perspective of the CDS implementation process and outcomes as possible. Although largely qualitative in nature, the review did also seek and analyse quantitative primary and secondary data, to triangulate findings from the qualitative interviews. Dr Andrew Hartnack led a small team of experienced researchers in order to complete the review within the given timeframes. These researchers were Mr Rory Liedeman, and Mr Anthony Muteti, with administrative support provided by Ms Helen Hacksley.

The following methods were employed: Briefing interviews The first activity performed was briefing interviews with key members of the CDS implementation team. These were David Harrison (Lead), Sandra Ngwena (Project Manager), Lebo Motshegoa and Angela Stewart-Buchanan (Demand Acceleration Task Team) and Vanessa Rheeder (Finance Manager). These interviews were conducted by the lead reviewer, all online except for one. These briefing interviews provided clarity on the project background and achievements, the terms of reference, documentation to be reviewed, and the key informants to be sampled.

Desktop review The document review process also commenced soon after contracting, after the documents had been provided by DGMT. Key documents reviewed included project documentation, most notably all presentations; weekly reports; six-weekly donor reports; donor meeting minutes; the project final report; reports of project sub-components; and several reports from project partners. In addition, available surveys on the COVID vaccine programme were also sourced and reviewed.

Not only did findings from both the briefing interviews and the document review feed directly into the key informant research tool development, but they also fed into the overall review findings. The project's weekly and six-weekly donor reports were particularly useful in providing a detailed understanding of the way in which the project was implemented, and the complex and shifting context in which it operated.

Key informant interviewee selection In-depth key informant interviews, with a wide variety of individuals involved in different aspects of the CDS, were another primary data source for this review. These key informants came from every layer of government; the funders; civil society (non-governmental organisations (NGOs), community-based organisations (CBOs), faithbased organisations (FBOs), labour); the private sector, and people who had participated in the initiative in various roles. A comprehensive list of desired key informants and their affiliations and contact details were developed following briefing interviews, with the assistance of the Project Manager. In some cases, a specific name was not known at that stage, but some key informants later refered us to other suitable individuals. This was the case, for example, with district officials, or technical support personnel and their government supervisors. Sampling for this review was therefore a combination of purposive sampling and snowballing – aimed at including people with direct insight into the CDS, its implementation and outcomes. Following the development of this comprehensive list of selected key informants (around 60 in all), they were each contacted by email by the CDS Project Manager. An attached letter signed by Dr David Harrison (DGMT) requested their participation and explained the aims of the review. A member of the review team was dedicated to setting up interviews, communicating with all interviewees, and managing the interview schedule. In many instances it took numerous emails and phone calls to set up interviews, due to people’s busy schedules. A few of the initially selected informants proved uncontactable and were replaced by similar interviewees.

Key informant interviews Key informant interviews took place largely over online platforms such as Zoom and MS Teams. Only two Cape Townbased interviewees were interviewed face to face. Online interviews worked well as they allowed the review team to easily reach people without having to inconvenience them, or spend large amounts of time and money on travel. Online interviews also allow for flexibility. For example, if someone missed an appointment, it was easy to quickly reschedule the meeting over email. Such flexibility with government officials was particularly useful. An informed consent form was developed to ensure that each interviewee consented properly to an interview before it commenced. Initial agreement was obtained over email, with the informed consent form also being read out to each interviewee at the start of the interview. Informants 14

agreed verbally before each interview commenced, with such approval being recorded by the interviewer. Anonymity and confidentiality were offered to key informants, although they were requested to go on record to give their views on the initiative. This was a very complex review which sought in-depth information from a wide variety of interviewees. A standardised research tool or set of questions could therefore not be used for all informants. Twenty different key informant interview research tools were thus developed with questions tailored for different kinds of interviewee (e.g. different levels of government, donors, NGOs, health workers etc.). These open-ended semi-structured research tools were used as a discussion guide, with the aim of obtaining qualitative data from each interviewee. The focus of these tools was guided by the review questions, as well as by feedback obtained during briefing interviews and the document review. A team training workshop was held in February to ensure that the review team was trained in the administration of the research tools. The team of three interviewers divided the interviews between them, but due to the complex nature of the topic and the seniority of interviewees Dr Hartnack ended up conducting almost two-thirds of the interviews. A total of 59 interviews were conducted between February and May 2023 (see Appendix 1). Sixty-four individuals were included in the interview process because a few interviews had two people in them. Most interviews were recorded, but interviewers also took detailed notes. In a few instances, interviews were conducted by telephone and these could not be easily recorded. Interviews were generally close to an hour long but in some cases they were slightly shorter depending on how involved the interviewee was and what their level of knowledge of the initiative, its outcomes, challenges and its implication for broader systemic issues was. Interviews were all conducted in English, but the research team had fluency in Afrikaans, isiZulu and isiXhosa, should English not have been preferable.

Online survey During the course of the project it was identified that, to obtain deeper insight into the experience and impact of technical support, an online survey could be sent to former employees still in contact with the DGMT. The survey was developed in Google Forms by Dr Hartnack, and it was subsequently sent to 88 former technical support personnel. By the end of April 33 responses had been received, a fairly good response rate of 38 per cent. These surveys provided another rich layer of data from the districts, in addition to the in-depth interviews and the document review.

that it can be difficult to schedule interviews with senior government officials in particular, which was a key risk. Likewise, more junior government officials can be reluctant to agree to interviews unless they have specific permission from their line managers. This process can take time and a convoluted communications effort. These were indeed the main challenges faced during the review process, especially getting hold of and securing interviews with district health officials. However, perseverance on the part of the team, and assistance from DGMT, assisted all interviews to be completed by early May.

Data capturing and analysis Data gathered in the key informant interviews was in the form of detailed typed or written notes gathered during interviews, and also in the form of digital recordings. Each recording was sent to Mr Liedeman, who saved it before running it through a transcription programme. This programme produced a good quality transcript, which was then cleaned by the person who conducted each interview. To track the results of all interviews, and provide a first level of analysis, a data analysis matrix was developed using Google Sheets. This had all the review themes listed across the top row, and each interviewee was listed down the first column. Directly after each interview, the interviewer was tasked with filling in each column with the key findings which emerged during the interview. This allowed for the ongoing monitoring of interview quality by the lead researcher, and it also provided a real-time idea of the emerging themes and findings. This tool also acted as a key thematic analysis fulcrum during data analysis, allowing for comparative analysis across different types of interviewees. All interview notes and transcripts were also thematically analysed by the lead reviewer, with support from all other team members. Through this process, the findings of this review on each of the key topics were identified. The survey was analysed by importing the results into a Microsoft Excel spreadsheet. These data were also analysed thematically and fed into the broader analysis presented below.

Assumptions and risks This review was conducted between January and May 2023. One of the key assumptions and risks identified at the outset was that key informant details would need to be provided quickly, and that they could be contacted and interviews scheduled within the first month of the project. It was known 15

4. FINDINGS This section sets out the findings of this review, as obtained from the primary and secondary sources outlined in the previous section. The first part outlines the process of implementation and questions related to how this process was carried out. The second half outlines the outcomes of this initiative, and how it was experienced by various beneficiaries.

The aim of the CDS was to prevent as much severe COVID-19 disease and death as we could as quickly as possible and to preserve the health system's capacity.

4.1 THE NEED FOR, ANTICIPATED PURPOSE AND OUTCOMES OF THE CDS INITIATIVE Before outlining the activities carried out by the CDS initiative and assessing the implementation of these activities and their outcomes, it is crucial to understand the need for the initiative, and what its anticipated purpose and outcomes. These were informed by the context in which the South African government sought to implement its vaccination programme, which will also be outlined. As discussed above, various role-players from different sectors of society had already been highly involved in the response to COVID-19. In early 2021 these bodies also turned their attention to how they might best support the vaccination programme. These role-players sought to align their intentions with those of the government’s Inter-ministerial Committee on Vaccines, which was constituted in January 2021 to lead the programme. This body, however, did not have a clear strategic vision at that stage. As Dr David Harrison, CEO of DGMT, also found at the time, despite the many different donor conversations with the government, there was no functional collaborative structure to enable government and private foundations to work together, a gap that quickly needed to be plugged:

“The private sector, through BUSA-B4SA,4 was also seeking to support. But it was quite interesting. I mean, in trying to understand what was going on I engaged with B4SA and trying to understand what they saw as the mechanisms of collaboration with government. And they outlined a very elaborate structure of cooperation. So, I came in thinking that we were late to the party, that all of these structures were in place, only to discover that, I think there was quite a big difference of opinion, or difference of perspective between B4SA and government, as to the respective roles and the existence or not of those collaborative structures. So when we came in, all of that stuff was still up in the air: there was not yet…except for a couple of overarching governance structures. But the operational structures for collaboration were not in place.” At its heart, therefore, the CDS mechanism that was established sought to build this collaborative structure and work with government in a genuine partnership, rather than in a

dictatorial manner, or in a way that set up parallel structures and implementing systems. This was a very important foundational aim, given that other funders and NGOs have sometimes been known to work in ways that run parallel to government, or possibly even dictate to it. This aim was also important in the context of the various corruption scandals which had engulfed the government’s COVID-19 response in 2020, with the risk that donors would not again seek to partner with government.5 The CDS sought to maintain control over the funds it raised, and to create confidence that other funds could use the mechanism with confidence, while still being a genuine partner to government. This aspect of the CDS, and its implications for the success of the initiative, will be discussed at length throughout this review.

At its most basic and straightforward, the aim of the CDS was to “[p]revent as much severe COVID-19 disease and death as we can as quickly as possible; and preserve health systems capacity.” 6 Bernadette Moffat, of ELMA Foundation, agrees that the motivation was clear: “We wanted to support the government to get vaccines into arms and to respond to the crisis initially.” Thashlin Govender, from another of the core donors (Dell Foundation), also articulated this direct initial aim of the CDS: “The Department of Health had a team, but their capacity was thin. We wanted to support the bureaucrats with their strategy, and how to implement the vaccine programme, so we could get the vaccine to the poorest and most vulnerable in the quickest and safest possible way. So we had a unique but compelling opportunity as funders to play this role.” Allan & Gill Gray Philanthropies does not normally focus on health issues but was attracted to work with other funders with this experience in a coordinated manner which could really partner with and assist the government. A fundamental reason for being involved was to ensure that the vaccination programme was as equitable and efficient as possible, explained Kirsten O’Sullivan of the organisation. There was agreement from the outset that the CDS would not be paying for the vaccines themselves: other bilateral donors had already been talking to the government for months about this aspect

⁴ Business Unity South Africa and Business for South Africa, two important private sector bodies involved with the COVID-19 response and the Solidarity Fund. ⁵ See Harrison, Harnessing the thunder, p. 31. ⁶ CDS weekly report, 10 September 2021; slide 3. 19

of support to the programme.7 Instead, the CDS would look to fund access to vaccinations through a multi-faceted support approach.

an effective mechanism; there needed to be an agency of support that could coordinate things, and yeah, very few foundations or funders are set up to do this.”

As alluded to in the above quotes, speed and urgency of response was a major factor that the donor group considered in January 2021. Other developing countries had already procured vaccines to inoculate their general population by that stage, but South Africa’s response was tardy, according to David Harrison:

The group realised, as Harrison explains, that “One of us is gonna have to step up to the plate to make this happen.” Because of DGMT’s deep experience in the development sector, and David Harrison’s public health background, it was decided that DGMT would be the key agency which would coordinate the combined efforts of the donor group. A memo was written and circulated to the five core donors, and this was later developed into the February proposal to the NDoH.

“We were already on the back foot by January. Brazil had already received its first vaccines for populationbased vaccinations. We were late on the market to procure and so it was just a sense that there needed to be momentum in the right direction… Phase One [for healthcare workers] had just been initiated so that was already underway and we could see there’s a mechanism now to vaccinate health workers, but how are we going to make the general public vaccines work? And so, yeah, it was to say we’ve just got to step into the breach and give support to get that on the way.” This desire for speed aligned with other important players, such as the Solidarity Fund, as Wendy Tlou explains: “Our aim was to be a rapid response vehicle, because government is not good at rapid response, but it has the reach and scale.” Dr Edzani Mphaphuli, who became a key member of DGMT’s core implementing team, argues that the NDoH urgently needed strategic support, technical skills and human capacity as they quickly became overwhelmed and had to continue managing their regular portfolios. Several members of the donor group – who already enjoyed a close working relationship – therefore convened to discuss the situation in January 2021. According to David Harrison, besides urgency, several other concerns drove their desire to meet and strategise together: “It obviously came off the back of the fairly chaotic first phase [of the response to COVID]…and you know the sort of thing that struck me there was just how much effort was being wasted by multiple approaches; very unstrategic approaches to government. Obviously there was the Solidarity Fund, and in a way the Solidarity Fund was set up to largely be reactive to requests from government and civil society.” Again, what these donors witnessed, according to Harrison, was that this “chaotic” and uncoordinated scenario was at risk of repeating itself in the context of the vaccine rollout: “We saw a number of other funders that were circling around the Department [of Health] but couldn’t really land. And a lot of it was just exactly this: that there needed to be

Within this context, Harrison explains the intended purpose of the CDS at the outset: “It had two main drivers: The one was that, given the unprecedented disaster, every sector had to take the lead and crowd in support. Secondly, it made sense for this to be a coordinated approach, especially from foundations who were willing to work together so that, you know, we didn’t actually end up causing distractions for government. So that they could focus on the task at hand while… in essence DGMT could provide the background corralling of supporting, particularly for foundations.” The need for this coordinated approach is echoed by Zameer Brey, of the Gates Foundation, who was quickly seconded into the core CDS support team.

According to Brey, the key anticipated outcomes were “To develop a coordinated mechanism for donors to support government”; “To influence big decisions around optimal vaccination strategy”; and “To provide a fast, flexible way to second and recruit skilled personnel to government.” Were these aims in line with the needs of the NDoH with regards to rolling out an effective public vaccination programme? Dr Lesley Bamford, a Child, Youth & School Health Specialist at the NDoH, who was put in charge of implementing the COVID vaccine programme, explains that indeed, the support offered by the CDS was welcomed, especially because the government lacked its own capacity: “So we have quite a strong childhood vaccination programme, but we’ve never had an adult vaccination programme. So… it was quite challenging. There was no system to slot into since we were starting from scratch. And there were some linkages with the childhood vaccination programme, but our vaccinators, who vaccinate from our childhood vaccination

⁷ Interview with Chris Austin & Tori Bungane, UK Foreign, Commonwealth & Development Office (FCDO), 20 March 2023. 20

programmes, are very embedded within child health services. So it’s quite difficult to quickly redeploy them to start vaccinating adults. So that was where the biggest gap was, and you know, government health services are not known for their flexibility and adaptability. And I think that was where the donor support really assisted us in very rapidly employing people who could assist with some of the coordination and setting up the vaccination systems.” Gaurang Tanna, who was also a senior NDoH official working on the vaccination programme, agrees that government capacity was stretched, and ran the risk of being even more so by having to “give bandwidth” to multiple funders, all with differing requirements. He explains that although smaller donors carry the advantage of agility and flexibility, they come with the “opportunity cost” of requiring taxing ongoing liaison which hampers service delivery: “You are spending less time on doing the actual delivery of the programme and more time on trying to coordinate donors.” The CDS mechanism, he argues, allowed for the flexibility and agility, while only requiring one point of contact.

The anticipated purpose and outcomes of the CDS was therefore in direct alignment with the needs of the government and the country for a rapid, coordinated, soundly governed pool of funding, using a mechanism which could assist the government with strategic and technical support, which was clearly needed. This mechanism would allow fast and effective recruitment and deployment of technical skills which would assist the vaccination programme to get up and running. It would also allow for multisectoral collaboration without the duplication of efforts by those seeking to be involved in the vaccination effort. Although not an initial aim of the CDS, the platform would in time also allow for innovation and the testing of new approaches for responding to health emergencies, and general development challenges. These are outlined in the following sections.

Dr Velile Ngidi, a long-time employee of the KwaZulu-Natal DoH, who became a Provincial Facilitator for the CDS, agrees that at provincial level the DoH did not have enough capacity to deliver the vaccination programme at scale. She argues that their existing personnel were pulled in many directions, and they did not have direct ownership over the programme, so technical support was needed to drive it. Gugu Ngubane, who represents the Solidarity Fund, also stresses the value of providing both technical support to the government, and assistance with planning and strategising: “So the whole idea of providing technical assistance and deploying human resources to the National Department of Health, to the provinces, to the district, it just makes sense because it was one of the areas of support that we had identified ourselves when we did a situational analysis of our own of what would be the areas and resources that would be required for the Department to be able to respond more efficiently. And therefore this whole collaboration provided that opportunity. I mean it has never ever happened … in our lifetime, that we are faced with a pandemic where you have to consider whole population vaccination, right? So that needed serious coordination and serious planning. And the reality of that is that whilst it is a mandate of the Department of Health to be good at planning, it needs far more people than just the Department of Health, because they are coordinating adults now.” Ngubane says this need for capacity and support became particularly important in the context of setting up new vaccination sites which did not overwhelm the existing healthcare facilities, nor allow people to crowd together in contravention of the social distancing regulations. 21

4.2 ACTIVITIES AND OUTPUTS FUNDED THROUGH THE CDS INITIATIVE This section provides an overview of the activities undertaken by the CDS initiative between February 2021 and June 2022. Further sections will provide more detail and analysis of the achievements, outcomes and effectiveness of these activities. A first major activity of the CDS was the coming together of the donor group in early 2021, and the drafting of a proposal to the NDoH in February 2021 outlining the group’s desire to offer coordinated operational and strategic support to the vaccine programme. This five-member donor group, outlined above, committed an initial R69 million over one year (March 2021–February 2022), on condition that the Director-General of the NDoH approach the Solidarity Fund to match this amount. An agreement was eventually signed with the Solidarity Fund for this funding (May 2021), and during the course of the project the initial investment by the core donors was increased to R82 million.

In all, therefore, the CDS raised almost R152 million to support the vaccine programme, but it was also able to become a lever for the raising of a further R574 million which would be channelled by additional donors through the CDS mechanism. DGMT was designated by the donor group to be the holder of the funds, and to manage them and the implementation of all the planned activities. DGMT then quickly established a Project Management Office (PMO), led by existing DGMT staff, who were seconded to the project. David Harrison was seconded full-time by DGMT to become the Project Lead, while a Project Manager (Sandra Ngwena), and a Financial Manager (Vanessa Rheeder) were also seconded from other roles. Administrative support was also made available to the PMO by DGMT. This PMO was responsible for coordinating all of the planned activities (with their respective leads), and reporting to the donor group and other partners on how the funds were being spent. Detailed weekly donor reports commenced in March 2021 and continued right through until June 2022, while comprehensive donor reports were also prepared for the 6-weekly meetings of donors and the managers of the various CDS activities. The CDS activities initially planned in February 2021 evolved over the project period, which concluded 17 months later. This evolution is best understood through Tables 1 and 2, presented below. Table 1 shows the originally planned output in the left-hand column, with specific aims in the middle column. The right-hand column summarises what these activities achieved, and more importantly how they gave rise to more robust or new activities in response to the changing situation.

Table 1: Summary of activities planned and implemented by the CDS

Original planned output/activity and target

Output as it evolved

• Recruitment of the core team

By 31 March 2021

In place by mid-April

• Recruitment of provincial and national capacity

50% by 31 May 75% by 30 June 95% by 31 July

Delayed – 81% achieved by October 2021

• Team of professionals recruited and seconded for technical support for vaccine delivery

Target of 174, conditional on needs analysis as provinces and districts refine implementation plans

243 appointments made over the project lifespan, most at district level

• Development of NDoH strategic plan rollout

Key elements of strategy defined

Provided direct support to vaccination leadership

Drafts based on wide consultation

Many versions refined and shared

Final draft submitted to NDoH for political approval

Official plan never signed off, but implemented de facto – with CDS working to ensure key elements of the strategy were protected

High-level implementation plans

All provincial plans put into place and updated

Business plans in place for use of conditional grant funding, outlining vaccination sites, human resource and management systems planning

All provinces submitted business plans

Sufficient sites identified and readied to meet vaccination demand (starting with one in every sub-district)

Over 3 000 sites in operation at the peak across public and private sectors

• Provincial implementation plans

• Adequacy of vaccination sites by province

Provided a range of IT equipment to vaccination sites, including tablets and barcode scanners KfW (German Development Bank) later provided a large amount of funding for DGMT to procure IT and cold-chain equipment for vaccine sites Vaccination outreach sites later added: With funding from Solidarity Fund, outreach became a major component of the programme, with 246 sites reaching the most marginalised. This activity was prioritised not only to push for uptake, but also to ensure vaccine equity

• Local (area-based) service delivery plans

Guide to area-based coordination and vaccine delivery

Guide and toolkit developed, refined and distributed after delays Empowered area-based teams an added output: NGO Challenge Fund introduced, enabling 112 grants to be given to local NGOs to support area-based teams CDS also enabled focused support for priority districts, as well as provinces, which struggled to implement the programme

Table 1: Summary of activities planned and implemented by CDS continues... 24

Original planned output/activity and target

Output as it evolved

• Plans for management of surge capacity

Approval and funding was secured, and the LEAN Institute Africa contracted to provide quality improvement for surge sites. Transport options were also explored to bring people to sites, but these proved less worthwhile than targeted outreach

Proposal approved by NDoH

Solidarity Fund support

• District-level information system

Effective district-level dashboards (combining EVDS and other management system data, linked to district monitoring and surveillance)

Lack of access to the EVDS and live data confounded this activity, but dashboards were developed and analytics performed using the inadequate/delayed data that was sourced

Distribution of tablets and barcode scanners to sites in need

This was achieved, adding capacity at district level

• Workplace sites

Sufficient sites identified and prepared to meet vaccination demand

Workplace sites not initially planned as an output, but an occupation health focus was quickly added. Although slowed by registration barriers, and reimbursement glitches, this was a major activity, in partnership with business and labour sectors

• Distribution of vaccine uptake by province

Dashboards of vaccine uptake

Although always a key activity, implementation was restricted by low access to live data in the EVDS

• Rollout of public communiations strategy for vaccine information dissemination

Effective call centre in place

This became the National Contact Centre

Phase 2 expansion of call centre

Not initially planned: three regional service providers appointed to spread reach of National Contact Centre

Communications plan integrating rollout data into public communications strategy

Working with multi-sectoral partners and through the Contact Centre, communications became a key focus of the CDS

Coordinated multi-media demand strategy

Not initially planned: In response to the urgent need for demand creation, a multi-sectoral Demand Acceleration Task Team (DATT) was put into place, undertaking many activities

The CDS platform also assisted to build EVDS functionality – ensuring WhatsApp and USSD registration channels were in place, and that primed and frequent SMS communications were sent to users

Introduced incentive strategies and other social mobilisation to reduce barriers among key groups KeReady youth programme introduced to generate demand among younger age groups • Integrated public–private vaccination programme

Alignment of B4SA and NDoH workstreams

B4SA slowed down its involvement, but made input to the workplace initiative Mobilisation of additional funding became a key activity as the initiative proceeded – including securing more from the Solidarity Fund for demand creation, mobilising funds for the NGO Challenge Fund, and negotiating with new donors such as KfW and GIZ to incorporate their support into the platform 25

For all of the above activities, project leads were recruited, and weekly donor reports included regular updates on all of these “workstreams”. Workstreams regularly reported on included: project management; national capacitation; provincial support; recruitment; vaccination delivery; information and communications; partner amplification; occupational health; civil society; contact centre; demand creation/DATT, Passenger Vaccination Transport; NGO Challenge Fund, outreach; and KeReady youth programme. As is apparent, these activities covered a full range of supply side and demand side activities to support the government’s vaccine programme. This table of outputs, however, does not tell the full story of the unfolding process of implementation in response to the COVID pandemic and the needs of the vaccination programme. In reality, as Project Manager Sandra Ngwena articulates, implementation had to be a highly flexible, responsive and innovative process, which developed over time: “The analogy we liked to use is we were building the train track as we were moving on it.” As can be seen in Table 2, which provides a high-level summary taken from weekly and six-weekly donor reports, many activities evolved in response to realities experienced on the ground regarding vaccine uptake, access or progress. For example, the outreach initiative was a direct response to the concerning inequities of vaccine uptake and availability in the early part of the vaccine programme. And the introduction of the Demand Acceleration Task Team (DATT) was a response to the urgent need to create demand and avoid stagnation as the programme progressed and supply-side concerns receded.

Table 2: CDS implementation timeline at a glance

Activity/event • CDS proposal to NDoH (6 February) • Agreement with foundation funders • First weekly donor report (26 March) • Core team in place by 31 March • DGMT commits R10 million, a further R138 million awaiting approvals • DGMT letter to Solidarity Fund for matching funding • 1 million J&J vaccines to arrive • Solidarity Fund approves funding for National Call Centre • Official agreement for CDS to support NDoH signed (26 April) • 533 individuals and 35 organisations apply for technical support positions • Solidarity Fund agreement signed • United States Food and Drug Administration (FDA) hold on J&J vaccines • Surge sites concept approved by NDoH • Redcap occupation health survey goes live • Call Centre goes live (17 May), averages 8 000 calls per day • Demand generation strategy agreed by NDoH • Procurement of surge sites ongoing – Lean appointed for quality improvement • Discussions with Uber to transport people to vaccine sites • CDS working well, but constrained by lack of access to key decision-making channels • Lack of access to EVDS data a blockage • DGMT escalates lack of system and data access to NDoH • DGMT and Yellowwoods allocate an extra R8 million for printed material • Regional service providers trained for the Call Centre • Pilot of SASSA queue outreach • Challenge Fund established, NGO screening commences • KfW discussions for procurement of IT and cold-chain equipment • KZN riots affect Call Centre work and vaccine delivery • KfW approve R225 million for cold-chain and IT • Regional service providers added to Contact Centre work

Month

Activity/event

February 2021

• Phase 1 (Sisonke Programme) commences

March 2021

• National strategic plan being “distilled” • Need for public communications flagged, driven by good strategy

April 2021

May 2021

June 2021

July 2021

• CDS team continues strategic inputs • Standard area-based planning and coordination unit approach adopted • National mapping of vaccine sites • Provinces prepare business plans for conditional grant funds • NDoH agrees to develop a communications plan • 3 357 vaccination sites identified

• USSD and WhatsApp platform goes live to 7 million users • 2 178 technical support applications • Phase 2 of the vaccine programme launched, 17 May • Digital Vibes Scandal breaks, undermining NDoH communications in particular • 450 tablets, 600 bar-code scanners and 27 laptops purchased for provinces • Occupational health stream goes live – companies register

• EVDS scheduling system acting as a break on uptake • Equity of vaccine access becomes a key theme – most vulnerable excluded • First discussions around outreach and SASSA queue strategy • DGMT allocates R10 million additional funding for NGOs to support area-based teams • 61 technical support personnel placed • Multi-media demand generation strategy agreed • Vaccine supply good – attention turns to demand generation • Solidarity Fund invests R144 million in demand generation (R20 million of which was channelled through CDS) • CDS shifts to more focused role

Table 2: Coordinated Donor Support Implementation Timeline at a Glance continues... 27

Activity/event • Continuing challenges with equity and occupational health site registrations • Improving access to EVDS data • 92 outreach sites running • Demand Acceleration Task Team (DATT) established • 33 NGOs sign Challenge Fund grant agreements • Recruitment of district communicators commences • DATT positioned as a key pivot for support • Selected EVDS data being granted • Desire for outbound calls to drive demand • 127 technical staff in service • 12 000 rides on Uber provided • Surge site viability questioned • First Vooma Weekend held (1–3 Oct) • First dose vaccines up to 25% • Bojanala District identified as a priority focus • 100 NGOs working with area-based teams • Digital Vaccine Certificates live • Vooma Vouchers to be introduced as a “game changer strategy”

Month

August 2021

Activity/event • Political focus on demand generation • NDoH transport proof of concept running • GIZ completes appraisal for funding • Mpumalanga turnaround strategy commences • 94 technical assistance personnel placed • Area-based guide and toolkit circulated to provinces

September 2021

• Introduction and planning for President-led Vaccination Vooma Weekends • High-capacity DATT appointed • National incentive programme idea explored • Good vaccine supply, over 3 000 sites active • Solidarity Fund agrees to reallocate deficit to demand creation

October 2021

• Roll Up Your Sleeve communications campaign launched • Sotho and Xhosa services added to Contact Centre • Planning for 1 November Vooma Voting Day outreach • Solidarity Fund rejects funding for incentives, but other funders agree

• Vooma Voting Day held • Vooma Vouchers launched • IT and cold-chain procurement to commence • 202 technical support personnel in service • Phased exit of CDS planned • Focus on Bojanala and other priority districts continues

November 2021

• Third Vooma Weekend • Omicron (4th) wave hits

December 2021

• Holiday period sees muted vaccine programme

January 2022

• Transition planning in place – integration into routine health services • DGMT prepares for handover • Outreach has 185 sites, 562 054 shots completed to date • Passenger Vaccination Transport campaign • Intensive radio and other communications ongoing

• Vaccine programme battles to restart after holidays • Restricted access to EVDS still hampering demand generation • NDoH continues refusal for outbound calls from Contact Centre • Demand generation turns to 18–35 age group, identifying value proposition

Table 2: Coordinated Donor Support Implementation Timeline at a Glance continues...

• Outreach sites increase to 100 • Vax Champs launched • Second Vooma Weekend successful • Post-election slump in vaccine demand • Temporary data dashboard being used to support delivery planning

Activity/event • Vaccine uptake still not recovered, strategic levers not available • Site closures a concern • Procurement of IT and cold-chain equipment going well • Breakthrough in API (application programming interface) for network providers to provide free data for vaccinated people • KZN SANTACO passenger campaign • KeReady2Flex challenge launched • Challenge Fund NGOs to help with youth mobilisation • Contact Centre – over 3 million calls answered • Scaling down of technical support to provinces • Right to Care to take over technical assistance • KZN SANTACO campaign a great success • State of disaster lifted • Outreach sites pass 1 million vaccines • 84 NGOs register for KeReady2Flex challenge • KfW provides 14 million euros to fund 37 mobile outreach vehicles for PHC in targeted areas. DGMT to procure and manage • Some views of the internal dashboard being incorporated into NDoH dashboard • Transition planning with NDoH • KeReady communications continues to target younger age groups as primary outreach vehicle • CDS completes handover to NDoH and RTC • CDS Close Out Report submitted

Month

February 2022

Activity/event • Outreach: 194 sites have completed 641 646 jabs • Three young doctors recruited to provide youth-focused message • School vaccines now a focus • KeReady programme of action for youth launched • Outreach: 211 sites complete 747 604 jabs by month-end

March 2022

• DGMT finally granted limited access to EVDS • Area-based guide had limited distribution • Outreach surges ahead: 253 sites by month end and 943 913 vaccines • Integration of National Healthcare Workers Helpline into Contact Centre • The CDS initiative, which was meant to close in March 2022, is extended to July, given the need for ongoing support.

April 2022

• KeReady campaign impacts starts showing in youth numbers • R21 million leftover CDS funds channelled to outreach and DATT • Handover to Right to Care commences

May 2022

• Cape Town Society for the Blind wins KeReady2Flex challenge • KeReady outreach brings at least a quarter of a million youth to be vaccinated in its first two weeks • Various aspects wind down and report

June 2022

• ELMA and Gates Foundation agree to continue funding Contact Centre • Planning for KfW mobile outreach implementation • Final Weekly Report (17 June)

July 2022

• No national strategic plan ever signed off, but implementation continued

In the following sections, these activities are further outlined, and their effectiveness and contribution assessed in detail. It is also important to put these activities into perspective in terms of the amount of funding that was invested in each. As Figure 1 shows, the bulk of spending in the CDS initiative (48 per cent) was on capacitating the government at national, provincial and district level with personnel who could provide high-quality technical support. This amounted to over R71 million during the course of the project, which was spent largely on salaries for over 200 individuals at different levels over the course of a year.

Figure 1: CDS budget spend on activities

Travel

R358 551

Service innovations R3 235 943 Project management costs R3 695 802 Youth campaign R5 387 230 DATT R5 791 677 Programme costs

R10 461 254

Offset strategy vouchers

R23 210 032

Demand generation R25 000 000 Personnel R0

R20 000 000

R71 023 173 R40 000 000

R60 000 000

R80 000 000

The next most significant amount was spent on demand creation, with the costs of establishing the DATT alongside other crucial demand generation materials and activities coming to R30 791 677 (21 per cent). The cost offset strategy (incentives) took up the next most significant portion of the budget (R23 million). Programme costs, project management costs and travel only took up R14.5 million (9.7 per cent).

That the balance between flexibility and sound governance was achieved is reflected in the views of the other funding partners in the CDS.

4.3 GOVERNANCE AND IMPLEMENTATION STRUCTURES AND PROCESSES: STRENGTHS AND WEAKNESSES Governance structures and processes

As with the management of any large fund, sound and robust governance structures and processes were essential. But in the context of the COVID-19 response, these also had to allow for speed, flexibility, responsiveness and innovation. In this section, we outline the governance structures and processes which were used for the CDS, and assess the extent to which they were fit for purpose within the COVID vaccination programme implementation context. First, a brief outline of the broader governance context is useful. As alluded to in the previous sections, the government response to COVID-19 was slower than required, given the nature of the emergency. Not only were these delays due to political or strategic deadlocks or barriers, but government bureaucracy, financial management systems, and tendering rules and regulations meant that fast implementation of crucial aspects of the response was hindered, despite there being an official state of disaster. State governance requirements also do not favour spending on innovative or experimental projects, which could be found to be “fruitless and wasteful expenditure” if they don’t work out. The Public Finances Management Act (PFMA) and the attention of the auditor general typically makes government processes slow and laborious, while government officials at every level are also forced into conservativism to avoid potential repercussions. There was therefore a clear need for an independent vehicle, unencumbered by government rules and regulations, but still managed soundly, which could receive and use funds quickly to deploy and procure critical resources into government. Professor Nicholas Crisp, who was the acting Director General in the NDoH at the time, sums up the governmental landscape and some of its barriers: “So never mind a crisis situation, even in an everyday situation, it’s actually ridiculous the way that procurement works and the way that people get employed, and government is just way too slow to respond to anything. So there’s absolutely no doubt in my mind that if there had not been a flexible approach with significant money to get competent people [it would not have worked] … And also because the salaries we pay are fixed, and the way in which we have to advertise, the periods we have to advertise, and then it’s got to be permanent employees, and then they’ve

got to go for competency testing and get their certificates verified, and … and … and … and … and – It’s just too many hoops to jump through! I mean, in my day job, I’m supposed to be building the National Health Insurance, and in five months, after advertising 44 posts, we managed to employ one person so far. Can you imagine trying to address a pandemic or even respond to an epidemic if you have to deal like that?” According to Crisp, far from preventing corruption and malpractice, these bureaucratic processes actually foster corruption at the same time as preventing effective service delivery: “I have been in the public sector before from 1984 to ‘99. I was even a Head of Department then. And then I came back 21 months ago. And what government has done is basically break every single system and make it almost impossible to do their work. So I’m not convinced that having all these socalled checks and balances improves the situation. What it does is it creates perverse incentives for people to defraud the system to get things done. So if it’s incredibly difficult for me to get a licence, or to get a this or to get a that, or if there’s inconsistent application so that I have to second guess the system, the easiest way for me to get what I want as a supplier either of goods or services, is to pay somebody to facilitate the process. What we do when we complicate the system and do away with its transparency, is make it even more likely to commit corruption.” Crisp is therefore in favour of the much more transparent and flexible governance systems adopted in the non-state sector. Indeed, as is outlined, the CDS did introduce a system that was much more fit-for-purpose than the one he describes. It did, however, have to be robust, to win the confidence of the donors who entrusted funding to the CDS platform. Wendy Tlou, of the Solidarity Fund (the largest single contributor to the CDS), explains that they in particular demanded a robust governance system before agreeing to make their funds available to partners such as the CDS: “We obviously were quite keen on making sure that funding went to the things that we had agreed that it would go towards and that there was proper M&E and impact reports that were submitted to us on a weekly basis, so that we understood where this money was going.”

She further explained that the Solidarity Fund ensured that it had very good contracts and reporting templates, and a team which monitored implementation closely. In this way, they ensured robust use of the funds, while still allowing for flexibility and evidence-based shifts in where the funds were being used. Gugu Ngubane, who also played a leading role in the Solidarity Fund, agrees that they ensured robust accountability and governance, while allowing for flexibility: “DGMT was responsible for reporting to us in terms of accountability against the human resource plan that was agreed with the Department of how many people are needed. And we were involved in some of the interviews as well. So there was control and there was proper governance in terms of making sure that the funding is properly managed … So we know that there’s so much corruption in this country. And the PPE scandal surfaced this very quickly, right? And, I say it was a necessary devil, because in the planning then the controls were more tightened. And so in terms of just anticipating risks, anticipating those kinds of gaps, where could corruption pop up in this? It then became just a natural way of planning, in natural design and the natural way of implementing and coordination. I mean we were tough… working with the Fund was difficult for service providers because of reporting weekly. And then doing one hundred per cent verifications of whether what you claimed you did is exactly what you did. It was very uncomfortable and painful for our service providers, but it had to be done because we learned lessons from the PPE scandal. And also having the Zondo Commission as a cloud over the country was really, really helpful because every time you do something you have to ask yourself ‘Is this the best value for money? Is this impactful? Will I be able to answer if I’m asked why did you take this 10 years down the line? Is this justified?’” These reflections from government and private sector roleplayers situate the balance between the kind of unencumbered flexibility and speed of response that was necessary, and the accountability that was still required: a balance that the CDS appears to have achieved. The model that was adopted by the CDS was influenced strongly by DGMT’s existing governance structures and policies, track record and personnel, as well as its close existing relationship with many of the partners. Approved funds were placed in a dedicated account, managed by DGMT and overseen by the DGMT board, CEO and CFO. All of DGMT’s normal governance and accounting controls were applied for the allocation and use of these funds, which could only be used in accordance with the various grant agreements and contracts with funders, grantees and service providers. Vanessa Rheeder, who was the Finance Manager for the CDS, explains as follows:

“We had a strong governance team. We had David seconded in, overseeing the whole project. We had Sandra Ngwena as Project Manager, who worked alongside DGMT for many years. So I think we found, from a structural perspective, having people who worked with DGMT, or DGMT employees, provided a lot stronger foundation than contracting new employees that hadn’t worked with the organisation before and that maybe aren’t also familiar with the NGO background and way of working.” Rheeder herself is a Chartered Accountant who was seconded to the team to ensure watertight accounting, reporting and financial management throughout the project. These personnel, including other role-players like DGMT’s chief financial officer, and DGMT board members, were thus an important aspect of the governance structure, and the confidence that funders had in it. David Harrison explains that the governance structure allowed several levels of flexibility depending on who the funder was: “So level one is DGMT, where we’ve got solid financial management structures, as you know. But we try and keep it as nimble as possible. We could turn around things overnight. Level two would be other foundation funders, most of whom were quite flexible and in fact had put their trust in DGMT, so they’re not requiring constant feedback, constant approval, but they basically said ‘you can go for it’. There were just one or two of them where we had to sort of keep getting some sort of approval from them. Level three is the Solidarity Fund, which became increasingly cumbersome over time. And level four, it would be the bilateral funders. So, in the main, because we were trying to make things happen fast, it was important for us to have the flexibility to use DGMT and some of the other core funders’ funding at our discretion, even as we waited, for example, for approval from the Solidarity Fund. And even where the Solidarity Fund wanted to give money, for example, to roll out mobile health services, but we had to wait for their strict governance structures, DGMT was able to put its own money at risk. Sometimes entirely its own money at risk; sometimes in partnership with some of these flexible funders.” Harrison explains that DGMT and these flexible funders were “[w]illing to put 15 million rand at risk to keep things moving from day to day, because it wasn’t huge amounts of money that we needed from day to day…And I guess the boards of all of these foundations just said ‘Look, we’re not gonna need to have to sign off at our quarterly board meeting on this: we trust you to make those decisions and to use the money as it needs to be.’ And, the quid pro quo was, you know, a weekly management report [where] there was a slide deck every Friday presented to the funders. So, you know the communication is what created the confidence… that’s a key one.”

Figure 2: A visual representation of the multi-layered governance structure of the CDS Each concentric circle represents not only the kind of funder and the level of oversight and control they required, but also aligns with the scale of funding they put through the CDS mechanism, or trusted DGMT to implement. DGMT is at the centre, as the fund-holder and implementer of the agreed CDS core activities and spin-offs.

Bilateral partners – highest level of oversight

Solidarity Fund – required DGMT to seek sign-off for deviations

Other core funders – trusted DGMT to make strategic deviations

DGMT – fund holder. Subject to all internal controls; goverance processes; grant agreement stipulations

Board oversight from all of the funders was therefore maintained throughout the project, not only through the detailed and evidence-based weekly funder reports prepared by the DGMT Project Management Office, but also through more regular communications where necessary. As explained by Harrison, smaller amounts to ensure day-to-day activities could continue unhindered, or to ensure that crucial bigger projects could be “taken over the line”, were put up by DGMT and the other core funders who entrusted DGMT to make these decisions. For other funders, or for more significant shifts in strategy around how funds might be used, DGMT used email communications to the board members to obtain quick and efficient sign-off. The normal process of waiting for quarterly board meetings was suspended in favour of a more immediate electronic sign-off process. Even the Solidarity Fund, with its stricter requirement, was able to adopt this faster method of governance, as Gugu Ngubane explains: “Just because it was an emergency and it had to be agile did not mean that governance had to be overlooked. So it still went through exactly that thing. Decisions that are made needed to be submitted, reviewed and approved, go to boards and everything. But you know what was beautiful here is that, for example, I’ll just speak for the Solidarity Fund. Our board met every week, every Thursday. Our EXCO met every morning at 7:30. So David will tell me there is one, two, three, four, five [things]. I’ll say ‘David could you send an e-mail please because tomorrow morning I will present it to our EXCO’. And our EXCO, that is a mixture of the board, the chairperson of the board, the deputy chair of the board and two other members, and then the executive. So every morning they were ready to review submissions and to then approve so that there is zero delay in terms of decision making. And when it’s needed, a full board: when it was a huge matter, our board was ready every day to meet at any time. Sometimes we would call a board meeting on a Saturday. Like literally something happens at six in the morning, there’s a board meeting at 2 p.m. and everybody would be there and they were ready. So we were in that unusual mode of work. So governance was not overlooked at all. Everything still went through those bureaucratic governance processes, but in a very rapid and unprecedented way. And so yeah, it allowed the whole thing to pivot: when new information came up, you weren’t just rigidly stuck to the same thing you agreed right at the beginning, but you could then pivot resources depending on what the various agreements and priorities were.”

The above detailed reflections are necessary to capture the dynamic yet solid way in which the governance structures worked for the CDS initiative, based on the reality that the Coronavirus was constantly changing, along with socioeconomic dynamics, and that the use of funds had to mirror these rapidly developing realities. That the balance between flexibility and sound governance was achieved is reflected in the views of the other funding partners in the CDS. Zameer Brey, from the Gates Foundation, commented as follows: “There were many times in the project we needed to shift course … and it could be on something relatively arbitrary. I mean we were running a 10 million US Dollar fund as we saw it, right? And we pitch an idea today about printing pamphlets, for example. Or providing taxis and transport for people to get them vaccinated. David was up for innovation, but he never dropped the ball on the due diligence. He would make sure we went back to the donor community; a quick e-mail and he’d say ‘Colleagues, this is not what we’ve discussed but it is an emerging opportunity. As the technical team, we fully support and endorse this, but we want to make sure that financially you’re okay for us to redirect funding from line item Y to line item Z, because we think that’s what the moment requires. But until we hear from you, we will not proceed.’ So I think it was just incredible, an incredibly smart, almost intuitive balance that David had of flexible governance. Flexible, but robust governance. And so I don’t think, as far as I know, there’s a single decision that we can’t trace back and say oh, David took his decision like unilaterally, or you know, one of the partners pushed an agenda, because there’s a paper trail of some sort.” Thashlin Govender of the Dell Foundation, who was also seconded to the core CDS team, explains that even though the Dell Foundation does not normally focus on health issues, it wanted to participate, especially in a co-funding arrangement: “We were very keen to participate. We were very keen to put our money into the same pot of funding as the others, but obviously wanting to make certain that governance and the financial kind of controls were in place. Because, you know, the last thing you wanted in a fund is putting money into this pool and then finding it getting lost, right? ... I think David and the rest of the team did an incredible job in providing weekly reports as well as monthly reports so that the donors were a hundred per cent aligned to what, or kept up to speed as to what was happening; where the blockages were, and what were some of the risks that we were trying to mitigate.”

For ELMA Foundation, the fact that the governance structures and budget were collectively developed at the outset was crucial, as articulated by Bernadette Moffat: “For us, it was bringing our collective experience in responding to emergencies. Plus, our long partnership with DGMT, plus the partnership with Michael and Susan Dell; with the Gates Foundation. It was bringing all of these collective experiences to how do we accelerate the response. It’s not as though DGMT was a new partner for us or an unknown. We knew them extremely well. We didn’t have to redo any due diligence with them. We negotiated with them and with other funders, a governance structure. That and the development of a budget – that was not solely the work of DGMT. It was the work of the collaboration, and obviously different partners came in at different times into this collaboration. But right from the get-go it was that we had to develop this budget together, we had to buy-in because it’s a crisis that you are going to have to make changes.” Her colleague, Zodwa Mbambo, agrees that the existing relationship with DGMT was one of the key strengths of the arrangement: “When we are working with a grantee like DGMT, where there are existing grants with them, it’s always easier for us to move forward. Like I said, in the beginning we would have accepted any other grantee that the government or other donors proposed, but for us, it’s easier to move quickly when it’s a grantee that we already have some partnership with. So … the due diligence didn’t fall away, but it’s the way that we work with an organisation that we are familiar with and that we already have existing grants with. It becomes a little bit easier because you already have all of their information and due diligence. And secondly, the grants management part of it didn’t differ significantly from how we manage all of our grants, even though there was some flexibility.”

Two implementing agencies of the German Ministry for Economic Cooperation and Development also took confidence in the CDS platform, and DGMT’s role in the CDS, to invest major amounts of parallel funding to support the health system and the vaccine programme. KfW Development Bank and GIZ both cited DGMT’s solid reputation, track record, previous work with KfW, and the faith that other funders had in the governance and implementation of the co-funded activities, as reasons they were confident to allow DGMT to manage large amounts of funding on their behalf. In the context of the COVID-19 pandemic both of these agencies, which normally provide financial or technical support directly to government entities, decided that it would be more effective to channel their funds through DGMT in order to ensure that its support for the government was guaranteed to realise swift results.

The fact that the CDS was a close partner of the NDoH, rather than working in parallel, was another crucial reason why these bodies chose the CDS and trusted DGMT to implement their grants. Governance of these funds was strictly controlled, in agreement with all parties. Matthias Hahl, from KfW, explains that just as in normal government-to-government cooperation agreements, both governments decided jointly about the implementation setup – in this case agreeing to implement the support through DGMT: “KfW concluded two Supplemental Financing Agreements with NDoH on behalf of the Republic of South Africa as the recipient of these funds. NDoH on-channelled the contribution legally to DGMT through a bilateral agreement (MoA). NDoH, DGMT and KfW concluded a tripartite agreement stipulating the details of the project.”8 The KfW contribution was not pooled, but transferred upon forecast to a special account opened by DGMT for the purpose of the project. Different agreements governed the two projects KfW channelled through DGMT as the larger one sought only to procure and distribute equipment, while the second project involved the procurement of mobile health units as well as for DGMT to manage the teams using these for over a year. GIZ also felt confident in DGMT and the CDS governance arrangements, over-riding an assessor who raised potential red flags regarding CDS governance, on the basis that these were unfounded and irrelevant.

Both partners were highly satisfied with the implementation and the way in which DGMT handled the funds and all aspects of the agreements. Interviewees from the corporate sector likewise felt that DGMT and the CDS governance structures were highly effective and robust, while allowing for an effective response. Of all those interviewed, the only possible governance concern was raised by Gaurang Tanna, formerly of the NDoH: “You know, I really can’t think of any clear downsides apart from the fact that, I mean, the one thing you do want to be cautious about is you don’t want a coordinator to be a player and a referee at the same time.”

By this, Tanna was suggesting that DGMT might potentially have undermined its governance structures because it was not only one of the core funders, but also the project implementer. He noted that some funders which enter co-funding arrangements prefer to contract an independent implementing agency to implement the project. However, this factor does not appear to have any negative impact on the governance or implementation of the CDS. Indeed, DGMT’s ability to put its own funds at risk to move things forward quickly was a major advantage, as was its ability to leverage additional funding based on its own strength as a grant-maker and not merely a project management firm. Implementation structures and processes Implementation structures and processes were closely aligned with the governance structures described above, and, as with governance structures and budget, were agreed through the collaboration of all the partners at the outset. These activities and how they evolved between February 2021 and June 2022 have already been described in section 4.2.

The initial focus on providing personnel, and technical and strategic support to the NDoH in order for it to roll out the vaccination programme determined that a strong core team was needed to drive the implementation. A Project Management Office, led by Sandra Ngwena, was established. This PMO, under the guidance of Project Lead David Harrison, drove the implementation of the various workstreams. By mid-April a high-level core team had also been recruited to lead these various workstreams, in partnership with senior NDoH counterparts. As Table 3 (below) shows, the core team was also led by David Harrison, with Edzani Mphaphuli and Theresa Mwesigwa heading up provincial and district capacitation. Zameer Brey (seconded from Gates Foundation) and Bridget Dube (seconded from Genesis Analytics) led the registration and communications component. Thashlin Govender (seconded from Dell Foundation) led the public-private service integration stream and the development of the area-based planning guide, while Candy Day was headhunted to work with data and information systems. Khumbuzile Bhengu was also hired to manage the development of the call centre. Each of these initial roles had senior counterparts in the NDoH, as shown in Table 3.

⁸ Email correspondence with Matthias Hahl, KfW, 25 May 2023. 37

Table 3: CDS core team and NDoH counterparts, May 20219

Technical lead David Harrison

Policy, public and partners

Management/ Systems

Drafting (and redrafting)

Delivery

NDoH counterpart

Call centre development

Lesley Bamford and Anban Pillay

Donor interaction

Popo Maja

Public communications Edzani Mphuphuli Theresa Mwesigwa Zameer Brey Bridget Dube Thashlin Govender

Partner amplification (Occupational health services)

Candy Day

Provincial & district capacitation

Provincial & district planning for rollout

Gaurang Tanna

WhatsApp & USSD support (registration and communications)

Service design, planning and site readiness (surge capacity)

Marion Schofeldt

Shaidah Asmall

Public private service integration (mining houses/public sector)

Area-based planning and coordination system toolkit

Barry Kistnasamy

Information systems support especially for area-based teams and districts, monitoring and internal comms (DoH) and data integration with private sector

Call centre development

Milani Wolmarams

Project management

Vanessa Rheeder

Financial Management

Helen Johnson

Administrative support

Shaidah Asmall

Thulile Zondi Popo Maja

Call centre project management

Sandra Ngwena

⁹ From 14 May 2021 Weekly Donor Report (slide 9).

Gaurang Tanna

Phase 1b support

Khumbuzile Bhengu

Chandra Roberts

Rob Botha

Popo Maja

While DGMT led the implementation, and the PMO was housed with DGMT and overseen by David Harrison, each workstream had its own leader, seconded from other organisations and each with their own expertise to bring to the team. This expertise added to and supported existing expertise within the NDoH. As Zameer Brey articulates, the structure actually mirrored the NDoH structures: “The donors agreed that, you know, David, for multiple reasons, was by far in the best position to lead from the donor perspective. But he would have some lieutenants, some folks that he could call on to support the different streams. And the way we set ourselves up was not as a separate structure, but to actually mirror the structure the Department of Health was trying to put forward. And so on that structure, it had somebody that would lead on service design, somebody that would lead on, I think there was data, there were a few different streams like demand generation. So the stream that I ended up leading from the donor side was around the service design and the model. And my counterpart at that time was Gaurang Tanna in the NDoH. And so the idea was to have a Department of Health official paired-up with the donor technical assistance.” Working with the PMO and NDoH colleagues, these leads implemented whatever activities needed to be undertaken to quickly and effectively deliver results in their workstreams. Over the course of the project, new skilled personnel were brought in to lead specific streams. For example, Angela Stewart-Buchanan and Lebo Motshegoa were brought in in September 2021 to manage the Demand Acceleration Task Team (DATT) and work on communications, respectively. Candy Day later shifted across to the National Contact Centre, while others such as Waarisa Fareed were contracted to lead the outreach strategy. Each of the workstreams also had teams working under them in various critical roles throughout the project.

good management policies and systems were put in place, mirroring existing DGMT systems: “There was a lot of transparency in the process around recruitment. And then there was another process around staff management, for example, and there were certain provinces reporting to Theresa and certain provinces reporting to Edzani and those two people were managing staff, they were managing compliance in terms of the policies that were put in place like travelling, getting travel signed-off beforehand and checking that people had come to work, those sorts of things. And dealing with disciplinary hearings if someone didn’t come to work and that kind of thing, with oversight from Sandra, the Project Manager. They’re all with the outsourced payroll provider, and every contract goes through Sandra, David and myself. You know, David signs all contracts, so there can’t be a case of any, for example, adding a fake person, getting the someone on the payroll through the team at all. And we were like the key role players.” Added to this overarching implementation structure and team, each of the specific workstreams and activities had their own implementation processes and structures. These are outlined, and their effectiveness and contribution assessed in the next section.

Implementation really did rely on human capacity as well as the leadership, structure and policies provided by DGMT and the core group. During the course of the project various organisations were also contracted to assist with implementation of particular aspects. For example, a recruitment agency was contracted to assist with hiring technical support personnel, a payroll firm handled salaries, and various organisations provided support in data analysis, quality improvement and so on. Vanessa Rheeder, who managed finances in the PMO, argues that implementation structures and processes were very good. For example, in the complicated process of hiring and managing hundreds of technical support personnel in every province,

4.4 THE EFFECTIVENESS OF CDS ACTIVITIES, FACTORS ENABLING AND CONSTRAINING SUCCESS, AND THE DEGREE TO WHICH INTENDED OUTCOMES WERE ACHIEVED

This section focuses on each major activity implemented by the CDS, in collaboration with other partners, and their effectiveness and degree to which their planned outcomes were achieved.

Mobilising the core team The core team, as outlined in the previous section, was quickly agreed upon by the funder group, with David Harrison leading, and two other funders seconding senior people to play critical roles. Harrison was able to use his extensive network and history in civil society to bring others such as Candy Day on board, while DGMT seconded other staff onto the team. This high-performance core team was in place by mid-April 2021, only two weeks after the initial target of the end of March. The leadership of this team was crucial. As Zameer Brey, himself a member of the team argues, Harrison provided excellent leadership due to his position and experience, which allowed him to lead both the donor group and other stakeholders: “David’s ability to navigate the network of organised labour, or business, or other government departments [was key], being that he was in a very unique and advantaged position. I certainly think David was exemplary throughout the process. I think his strategic ability to synthesise something fairly complex into one slide or one page was exceptional, and his ability to keep the donors’ attention captive by reporting regularly and robustly.” Brey also mentioned humility, the ability to listen to all sides, yet not “sugar coat” the challenges, and his commitment to social justice and equity of access as crucial qualities Harrison brought to the team. Zodwa Mbambo, of ELMA Foundation also feels that Harrison’s leadership was essential for the NDoH: “I will say that had David not basically been seconded into government to lead this technical assistance effort, implementation would have been much more limited. The fact that he was seconded into government and therefore could, on a daily basis, work with the limitations … in terms of streamlining decision-making [was critical]. As difficult as it was to get decisions, it would have been almost impossible without having that technical assistance and leadership in NDoH. So I would say they were very effective in that

regard. Would another person other than David have been that effective? I think there are not very many people who could do that. And so in that regard, I think David was unique in terms of his knowledge of civil society, his knowledge of government systems and his expertise as a public health person.” One of the key reasons why this leadership and the core team was so valuable is, as Lesley Bamford points out, because government role-players were overstretched at the time: “I guess one of the other challenges is even though there were people in government who could have driven it, you all had your own portfolios and work plans and strategic things that you still had to try and drive, and nobody had a specific mandate to only run the vaccine programme. Which I guess must have been a challenge and why this was quite a welcome intervention as well.” Michael Currin, a DDG in the Government Communication and Information System Department (GCIS) felt that the core team’s approach and integration into government was good, and created a true partnership: “They really were outstanding, and also the manner of the approach, the professionalism, the collegiality. It really, really was a value-add all round. Nothing I could say to you like ‘You know what, these guys dropped the ball here.’ Some people say I’m easy to please, but my approach to life is you’ve got to give credit where credit is due, and if there is a problem you point it out. Honestly, I’d be hard pressed to say there were any problems.” The other members of the core team and PMO played a fundamental role in assisting the NDoH to implement the various aspects of the vaccine programme, as is shown below. The PMO’s role in coordinating the wider teams, communicating, reporting to donors and other partners, liaising with stakeholders, and contracting service providers also can’t be ignored. Indeed, without this central logistical fulcrum, implementation would have been impossible. The mobilisation,leadership and work of the core team (including those added later in 2021) was therefore highly successful and critical to the success of the whole CDS endeavour. A key success factor was the way the team positioned itself as a true 41

partner, and integrated itself within its government partners. Besides the NDoH, which clearly felt that the core team was of high value throughout, other government partners also felt that the approach of the core team was perfect, as Michael Currin articulates: “The posture was, you know, that we add value, we are partners, we have the same vision, we have the same end goal – we use, we leverage, we improve [what government is doing].”

Development of NDoH strategic rollout plan

One of the most important tasks of the core team was to quickly assist the NDoH to develop the strategic rollout plan and ensure that it was implemented. As key government role-players such as Lesley Bamford and Gaurang Tanna attested, government required support because its own strategic minds were stretched in many directions at that point. A challenge from the outset was that the CDS proposal to the NDoH was submitted in February 2021, but the official agreement was only signed at the end of April, which meant that these first crucial activities were conducted outside of an official agreement and in a limbo situation. This presented the risk of the CDS core team working in parallel with the government, rather than feeding in as proper partners to the process. Nevertheless, the core team pressed ahead with the strategic planning process while also cultivating the partnership with colleagues in the government. The aim of the process, as recorded in a 20 April 2021 presentation to the donors, was to “Build an effective national strategy for implementation that all critical stakeholders support and want to be part of”. The approach, as also outlined in the presentation, was to first develop a range of key objectives, and then to define strategies for each objective. An objectivebased planning approach was used, which sought to ensure all of the necessary “cogs” were in place to drive the vaccination strategy. These included ensuring effective leadership; ensuring financing and procurement; effective management systems; public trust and confidence; plans for supply and demand; areabased coordination; vaccine safety; regulatory compliance; and the mobilisation of human resources and all sectors of society. Clear communications were identified as a golden thread linking all of these objectives. Five “key pivots” were also identified to drive the vaccination programme: ensuring effective leadership and clarity; maximising the speed of national rollout; ensuring fair and efficient access for all; standardising delivery processes to ensure quality; and minimising service transaction times. ¹⁰ See Weekly Donor Reports 26 March 2021 and 16 April 2021. 42

Activities were closely aligned to these objectives and key pivots and are also reflected in the areas which the CDS then invested in. The development of this draft plan was followed by a review process, with the Inter-Ministerial Committee, and the National Vaccine Coordinating Committee, to ensure that both the strategy and operational plan were clear. The team worked closely with Lesley Bamford (NDoH Lead: Implementation Planning), Anban Pillay (NDoH Lead: Procurement and Contracting), and Popo Maja (Public Communications) in this strategy development and review process. Where weaknesses were identified, further analysis and operational planning took place, refining the strategy, before broad agreement was sought for the final strategy and it was incorporated into the national strategic plan for phases two and three of the vaccination programme. Numerous drafts of the strategic plan were produced and circulated to obtain input from a wide array of stakeholders. The final draft, based on this broad consultation was then submitted to the NDoH. On 20 April, it was reported (in the weekly report) that “The plan is being used internally, but is still being politically negotiated”. In fact, this strategic plan would never be signed off and released, as the July 2022 CDS Close Out Report testified. However, this strategy was implemented despite this lack of political sign-off, something the CDS team had no control over. The lack of official clarity had knock-on effects, for example on the speedy development of a clear public communications strategy.10 The core team therefore made concerted ongoing efforts to get the plan finalised. In the 30 April weekly donor report it was noted that the “impasse” with the National Implementation Plan was “unlocked”. However, in the 7 May weekly report, it was noted that the plan was still “caught in a washing machine between the Ministry and the NDoH.” The same report stated “We have taken it as far as we can and it is up to the DG to finalise it.” Zameer Brey feels that despite no official sign-off, the CDS input into the strategic plan was a key achievement of the initiative: “I think our ability to influence some of the big decisions, I would give that a tick. And using data and evidence, So, for example, the policy decisions – within days and weeks, debating what would be the most optimal vaccination strategy. And ultimately, the one we proposed became The Strategy! I mean, we don’t need to take credit for that, right, and it certainly was a collective decision with the Minister at the helm. But the point is to keep it simple, we agreed that age should be the only way we approach this, for multiple reasons. But at the time there was a prevailing narrative that said ‘Oh, we’ve got to think about co-morbidities and the firemen, etcetera’.”

As Brey suggests, particularly with the lack of official adoption, the core team had to fight to protect the initial strategic logic of the plan. For example, in the 2 July funder report, it was recorded that the agreed age-based strategy was still being undermined: “there is increasing erosion of the age-differentiated approach through accommodation of different categories of essential workers and poorly managed opening of registrations to 50+ years of age”. As time went on the plan was implemented de facto, with the support of key government officials, even if it never enjoyed official release.

“What we were trying to do is get the capacity in place for the acute situation, that was as efficient and operated in as integrated a manner as possible. We wanted a really smooth machinery. What we didn’t want is to have two engines. In each province you wanted one engine, and you didn’t want people to waste time fighting over who does what. So it absolutely made sense for us even if it was for a temporary period, to try and ensure that from the outset and from the operational point of view everybody operated in an integrated way within some line management structures.”

A factor that hindered the ability of the core CDS team to influence policy, at least at first, was that despite the partnership with the NDoH, the DG initially did not “allow access of CDS team to the highest level NDoH decision-making structures” (June 2 weekly report), leaving the team feeling they were “operating behind a veil”. However, the team used this time to focus on key activities and strategies to get the plan rolling, without the need to sit in time-consuming meetings. When Nicholas Crisp was appointed Acting DG of Health in the middle of 2021, the relationship and access to government partners radically improved. Nevertheless, as shall be outlined below, throughout the CDS initiative, there were issues that the core team had to continue pressing the NDoH on, most notably their access to the EVDS.

Lesley Bamford agrees that the speed at which the CDS mechanism could establish a management platform and bring in capacity was crucial:

Despite the ongoing work this took, this strategic input was highly effective, contributing significantly to the achievements of the vaccination programme, as recorded in the donor report of 14 March 2022: “We made the case and pursued to adoption the proposal for age-based sequencing (as opposed to the ill-defined groups – essential workers, people with co-morbidities, those in congregate settings and people aged 60+ – which were intended to be the first group.) The consequences of our work were that relatively high vaccination coverage was achieved in people aged 50 years and older…”

Providing national and provincial capacity through the recruitment and seconding of professionals to support vaccine delivery As outlined in section 4.2, the augmentation of national, provincial and district capacity was the central activity of the CDS initiative, accounting for 48 per cent of the total budget. The aim of this activity was to provide technical skills without DGMT or the CDS creating a parallel or competing structure, but rather to fully integrate into government structures. David Harrison articulates that this was important because of the need for a quick response:

“For the most part, all the vaccinations were delivered by Government officials, if we talk about the public sector. But there wasn’t a management structure that could rapidly have set up that service delivery platform. So, I think from a service delivery point of view that was really very helpful that [the CDS team] were able to step in, and quite quickly put vaccination coordinators in place at provincial level, in a way that government would not have been able to do, because our recruitment and appointment processes are at the best of times, quite slow. And we were also under strain during the pandemic.” The appointment of Dr Edzani Mphaphuli as the national lead for provincial coordination was a fundamental part of ensuring that this management structure for capacitating the provinces and districts was in place. Mphaphuli worked closely with all provincial structures to ensure that there was full collaboration in the process, arguing that she was fully seconded to the NDoH and that provincial departments did not see her as coming from outside, but rather as someone working within government. Each Provincial Department of Health was tasked with the development of implementation plans for vaccination rollout, as well as business plans for conditional grant funding (from Treasury), outlining vaccination sites, human resources and management systems planning. Mphaphuli’s role was to provide strategic support and guidance to the provinces in this process, and especially to identify human resource gaps which needed to be filled. She was aided in this guidance and consultation process by specifically recruited provincial facilitators, employed by DGMT but seconded to each province. These provincial facilitators supported the DoH Vaccine Coordinators in each province. According to Mphaphuli, through this consultation and planning process, they identified technical support needs in five main areas: • • • • •

Cold-chain and logistics; Vaccine management (including pharmaceuticals); Data analysis and IT support; Communications; and Area-based planning and coordination. 43

Each province determined which of these particular skills it needed at which level and in which place to support its COVID-19 vaccination rollout. But, as David Harrison explains, timing and practicalities ensured that the selection of skills had to be structured: “It was a reconciliation of top down and bottom up. We had to define in broad terms the categories of staff we wanted to hire. There’s no way we could recruit bespoke for every single district in the country. So, we said broadly these are the categories at a provincial level, there are three roles. One is, let’s say, general health systems support, which gave a lot of latitude. The second was cold chain and IT and the third was EVDS support, so more information and informatics as opposed to IT procurement, or IT systems. At a district level there was the health systems support, and it was the EVDS or data systems or MIS support, and then, as you know, we then approached NGOs and asked them to second, and we paid for the secondment of a communications support person into district management teams just because many of the district management teams did not have specific communications personnel on board. So that was the framework and the approach. And then we could go to the provinces and say ‘Is there a need for any further refinement of this?’ And there pretty much wasn’t, because their needs were pretty universal. But the important thing for us was that all of the provinces were involved in the selection of the candidates. So at a district level, at a provincial level, the recruitment of the candidates was done jointly by DGMT and by Department officials at that level, and before DGMT signed the agreement, it had to be signed off by the Department that they were happy with the candidate.” Weekly reports from 2021 report on this ongoing collaborative process of technical skills recruitment, as shown in Table 2. The PMO, together with Edzani Mphaphuli and the provincial facilitators, spent much of the year engaged with the process of advertising posts, receiving thousands of applications, triaging these applications, creating shortlists of suitable candidates, interviewing shortlisted candidates, selecting these candidates, contracting them, and placing them in the government unit they were being deployed to. This was an extremely difficult and laborious process which had time-based targets for the recruitment of 174 skilled individuals – later increased to 243. The initial plan was for 50 per cent of capacity to be filled by 31 May 2021, 75 per cent to be filled by 30 June, and 95 per cent by 31 July. The first two targets were not met due to the delay in the launch of the project, but by early June recruitment was in full swing, and 84 per cent of the revised target was met by November 2021. Most technical support personnel were placed in the districts, peaking at around 150 individuals across the provinces between November 2021 and March 2022. ¹¹ See the project Close Out Report, Page 17, for more details. 44

Provincial and national support peaked at about 25 individuals in each category.11 The process of finding, at short notice, suitably skilled and available candidates willing to work on a short-term contract in outlying districts presented challenges. An under-capacitated team had to put in long hours to ensure this urgent capacitation process took place, as Edzani Mphaphuli explains: “In the team there was no HR support, so basically there was no funding for HR support within the team. So we basically were everything HR … It would have helped if there was an HR person in retrospect on board. They would have slowed down the processes for sure because I’m sure they would have wanted to stick to the book. But it would have helped in terms of the stress levels in the team. Just the sheer load! Like, I was literally – there were days where we would be spending like the whole week going through, shortlisting, going into the morning – 4AM! Because we need to have the short list, do the interviews tomorrow, and be in interviews up until like 9PM at night. So it was hectic, but it had to be done. I think we were all in that period of ‘If this doesn’t happen now, the country is at risk’. And everybody understood that and that’s what made the team work because there was a big goal which was much bigger than ourselves.” In some provinces this process was more difficult than others, necessitating collaboration with NGOs to second their staff for a year to DGMT, so that they could be further seconded to the government. By April 2021 35 NGOs had applied to participate. According to Project Manager Sandra Ngwena, this did not work as well as envisaged, with sticking points arising around who would cover longer-term benefits of these employees, among others. In the Eastern Cape, where it was particularly difficult to find candidates, an NGO – Beyond Zero – was commissioned to provide capacity in that province.

Despite these challenges and the delays and slower than planned rollout, the recruitment and placement of these technical support staff at provincial and district levels was largely effective, although there were differences between the provinces. How well integrated were these personnel within the units they were placed in, and how effective were they at assisting with the vaccine rollout? Sandra Ngwena argues that the level of integration was encouraging:

“I think even we were surprised at how well integrated they were. Because we had done it in such a deliberate way and required the partnership and buy-in of government at all levels before we even spent a penny or put a foot anywhere, they were extremely well integrated into the system and it worked surprisingly well.” David Harrison also holds a positive view of the effectiveness of the integration of technical skills personnel: “It was almost fully integrated and it really was. Inevitably there were some initial questions and we’re obviously painting broad brush strokes here. I mean there were some skew bristles, but in the main, that’s the day-to-day problemsolving that’s required to make an undertaking like this work basically. But if you just step a little bit back from that, and not that far back, they were amazing people and a great operation. There was never a sense from the provinces, a sense of resistance.” Nicholas Crisp also felt that in the broad view, the secondment of technical support staff was effective: “The people that they managed to recruit were pretty competent – the kind of people who don’t want to work for government anyway!” Edzani Mphaphuli, who had a birds-eye view of the placement and integration process across provinces was also positive about their impact, arguing that if there was no technical support in the Northern Cape and Mpumalanga, their vaccination programmes would have “collapsed completely”, while the Eastern Cape would have also struggled. However, there is a more nuanced story to tell, which includes not only these positive broad outcomes, but also the realities and challenges of trying to place a large number of skilled people nationwide in a very small timeframe. Lesley Bamford expresses this reality thus: “I think the single biggest factor was that it was speedy, and with some flexibility. But speed was of the essence. And then they recruited people, you know, as always it was a mixed bag. But a number of people were very skilled and very competent and stepped up and took the lead.” Gaurang Tanna, who was also a NDoH official at the time, holds a similar perspective of the realities: “The national guys were quick because I think David headhunted them, and we could get the right skill. At the provincial level, it was very much a mixed bag. There were some provinces where they just couldn’t recruit. There were other provinces where they recruited really good technical assistants. And then there were some provinces where they recruited, but really not good quality – we could do without those. I actually think that was just because the skill availability sub-nationally is low, and also you must

not underestimate the fact that this was like a one-year appointment. Not many people want to change jobs for a one year position…And, by the way, you were looking for some really specialist skills: you were looking for people that had some public health experience that were either data scientists or a technician by profession, so the narrower you go the smaller the pool of people you can recruit from… And we had to be a bit more specific, mainly because there was no time to train them to really hit the ground running. So, you needed people to hit the ground running, and you wanted skilled people, but then you also had a very small pool of people to recruit from.” The provincial facilitators from the Free State, KwaZulu-Natal and Gauteng who were interviewed were largely positive about the placement, integration and effectiveness of the technical support staff, although they too raised inevitable challenges. Dr Velile Ngidi, who was the KwaZulu-Natal facilitator, felt that most staff were well integrated, but that they could not find cold-chain and pharmaceutical staff, despite this being a pressing need. Ewan Harris in Gauteng felt that there was good integration of staff at provincial and district levels and that the technical support personnel and government staff “really worked closely together and formed friendships”. He did, however, concede that this good relationship took time and there was initial suspicion. Department of Health district officials from all three of these provinces likewise felt that not only had technical support personnel been relevant to their needs, but had also contributed positively to their work. Jabulani Mndebele, Chief Director in charge of districts and the COVID vaccine rollout for the KwaZulu-Natal DoH, stated the following: “The intervention came at the right time. We had no policy guidelines, we had to develop these and we learned as we progressed. This was a totally new disease so we thought China was too far away from us, and did not prepare. Dr Ngidi and the three technical support people in the office transformed the response to COVID in dramatic fashion. Policy guidelines were developed, reporting mechanisms were designed, data capture moved from manual to EVDS, and turnaround improved: a problem could now be solved within 48 hours.” Dr Mzobe and Jacob Sikwane, district officials in Gauteng’s West Rand similarly stated: “The Technical Support came in handy you know and this is not only for the district, but it came in handy for the province, because I must say that when we started our uptake was a bit slow.”

Dr Mpho Shabangu, of Tshwane District, added the following assessment:

“The availability of the technical support lessened the burden placed on staff and also improved reporting strategies. Systems were developed to help daily aggregation of data. This proved effective because province wanted these figures daily.” The Western Cape, however, provides a mixed picture. District official Hillary Goeiman was very positive: “The quality of seconded personnel was so high that it took them a short time to integrate with us. We never felt like we had outsiders at every level in the province. It was a great relief having the technical support team and the resources provided by the DGMT. It helped take things forward quicker. Each COVID wave was equally met with a committed wave of staff that responded fast, and five million vaccines were administered. The technical ground work was enormous, so the technical support had to be equally prepared.” However, her colleague in the Western Cape, Dr Giovanni Perez, while largely positive, questioned the quality and input of some of the placements. He argued that the Department was already quite well capacitated and that some of the technical support personnel were disappointing and offered little besides being a “useful pair of hands”. Indeed, he felt that his unit would only have wanted to retain 40 per cent of the individuals seconded to them, who were providing a useful function in the data analytics field. However, a senior Western Cape Provincial DoH official, Dr Hassan Mohamed, expressed no such qualms, pointing out that the personnel were “indispensable” because the unprecedented scale of the response and the speed required necessitated the deployment of extra skills. Experiences and perspectives of technical support staff themselves were also obtained from every province, through five in-depth interviews and the survey which 33 individuals responded to. The survey results indicate that their experiences of being placed and of integrating into their respective government units was largely positive. Eighty-five per cent of the respondents were placed at district level, and 57 per cent were supporting EVDS and data analysis. Table 4 provides the key quantitative results from the survey, illustrating that most technical support personnel had a positive experience, felt well-integrated, and believed their contribution was good.

Table 4: Key survey results Good – 54.5% Overall experience of working with government

Excellent – 36.4% Average – 9.1%

Success in helping department reach its goals

Highly successful – 81.8% Partially successful – 18.2% Very well integrated – 66.7%

Integration into government unit

Well integrated – 21.2% Partially integrated – 12.1% Well – 60.6%

Extent to which department achieved its vaccine goals

Very well – 33.3% Partially – 6.1%

Experience of recruitment

Experience of placement and support by DGMT

Very good – 84.8% Good – 15.2% Very good – 77% Good – 23%

Some of these positive findings are reflected in the qualitative reflections of interviewees and respondents:

“Coordinated effort from all levels of structures to strategise plans. Having weekly technical support for each subdistrict was very much fruitful” – survey respondent, North West.

"Having technical support personnel made a huge difference, especially having someone who hit the ground running. Having worked for Department of Health and having knowledge about COVID-19 and vaccine rollout background, and knowing people in key areas within the department, I was able to take a lot of the work load at the district and worked with minimum supervision to speed up the workload” – survey respondent, North West

However, there were also some negative experiences recorded by interviewees and survey respondents: “Well, I received no introduction to the unit. I was literally just told when to start and asked if I have received the tablet. So it would not have been a very good experience to someone who did not at least know some of the people in that government unit” – survey respondent, Western Cape. “There was no time for a proper induction, but it was okay in the circumstances” – interviewee, Western Cape. “Poor support from districts” – survey respondent, Limpopo.

“I found the Department of Health in Limpopo to be the best. The technical support team was warmly received, valued and well-respected. This helped us to quickly integrate. They even asked me to stay, and the officials were not territorial. The department staff really appreciated the technical support for many reasons: One, they could focus on other things; two, decisions were going to be based on data evidence; three, they had no expertise to run the Health App so they had an opportunity to learn. But it was also the first time this approach was used, so there were a few challenges at the lowest levels where staff members had not received proper explanations about our secondment” – interviewee, Limpopo. “Among the best experiences of my career” – survey respondent, Free State. “I worked very well with people I was placed under, we had a good rapport” – survey respondent, North West. “They were really welcoming and warm to me” – interviewee, KwaZulu-Natal. “In the end after our contracts lapsed we had managed to make the DGMT well known for steam rolling vaccination in Ehlanzeni” – survey respondent, Mpumalanga.

“My role was not understood” – survey respondent, Gauteng. “Department of Health did not appreciate the guidelines laid out in the vaccine rollout template, hence they experienced challenges” – survey respondent, Mpumalanga. “Other DGMT staff members that did not perform and it increased my workload. The DGMT support to deal with internal DGMT staff issues should improve. Disciplinary procedures should be strengthened” – survey respondent, Western Cape. “The district I was supporting was huge. I couldn’t reach some sites as they were far away from me and I wasn’t supposed to exceed 1 000 km travelled in a month. This made it difficult for me to reach all sites in a month” – survey respondent, Free State. “The pandemic led to a significant increase in demand for technical support services as many individuals and organisations shifted to remote work and online learning. Technical support personnel had to manage an increased volume of requests for support, which could be challenging to handle” – survey respondent, Mpumalanga.

“We helped with timely information and continuous improvement strategies on rollout plans” – survey respondent, KwaZulu-Natal. “Supporting the implementation of vaccine registration and tracking systems: Technical support personnel helped ensure that vaccine registration and tracking systems are designed and implemented effectively. This involved troubleshooting issues that arise during implementation and ensuring that the systems are secure, user-friendly, and accessible to all eligible individuals” – survey respondent, Mpumalanga. 47

Supporting provincial implementation plans

Technical support personnel most commonly reported large distances and lack of transport as key personal challenges they faced. They raised similar challenges faced by them and their colleagues in the course of implementing the vaccine rollout. Almost half cited difficult-to-reach target groups as a challenge they faced; poor communications were cited by 39.4 per cent of respondents; large distances to cover were cited by 33.3 per cent; lack of key resources were an issue for 30.3 per cent of respondents; inadequate demand creation was an issue for 30.3 per cent; poor coordination was cited as a concern by 21.2 per cent; and vaccine misinformation was seen as a challenge by 18.2 per cent of respondents. Interestingly very few cited limited access to data and poor data quality as a challenge (13%). There were inevitably problems with recruitments not working out for various reasons, or with disciplinary issues in some provinces. The PMO was responsible for dealing with such cases, but human resources support was later brought in to assist. The quick nature of deployment does seem to have undermined induction processes, and some staff clearly were not able to “hit the ground running”, as was intended. Overall, however, the experience of this technical support was positive, and it contributed greatly to the achievements of the vaccine programme.

While the PMO of the CDS initiative had direct control over the recruitment of the core team and of the technical support personnel for provinces and districts, outcomes such as assisting with provincial implementation plans sought to support key elements of the vaccination plan, but were not under the direct management of the PMO. As alluded to above, Dr Edzani Mphaphuli and the nine provincial facilitators worked very closely with the DoH Provincial Vaccine Coordinators in the drafting of these implementation plans. As a result, provincial implementation plans and business plans were drawn up, identifying key strategies and resources needed. Some provinces were delayed in this process and needed more support than others. However, by July 2021 all provinces had drawn up plans, and these were being improved and refined on an ongoing basis. Lesley Bamford’s above opinion that the CDS supported the fast development of a management structure for implementation is backed up by the assessment in the 14 March 2022 Donor Report (slide 3) that:

"A key achievement of the initiative was that “[we provided the implementation backbone for the vaccination programme at provincial and district levels, through the contracted support teams.”

Five “key pivots” were also identified to drive the vaccination programme: ensuring effective leadership and clarity; maximising the speed of national rollout; ensuring fair and efficient access for all; standardising delivery processes to ensure quality; and minimising service transaction times.

Local area-based service delivery plans These plans also had to be developed by districts, outlining exactly how their area-based teams would implement the vaccination programme. The CDS initiative supported this process in two main ways over and above the technical support personnel they provided. The first way was in the development of an area-based guide and toolkit which local teams could use to effectively plan their service delivery. The need for such a guide and toolkit had been identified in April 2021, when the concept of a “Standard areabased planning and coordination unit” as a unit of replication was adopted.12 At that time, the urgent mobilisation of areabased vaccine delivery unit teams was also a priority. The CDS assisted these teams by developing the guide and toolkit. Thashlin Govender, an epidemiologist seconded to the CDS core team from the Dell Foundation, played a particularly important role in the development of the guide. He explains the guide and its development thus: “The toolkit was around being able to define what areabased teams were…and then what was the call to action, and what were the facilities and the equipment that we needed to be able to create in order to run a vaccination programme. And so it was basically putting all of those resources into one document that could be given to a vaccine area-based team, and allowed them to be able to have a much more coordinated approach to pulling in people and actually implementing the vaccination programme. There were many iterations and versions of it – David would know. David had the scars of writing the strategy for the vaccination programme that took the form of many, many versions. And I have the scars of writing the vaccination toolkit, and it was many, many versions. And it gives you the sense of how complex it was as well, in being able to get folks within the Department aligned on certain things. Because typically, it’s a perfect storm, right? You have this huge sense of need, people are dying, it’s the singular focus for the country, but there were still things that basically made things move slow and it wasn’t moving as fast as one would have anticipated.” Despite the partnership with government and urgency of the situation, Govender feels they still had to do the normal laborious brokering and workshopping processes to get it signed off, printed and distributed. In mid-May 2021, the draft guide was circulated to the provinces,13 and in early August it was approved for distribution:14

¹² Weekly Report, 20 April 2021. ¹³ Weekly Report, 14 May 2021.

¹⁴ Weekly Report, 6 August 2021. ¹⁵ Weekly Report, 25 June 2021.

“I still felt like I was caught in the cobwebs of the bureaucracy. Were the teams able to take the toolkit and make it work generally even in different provinces? I guess the challenge is that different provinces have different platforms, different systems, different leadership. And, you know, I’m sitting here having written it, I don’t know whether every single district received it, whether every single community health centre received it. Perhaps they did. I also don’t know as to how they followed it and whether it was helpful. There would need to be an evaluation done downstream around that, you know, order to be able to report about whether that asset was actually useful or not. But was it made available? I can say yes, we worked on it, we made it available, it was a core part of the budget.” The guide and toolkit was undoubtedly a valuable resource for area-based teams, but its distribution and widespread use seems unfortunately to have been suboptimal. In the Weekly Report of 14 March 2022, it was reported that the area-based guides had limited distribution, and no clear plan for getting them out to where they needed to go. Again, this was out of the control of the CDS as it was up to the NDoH to circulate them and ensure they were used. With this reality in mind, by the end of June 2021, DGMT allocated an additional R10 million for NGOs to participate in area-based teams “to bring public, private and civil society together”.15 The companies Tshikululu Social Investments and Discovery also became involved in funding this endeavour, which became known as the NGO Challenge Fund. In the Close Out Report, the results of this endeavour are recorded: “A total of 112 grants of R100 000 were awarded to NGOs across all 52 districts to enable their participation in areabased teams and respond to some of the key local challenges (especially transport).” However, it is also noted that of these 112 NGOs, 45 per cent were found to be “very effective” in this role, 35 per cent were “fairly effective”, and 20 per cent were seen to be a “poor investment”. Nevertheless, this use of NGOs was a major support at district level and assisted in empowering area-based teams in many districts. Along with the secondment of district communicators, the Close Out Report notes that “setting up this infrastructure … proved to be a vital cog in driving communication to sub-district level.” As the vaccination programme went on, it also became apparent that certain districts were doing particularly badly, and that more intensive support would be needed for them. Indeed, the provincial support team in Mpumalanga embarked

on a turnaround strategy in August 2021 because the whole province was falling behind. By October, Bojanala Platinum District (North West) was identified as a priority focus area for CDS staff and NGOs assisting the area-based teams. This district became a “flagship” project for support, with Zululand and uMzinyathi Districts in KwaZulu-Natal also flagged for support in November 2021. In 2022, eThekwini was added as a focus for intensive support. These focussed support efforts assisted these districts to recover and perform better with their vaccination targets. Ensuring adequacy of vaccination sites This is again an outcome of the vaccination programme which the CDS supported without being in control of it. From a strategic perspective, the core team strove to ensure that the government adopted the most sensible approach, where areabased planning was implemented, which could reach the most vulnerable in as fast a time as possible. The aim was not only to ensure that there were enough sites in the right place, but also that each site was adequately capacitated. Aside from the rapid capacitation of many ordinary sites, the need for 10–15 mass vaccination sites in strategic places was also identified, for an anticipated surge in vaccination demand. By mid-April 2021, national mapping of sites was taking place, along with the development of a site typology, and the description of the end-to-end site process and required logistics. This process fed into the development of the provincial implementation plans, which the CDS assisted.

The strategy adopted was to identify and capacitate one vaccination site in every sub-district as a start, adding more where demand was higher. At its peak (November 2021), there were over 3 000 active sites operated by both the private and public sectors. As reported in the Close Out Report, slow reimbursement of private sites and lower than expected demand led to the premature closure of sites in the early part of 2022. Indeed, in the 26 February Weekly Report it was noted that there was an urgent need to “prevent a ‘death spiral’ of low uptake and site closure”. This trend was not arrested. On 8 April 2022 it was reported that there was low enthusiasm for vaccines, and that “The reversal of these trends will require some form of external shock.” To assist the capacitation of vaccination sites, the CDS procured and distributed 450 tablet computers, 600 barcode scanners and 27 laptops in May 2021. Many of its technical support personnel were also placed at the sites to bolster their capacity in various ways.

The CDS mechanism was also able to leverage significant additional funding from KfW, the German Development Bank, to properly capacitate vaccine sites: R225 million was approved in July 2021 for cold-chain and IT equipment, which DGMT was to procure. Unfortunately the required international procurement procedures meant that the cold-chain equipment only arrived after the vaccination programme had downscaled, but it has been highly useful for the longer-term capacitation of provincial DoHs, and their readiness for future pandemics. The upsurge in measles cases in late 2022 and resultant mass vaccination campaign benefited from the newly installed cold-chain infrastructure in over 2 300 clinics. As recorded earlier, technical support personnel raised challenges which suggest that vaccination site adequacy was uneven, even if they were largely positive about their ability to deliver vaccines. Almost a third said lack of key resources hampered their work, while the 40 per cent of respondents complained of poor communications. Almost half of respondents raised the problem of difficult-to-reach target groups, a third complained of large distances to cover. All suggest that many vaccination sites did struggle to adequately reach their goals. It was because of these issues that the outreach strategy was introduced later in 2021 (see below), and that the NGO Challenge Fund was established, along with the placement of district communicators across the provinces. Again, some feedback from technical support personnel who completed the survey, along with other interviewees, is useful in highlighting vaccination site deficits: “These posts should’ve been filled earlier or as soon as the campaign started. As the IT infrastructure needs affects the quality of the data and a lot of audits had to be done in order to rectify problems” – survey respondent, Western Cape. “Given the limited resources at district, sub-district and facility level, much could have been achieved had vaccine storage and transportation conditions been less stringent. Increasing cold-chain capacity at facility level was all that was required, at least in the district I was supporting” – survey respondent, Free State. “The programme was viewed as ‘An add on’ by staff ... leading to poor achievement” – survey respondent, Gauteng

“I know that at times the things that we have identified as a district as a need, they could not be fulfilled entirely by the partner, in this case DGMT. Not because they did not want to, but because they also have their own limitations. And in terms of monitoring and management of adverse events, there’s still a limitation in the human capacity. It was about two people that were identified from the district covering more than 50 facilities” – district officials, Gauteng.

given the lower than expected demand”. Perhaps had there been another very serious strain of COVID at the end of 2021, resulting in a spike in deaths and hospitalisations, these surge sites would have been as important as they were planned to be, and the work of Lean would have been better welcomed. As it was, the surge sites were closed down in the first months of 2022 as demand fell dramatically. District-level information systems

”In the Eastern Cape we have only 58 per cent of our facilities having network coverage, and that’s if and when ESKOM has electricity, otherwise it is even worse than that! Furthermore, as technical support, I was responsible for cold-chain capacity building. South Africa as a whole has had major gaps in cold-chain capacity…” – technical support interviewee, Eastern Cape. In early May, the NDoH approved the concept of surge capacity sites in three large provinces; the Western Cape, KwaZulu-Natal and Gauteng, with funding from the Solidarity Fund. To support the development and smooth running of these surge sites, the CDS appointed the Lean Institute Africa Institute to provide quality improvement services to each of these provinces. Partnerships with several transportation providers, including Uber, were also initiated to increase access to these surge sites. While several sites were established in the metropolitan areas of these provinces, Lean found it highly difficult to work meaningfully with them. As repeatedly recorded in Weekly Reports, and by Lean CEO Samantha Allen, only in the case of the surge site at the Cape Town International Conference Centre did Lean have any significant input into helping them design their systems and processes. Even in this case, they faced change management and resistance issues from provincial staff. They were provided a personal introduction at this site, which helped them to play their intended role to some extent. At the Athlone surge site, however, where there was no personal introduction, they did not have any success in assisting them, while a similar scenario unfolded in Gauteng and KwaZuluNatal. To properly play their role, Allen argues that better highlevel introduction was needed, along with proper local-level introduction to surge site managers.

The main challenge was really that the envisaged surge “never materialised”, as recorded in the CDS Close Out Report. Demand dropped 45 per cent from October to November 2021 “as the eager and willing sub-set of the population completed their vaccination”. In fact, as early as 23 September is was reported that although operators had been identified, “the viability of this [surge site] approach is now in question ¹⁶ Weekly Report, 23 April 2021. 52

One of the key ways in which the CDS envisaged ensuring that vaccination sites were adequately capacitated and functional was through supporting the functionality of district-level information systems so that districts could analyse and use their own data to coordinate their response.

This applied not only to where they should put key resources such as vaccines and vaccinators, depending on demand trends, but also to how they used communications and demand generation to ensure they could reach their vaccination targets as quickly as possible. In other words, access to data was crucial for both supply-side and demand-side activities, especially in the urgency of the emergency. Because of this, Candy Day was seconded to the CDS core team for a year specifically to lead information systems support for area-based teams and districts, as well as to support DoH monitoring and internal communications systems, and support data integration with the private sector. She was seconded from the Health Systems Trust, with a background in pharmacy, data visualisation and working with information. Like others in the core team, she had NDoH counterparts whom she was meant to work with closely. Ideally, she and the technical support personnel in every district should have been provided with full access to the EVDS so that they could develop data dashboards to assist each district to run a highly datadriven and responsive vaccination delivery programme.

Access to the EVDS data was probably the greatest challenge and barrier faced throughout the CDS process. In April 2021 it was recorded that the NDoH had agreed that a dashboard from EVDS data would be desirable.16 A month later (28 May Weekly Report), data access is noted as a challenge while on 2 June it is said to be the “biggest constraint”, with the issue being raised in writing with the NDoH. The core team persevered with their attempts to show the government how

valuable access to EVDS data was. On 25 June it was reported that the team was “working to ensure data is being used more proactively, but it remains a challenge”. One strategy the team adopted was to create “a mock-up management dashboard that provides suggestions on data visualisation and use for NDoH”.17 Despite this clever approach, full access continued to be denied, and the team relied instead on second-hand and outof-date data from the EVDS, supplied to them from sympathetic officials on Excel spreadsheets. By 17 August it was reported that there was slightly better access to data, with the Weekly Report noting that “we know what but not why”. The same report also recorded that Candy Day would work with Gaurang Tanna to support data analysis, a positive shift as previous contact persons had seemingly proved obstructive. A slow positive shift was observed by the beginning of September, with the 3 September Weekly Report recording that “Selected data access has finally been granted”, allowing analysis of vaccine coverage and the identification of focus areas for demand generation. Despite these small wins in the last quarter of 2021, the 21 January 2022 Weekly Report again raised that “restricted access to the EVDS continues to hamper demand generation”. It was only in the first week of March 2022, eleven months later, that DGMT was finally granted better access to the anonymous analytics component of the EVDS. By this time the urgency of using a data-driven rapid response had passed.

According to a range of interviewees, this lack of access to EVDS was a major factor constraining the work of the CDS and their ability to support vaccination sites and contribute fully to the success of the programme. For a start, Candy Day was unable to play the role she was seconded to play, as she explains: “There were a number of primarily political obstacles. And being on the outside of the Department of Health and with the particular personalities involved, basically we received access to the underlying information system in month 11 of 12, which was of course quite challenging because for 11 months of the secondment I was practically unable to do much of what I had been employed to do. We did our best to work around it in the sense that we still provided input to their team. We kind of came up with conceptual frameworks and suggestions and guidelines around how the monitoring and evaluation could be done.”

Day explains that several “champions” had to take personal risks to provide what little data was available “in order that we could do the analysis and have the information needed for planning and response.” This was far from ideal, though: “We often had to work in a very inefficient and frankly insecure way, and it was actually putting the data at greater risk, not being able to just access the system directly, but having to work with Excel csv exports of increasingly large datasets, and then try and do some planning and analytics from that. But a major obstacle to that is by not having the detailed broad level data you can’t do any linkages; you can’t do simply some of the more sophisticated analyses. I think one of the big shortcomings of the programme is that there was much less transparency with the data than would have been desirable, and there was much less use of the data for informing implementation and assessment of the programme. I mean everyone was really hampered to a large degree and there was a lot of distrust about sharing and using the data at every level. And it wasn’t something that affected just us.” Sandra Ngwena, like many other interviewees, also feels it was the biggest challenge and missed opportunity of the initiative: “The biggest difficulty we had with this project from a government point of view was access to data. Even though we were partnering with government and had people working on the EVDS, actually getting access to the EVDS data was a fight – a bitter fight to the end, and was really one of the big shortfalls for us in terms of our ability especially to be reactive. Even how they shared the data internally: the province couldn’t get access to the back end of the EVDS to be able to know at a sub-district level how many people got vaccinated … It wasn’t POPI [the Protection of Personal Information Act], we checked:18 there was just a bit of a structure internally within the Department of Health and within what was the EVDS team which really created such a barrier to our ability to be reactive in the best possible way because we just couldn’t get to the data at the necessary level … It was flagged as a real missed opportunity that you have created this platform that gives you all this data, but you’re not segregating it to the districts, to the provinces, in a way that allows them to be targeted. It has been a real missed opportunity.”

¹⁷ Both quotes from 25 June 2021 Weekly Report. ¹⁸ Ngwena is referring to the fact that DGMT sought a legal opinion on POPIA and access to the EVDS data, which confirmed that POPIA should not have been a concern. 53

Despite many letters, emails and calls to the NDoH, gaining full access to the data was ultimately something out of the control of the PMO and the core team. Zameer Brey reflects on this reality: “There were a few battles which we just did not win. And they were battles in my mind that should never have happened to start with … a simple issue was that we never had access to the vaccination data. So this is not individual data, this is aggregated data, by facility, by sub-district, by district, by province, etcetera. We were asked to fly the plane blindly. We were asked to change direction blindly. The data we would be given would be inadequate. And so, it dawned on us at some point that we were being asked to do things that we just couldn’t do in a way that was grounded in real data, but we were sometimes guessing … And I think that what we ended up – I mean I don’t know what the headline on this one should be – but I feel like it was the worst example of POPIA applied to a crisis. That those five letters were dangled so many times in front of our faces that I still have a sinking feeling that it – the way the data was held closely – compromised our ability to be more responsive.” It was not only members of the CDS who were frustrated about the lack of access to EVDS data. Officials in the Western Cape revealed that for three months in later 2021 they were provided with proper EVDS data which enabled their data analysts (including technical support personnel) to work on it. This allowed them not only to establish a call centre to contact almost 8 000 people who had not come forward for their second vaccination, but it also allowed them to conduct neighbourhood analyses which told them which areas of the province needed a particularly strong demand generation focus. Interestingly, after Dr Giovanni Perez requested more than just a daily summary report, he was provided with regular Excel spreadsheets showing names, phone numbers, dates of first vaccination, and addresses, which allowed this level of analysis and real-time response. This Western Cape experience shows what might have been. However, three months later, officials in the NDoH put a stop to this data access, citing POPIA regulations. The effectiveness it added to the province’s response was lost. According to Perez, the fact they had seen the potential of working with the data in a sophisticated way made it very painful to no longer have access. He argued that the Western Cape should have launched its own EVDS as it had been planning to do, rather than using the national EVDS, so that it could have maintained control over this data, and thus its response. Top NDoH officials who were asked in interviews why there was this data-access problem emphasised that the government has a responsibility to protect their clients’ personal data, and they could not simply release it to other parties, even if it would have improved the vaccine response. In the light of the widespread fraud associated with procurement of personal 54

protective equipment (PPE) and the Digital Vibes scandal in which sound procurement processes were bypassed, the Office of the Auditor General was a stickler for detail. There was clearly a nervousness about the new strict POPIA regulations, which came in during the COVID pandemic, but also a suspicion about releasing data to civil society partners. Even Gaurang Tanna argued that providing partners with access to the EVDS is a “double edged sword”. But he also revealed that part of the challenge had to do with the way the EVDS was designed, and the speed at which it was designed. While top NDoH officials like him were highly aware of how critical it was for districts, in order for site managers and area managers to be able to access the data and use it for their complex planning and rapid response purposes, the EVDS designers, working under great pressure, concentrated largely on the data-capturing functionality of the platform. This means, as Tanna explains, that: “The tools that were needed for that kind of decision making, I’m afraid that wasn’t really available at the speed at which they were required. And it took a little while to negotiate access. And I think then also when access was provided the tools were developed in the way the team thought that would be most useful, rather than asking the service team to shape the tools and what they would look like. Because it was the end user who knows what shape and size and format they need the data, and not the people who generally collect the data from the system. So the tools weren’t really ground-checked with the end user, and they weren’t really given a chance to be co-developed.” On top of this reality, Tanna explains that the EVDS team were also wary about giving access to outside parties as they felt that they would not have the training to interpret the data properly: “I do think the team was maybe a little bit overly cautious in thinking that if we give this data to a person who doesn’t know how to interpret data, they may misinterpret it and it will put the Department in a somewhat bad light, you know. So they saw it as a kind of a risk.” Because this EVDS data access was so inadequate, CDS reports concluded that this was one of the major areas in which they failed to make an impact. In the Donor Report of 14 March 2022 it was recorded that “[w]e failed to persuade the NDoH to allow for broader analysis and utilisation of data – the vaccination programme has been driven with the handbrake on.” The Close Out Report similarly records the following assessment: “This has been one of the most significant weaknesses of the vaccination programme. A reluctance to enable local health services managers to analyse their own data has constrained local responsiveness and likely contributed to a lack of programme momentum. Some of these data are available centrally on public dashboards, but not in sufficient detail to enable operational planning.”

This issue, and how to ensure proper access to data, without the hindrance of political and bureaucratic barriers, and regulations such as POPIA, is one of the major lessons of the CDS experience, which needs to feed into planning for future health emergencies.

requires engagement with the occupational health stream within the Department of Health, the private sector etcetera. So we actually had a team, and that was their mandate and work that they did.”

Workplace sites

On 10 September 2021 it was recorded in the Weekly Report that there was growing use of private sites by the uninsured, partially due to the availability of these occupational health sites. By 22 October, it was reported that occupational health sites had provided 485 000 doses so far, but later in the month reimbursement challenges for private providers was flagged as an issue. By the new year, declining demand meant that many private and occupational health sites were looking to close down, and by the end of March this stream entered a period where the focus was on reimbursements, handover and exit reporting.

The occupational health workstream was an important element in ensuring that the vaccination programme reached not only the most vulnerable members of society, but also the most valuable members whose rapid return to the workplace was critical after months of lockdown measures. The CDS did not have direct control over this aspect of the vaccination programme, but it collaborated strongly with partners from the private sector and organised labour to ensure the most effective strategy to enable workplace sites to vaccinate their workforces. Early on in the CDS journey, getting workplace sites registered to provide vaccinations was a prominent discussion point on the agenda. In early May 2021, the Redcap survey was launched, to gauge occupational health site capacity. In its first 24 hours, the survey had received 1 000 responses, according to the Weekly Report of 14 May. By 21 May, it was reported that the Redcap survey had 18 750 responses from companies representing a combined one million workers. Later in the month the occupational health stream (of the vaccination programme) went live, with 90 sites getting their registration expedited so that they could start vaccinating their workforces. However, from the outset, registration of these sites proved laborious and challenging. One month later, occupational health site registration was still ongoing, with blockages in the registration process still being experienced. Despite these challenges, employers in the mining and automobile industry, among others, were successful in vaccinating their workforces at occupational health sites. Sandra Ngwena explains that the next challenge was to try to pivot these services to reach more broadly: “The mining houses were exceptionally well-equipped to implement rollout because they have their own standing occupational health clinics. Every mine actually has a fullyfledged clinic and services. They just had to get registered to be able to vaccinate, and they could do it. But that means that they vaccinated their people incredibly quickly, and then you have the site that was geared up to do it, but wasn’t doing anything. So in terms of that occupational health stream, we had the discussion around how do we get those companies and entities that have an occupational health structure to vaccinate more broadly than that. But that

By the end of the initiative, more than 800 000 vaccinations had been administered by the occupational health sites, a significant contribution to the overall achievements of the programme.

Rollout of the public communications strategy Although assisting with the communications strategy was an aim of the CDS from the outset, the extent to which the CDS would be involved with funding and implementing the communications strategy was not anticipated at the outset. As Sandra Ngwena explains, the May 2021 emergence of the Digital Vibes Scandal meant that the NDoH needed much more comprehensive support: “Another arm we ended up getting involved with was communication around vaccines, which had not been anticipated. But again…the reality of what happened was the Digital Vibes thing kicked in at the beginning of 2021. So the Treasury froze all communications budget for the Department. So they had exactly zero rands to provide communication on vaccines. So, our fund actually ended up paying for the pamphlets, the languages, the signage that was needed at the vaccination sites … So because of that, we actually ended up having to have a communications arm of people who played a very active role. And we brought in a communications Project Manager to work directly with the Department on the website, on the content, on the material, on everything. So communications ended up being one of the frontiers that hadn’t been planned for.” Indeed, so important did communications support become that a separate report is probably needed to do it full justice. This section summarises its main achievements, contribution, 55

challenges and limitations. Weekly Reports show that communication was very much at the forefront of the CDS thinking from the beginning, with early reports bemoaning that clear communications were not possible until the strategic plan was developed. Very soon, a good relationship was established with the communications unit within the NDoH, with agreement by the end of April 2021 that a communications plan would be developed (23 April Weekly Report). One of the key gaps that DGMT had already picked up in its previous COVID relief work was the lack of a proper, integrated, national call centre for COVID information. The National Health Laboratory Service (NHLS) had a call centre, but its capacity was already overwhelmed, as were other existing regional call centres. What was needed was an integrated inward and outward-facing communications platform, which could be a point of contact for citizens, as well as a platform for data and insight gathering that could feed into the response. Andy Searle of Business Process Enabling South Africa (BPESA), the industry body for global business services, explains that South Africa has seen the rapid growth in the call centre subsector in the last seven years, with up to 20 000 jobs being created in the sector per annum. In this period, South Africa has become known as a reliable delivery destination by companies in America and Britain in particular. BPESA was not only centrally involved in the growth of this industry, but also had good links with government and social partners such as Harambee. This, according to Searle, helped BPESA to make for “A good partner that could mobilise quickly to support the Department of Health when it came to standing up a communications centre at very short notice and at quite a sizeable scale.” He further explains the genesis of the plan by civil society and private sector partners to come together to support the government in this area: “David [Harrison] had connected with the chairman of our board, who was working with Harambee at the time. And they were discussing about the DoH communications solution and they noticed that there was no call centre component. And with the networks we have – globally, we had been following the progress in the UK in their COVID response, using industry to supply their call centre, and suggested doing the same locally. And so David and the DG Murray Trust, together with others…engaged with the Department of Health and said ‘Let’s do a similar thing’, and they coordinated putting together a proposal. So that’s how the sector got involved to use its capabilities, to use its experience to support the Department.” In February 2021 it was hoped that the call centre could go live by 1 May, a very quick turnaround. As it turned out, the Solidarity Fund only approved funding for the National Call Centre in later April. In the interim, however, the CDS and BPESA were able to do a lot of groundwork, including the contracting and selection of role-players, such as Project Manager Khumbuzile Bhengu, 56

and partners who would supply personnel. All contracting was facilitated by DGMT and signed off by BPESA and the NDoH. The national call centre eventually went live on 18 May 2021. Searle explains that this innovative partnership and unusual approach was necessary to ensure rapid mobilisation and sound delivery: “I think it had a very positive and important impact on the rollout. So, first of all, in terms of giving citizens confidence in the Department’s own response – you know their DG and Ministers were communicating updates on the vaccine platform and the call centre, which they would not have been able to fulfil had they not followed this model. So, for example, through the contracting process we were able to mobilise everybody under a letter of intent, as opposed to a signed contract. And we only had four days, having signed that letter of intent, to have a hundred people trained, ready and switched on to go live, and equipped to support citizens’ calls across the country. You know, four days! And that was achieved. And the mechanism to achieve that was through these contractual letters of intent – which the government does not work that way. And it gave citizens a lot of confidence that those channels of communication are open for them to query, find out…The services were very quickly extended from English into multiple languages across the country. The call centre operated across the country specifically to cater for that.” Although the setup of the call centre was outsourced to BPESA, it needed skilled health communicators to develop content, train the call centre agents and be the interface between BPESA and the NDoH. Because Candy Day’s role in data analytics was hindered, she moved across to support Khumbuzile Bhengu on call centre management, and to ensure that it was data driven, that messaging was aligned to the rapidly changing pandemic and response, and that there was proper monitoring of performance and outcomes. BPESA was able to ramp up or down the call centre capacity in response to fluctuating public demand for its services – something it could do because of its close ties with the larger call centre industry, which could second and reabsorb agents as required. This was a key factor in making the call centre cost efficient yet agile and effective in the context of rapidly rising and falling demand for information as COVID waves and other factors played out. Likewise, the ability of Bhengu, Day and their team to retrain call centre agents, and adapt their messaging in response to real-time events was a key success factor. The addition of regional service providers Altron (Port Elizabeth) and Sigma (Johannesburg), joining the KwaZulu-Natal centre, created the successful architecture which spread the risk of floods, riots or strikes, enabled agility, and accommodated callers seeking information in different languages. This enabled the establishment of what came to be called the National Contact Centre.

Demand was high for the service that this Contact Centre offered: within five days of launching, there were 20 000 calls.

By the end of May, it was reported to be “building momentum”, with 9 000 calls received per day (28 May Weekly Report). The Contact Centre continued to develop well, with more efficiencies and monitoring systems being added, although the July KwaZulu-Natal unrest did curtail the ability of the team in that province to do their work. The appointment of the regional service providers late in July mitigated similar potential disruptions. As demand-creation activities were ramped up from September 2021, the role of the Contact Centre in running campaigns and driving demand increased, for example through the Vooma Voucher campaign, launched in November 2021.

By March 2022, the Contact Centre had handled three million calls, helping callers with a range of vital first-line issues, such as EVDS registration issues, appointments, access to vaccine certificates, and general enquiries. The partnership with the NHLS call centre allowed for referral of clients to qualified nurses for second line support, while further referral to doctors also became possible. By the end of June 2022, 3.5 million calls had been fielded. Throughout the lifespan of the CDS, the National Contact Centre also sent out millions of SMS communications to people registered on the EVDS, providing reminders and health information to them. Over time, WhatsApp and email services were added, expanding the ways in which clients could be assisted. However, despite the clearly positive impact of this vital component of the COVID response, the major drawback was that the NDoH never provided permission for the Contact Centre to call those who were shown in the EVDS as having had one vaccination, but who were not coming forward for their second shot. Numerous attempts were made to persuade the NDoH to allow for this outbound call function, which could have enabled many more people to be fully vaccinated. However, POPIA was cited as the reason that this was not possible, and permission was never granted. Even the tenacious David Harrison conceded that he eventually gave up on the issue. In the Western Cape, where this function was possible for three months, almost 8 000 people were called, with agents able to assist many of them to overcome the barriers preventing them from coming for their second vaccine. This suggests that had this been possible through the National Contact Centre, it would have played a valuable role in driving demand. It also may have increased people’s confidence that the government

cared and that the system was working well. As it was, the Weekly Report of 4 February 2022 concludes: “A few strategic levers at our disposal have not been used optimally [such as] outbound calls for second dose defaulters.” The Contact Centre was but one service aimed at ensuring the success of the public communications strategy. Indeed, in strategy models for the CDS it was positioned, by September 2021, as a key “bridge” (along with area-based team activation and support, and district analytics) between the demand side activities and the supply side activities needed for vaccination programme success. On the demand side the “communications dynamo” became increasingly important, especially in the context of falling demand and growing misinformation and conspiracy theories.

The CDS therefore played a key role in driving the communications strategy through multiple content development and communications streams, to support communication across multiple channels, including the NDoH’s SAcoronavirus website. In this endeavour, they participated in a multi-sectoral joint platform called the National Communications Partnership, set up by a range of stakeholders to help drive demand for the vaccine. The CDS team also participated in the weekly Risk Communication and Community Engagement (RCCE) committee meetings, providing input into the strategy to ensure the correct messaging got out to the public. Siven Maslamoney, of Yellowwoods, is a behaviour change communications and design expert brought in to support the CDS communications work. According to him, there were three main areas which the initiative targeted. One was the deployment of communicators from the NGO sector to support district teams at a local level. He played a key role in recruiting and training around 35 such communicators, and in designing a programme for them. Secondly, a grassroots campaign to engage local role-players to build trust around demand was fostered, together with partners from NGOs, CBOs, labour, business, traditional leaders and so on. These various local partners would communicate a centrally developed message. This was quite a challenge to coordinate. As Maslamoney says, “There was one song but many singers”. The third arm of the strategy was to have a centrally managed communications campaign using partnerships with community radio stations.

The CDS brought in an experienced radio producer and her team to produce a host of radio pieces for community radio stations with a listenership of millions. Lettie Dube was the radio producer, whose team very quickly produced a host of regular radio shows in multiple languages. Of great importance was that there was a very strong evidence-based message for all of these communications products. Michael Currin, of the GCIS, could not speak more highly of the CDS’s leadership in providing this public health leadership:

the team was able to produce a range of communications products and messages. One area in which the CDS was particularly helpful was in putting in place sophisticated social media platforms and messaging, something that NDoH and their provincial counterparts did not have. As Velile Ngidi testified about KwaZulu-Natal: “We had to adjust a dinosaur organisation where IT and social media are not strong.” Leburu testifies that the CDS support team is still assisting them on these crucial roles:

“The DG Murray Trust colleagues, when there was that capacity injection, they really, really excelled. They did it very professionally, very well. They even had that ability to generate the content themselves, also with partners. So I think the other area that I really want to say is the actual thought leadership, the brains, the content. Yoh! It was just remarkable. Understanding of the pandemic, understanding of virology and the concept of vaccination, and understanding of the sort of catalytic role of public health, and in a wider social development context. That was very, very – that’s where I took my hat off to Harrison. You know honestly, their depth of content – absolutely unequalled!”

“Yoh, we are perfect! With social media, you can check it out, we’ve got messages every day. Through who? DGMT! All those posters that you can see. So from my Department, I would send one or two posters per week, because my graphic designer is busy with policies, or guidelines, and he’s by himself – there’s no one whose helping him. But here, I just call them [CDS communications team] – ‘Guys, I need a poster on this and this and this.’ In two hours’ time, I get the poster! Sometimes I don’t even have to tell them. They just look at the health calendar, and develop the posters for me. The content is perfect. I don’t even need to correct it, because they also do research. All our things we want to base them on research … but we don’t have money for research.”

Siven Maslamoney felt similarly about the sound, evidencebased approach of the communications campaign: “So the people we had – what we trusted was not just our communications experience, but we had really good health experts advising us, David Harrison being one of them. I mean, he ran one of South Africa’s largest HIV/AIDS campaigns, and he was very sensible about his previous experience but very open to new ideas. So I feel like, in this particular strategy, the combination – what we did…is that we worked off really good public health advice. And the social listening campaign was certainly helpful. It wasn’t the only thing we used, but it was a really good input. There were a few inputs that I had access to. The one was we had the social listening campaign, but the Centre for Behaviour Change at UCT also provided input on the COVID work. So there were a number of inputs that we listened to. And we were agnostic – and I think that was important that we were agnostic. So we were open and agnostic, but had to get things done. But I would say the spirit of the work was that the donor response team was certainly open to listening, to the Department of Health, to the other non-departmental health experts, communication experts, because of the nature of the structure. We were both large – and that was significant – but also not aligned to either NGOs, trade unions, business, or the Department of Health, so we were properly agnostic, in a good sense of the word. So that made us unusual.” Nombulelo Leburu, the Director of external communication in the NDoH also sings the praises of the CDS, not only for the range of support options provided by the CDS communications team, but also for the highly quick and efficient way in which 58

Fortunately, the investment of the Solidarity Fund, DGMT and the other CDS donors, ensured this highly sophisticated communications architecture was put in place, proving to be most valuable in the dissemination of multi-media communications products, as well as investment in social listening, monitoring, research and community engagement needed to drive a public communications strategy. Without this support, the vaccination programme would have reached far fewer people. However, the campaign operated under considerable constraints, over and above the battle against social -media-spread misinformation and diminishing trust in the government. Siven Maslamoney raised a major constraint, namely the hollowing out of a once vibrant grassroots civil society movement capable of advocating for positive health messaging on a range of issues. According to him, the HIV epidemic focussed people and funding on a single disease, serving to destroy the “once strong networks that don’t exist anymore”. To his surprise, Maslamoney found that during the COVID response, this network of volunteers and community champions was very weak, making the sharing of health information at community level much more difficult. This, he argues, is one of the main lessons for South Africa in preparing for future health emergencies since:

“You can’t build a response in an emergency, without relying on the roads built before the emergency.”

In the evolution of this CDS communications work, the growing awareness that demand acceleration was going to be the major challenge to meeting vaccination targets soon took centre stage. In May 2021, the NDoH agreed to a demand-generation strategy, and the Solidarity Fund was approached for funding. However, despite agreement on the need for this multi-media strategy, by early July, it was still not in place.19 However, as supply-side issues were resolved, government attention started turning towards demand generation, not only to meet vaccination targets, but also to avoid wastage of the vaccine stock. At this time (end of July 2021), the CDS agreed to undergo a strategic shift to a more focussed role aimed at ensuring additional vaccine uptake of 10 per cent. In the 17 August Weekly Report, it is recorded that “There is growing concern about the levels of vaccination demand – and political attention being paid to it.” These delays in political buy-in were out of the control of the CDS, but in the background they were preparing the structure of a demand acceleration team and strategy. Thus, when the Demand Acceleration Task Team (DATT) was officially established in later August, the CDS team was ready to roll it out. David Harrison was asked by the NDoH to lead the DATT, as Nicholas Crisp recalls: “We basically appointed him and said ‘You are our guy – we don’t have somebody else to run this DATT programme’.” Within the team the Project Manager and health communications specialist was Angela StewartBuchanan. She worked closely with Siven Maslamoney (communications channel activator), Lebo Motshegoa (overall content management) and Lettie Dube (media interface – radio). Khumbuzile Bhengu and Akona Gwiliza conducted district mobilisation. Demand and response analysis was provided by Candy Day and Peter Benjamin, while services such as context and language translation, graphic design, social media, and radio engineering were outsourced. Of critical importance in the DATT strategy was the involvement of partners from key sectors of society to mobilise their various constituencies and spread the messaging in these networks. Nomalizo Xabana and Timothy Schultz were therefore brought in as business mobilisers, Pauline Maketa mobilised civil society partners (including NGOs, CBOs, FBOS and traditional leaders), Abraham Daniels and Adrian Williams from NEDLAC and COSATU mobilised the unions and labour, and Lebo Motshegoa mobilised the youth.

¹⁹ See 2 July 2021 Weekly Report. 59

Sandra Ngwena explains the thinking behind the DATT approach: “When DATT was put together, it almost had to create another structure. We had to have representatives from the different streams we wanted to reach. So we had communications, but wanted to reach labour, traditional leaders, religious leaders … Within labour we had to be realistic about how to access workers. Lots of the high-volume areas were union-driven, so we hired union organisers who were both brought on board: one for agriculture and another around the workplace. A lot of it was about 'Should employers mandate vaccines or not?' but we wanted to drive the workers to get vaccinated. Pauline Maketa mobilised traditional and religious leaders, so her role was to get them to buy in and go into their communities, and to meet the Zulu Royal House for example, to drive vaccines. So demand acceleration tried to push in different sectors, and we had business representatives too. Tim Shultz from B4SA drove this. So, in the creation of DATT, we hired people for seven months to do this mobilisation.” The activities of these role-players focussed the communications into an intensive multi-media and multi-sector demandacceleration initiative over the next few months. Community radio programmes, posters and flyers, social media posts, SMS notifications and community workshops and engagements were all used to spread the messaging coming from the team. As noted above, the Contact Centre was not able to be fully utilised in these endeavours as a demand-generation strategy due to their lack of permission to call clients. As Siven Maslamoney and others point out, these demand-generation strategies had to be highly strategic and coordinated with provincial and district health services to ensure that the messaging and demand creation aligned with local service delivery and supply. It was not good, and counter-productive, to create demand, only for there to be no delivery of the vaccination locally. By 23 September 2021, it was reported that there was far greater coordination of communication across sectors as a result of the DATT.20

Weekends in mid-November, and early December. All of these days led to increased accessibility of the vaccine to people who may not otherwise have come forward. The 18 November Weekly Report records that “Statistics show Vooma Weekends galvanise public support and increase uptake”.21 The Vooma Vax Champs campaign was also launched, to create a network of ordinary people to become champions.

In September 2021, attention also turned to another strategy which sought to offset the financial barriers of getting vaccinated (e.g. transport, or time away from livelihood) for vulnerable people. This was the incentive strategy which later became known as the Vooma Vouchers, in which over 60s were given R100 vouchers through Shoprite. The Solidarity Fund disagreed with the strategy and rejected a request for funding, but the other five funders agreed to reallocate R25 million of the funding towards this strategy. The Solidarity Fund’s reasoning was that it was unethical to offer money to hungry people in return for getting a vaccine that they may have had reservations about. Strong research showing the efficacy of incentives, however, convinced the CDS to go ahead with the vouchers. From later October 250 000 people received these vouchers in the pilot phase, and in November this “game changer strategy” was increased to R200 and expanded to over 50s.

A review published in the British Medical Journal found that the Vooma Voucher programme was associated with a 7.15–12.01 per cent increase in daily firstdose in the first month of its introduction, an effect size slightly higher than similar Covid-19 vaccination incentive programmes in other countries. 22

Various high-visibility campaigns to drive demand were also planned at this time, including the concept of “Vooma Weekends”, where the President and various leaders would come out and encourage vaccination at sites which were specially opened on these days. The first such weekend was held from 1–3 October 2021, with monitoring records showing a spike in demand as a result. A special November 1 voting day vaccination campaign was also held (with 1 000 pop-up sites targeting voting queues), along with two more Vooma ²⁰ 23 September Weekly Report. ²¹ Several in-depth evaluations of the impact of the Vooma Weekends were also produced, with detailed analysis of the vaccination numbers over each. See, for example Harrison, D., Bamford, L. and Tanna, G. (8 October 2021) “Evaluation Report Vooma Weekend (1–3 October).” Presentation found at https://sacoronavirus. co.za/2021/10/09/evaluation-report-vooma-weekend-1-3-oct/ (Accessed 12 May 2023). ²² Chetty-Makkan, C.M., Thirumurthy, H., Bair, E.F., et al. 2022. Quasi-experimental Evaluation of a financial incentive for first-dose COVID-19 vaccination among adults aged ≥60 years in South Africa. BMJ Global Health 7: e009625. 60

The majority of those interviewed agreed that this communications and demand generation strategy was highly effective, driving up demand through careful, targeted messaging, community engagement, incentives, and visible leadership. Michael Currin, for example, explains the power of community mobilisation through the Vooma Weekends:

on the National Economic Development and Labour Council, argue that their involvement was critical, but should have come earlier to be more effective. Critics like COVID Comms argue that the approach should have been more grassroots and consultative. Nevertheless, the Donor Report of 14 March 2022 records this as one of the main achievements of the CDS:

“Through this imbizo, it was a blitz, door-to-door, it was grassroots. I went to all three of them and honestly they had a lot…the first one I was in Port Shepstone with my then Minister. And I mean, we had a massive blitz where we walked through the CBD of Port Shepstone towards Gamalakhe, and you know it was funny because I had an incident there where I came to a lady sitting on a bend on the street selling fruit, a youngish lady. And then I said ‘Hi’ … and I asked her if she would take the vaccination. And she said ‘No, no, no’, and she became so rude and she just ignored me. Anyway, I left her there and I went on pamphleteering up the street and I got to an older lady later, and we chatted, and she said ‘Oh definitely…no we’ve got to do this; this is how we stopped other diseases when we were young.’ But anyway, a couple of hours later, we go up the street and there was the mobile vaccination site, in the gazebo. And who do I find in the queue there? I find my nay-sayer! She’s standing in the queue filling in the vaccination form. So I said ‘Oh, here you are!’ And then the next minute I looked to the left and there is the older lady that had been so keen. And it turns out it’s her aunt. She says, ‘No, I told this one, she’s not going to give you trouble. She’s coming here to vaccinate now!’ So there the two of them went in and got vaccinated. Now for me that’s quite a powerful sort of image, because it shows you the influences, it shows you role modelling, and I think that’s where we worked very well too.”

“We coordinated demand acceleration efforts (within the constraints of the system). These efforts kept a steady number of people coming for vaccination, although significant external factors recalibrated the trajectory downwards…” Despite the challenges, government partners also feel very positive about the DATT and its contribution, as Nicholas Crisp articulates: “The major massive impact has been in the demand acceleration and creation, and in that communication space that was phenomenal.”

Currin, like Maslamoney, Pauline Maketa, Candy Day, Angela Stewart-Buchanan and others, strongly believe that this combination between centralised messaging and proper grassroots engagement was one of the key success factors of the demand-acceleration strategy.23 There were barriers and factors beyond the control of the team, however, which muted its impact. We have already discussed the lack of a vibrant grassroots network, and the inability to use the Contact Centre to its full demand-generation potential. Other challenges were presented when a “post-election slump” slowed down the energy of the programme, and the same deflection of momentum was experienced when the Omicron wave over December 2021 was comparatively mild. As a result, vaccination struggled to pick up in 2022, and public and private sites started closing down. Some, like Adrian Williams, who represented organised labour ²³ A very detailed and sophisticated monitoring, evaluation and analysis system was led by Candy Day and others within the CDS. See the many detailed reports and presentations produced by this team, which provide a deep-dive into the Contact Centre dynamics, outcomes of the Vooma Weekends, communications and DATT impact, among others. Two such documents which have informed the analysis here are C. Day (April 2022). Summary of Support to the COVID-19 Vaccination Programme: April 2021–March 2022, unpublished DGMT report, and C. Day and J. Werne (December 2021) Vaccination Programme Analytics Lessons Learnt. DGMT unpublished PowerPoint Presentation. 61

Hard-to-reach and high-risk individuals

A final major activity of the CDS in its quest to reach the most vulnerable, increase demand in hard-to-reach areas, and ensure equity of access to the vaccine, was the multi-dimensional outreach campaign that it introduced in June 2021. Weekly reports from the first months of the vaccination programme show a continual concern by the strategic thinkers on the core CDS team that vaccination data was showing growing inequities of access as insured and wealthier individuals rushed to protect themselves, and more vulnerable, marginalised and rural poor struggled to be reached. Zameer Brey sums up this concern: “DGMT, and certainly David’s commitment to social justice underscored so much of what we did, and you know, it resonated both in speak and in action. And I remember there were times when some of the most pressing challenges in the vaccination programme, when you came to David with a technical challenge, he certainly would give you an audience and he would try and help resolve it. But when you came to David with something that seemed to impact equity, he would give you all the time he had, and more. And it would really bother him, for example, that when we started the vaccination programme, in certain parts of the country we were vaccinating those with medical aid at five times the rate of those without medical aid. Let alone that within those categories, the social gradient of the haves and the have-nots was even steeper, and so for example if you took a medical aid then you categorised that by quintiles, and you said the wealthiest compared to those who just qualify for like a basic hospital plan. And you then contrasted people dependent on the public service who didn’t have medical aid, but were still on a salary, compared to those on social grant, it wouldn’t be unreasonable to say that the wealthiest vaccinated at probably 10 or 20 times the rate of the poorest in this country. And that was something that really bothered all of us and kept us up at night, because we were providing a service that in many ways was perpetuating the inequities the country has been dealing with for decades. And by no fault of any single person, but by just the failure to acknowledge that the system is designed to give you a particular set of outcomes. And if we didn’t change that, this was the outcome we were going to get.”

With this structural imbalance in mind, the CDS team sought ways to address it. The Weekly Report of 25 June records that: “We are facilitating discussions with the NDoH and the SA Post Office, Boxer Stores, and Massmart stores which provide grants to the elderly on a monthly basis to see if there is an opportunity to reach 60 plus people in these monthly queues.” This idea in fact first came from Jane Simmonds, who was running a study for the South African Medical Research Council screening people for chronic diseases in South African Social Security (SASSA) grant queues. She realised the potential of reaching this constituency of 4,2 million elderly people in their monthly grant queues and wrote to the NDoH repeatedly to raise the idea. After a few months of silence, she was referred to Gaurang Tanna and Zameer Brey, and the idea was embraced by the CDS, which quickly put a task team together. In Simmonds’ words, an “incredible public–private partnership was put together”, without which the initiative would have failed. Partners included the NDoH, SASSA, SA Post Office, Boxer Stores, Massmart, Clicks and the CDS, which appointed Waarisa Fareed, an experienced national outreach programme lead with a health economics background. The initiative, which Zameer Brey describes as one of the most significant of the CDS initiative, commenced with a pilot phase at 12 SASSA grant sites in early July 2021. Following this successful pilot, more SASSA payment sites were added countrywide, followed by even more widespread outreach to community sites, malls, taxi ranks and other isolated areas. Three clinical operators were initially contracted to deliver the vaccines to a range of outreach sites, working with local DoH sites to manage the vaccine according to protocol. These three were Right to Care, Reaction (Mpumalanga) and Oram (Eastern Cape, Western Cape and Mpumalanga). As the outreach programme expanded, eight more clinical operators were added. CDS Weekly Donor Reports record the steady progress of the initiative over the next nine months. It was scaled up in August, together with efforts to get the private sector to vaccinate uninsured people. The CDS was keen to expand outreach quickly after the pilot showed it was a good model for expansion. Despite delays in expansion in August, 33 outreach sites had been established at SASSA pay points and elsewhere by early September. A month later, expansion was still labelled “too slow”, with 54 sites operational. By the end of October, there were 71 active sites, with 164 established by mid-November.

This increasingly effective expansion saw the administration of 230 000 vaccinations at these sites by that point – largely of people who would highly likely not have come forward themselves if not reached in this way. Around this time, some challenges were recorded at outreach sites. Some clinical operators had to withdraw from poor performance sites. The Weekly Report of 29 November notes that “current funding models [are] not feasible for clinical operators in a rural context”. Indeed, several of those interviewed raised the fact that outreach of this nature, which takes health services to the people who need them, is both complicated and expensive, despite being highly necessary. Outreach continued in the Christmas holiday period, and by mid-January 2022 there were 185 active outreach sites, which had administered 562 054 doses. The programme was extended to March 2022, given its success. Steady progress continued, and by early February there were 194 sites operating, and 678 597 vaccines had been provided. By early March there were 222 sites, with 754 404 vaccines delivered. School sites were also added to the outreach focus in March, proving another highly effective strategy and partnership with the Department of Basic Education. Due to the push of the outreach programme, 253 sites were active by early April in every province of the country.

By 8 April, one million vaccines had been administered through the programme, an incredible achievement given that it was implemented at a time of rapidly falling uptake of the vaccine in the general population. A range of interviewees, including Jane Simmonds, Zameer Brey, Waarisa Fareed, Bridget Dube, and representatives of Massmart and Clicks, reflected very positively on the process of implementation and its outcomes. In general, the SASSA pay point and shopping mall outreach sites were more successful than the sites in the community such as halls. Not only was there limited foot traffic to these often isolated sites (meaning limited uptake), but they required a lot of effort to get to: shortening operation time, introducing transport challenges, making coordination with clinics difficult and, in a number of cases, posing security risks to outreach teams. Bridget Dube, from Genesis Analytics, who was seconded to the Gates Foundation to support the CDS, recalled that feedback from the pilot phase was really positive. Typically, 30 per cent of queuers would get the vaccination on the day, 40 per cent had already been vaccinated, and 30 per cent refused. However, 80 per cent of the pensioners thought it was a very good idea 64

to reach them in the SASSA queues. The team designed a very well thought-out process, based on their analysis of various scenarios and typical client journeys through the SASSA queue experience. Teams were trained to register clients while they were queueing and ensure that they had been allowed to do their shopping and other business either before or after their jab. Bridget Dube reflected on the outcome thus: “It was an effective strategy. Yes, one million is small in the context of the whole population, but it was a major success in terms of reaching people who would normally not have been able to get vaccinated.” Jane Simmonds holds a similar view: “If there was no outreach programme, very few of these individuals would have been vaccinated. I mean, take Lusikisiki as an example. At St Elizabeth’s clinic you may get eight people in the queue, but in the SAASA grant queue on the same morning, you will have 400 people, and over 100 would get vaccinated.” Many sites in malls also remained open throughout the month, opening up these services to other shoppers once the SASSA days were over. Massmart and Clicks representatives Alex Haw and Bronwyn Macauley also testified that their experience of being involved was highly beneficial to their companies, who were looking to continue collaborating on social outreach projects.

As the vaccination programme went on, another cohort of citizens became a particular focus for tailored outreach and demand creation services – young people. The DATT specifically included a youth mobiliser because, although youth were at lower risk, it was acknowledged that to reach 70 per cent of the population, large numbers of youth would have to be vaccinated. It was also clear the mainstream messaging was not resonating with the youth. Although the DATT had this youth mobilisation focus, which already reflected in some of its messaging in the last quarter of 2021, it was not until early 2022 that a programme of action targeting young people became one of the key levers to drive demand. A process of engaging the youth, hearing their voices, and developing a value proposition for them was undertaken in January. By early February the strategy for this programme of action had been outlined, including communications with a strong youth identity; content generated by young people themselves (especially on social media and local radio); rewards for vaccination advocates; the introduction of a youthful panel of health professionals; incentives for vaccination (such as free data, lucky draws and retail discounts); and outreach to youth

venues such as schools, colleges and recreational venues. At this time, three young doctors were contracted to galvanise the message – these individuals were on numerous panels, podcasts, question and answer sessions, radio programmes and social media events over the next months.

High-frequency public service announcements on 16 radio stations, 15 campus stations, and 45 community stations, along with social media platforms, were broadcast, targeting youth. By the end of February, the campaign had a name – the KeReady programme of action. Lettie Dube explains why this campaign was important: “One of the major constraints was that the youth felt they were left out of decision-making processes around vaccination. They did not trust politicians who spoke on many media platforms. Youth wanted to get more involved because they thought it was unfair that politicians spoke on their behalf and at the same time they were misusing COVID funds. The enabling factors were that consultation was eventually made and the youth got involved in so many ways in driving demand creation, especially at schools and TVET colleges. Programmes such as music attracted many and the involvement of young doctors restored trust.” In the third week of February KeReady was officially launched, with activities such as the KeReady2Flex challenge drawing great interest from young people wishing to share COVID messaging in creative ways. Although the campaign was launched with great energy, initial outcomes were slow to show. On 25 March it was reported that vaccine coverage was “crawling – despite KeReady and SMS campaigns”. Only by early April did the data start showing a shift for the youth as a result of KeReady. The Weekly Report of 8 April records that the KeReady impact was finally starting to show itself, with a clear vaccination rate increase in targeted age groups. Later in the month (22 April), even more positive reports were made, with KeReady said to have changed the age mix of the first dose: “Vaccinations in 12-19 year olds [are] significantly greater than would have been expected without the campaign.” Indeed, there were 251 000 more than expected at that stage.

“The DG Murray Trust recruited three doctors. They specifically looked for young people so we could basically reach out to other young people. We were recruited to basically be the ambassadors for KeReady, for myth-busting, and to find out where the areas of concern were. How we did this was that we spoke at face-to-face engagements in the public settings. So, we launched in February last year, 2022, in the TVET college, where we were joined by the Minister of Health … and we had a panel discussion and open dialogue with the students there. We also did weekly radio interviews as well. And then we also created with the comms team, a brand on social media. So, we were on, and we are still on, social media like Instagram, Facebook, Twitter, TikTok, all of those. And we would have health promotional videos if we picked up anything on the social listening reports, then we would address those concerns directly by videos, Twitter spaces, Instagram lives, so that we tackled each topic as well. We also had a podcast where we did 10 episodes on COVID-19 and the COVID pandemic, the vaccinations, and then we split up the topics like men’s health, women’s health, teens, traditional leaders as well… We also have a website, and then we’d also do outreaches as well … We tried to have a big range. And then we’d also support the SAcoronavirus hotline. So if there was say, for example, an issue of the Guillain-Barre [Syndrome], then we would research that and then provide the call centre with some medical advice on how to answer questions. And we would also promote the SAcoronavirus hotline as well for people to make use of that … Oh, we have a WhatsApp hotline as well. We actually have over 50 000 subscribers to our WhatsApp. And we created templates on frequently asked questions with the comms team. And the people can ask directly if they are still not satisfied with the answer. And then we go on to those questions directly as well on any myths or concerns.”

One of the major enablers of the success of the KeReady campaign was the inclusion of young doctors who had just completed their community service year but had yet to find work. These individuals were referred to the CDS by Nicholas Crisp because they were eager to put their skills to use and remain in the public sector. Dr Saira Carim describes the multifaceted role her and her colleagues played:

Dr Carim explains why the inclusion of young doctors was so important to the youth outreach strategy: “So basically it was for us as young doctors to be more approachable for young people, because as you know with the vaccine rollout, it started off with the older people, then people with co-morbidities, and then it was the young people. So it was like the young people were lost, so why should they care, and they thought COVID doesn’t really affect them. So we were brought in to talk to young people on the same level, and not as a strict doctor in a lab coat, dictating to people what they must do; it must be more of a conversation…We tried to make it a vibey campaign, using the language that young people use. Doctors are generally seen…as pretty reputable and when people take advice they would rather take it from someone they trust with a medical background.” According to David Harrison, this initiative became an “incredible phenomenon”, and they quickly developed “a big following”, as evidenced by the numbers subscribing to their WhatsApp line. It continues today, with eight young doctors of different backgrounds stationed around the country. Another enabler of success of the KeReady campaign was the willingness of the Minister of Health to allow it to be a stand-alone brand, representing the voice of young people, rather than what Harrison calls “political talking heads”, who had alienated the population with their constant media appearances. Of course, the KeReady launch event still resulted in political posturing and demands to follow “protocol” by some senior government officials, but the fact that the Minister of Health was convinced that the voices of young people needed to be heard, and that politicians and bureaucrats needed to stand back, was crucial. By late May, as other aspects of the CDS wound down and DATT was handed over to Right to Care, KeReady continued with print, radio, social media, and young doctor podcasts, and it continued in June as the primary outreach vehicle.

KeReady also provided the platform for a mobile outreach service to hard-to-reach populations in Gauteng, KwaZulu-Natal and the Eastern Cape. In addition to their commitment of 13 million euros for IT and cold-chain equipment, KfW provided another 14 million euros for a fleet of vehicles to take these multi-faceted services to informal settlements and peri-urban areas, something DGMT was asked to implement before handover to the DoH. As with the SASSA outreach programme, interviewees were very positive about the KeReady campaign and what it contributed to the momentum and achievements of the vaccination

programme. A detailed analysis of the campaign’s impact conducted by Genesis Analytics in April 2022 concluded that, among other things, the vaccination uptake among 12–19-yearolds was significantly larger than would have been expected without the campaign, reaching (within the first two weeks) 250 000 young people who would not otherwise have been vaccinated.24 The user experience of CDS activities The CDS initiative had a number of “users” at different levels, some of whose experience was easier to ascertain in this review process than others. The users whose direct experiences were available were the partners of the initiative from different levels of government, business and civil society who participated in interviews. Many of these experiences and views on the CDS and its specific activities have already been presented above. Notwithstanding the various challenges that were faced in certain areas, the user experience of these partners was overwhelmingly positive, especially in terms of the leadership, strategic input, coordination, efficiency, support (financial and technical), flexibility, agility and collegiality of the CDS, as implemented by DGMT. It was striking how top-level government officials, down to district-level officials all felt that the initiative had been highly welcome, truly collaborative, and of great use in their endeavours. To provide a few more examples: “From my perspective, it was just easy. There wasn’t a lot of bureaucracy that we had to deal with. What was happening behind the scenes was not visible to us. But I think that comes back to the issue of speed…it was funding that came with remarkable speed and very few strings attached from our perspective” – Lesley Bamford, NDoH. “Please give them more money so they support us. If they go, I’m dead!” – Nombulelo Leburu, NDoH. “I don’t think we would have been as effective without additional support. I mean, there was huge pressure on the health system. And you know, things like the vaccine effort, we’ve done that before, but we’ve never tried to vaccinate most of the adult population. I mean, it just was unprecedented. So we needed assistance, and fortunately DG Murray Trust and other funders came along and assisted us nationally. And particularly in this province, when I think of their role I would describe it as invaluable, and I think we would not have been as effective without it. The support was absolutely crucial” Professor Hassan Mohamed – Western Cape DoH.

²⁴ See Genesis (April 2022). Evaluation of the COVID-19 Youth Vaccination Programme. Report prepared by Genesis for DGMT. 66

Civil society and private-sector partners also largely had a positive experience of the CDS, even where overarching challenges may have made their work challenging. The interviewees from the labour sector were particularly effusive, although they felt they should have been part of the process from the beginning. Adrian Williams of COSATU and DATT member provides this opinion: “OK, I must be honest, I can only compare it to somebody else I immediately worked for. I worked for [another organisation] and I would say that DGMT did a far better job than [they] did. The implementation was very, very good, I must be honest, the management processes were good; the way in which they worked with all of us. Remember who we are: there was labour and business. I’m not very friendly with business, like I’ve challenged them before you know in real terms, I made speeches about the guys in banking in South Africa in Parliament and so on. And so they’ve [DGMT] managed it very well and I think we worked very well together.” Partners from the retail sector who participated in the outreach programme were also highly satisfied with their participation and their experience of the CDS. They felt that this had built a platform for more collaboration between government, civil society and business. Pulane Baloyi of the South African Council of Churches, which played a significant role in the communications partnership, also describes the SACC’s positive experience: “The DG Murray Trust was a critical partner. And what I liked in terms of how they funded us is that they were aware that we were getting Solidarity Fund funding to implement the vaccination campaign in particular districts, in communities where we were piloting another programme … So what we appreciated through the Challenge Fund is that we could determine where we felt our implementation had to be strengthened. So we appreciate the fact we were given that opportunity to strengthen implementation in the areas we felt were the most challenging. So they’ve made funding available, but they gave you some say. They weren’t too prescriptive – like ‘You guys have to spend it like this’. They sort of said ‘You guys are implementing and you know where your needs are, you can channel it there’. They also let us use the funding without insisting on their branding.”

about the pandemic in South Africa. Funded separately by the Solidarity Fund, they also became involved in the CDS, but disagreed with the approach and direction taken by DGMT. Former Director David Lydell explains that when the DATT was created it did not conduct a proper landscape analysis to ascertain what communications and demand creation activities were already taking place. It just came in with large amounts of funding and took over the communications landscape without consulting properly with those already “in the game”.

He argues that the DATT should rather have looked to fund and support existing communications initiatives more than it did, including those like COVID Comms who were using grassroots engagements to drive messaging. COVID Comms also differed strongly on the use of incentives, arguing that its grassroots engagements showed that people felt they were manipulative and demeaning. They were also publicly critical of government, and felt that the CDS was too close to the NDoH to properly speak truth to power. The publication of a critical op-ed article by COVID Comms was a particular bone of contention as it potentially undermined the partnership between the NDoH and CDS. COVID Comms also did not agree with the Vooma Vax Weekends approach, nor did it think the messaging around the youth campaign was correct. There were therefore several areas of disagreement which made working in the CDS difficult for COVID Comms.

However, there were some private sector and civil society partners who did not have as positive an experience of the CDS, especially the DATT. While the Solidarity Fund was a major funder for the CDS mechanism, it also funded a number of other initiatives, especially those involved in the National Communications Partnership. The Solidarity Fund had a specific strategy, on which it worked with its partners. COVID Comms is an NGO which was formed in 2020 by communications professionals to drive public health messaging and content 67

Wendy Tlou, from the Solidarity Fund, felt similarly that on some issues the CDS pushed its position too strongly and aggressively without considering the perspectives of others in the communications landscape. The major sticking point was on incentive vouchers, to which the Solidarity Fund refused to contribute. Although they did provide major support for the printing of communications materials, the outreach and the DATT in general, they did not contribute to the incentives because they also felt these were controversial and risked manipulating desperate people. The very strong position of the DGMT on such issues came across to Tlou as a failure on their part to collaborate respectfully.

Such conflicts and misunderstandings were perhaps inevitable given the very high stakes of not only addressing the pandemic at the time, but also for the various role-players jostling for their space within the response and beyond. In interviews, certain other large role-players such as B4SA also hinted at a slightly adversarial attitude towards the role of the CDS, and who should take the most credit for supporting the vaccination programme. However, the fact that this review specifically sought the views of those known to be critical of the CDS shows that the intent is to document all lessons, positive and negative, and to learn lessons from these that can improve future collaborative responses. For other “users” of the CDS initiative, especially the beneficiaries of the vaccination programme (i.e. the general public), it is very difficult to accurately gauge their experience of the CDS per se, or to separate it out from their general opinions of vaccines and the vaccination programme. Given the various socio-economic and political issues at play, it is also difficult if not impossible to tell what has influenced people’s perceptions of COVID vaccinations. This is especially so because of the global influence of social media, television and religion and their widespread ability to influence local opinion.

Even if there may appear to be a correlation between some kind of public initiative and phenomena, such as social media commentary or changing vaccination uptake, to determine causation is almost impossible, especially given the numerous influences working on people simultaneously.

The question of how the public viewed the vaccination programme over time and to what extent the communications and demand acceleration activities influenced them could be the subject of an in-depth study of its own. Here, we provide an overview of some extracts from social listening reports and social media which provide a brief sketch of the kinds of experiences the public had in relation to the vaccination programme.

The Weekly Social Listening Reports produced by the CDS team and hosted on the government’s SAcoronavirus website provide a detailed summary of the complex and polarised world of vaccine opinion in South Africa. An analysis of reports between August 2021 and January 2022 (as the communications and DATT elements ramped up) show continual challenges with anti-vax sentiment (especially on social media), misinformation and hesitancy, despite there also being a strong pro-vaccine sentiment, which does appear to have been influenced by the activities of the CDS and its partners. The following statements have been extracted from various reports illustrating positive and negative findings: •

Vooma Vaccination Weekend: Indications from many districts that Vooma Vaccine Weekend has led to increased vaccinations that weekend and in the following weeks, with the presence of political leaders and celebrities attracting many people. There are also reports from several districts frustrated that the initiative did not come to their area. An anti-vaccination protest happened in Cape Town during the weekend. (Social Listening Report 13 October 2021)

Indications from many districts that Vooma Vaccine Weekend has led to increased vaccinations that weekend and in the following weeks, with the presence of political leaders and celebrities attracting many people.

•

Increased vaccine acceptance: Multiple anecdotal evidence that there is a small shift in public sentiments from vaccine hesitancy towards more keenness for vaccination, in many parts of the country. However, many logistical barriers still limit people actually vaccinating – long waiting times at vaccination site, some sites not easily reachable and the affordability of transportation cost, e.g. in Eastern Cape switching resources to vaccinate in rural areas (Social Listening Report, 22 October 2021).

•

Vooma Voucher scheme: The R26m pilot scheme incentivising older people to vaccinate was received with mixed reactions. Many positive comments, some saying the resources should be re-directed for job creation believing that a lot could be achieved “If only they spend half as much time and effort into creating jobs as they do with these vaccine drives” (here), others hostile saying that this is bribery exploiting poor people. (Social Listening Report, 5 November 2021)

•

Social media conversations where pro-vax engage anti-vax people are increasingly being seen on social media. With the increasing knowledge about vaccination, debates are becoming more prevalent. Pro-vaxers ask for claims of severe side effects to be supported with evidence. (Social Listening Report, 19 November 2021)

•

Vooma Vaccination Weekend increased vaccination numbers. On the weekend 12–14 November over a quarter of a million vaccine doses were given, over double a usual weekend, though less than the ambitious target. The seven Vooma Weekend social media banners posted on NDoH Facebook this week promoting vaccine acceptance received more positive public comments in agreement with vaccine update but also questioning the government’s support. (Social Listening Report, 23 November 2021)

•

Public queries on Vooma Vouchers: R100 grocery vouchers are now offered to people over 50 years old vaccinating for the first time. Many like this, while some call it bribery. Many people younger than 50 are requesting to receive the Vooma vouchers as well. There are also conversations that R100 is too small amount and it is a shame to coerce the poor and needy with a pittance. (Social Listening Report, 23 November 2021)

•

Vaccine workshops organised by COVID Comms in communities around South Africa are oversubscribed, with over 100 people trying to attend one discussion, showing that people have interest in hearing about the vaccine and need more information. The biggest issue emerging from the workshops is trust – people see the COVID pandemic and vaccine as an opportunity for more government corruption. There are misunderstandings about how long the vaccine sticks around in your body. The vaccine sites map released by COVID Comms has been visited by over 47 000 user in four days. (Social Listening Report, 3 December 2021)

More directly, public engagements on the Facebook page of the KeReady campaign from the first half of 2022 show that there was some engagement with the many very useful resources posted on this platform. What was particularly popular was the KeReady2Vax competition. For example, while most posts have about eight reactions, a post on this competition from 9 May 2022 garnered 1 100 reactions and four shares. Content on issues like childcare are also popular: a 10 November 2022 video about this topic received 3 600 reactions, 53 shares and 82 comments. While there are some negative sentiments, especially around the vaccine, there are also positive sentiments on many posts. Together with the CDS’s own analysis of vaccine uptake after Vooma Weekends, the youth campaign and the Vooma Vouchers, these sources indicate that CDS activities were appreciated by users who engaged directly with it. However, anti-vax sentiment and suspicion remains and is now providing a challenge in the ongoing measles outbreak. To conclude this section, it is clear that the support provided by the CDS in a number of areas was fundamental to what the vaccination programme ended up achieving.

The initiative effectively coordinated key components of the vaccination programme, including the National Contact Centre, the outreach programme, and public communications, while providing the implementation backbone for the programme at provincial and district level. It also provided invaluable strategic focus and support for the NDoH, ensuring that a simple yet quick and effective strategy was adopted, when a more complex and confusing one was proposed. Zameer Brey believes that the ability of the CDS to influence the “big-ticket policy decisions” is one of the key successes of the initiative, ensuring that an optimal vaccination strategy was adopted. He also points to the ability to be flexible, to innovate, to use a data-driven approach, and to “bring together unlikely partners” as key factors of success. Of course, there were factors beyond the control of the CDS, especially around gaining proper access to the EVDS and real-time data, which would have made the planning, demand generation and general response much more effective. As several interviewees have articulated using metaphors, the core team often felt like they were “flying blind”, “operating with the handbrake on”, or working “with one hand tied behind the back”. David Harrison expresses great regret that while the CDS initiative was largely successful, it got going too late, with tragic consequences:

“It helped greatly – but we were too late. Lives were lost because the programme got off to a late start. Brazil got going much faster and we lagged three or four months behind. Was it effective in facilitating the delivery of vaccines? Yes, undoubtedly. A network of 200 people in technical support, direct delivery support to the Department was really fundamental in ensuring that the systems were in place. If you hear otherwise from provinces I will be very surprised. So that was good. But our response was late, which cost 20 000–30 000 lives.” His frustrations with the two-month delay in signing the CDS agreement have already been recorded above. There were other factors outside the control of the CDS core team which affected the degree to which the anticipated goals were achieved. These included the riots, floods and municipal elections, all of which affected the momentum of the vaccination programme negatively. The refusal by the NDoH to allow for the calling of clients for their booster vaccine also compromised the effectiveness of demand acceleration efforts.

The fact that new POPIA regulations came in just as the pandemic unfolded provided a major stumbling block to quick strategic communications with individuals.

Nevertheless, as will be outlined in more detail below, the CDS provided invaluable support to the vaccine programme, helping 37 million vaccines to be administered between May 2021 and June 2022, and ensuring that over a million additional people were vaccinated through innovative strategies such as outreach, demand acceleration and incentives. By the handover of the activities to other partners, 70 per cent of the most vulnerable 60+ age group had had at least one dose of vaccine, 65 per cent of the 50–59 age group were vaccinated, and 50 per cent of adults had been covered. Although South Africa did not reach its target of 70 per cent of adults vaccinated, these achievements are impressive and should be understood in context, argues Professor Hassan Mohamed of the Western Cape DoH: “It was enormously successful! Getting to 50 per cent of the population was impressive as we had never before tried to vaccinate the entire adult population. And we reached 70 per cent among the most vulnerable 60+ age group. So it was an enormous achievement, and together with natural immunity it helped end the pandemic by contributing to herd immunity.”

The COVID vaccination programme has continued, slowly reaching more people with booster shots in particular. As at June 2023 NDoH statistics show that 22 751 181 of the eligible population had at least one dose (49.43 per cent). David Harrison reflects on the achievement of the vaccination programme thus: “We achieved high rates of coverage among the over sixties – those who needed the protection most. But lower overall coverage among young people. (In fact, adjusted for their ten times lower risk, proportionately more young people came forward than older people!) But eager as we were for everyone to be vaccinated, it became clear by the third wave that, with very few exceptions, the post-vaccine symptoms were as irritating as COVID itself for young people. And hybrid immunity ended up conferring even greater immunity than vaccines only. So we ended up in a good place – and our only real regret is that not enough older people were vaccinated in time for the vicious Delta wave.”25

²⁵ Email correspondence, Dr David Harrison, 30 May 2023. 71

As should already be quite clear, the CDS provided a unique contribution to the South African vaccine programme.

4.5 THE UNIQUE VALUE OF THE CDS MECHANISM As should already be quite clear, the CDS provided a unique contribution to the South African vaccineprogramme. This section further outlines its qualitative enablers of success. The first fundamental enabler of success was the strategic leadership and public health experience provided by the core CDS team, not only from David Harrison, but from the other members too. As Gugu Ngubane (Solidarity Fund) points out, “It needed a higher level, equally competent expertise and capacity [individual] to a National Department of Health leader of the vaccination programme”. David Harrison and others of his high-level team were able to work with top government officials, and besides not needing hand-holding or management, could also drive strategy and the agenda themselves. David Harrison and others of the core team are also highly experienced and connected in the public health and communications space, drawing in other highly skilled individuals such as Candy Day, Edzani Mphaphuli and Angela Stewart-Buchanan to the team.

The strategic leadership provided by this team also ensured that the vaccination programme included not only reopening society and the economy as a primary motivation, but also a strong focus on systemic support for the health system, and an uncompromising focus on equity of access. According to Kirsten O’Sullivan, of Allan & Gill Gray Philanthropies, neighbouring southern African countries had vaccination programmes led mostly by the business sector, with a resulting strategic focus on the workforce and reopening their economies. While this aim is understandable, it came at the expense of ensuring equity of access, a particularly important consideration in South Africa. Having this unique civil society team leading the strategic thinking ensured both a developmental and an equity focus was upheld, while also working with the business sector. Another point made by O’Sullivan was that besides the pooled funding approach, the pooled expertise between the CDS partners was of particular value in supporting the government and the vaccine programme. Along with this expertise, the work ethic and commitment of the whole team is also a fundamental indicator of success. Thashlin Govender explains how this played out:

“You know, I can’t even find words to describe it. But every time we had a Friday meeting or a Monday meeting, the eyes of the team would tell you as to how nobody slept. Everybody was working. It was really like that. Persistence was the thing. We work weekends, Saturdays, Sundays. I mean, you work seven days a week, 20 hours a day, and we had a leader that did it too. David did that, which made us want to work.” As pointed out by several of the funders, the pooled and coordinated funding approach was not new by any means. These foundations had previously been in similar arrangements with DGMT, including in the 2020 COVID relief projects. Indeed, the first year of the COVID crisis in many ways solidified a collaborative pooled funding approach between these funders which acted as a solid platform on which to build the CDS approach very quickly. For example, these partners did not have to go through complicated due diligence processes before granting their funds to DGMT because not only had they worked in this way before, with DGMT acting as banker in a pooled arrangement, but there were already existing grant agreements in place. This made the CDS mechanism very quick to launch, and provided confidence about the soundness of the governance arrangements. As we shall see shortly, this also allowed for the leverage of significant additional funding. Another unique and important factor was that DGMT, as a contributor to the fund and the implementing agent, was able to put its own money at risk in the beginning before other funders had committed, and thus ensure that crucial elements of the response continued unhindered.

The flexible governance structure was a key feature which allowed this agility in a context where quick decisions and resource allocations could be crucial. Besides creating a “coordinated mechanism for donors to support government”, as Zameer Brey described it, the CDS allowed for a unique kind of partnership and collaboration with the NDoH. All of the top government officials interviewed were quick to acknowledge that the CDS and DGMT acted as true collaborators and partners. Michael Currin, for example, cited the “posture” that DGMT adopted, which was not patronising, disrespectful or overly critical of government, but sought to genuinely support its efforts. At the same time, as Nicholas Crisp pointed out, the core team pushed hard on some issues and did not always get their way, and despite these robust conversations, he had nothing but praise about the nature of the partnership. This was because a healthy dose of pragmatism was infused into the CDS approach, as Zameer Brey comments: 73

“You know, all of that came with a dose of humility on David’s part, knowing that there were battles we won and there were some we were going to lose. But that shouldn’t, you know, detract us from why we were here.” While the CDS did try to influence decisions with both private and public communications (for example through op-ed pieces on popular media platforms), it did not resort to mud-slinging and unconstructive criticism, as could have been the case. The government partners do acknowledge that government’s rules and processes around employment and procurement are far too slow and cumbersome to be fit for purpose in a crisis, even in a declared state of disaster. The CDS arrangement was able to be flexible and to pivot funding strategically according to the developing needs of the response. This is another crucial unique success factor of the CDS arrangement. David Harrison argues that the “Key was that no money was physically handed over to government, and therefore no government procurement processes were needed. But while the technical support people were employees of DGMT, they were fully accountable to government.” This is another example of the close collaboration approach fostered by the CDS. Granted, it did not always work as smoothly as hoped at district level, but the approach allowed quick capacitation at local level while not building a parallel structure. Angela Stewart-Buchanan reflects similarly on the CDS arrangement: “I suppose the beauty with this whole structure was that it was able to be flexible, the DGMT holding it – you know, this fund from multiple donors, but in a way that allowed them to be strategic, flexible, and agile [which] was really important.” Thashlin Govender also points out the unprecedented flexibility of the arrangement: “Having also the flexibility with our boards to be able to keep that agility and ability to pivot was important. And I think each of the funders did that. So that was incredibly important, and in the normal operations in philanthropy, that typically does not happen. You don’t have foundations writing 20 million or 30 million rand cheques, putting it in at finance saying, yeah, do whatever you want to do, in order to be able to meet the objective. You don’t have that. That doesn’t work that way, but in this instance it was important and I think that on the flip side, DGMT did a good job of being able to take the funders along so that no one really thought like they didn’t know what this team was doing and they didn’t know what the funding was actually being used for.” 74

A similar perspective is provided by DGMT’s Vanessa Rheeder: “I think what also made it successful was to see in the end that most of the funding had been spent, and spent not just randomly, but very strategically. And we adjusted according to the needs of the project. If it had to have gone through the government, from what you’ve noticed about government systems, this flexibility is not really there and they would have just given the money back to the Treasury or whatever.” Several interviewees also pointed out that the partnership between the CDS and government at district level also worked well because DGMT do not normally operate in this arena. Being newcomers, it was argued, they were unencumbered by previous “baggage”, complicated relationships, and powerplays that may have hindered some other NGOs already working specifically in the field of health. Many interviewees commended the multi-sectoral collaboration that the CDS fostered, not only with government, but with many other business and civil society role-players, including organised labour. This collaboration between “unlikely partners” was seen as another key success factor.

A final factor that is both a qualitative indicator of success and a massive endorsement of the CDS model, its credibility, and the way it was implemented is that the CDS mechanism was able to leverage significant funding over and above the initial R152 million. An extra R574 million was channelled through the CDS, these additional funds coming from the KfW and its sister organisation GIZ, the Challenge Fund donors, ELMA Foundation, DGMT and the Gates Foundation. A particular endorsement is that the implementing agencies of the German Ministry for Economic Cooperation and Development, which provides bilateral government-to-government cooperation, in this instance chose to channel major support to government using a platform created by civil society partners. This shows that this kind of platform and its method of partnering closely with government while keeping the funds separate and having control over their use to implement what has been agreed, is an attractive option for bilateral funders as well. Matthius Hahl of KfW explains why they chose to provide EUR27 million for cold chain and logistics, and mobile outreach through the CDS:

“We thought it makes perfect sense to align with an established coordination structure within the NDoH and yes, DGMT had the lead. We already had an ongoing project with them. So when we establish a new project and we have to do a full-fledged project appraisal this is a process that can be quite time-consuming or can take quite long, But in the COVID response, obviously time matters. So we tried as much as possible to utilise existing programme structures and channels. Even if the content actually diverted a bit, but I think that was the agility that was required in COVID times to make things happen. And also having said that, I think this is also a reason for engaging and cooperating with DGMT, because they are familiar with the procedures and requirements of German financial cooperation, and what we knew from previous programmes and the experiences is that this organisation is dedicated to make things happen, to make things work, who responds to needs, and to focus on closing gaps.”

“DGMT is a serious organisation with excellent governance, and there was good dialogue between them and the other donors and the government partners. They were very flexible, professional, and good collaborators – we got what we expected. The coordinated nature also reduced the risk of duplication of efforts, and the pooled funding idea was very attractive for us. If it was just one donor, then it would not have been as attractive. The CDS’s official role with the NDoH was also crucial, to ensure their activities were aligned and that they were all pulling in the same direction. It was not just an NGO project in parallel with government. It offered safety for a donor but also with the close alignment with government implementation.”

In the two projects DGMT implemented with KfW funds, it cooperated with the NDoH in the first to assess vaccination equipment needs, and then DGMT procured 1 740 pharmaceutical fridges, around 8 900 cooler boxes, 5 600 temperature monitoring devices, and 3 200 IT units, before distributing them to the districts. In the second project, DGMT procured 46 mobile health units and is tasked with operating the mobile health teams performing outreach services, before handing them over to the government in 2024. Similarly, GIZ chose to channel R29 784 979 to support the CDS vaccine rollout. Claudia Aguirre of GIZ explains that the organisation is not normally a donor or grant-maker, but normally provides technical assistance and small grants. In this instance, because of the urgency of the need for support, GIZ decided to contribute money to DGMT for specifics like the Contact Centre and demand generation. Their major aim was to do it in a coordinated way that did not duplicate efforts, and to use a solid platform that would use the money properly. The government scandals around PPE procurement influenced their thinking here, but they wanted a trusted entity that was still aligned to the government strategy rather than working in parallel, so the CDS offered the perfect platform. Aguirre explains this further:

Wendy Tlou, of the Solidarity Fund, argues that we must not expect the government “to become what it can’t be, but we must partner with them to take advantage of what they are good at, which is scale and reach. And we provide what we can do, which is flexibility, good management, rapid response, innovation, and proof of concept.”

4.6 THE CDS CONTRIBUTION TO NEW PRECEDENTS OR PLATFORMS FOR NATIONAL DISASTER MANAGEMENT, MOBILISATION, COLLABORATION AND FUTURE SERVICE DELIVERY, AND LESSONS TOWARDS THIS END There are both positive, and some more hesitant views about the extent to which the CDS approach and activities have contributed to new precedents and platforms for disaster management or routine service delivery. However, a wide array of perspectives on the lessons arising from the CDS point to its potential as a model, and what should be done to protect and enhance new possibilities, and to build further resilience in the face of both emergency and longer-term challenges. One thing on which there is broad agreement is the potential and value of the CDS as a mechanism for pooling funds and expertise, and partnering with government on key strategies to address challenges without either overwhelming them or creating a parallel structure. Particularly where funds, human resources and products have to be mobilised quickly, without the delays typical of government, the platform is highly valuable. Wendy Tlou, of the Solidarity Fund, argues that we must not expect the government “to become what it can’t be, but we must partner with them to take advantage of what they are good at, which is scale and reach. And we provide what we can do, which is flexibility, good management, rapid response, innovation, and proof of concept.” Several of those interviewed revealed that donors were already exploring this model to address the ongoing electricity crisis, which suggests that the CDS mechanism has formed a precedent which will be used in future.26 Indeed, the multi-sectoral partnership between government, business and civil society is something that appears to have been solidified in the COVID response, with the embeddedness of the CDS approach being of particular value in fostering good working relationships and trust between them. As David Harrison remarked, the generation of trust was crucial at a time of political scandal and the ill-advised use of the “language of war” in government’s COVID response, and was something the CDS sought to foster. Edzani Mphaphuli emphasises that the “unbranded” nature of the support, where “everything was under the banner of the NDoH instead of different funders claiming credit” was important. Those from the business sector

felt strongly that their involvement in the COVID response (especially through the Solidarity Fund and DATT) had shifted the way companies work, and changed the way they understand their role in society and their attitude to working with government. Wendy Tlou (Solidarity Fund), Chris Austin (UK Foreign, Commonwealth & Development Office), and Martin Kingston (B4SA) all felt that stronger collaboration between business and government had been cemented and should be further enhanced ahead of future emergencies. Claudia Aguirre of GIZ also felt that the role of business and the Solidarity Fund was a key win that emerged, and the cooperation between all sectors was hugely admirable:

“In the context of South Africa, where the narrative is often business versus the government, it’s a beautiful example of how things can work together.” – Claudia Aguirre, GIZ But she warned that too strong a role by business and civil society should be avoided, especially if it creates dependency rather than encouraging government to develop its own capacity. Much as business had a strong role to play, the role of civil society organisations, especially developmental foundations has clearly been shown through the CDS. Zodwa Mbambo, of ELMA Foundation believes that the CDS “showed how many skills there are in civil society and business which we don’t always know exist, and we were able to bring them together to fight a common cause. It also built relationships between funders, which is really important as these need to be strong in order to mobilise quickly and effectively.” As has been pointed out, the strategic input of the core team was acknowledged by the NDoH as invaluable, helping to keep the vaccination programme focussed, simple, and data-driven, while also attentive to equity. This coming together of strategic thinkers with deep experience and knowledge of the issue, from government, civil society and business is a precedent which should be maintained. In the Western Cape, this has happened, as the committee of experts set up to advise the province’s

²⁶ See https://www.news24.com/fin24/opinion/martin-kingston-new-business-fund-will-help-end-power-crisis-by-securing-expertise-20230314

response is still in place. Michael Currin of the GCIS argues that the CDS provides a “blueprint for how civil society can work with government, allowing for disagreement, but also being collaborative and collegial.” He believes that the government is taking multi-sectoral partnerships increasingly seriously, which the COVID response has contributed to.

Another interesting partnership which was incubated through the CDS was the innovative use of transport operators to lift people to the mass vaccination sites, known as Passenger Vaccination Transport. Uber initially provided thousands of free rides, while later on the Department of Transport and the taxi industry became involved, helping those for whom transport was a barrier to get to vaccination sites. The taxi industry also allowed taxi ranks to become outreach sites, and used taxis to spread positive vaccine information. In KwaZulu-Natal, SANTACO held a successful campaign in early 2022. This was a great success, and on 1 April 2022 the Weekly Report stated that this “built trust between DGMT and the taxi industry”. This is another example of the “unlikely partnerships” which Zameer Brey has stated are one of the key legacies of the CDS initiative. The taxi industry is one of South Africa’s largest and most significant sectors, and harnessing it for social good is a major opportunity. The CDS approach has also created a precedent and model for how skills may very quickly be mobilised and embedded within government in times of crisis. Lesley Bamford explains it thus: “When you have a pandemic, you need a workforce to deal with it. But government can’t have people sitting around waiting for a pandemic. If one looks at it through that lens, then the DGMT mechanism really did help to mobilise a workforce quite quickly. That’s a good model from that perspective. And the fact that DGMT could employ them, but they could be seconded and still fall under the Department was quite a good approach. I’m sort of tangentially involved in some of the discussions around pandemic preparedness, and I haven’t really heard that discussion very much, the discussion around building capacity. They discuss Informatics and surveillance, etcetera. But the reality is when a pandemic hits you need people on the ground quite quickly.” Edzani Mphaphuli echoes this sentiment, arguing that the model shows that government departments do not have to be “hamstrung by their failure to make appointments to key posts.” From a financial management and governance perspective, Vanessa Rheeder agrees that the CDS is the best model for a staff or skills-focussed intervention in the future, but it may not work in every kind of emergency. Kirsten Walker, from GIZ, agrees with Lesley Bamford that in current planning for future 78

pandemics these human skills models are not being focussed on enough, with planners falling into the trap of developing Public Health Emergency Centres at provincial level which seemingly focus mainly on buildings and infrastructure rather than leadership and human capacity. The National Contact Centre is another tangible example of a platform which was built through the CDS initiative, and having been run by DGMT, will be handed over for the government to continue. It has great potential as an inwards and outwardsfacing communications tool in the primary healthcare space. Andy Searle, who was instrumental in setting it up, explains that it has now become a national health hotline with expanded functions, although the number of staff and regional footprint has been reduced. It has continued to be managed by DGMT and funded by donors, but it will migrate to be managed and funded by the NDoH.

If there is another crisis, the Contact Centre can be mobilised again, but it will now be useful in routine health services for the general public. Candy Day is also proud of how the Contact Centre was built, and new functions and ways of reaching people were added to support people and refer them to specialist health staff. She, however, points to how much more effective it could have been if EVDS data could have been used, both in service delivery and to drive demand through the Contact Centre. She believes this is one of the biggest lessons from the vaccination programme implementation, feeding into how future crises are handled. Zameer Brey also agrees that regulations such as the POPI Act should be amended so that they do not interfere with fast and effective disaster responses. Another approach which has been incubated through the CDS is the taking of health services to the places where people can access them. This was done through the outreach to pensioners, youth and those living in outlying areas. Waarisa Fareed points out that health coverage is limited, both in geographical reach and in the times services are open to the public. This excludes many people from easily accessing them.

While outreach is expensive, there is a strong argument that places where target populations already congregate regularly, like SASSA queues, can become places where screening for chronic diseases or other health needs takes place.

Bridget Dube and Jane Simmonds made the same point about the need to reach people where they are with health services. Gugu Ngubane is of the opinion that the CDS model should be used more purposefully to tackle other health issues such as chronic diseases, maternal health or even gender-based violence (GBV). For Gaurang Tanna, other innovations such as providing incentives to ensure that barriers to health-seeking are offset should be taken forward and applied to other communicable and non-communicable diseases. At present the KeReady initiative is the only outreach platform that has continued, enabled by the donation of a fleet of 46 mobile health units by KfW. These outreach teams reach young people in peri-urban areas with a range of relevant services. According to David Harrison, this programme is a great example of how an effective service delivery platform can be used to extend services to underserved populations. Among other positive enhancements that have occurred is the donation of cold-chain and IT equipment to district health services by KfW. Although the slow tendering process meant that delivery of this equipment was late, health services still benefit in the longer-term, for example in the current measles outbreak. According to Sandra Ngwena, many districts have also retained technical support personnel after the expiry of their DGMT contracts. In North West province, all six personnel were retained. USAID have also employed a number of them elsewhere to continue providing support to the government. Provincial and district health staff felt that their units had benefitted from having these individuals working alongside them. Nhanlhla Dikoane, who provided technical support in Limpopo, explains how there has been a legacy left there by the CDS: “In Limpopo we are utilising the same approach to deal with the measles outbreak, and I have been co-opted to deal with the data collection, analysis and management under an organisation called Right to Care.” In KwaZulu-Natal, Xolani Mtiyane was similarly positive about the CDS’ legacy for his district health unit: “There was so much cooperation from all sectors of society. Even now one such organisation employs the technical staff seconded to the provincial government.” Moremi Mohapi, who provided technical support in the Free State, believes that the support left a positive legacy in the data management arena: “We had to develop creative ways of increasing vaccine uptake, learning from other provinces and sharing success stories. It created urgency and new tools were developed to improve storage, supply, management and data collection.”

Marsel Opperman, who supported the Eastern Cape with vaccine management, also believes district health services benefitted longer-term: “The intervention proved that skills can be transferred, but at the same time it also exposed the huge skills gap in government. Some of the tools we developed during this time would benefit many government entities, especially the cold-chain management systems which were almost nonexistent.”

Another area where the CDS collaboration has potentially enhanced the development of new platforms is in the way in which private sector vaccination sites and public vaccination sites worked together, with private sites vaccinating uninsured individuals. While there were challenges with registering private sites quickly, and in reimbursing them, lessons were learnt which should feed into a much smoother process next time there may be an emergency. Lesley Bamford believes this was important: “Having one set of sites – both public and private sector – was key. These links and ways of working should be maintained for future pandemics.” Like others, she raised the fact that the EVDS has been used for the first time, which is also a legacy of the COVID period and “is a great platform for patient records”. The partnership between private sites and public health entities has also set a precedent which could be valuable in the context of the impending National Health Insurance (NHI). According to Bronwyn Macauley of Clicks, who led that company’s participation in the outreach programme, Clicks developed a more robust emergency plan which focuses not only on their staff and customers, but also on helping the NDoH to roll out a public campaign. This plan can be swiftly put into place in future pandemics. She argues that Clicks found this experience a good test case for how the NHI should work, and she believes that the private and public health sectors need to be aligned, with this experience showing the way it can work. Nicholas Crisp, himself leading the government’s development of the NHI, agrees that the vaccination of uninsured individuals in SASSA queues by private providers sets a precedent for private sector reimbursement for vaccination of the uninsured. The CDS’s 2 July 2021 Progress Report for Donors stated that it was hoped that the SASSA outreach could set such a precedent, and it appears to have achieved this aim.

Other legacies of the CDS are the toolkits which were developed and which can be used again in an emergency. One such is the area-based planning guide and toolkit, which was circulated to district teams. Another example is the toolkit that was developed by the communication team, as Angela StewartBuchanan explains: “The toolkit ... we had social media posts, we had voice notes, we had the press release, we had banners of all sorts and then they actually, as we progressed, got bigger as we knew what everybody wanted. But that link was then shared with the GCIS and Department of Health and then they just circulated it with everybody, and so it was two sets that were online that anyone could click through and now you look at all of the structures.” The SAcoronavirus website also has a vast array of communications products, including infographics, videos, statements, and weekly social listening reports, which provide a repository and template for future emergencies. It is clear that there are several areas where new precedents and platforms have been established, or where there is some potential.

However, several of those interviewed bemoaned that the many lessons and potentials arising from the CDS period are in danger of quickly being lost. Nicholas Crisp, for example, feels that government has gone back to bureaucratic business as usual, arguing that the collaboration and special dispensation of the COVID period has faded: “With the provinces, during COVID I could find anybody any time of day or night – it doesn’t matter their rank, or where they fit in the system – to get an answer and to deal with the problem. Now I have to write a letter for the DG to sign, to send it to the Head of Department!” The fact that such a senior technocrat has to navigate such protocols and bureaucratic obstacles within his own Department and its provincial partners is clearly concerning. Crisp says that he gets frustrated because he is a natural innovator, but still has to negotiate the cumbersome system. Velile Ngidi, who was the Provincial Facilitator in KwaZuluNatal, also has a more sombre take on the legacy of the CDS. She argues that the vaccination programme was a “vertical and isolated programme” which created dependency as provincial officials continued with their own jobs. This, she says, is making integrating it into the government difficult. Ngidi also agrees that government has gone back to business as usual and the opportunity for change is being missed. Thus, while there are 80

better disaster management plans now being put into place, she maintains that the lessons need to be applied properly to other health areas like diabetes. Priscilla Kgareba, Provincial Facilitator for the Free State shared a very similar view: “Unfortunately the CDS is acknowledged as a great achievement and platform for the COVID vaccination, but since then, the lessons have not been written up and fed into strategic planning for how to address future crises or everyday planning on things like maternal health. This is a big pity and sad because lessons should have been purposefully captured and then used to plan improvements in systems and ways of doing business and responding. Instead, although we remember the period fondly, it has gone back to business as usual and the usual planning processes. The lessons should have been very directly fed in, but as it stands, there is no contribution other than just enhancing the confidence of the teams since we worked well and collaborated together.”

Siven Maslamoney is also on the more pessimistic side on this issue. His sense was that the platform they created largely dissipated after the emergency, as the emergency was their primary focus. For him, the crisis surfaced how weak grassroots activism and voluntarism is in South Africa, after two decades of health activism being captured largely by one issue – HIV.

“We need to engage civil society again to get the local activists out on issues like non-communicable diseases, and we need large volunteer movements or mass movements of people and networks to run a campaign on these general health issues.” – Sivan Maslamoney He warns that unless this grassroots network is built up by the time the next emergency hits, it will severely undermine efforts to address it.

A final important lesson that was raised was how in future crises, the information space should be very quickly controlled to avoid what Hassan Mohamed called “the infodemic”. If a vacuum is created, it will very quickly be filled with misinformation and conspiracy theories. Dr Saira Carim, one of the KeReady campaign’s young doctors, put it thus:

“If there are misconceptions about a vaccine, don’t wait! Be open, people value honesty. In times of disaster, campaign early, hit hard and fast, have a conversation with people.” This was something that was eventually rolled out in the CDS initiative, but in future should be implemented from the outset. According to Angela Stewart-Buchanan, the government became much more attuned to the value of sophisticated communications and the use of social media during the pandemic, which augers well for future efforts. Prof. Mohamad also stressed how the next response must be more locally driven. He cited following global (WHO) guidelines around contact tracing, testing, isolation and quarantine as something that was largely inappropriate in the South African context, wasting effort that could have been applied elsewhere. Instead, he argued, community participation should be strengthened to get input from the ground-level on what approaches would work, rather than applying one blanket approach. Edzani Mphaphuli agrees, citing the EVDS as a barrier for many people: “A major lesson is that government must not just introduce international processes and platforms like EVDS that require pre-registration. Because the poorest don’t have cell phones and can’t register online. Any platforms must be geared to include the most marginal, not be based on the assumption by the rich people developing them that everyone can access a technological platform.” These interviewees felt strongly that a review process capturing all these lessons is a highly important step in ensuring that future endeavours are strengthened.

The fact that many longer-term benefits have come from the CDS can be seen as an unintended positive consequence.

4.7 UNINTENDED CONSEQUENCES

As this report has already outlined, the CDS was primarily an attempt to assist the government quickly and effectively in a health emergency, with the aim of saving lives in the most sensible way. Longer-term goals such as skills-transfer, the creation of new collaborative platforms, or the sustainable capacitation of government were not considered the primary aim. The fact that many longer-term benefits have come from the CDS can be seen as an unintended positive consequence. Many of those interviewed felt that the new modes of cooperation between multi-sector partners have occurred, along with more cooperative and less siloed forms of working between different departments and levels of government. Jabulani Mndebele, a Head of Department in the KwaZuluNatal DoH, expresses it thus:

units. Other funders invested in the Contact Centre, the DATT and continuing communications services. The value of a strong partnership between donors can be seen in terms of its ability to leverage more funding for the good. Probably the most significant negative unintended consequence of the way the CDS chose to work was some conflict that this caused with some civil society partners. These partners felt that DGMT and the CDS team were not as critical of their government partners as they wished them to be. While those such as COVID Comms favoured a more direct and critical approach, DGMT had to be much more measured with their NDoH partners. Zameer Brey sums up the very real risks involved with a hardline approach, and why the CDS opted for pragmatism:

The absorption of technical skills into district health services is also an unintended positive consequence of the CDS approach. Ewan Harris, the Provincial Facilitator for Gauteng, feels that the initiative “brought in a lot more skills in the data analytics field, and showed government how to go beyond simply generating data, to rather generating intelligence that can be used to make strategic decisions.” The positive experiences of many of those who were seconded to government for technical support roles also suggests that government can absorb and integrate skills coming in from other sectors. However, a drawback, as pointed out by Velile Ngidi, is that this may have created dependency in some provinces, because senior government officials never came to own the vaccination programme, but rather relied on the seconded personnel to run it. This makes it difficult to integrate now.

“I don’t think we had an easy way to hold government accountable for when they were not doing certain things, or when they were taking the wrong decisions. Because of our proximity we were able to, as donors, get really close to government, but I think also it created a sense that we are now part of the team. We can’t really go out there and lambast government for X, Y and Z. I don’t know that we would do that outside of such an arrangement, but I think we would have had more latitude to call out government and say this is not what we envisaged. And so, you have to maintain those relationships…I think even on the technical side, there were articles I needed to triple check whether I could put my name on, right? Because I was like, ‘Is this going to compromise my ability to do the work? As it is, we have a tenuous relationship.’ And, you know, I could easily have just published an article saying ‘These other people; this is wrong,’ etcetera. But that’s probably the end of my career. And so I think we were not in an easy position to call out government on this one. In fact, what was more surprising to me is that it was not all of the department. There were many well-intentioned people that were showing up every day saying ‘We’re going to do our best, we’re going to work together, we’re going to work collaboratively’, you know? I found the engagements with people like Lesley and Gaurang and others just incredibly positive. We wouldn’t always agree, but collegiality was exceptional.”

Another obvious positive unintended consequence of the CDS is the way the mechanism was able to leverage over half a billion more rands through partners who saw it as a sound way of investing in government, but doing so in a way that guaranteed quick and effective results. KfW Development Bank in particular invested large sums in capacitating district health services with IT and cold-chain equipment, as well as the 46 mobile health

The decision to go with diplomacy and pragmatism was ultimately the correct one, even if it led to frustrations and disagreements among civil society role-players. As Kirsten O’Sullivan (Allan & Gill Gray Philanthropies) pointed out, a far worse unintended outcome would have been the souring of the relationship with government partners, to the detriment of the larger cause.

“The relationship with stakeholders took the biggest shift. For once, we were using the same language, there was no competition, we worked together. There was transparency. The Minister went in public to talk about the challenges and those with solutions came forward. No idea was too small. For the first time the whole nation used one system to do things.”

The right tone to adopt with government was not the only cause for conflict with some civil society partners. The strategy direction, communications approach, and the use of incentives also caused some conflicts and rifts with other civil society organisations involved with the same work. Most notably the relationship with COVID Comms was difficult, while some within the Solidarity Fund also felt that DGMT’s approach with them was disrespectful and too forceful. There were clearly some inevitable personality clashes, misunderstandings and power plays during this very tumultuous time. COVID Comms also felt that the DATT came in without first understanding the work that was already happening in the demand creation space, taking over and undermining some of their grassroots endeavours. In interviews with the business sector, it also appeared as if there is still some competition over whether business or civil society can claim the most mileage out of their assistance to government during the COVID crisis. However, none of these misunderstandings appear to be insurmountable, and they must be seen in the wider context of very good cooperation between many different kinds of partners. Interestingly, Priscilla Kgareba shared that in the Free State it also appeared to her that the DATT came in without a proper assessment of the existing structures working at community level. She argued that various unknown NGOs were commissioned to work there without proper introductions, undermining the work of grassroots organisations and their ability to reach the youth in particular. A number of other interviewees stressed the need for a more grassroots approach. Pauline Maketa, the DATT civil society mobiliser, also provided feedback that traditional leaders felt left out of the planning for DATT and were consequently resistant at first as a result. The labour mobilisers shared a similar concern about the late inclusion of the unions. They all stressed the need to include all sectors of society in planning from the beginning, and to do so in a well-informed way. However, David Harrison and others felt strongly that they had made every effort to bring all stakeholders on board as early as possible so that by the time the DATT was put in place, there was already widespread buy-in. The various delays that were experienced at points in the CDS rollout also led to some unintended consequences. These hammer home the point that a speedy and unhindered response is crucial in crisis situations. As David Harrison has already shared (above), the delays in sourcing vaccines, and the delay in getting the CDS properly signed off, along with the delay in granting access to EVDS data probably cost up to 30 000 lives which could have been saved. Lesley Bamford also pointed to the initial over-focus on supply-side challenges, at the expense of demand-side challenges. Not focussing on demand creation from the beginning meant that the anti-vaccination disinformation was allowed to proliferate in the information vacuum. To be fair, the CDS team were pointing out this risk from the outset, but it took government partners a while to 84

fully get behind a smart communications strategy. There was also an assumption that the early and enthusiastic adopters represented the entire population, and all government had to do was provide the vaccine and demand would come naturally. Another assumption on the part of the government was that advertising alone would get the youth to come forward, when a much more hands-on, participatory and multi-media approach was needed. This approach was only brought in fairly late in the process. All of these issues contributed at least partially to the loss of momentum in the programme experienced around December 2021.

The lack of access to the EVDS and data to create sophisticated dashboards which could drive planning and demand creation also caused unintended negative consequences on the effectiveness of the vaccination programme.

Concerns about privacy aside, this also fed into the loss of momentum for the programme. Dr Giovanni Perez of the Western Cape DoH argues that this decision from the NDoH also fed into a loss of trust by the provincial government. The Western Cape had developed its own registration system just prior to COVID, but decided to use the EVDS in the national interest. But the fact that local level data could flow up to a national database, but was then restricted from flowing back down to local health authorities for their planning purposes had the effect of the Western Cape wishing they had rather used their own system, and retained control over the data. In future pandemics, this lack of alignment and trust between different layers of government could be highly detrimental. Lean CEO, Samantha Allen, also points to another consequence of not using real-time data to allocate resources in a smart way for both supply and demand. The mass vaccination sites (which Lean was attempting to assist) needed to reassess and realign constantly, based on current data about demand and how resources (vaccines, nurses) could be better allocated across time and space. Apart from the lost optimisation of vaccination numbers, there are major financial costs associated with not realigning and shifting resources in a smart way.

The CDS initiative initially raised over R151 million in funding between the core donors, an amount increased by R1.5 million in interest earnings over the course of the project.

4.8 THE COSTS OF MANAGEMENT AND SUPPORT The CDS initiative initially raised over R151 million in funding between the core donors, an amount increased by R1.5 million in interest earnings over the course of the project. As Table 5 shows, the initiative spent R148 163 622 on the various project activities between April 2021 and July 2022. There was therefore a small variance between income and expenditure, with R4 548 277 left unspent by the close of the project.

Table 5: Total income and expenditure April 2021–July 2022

Donor

Amount donated

The ELMA Vaccines and Immunization Foundation

R25 000 000

Personnel

R71 023 173

The DG Murray Trust

R10 000 000

Demand acceleration

R25 000 000

Allan & Gill Gray Philanthropies

R20 000 000

Offset strategy vouchers

R23 210 032

The Bill & Melinda Gates Foundation

R13 126 300

Programme costs

R10 461 254

The Michael & Susan Dell Foundation

R14 000 000

DATT

R5 791 677

The Solidarity Fund

R69 000 000

Youth campaign

R5 387 230

Interest income

R1 585 599

Project management costs

R3 695 802

Service innovations

R3 235 943

Travel

R358 551

Total income:

R152 711 899

Expense

Total expense:

Actual cost

R148 163 662

In addition to the initial amount, the CDS was able to leverage significant additional funding, as shown in Table 6.

Table 6: Additional funds leveraged by the CDS

Source

Extra leveraged funds

DGMT demand generation

R10 700 000

NGO Challenge Fund (various)

R10 000 000

KfW logistics and outreach support

R464 855 426

Call Centre repurpose (ELMA/Gates Foundation)

R55 000 000

Capacity support for vaccine rollout (GIZ)

R29 748 979

Total:

R570 304 405

Cost effectiveness is not assessed here, but the project management costs were kept down by DGMT providing the platform for the PMO, and seconding key staff to work on this project.

Having an efficient and lean team to run the project was undoubtedly one of its success factors.

However, as several interviewees revealed, their willingness to work long hours during the crisis is a hidden cost of this approach. Outside of a crisis situation, it is unlikely that such dedication could be maintained over a longer period. This factor is one thing to bear in mind in efforts to adapt the CDS platform to other uses.

The CDS proved that a major advantage in tackling emergencies is to have a pool of experts from all sectors of society to provide the optimal strategic drive of the response.

CONCLUSIONS AND RECOMMENDATIONS This report documents the process of implementation of the coordinated donor support to the COVID-19 vaccination programme. It reviews the effectiveness of all activities, and the outcomes of the initiative. It evaluates the initiative and its achievements within the complex context in which it was implemented, seeking to tell the story through a rich array of voices and perspectives of those who were involved at various levels. Providing such a review and documentation of this important contribution to the vaccination programme is crucial because of the many lessons which have arisen from the process. The major lessons are highlighted throughout, particularly in sections 4.5–4.7. Most broad lessons revolve around the ways in which multi-sectoral partners can usefully assist government in planning for and funding emergency health responses. They also pertain to how government might better work with partners to enhance outcomes in such situations, and how the various activities undertaken may be improved and utilised in future emergency responses or even in routine service delivery. The recommendations given here speak to the lessons which have been identified in this review. They are divided into four main areas:

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The CDS proved that a major advantage in tackling emergencies is to have a pool of experts from all sectors of society to provide the optimal strategic drive of the response. •

1. Preparedness for future public health disasters •

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A multi-sectoral partnership between government, civil society and the private sector, for funding, ideas/ strategy and skills mobilisation has been shown to be critical, and should be fostered even in non-crisis times so that it can be easily mobilised in emergencies. A collaborative framework for how the government and funders/civil society organisations might work together in emergencies was lacking at the start of the COVID pandemic. This has subsequently been built in the form of the CDS (among others), allowing for rapid response and multi-sectoral involvement. It is important to build

on and maintain these structures so that they are already in place when new emergencies emerge and can be mobilised quickly. It is also important to ensure that the political, legal and bureaucratic obstacles to mobilising these frameworks are removed to ensure a rapid response. In this regard, the use of letters of intent for the rapid mobilisation of the National Contact Centre shows that there are governance tools which are suitable in times of crisis. A mechanism must be developed to ensure that obstructive regulations which hinder a rapid and effective response cannot get in the way. In this case, the concerns around POPIA meant that the response could not be truly data-driven, undermining its effectiveness. Temporary suspension of some regulations in the broader public interest should be explored in situations which might warrant this.

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Government should be open to this kind of partnership and ensure there are structures to allow multi-sectoral experts to feed into strategic planning. Apart from anything else, the support of such experts can allow the government to continue to ensure that its key personnel are not overwhelmed, and can continue to oversee their regular areas of responsibility, even in a crisis. Protecting routine services during an emergency is important (e.g. social relief of distress, chronic disease screening, emergency operations etc.), as the COVID experience showed globally. Ensuring government workers can manage their normal duties is a priority, necessitating partnerships with NGOs and other employers to provide skills at all levels to assist to manage the emergency. 91

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Toolkits and guides developed through the CDS (e.g. area-based planning and communications) need to be circulated and stored in a way which makes them easily accessible and adaptable to new emergency situations. This will save valuable time and effort in any new crisis. Civil society, especially at grassroots level, is not as strong or vibrant as it should be. Strong networks of community activists are crucial in responding to crisis situations, especially in terms of going the last mile and communicating important messages widely. All sectors of society should concentrate on rebuilding community activism and engagement so that this can be a vital resource in a crisis. Crisis responses need to balance the inevitable top-down approach with a more consultative and grassroots approach. Involving people at community level, and those who work closely with them, from the outset is important to ensure there is buy-in and that people can assist with the response actively, rather than resisting it. The initial “command and control” militaristic lockdown approach and language of war, while possibly understandable in the context, clearly does more to alienate people and make them resistant to participating in a national emergency response.

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showed that just because a service is provided does not mean people will take it up, even if it may be in their own best interests. The use of politicians to communicate key messages during an emergency has its place. However, especially where confidence in politicians may have been undermined, there are many other experts who should rather be more prominent in sharing key messages. These include technocrats and experts within government who often do not get enough airtime, as well as experts from civil society at all levels.

In preparing for future emergencies, investments in human capacity and leadership are more important than investments in infrastructure alone. •

Government capacity at every level needs to be improved, but where this is not possible or practicable, the CDS technical support mechanism offers a way for skills to be seconded to government in times of emergency.

2. Improved delivery of health and other services

The vaccination programme showed that due to the unequal structure of society, privileged people were able to access protection far more quickly and easily than those from underprivileged backgrounds. •

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The CDS proved that a strong strategic focus on equity and overcoming barriers that prevent the less fortunate from accessing crisis relief is fundamental. Crisis responses should therefore be geared to serving the least fortunate in society first, even if this is more difficult. The various measures piloted in the CDS should be learnt from, including transportation assistance, incentives/ cost-offset schemes, and outreach efforts. Demand creation and communications in particular need strong community involvement from the outset, along with strong social listening, in order to get the messaging right in the various contexts and constituencies in which it needs to be heard. Local leaders, activists and influencers need to be involved in the development of communications and demand creation. The vaccination programme showed that demand creation and communications needs to be as important as supply-side concerns in a health emergency. They need to be implemented strongly from the outset to prevent the narrative being taken over by speculation, misinformation and conspiracy theories. The pandemic

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A major lesson from the CDS is that certain sectors of society benefit greatly from outreach services which reach them where they are. In this regard, elderly people already queueing monthly at SASSA pay points are a major opportunity for targeting with screening and referral for chronic diseases. Young mothers could also be targeted when they come to receive their child support grants. The youth also need outreach services that come to the settings they are normally found in, such as colleges and schools since even where there are adolescent and youth-friendly services at local clinics, these tend not to attract the youth as they should. As acknowledged by senior government officials in this review, government does need to become more flexible and innovative, but this is often prevented by the rigid frameworks and rules around spending. Partnering with other sectors is therefore important so that civil society or business partners can incubate ideas, innovate, experiment and prove new concepts, which government can then invest in and take to scale. Government has already been moving towards a multisectoral partnership approach, and better ways of ensuring inter-departmental cooperation, especially through Operation Sukuma Sakhe and the District Development Model. Lessons from the CDS around a multi-sectoral partnership and how it can work must be fed into these emerging cooperative ways of working to improve local development initiatives and service delivery.

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The CDS provided a test case for the private and public health systems working together to provide crosscutting services. This provided a basis for how the NHI could work. However, the vaccination programme experience shows that registration of private sites to deliver public services needs to be better streamlined, as do mechanisms for the reimbursement of private providers by government. The CDS showed that funders, businesses and civil society organisations can get involved in supporting government in numerous ways, not only with providing funding. The secondment of skills and provision of materials – for example for communications campaigns – are two good examples.

The establishment of the National Contact Centre has been a major benefit of the CDS initiative. •

•

This has been expanded and is going to be handed over to the NDoH imminently. This should be supported to be an important tool in assisting people to access primary healthcare services and referrals. It needs to be properly integrated and supported to continue to be as effective as it has been in order to play this role. The EVDS is another good tool which has been developed during the pandemic, and which should be used more broadly under more normal circumstances. Its full potential needs to be understood and utilised, and investments need to be made in data analytics and visualisation and the other skills that are needed to ensure the EVDS can be a useful tool.

Collaborative funding models should ensure that they can be true partners of government, rather than creating a parallel structure. •

3. Models of collaborative funding and technical support •

•

The pooled funding arrangement, with one of the suitable partners acting as banker and playing an implementation role, has great potential in both emergency and non-emergency contexts. Funders which collaborate and implement together outside of emergency situations have the existing relationships and trust needed to quickly mobilise in emergency contexts. Funders should foster such working relationships and agreements which can quickly be mobilised in an emergency. An added important advantage is that a collective of funders would make it much easier and less time consuming for government partners to deal with, as has been evident in the CDS. The role of such funders in pooling expertise is also important, within and outside emergency contexts. Funders with such mutual relationships should foster a community of practice arrangement where they can share ideas and advocate for structural, policy and systemic change as a collective.

Financial governance arrangements, which allow agility, speed and flexibility without losing their strength, are important to maintain. Although it is unrealistic to assume that the same round-the-clock style of oversight and approval can continue outside of an emergency context, funders should still incorporate mechanisms which allow for more flexibility and speed into routine practices, where appropriate. The CDS model shows that a multi-layered governance structure works well for pooled funding arrangements, with the implementing foundation able to put some of its own funding at risk upfront in certain instances, other partners allowing some flexibility, while others may require more rigidity, especially where their investment is large. However, if one of the partners is too rigid, it may slow down the speed and flexibility at which the whole arrangement can work. For the above reason, having one funder as the implementer – with a strong PMO – is more favourable than the contracting-in of an implementing partner. Another advantage is that having one of the funders implementing means decisions and pivots can be made faster, based on the direct experience of implementation, and without having to change grant agreements.

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The CDS model showed how this can be done, although there were areas where there were limitations on the partnership (e.g. in certain strategic decisions around the use of data). Although funders may influence policy and strategy through a collaborative approach, they should not seek to dictate to government partners and thus alienate them, but at the same time, government must be truly open to collaboration and to listening to the strategic advice of the funding partners. This kind of partnership between a collective of funders and the government is critical because of its ability to make large sums of money available for urgent needs such as technical skills, communications, demand creation, equipment, and delivery of services, yet spend the money in a way that is not constrained by government accounting systems and processes. This kind of partnership, where funders have control over the funds, but second skills or provide services to government partners, should be maintained for everyday service delivery challenges and future crises. The model where a structure like the CDS recruits and seconds technical support to government, but these personnel answer to government line managers, allows 93

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for a proper partnership and optimal use of these skills. It is particularly important for local public sector skills needs to be identified by the unit in question, and for them to be part of the recruitment process. There is also a need to ensure that good induction, and sound and streamlined performance review and disciplinary processes, are in place so that personnel are well integrated, and managed effectively, without being a burden on their line managers. Some provinces proved difficult to recruit the required skills in. In these instances, the secondment of NGO staff may be the most viable solution. However, issues around who pays for longer-term benefits need to be agreed upon first. There may also be an advantage in using skills based in other provinces which could work remotely on a part-time basis with the unit in question.

4. Costs of implementation informing future interventions •

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The CDS provides an example of a relatively lean model for assisting government with technical skills and services such as communications and demand creation. The National Contact Centre, for example, used a flexible model which could expand and contract depending on the need for its services. This relied on close relationships with the call centre industry to make available and to reabsorb call centre agents as required. Project management costs are also kept down if personnel can be seconded from some of the funding partners, as was the case of the CDS. These flexible and cost-saving arrangements should be maintained in future interventions. COVID also provided new ways of working with partners scattered across the country, but people worked remotely and online rather than face to face. This had major cost-saving implications and shows that for some layers of the workforce, it is unnecessary to spend large amounts on travel, per diems and accommodation. This money could rather be channelled into supporting the personnel working at a more hands-on level to overcome challenges such as accommodation, key equipment and transport, which district-based personnel raised as issues.

Lessons from the vaccination rollout show that major cost savings can be experienced if implementation can be data-driven and resources can be shifted flexibly to where they are needed, at the time they are needed.

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This was a somewhat missed opportunity in the COVID response as vaccination sites could not be as responsive and data-driven as they should have been. The surge sites also missed the opportunity to work with Lean to streamline their systems and services. In future, data analytics should be used more effectively (starting with access to recent data) to not only help implementation, but also to ensure cost-effectiveness. Outreach is essential, but is also costly, especially to deliver services to the most isolated places and people. For example, operating vaccination sites at a SASSA pay point at a shopping centre is much easier and cheaper than trying to follow the SASSA trucks around to each small stop they make in rural areas. A proper study of the costs and dynamics of providing outreach in relation to its various benefits is advisable.

Appendix 1: List of key informant interviews Interviewee

Organisation

Position/role in CDS

Date

Sandra Ngwena

DGMT

Project manager

1-Feb-23

Dr David Harrison

DGMT

Project lead

10-Feb-23

Lebo Motshegoa and Angela Stewart-Buchanan

DGMT

Demand Acceleration Task Team

10-Feb-23

Vanessa Rheeder

DGMT

Finance manager

28-Feb-23

Kirsten O’Sullivan and Lethabo Rampya

Alan Gray Philanthropies

Senior

10-May-23

Zameer Brey

B&M Gates Foundation

Senior

16-Mar-23

Bernadette Moffat and Zodwa Mbambo

ELMA Foundation

Senior

2-Mar-23

Thashlin Govender

M&S Dell Foundation

Senior

24-Feb-23

Gugu Ngubane

Solidarity Fund

Senior

3-Mar-23

Candy Day

DGMT

Communications/data

1-Mar-23

Chris Austin and Tori Bungane

UK FCDO – Development Director in the British High Commission for South Africa

Senior

20-Mar-23

Matthias Hahl

KfW

Senior

2-Mar-23

Claudia Aguirre

GIZ

Senior

14-Apr-23

Kirsten Walker

GIZ

Senior

19-Apr-23

Mohapi Moremi

Free State DGMT technical support

Province level

15-Mar-23

Tehilla Towani

KwaZulu-Natal DGMT technical support

Province level

23-Mar-23

Mthi Adonis

Western Cape DGMT technical support

Province level

5-Apr-23

Marsel Opperman

Eastern Cape DGMT technical support

District level

14-Mar-23

Nhlanhla Dibokoane

Limpopo DGMT technical support

District level

2-Mar-23

Dr Perpetual Chikobvu

Free State Health

FS District

17-Apr-23

Ntombela Bandile

Free State Health

FS District

Ayanda Soka

Eastern Cape Health

Supervisor

20-Mar-23

Hillary Goeiman

Western Cape Health

Supervisor

3-Apr-23

Xolani Mtiyane

KZN Health

Supervisor

3-Apr-23

Appendix 1: List of key informant interviews continues... 96

Interviewee

Organisation

Position/role in CDS

Date

Dr Tumi Malatji

Limpopo Health

Chief director

3-May-23

Dr Saira Carim

DGMT KeReady

Young doctor

15-Mar-23

Prof. Nicholas Crisp

NDoH

DDG

13-Mar-23

Gaurang Tanna

NDoH (then)

Vaccine coordinator

23-Mar-23

Nombulelo Leburu

NDoH

Communications

2-May-23

Dr Edzani Mphaphuli

DGMT

National provincial coordinator

22-Feb-23

Dr Lesley Bamford

NDoH

Vaccine programme coordinator

14-Mar-23

Michael Currin

GCIS

Acting DG

5-Apr-23

Dr Velile Ngidi

DGMT

KZN provincial lead

13-Mar-23

Ewan Harris

DGMT

Gauteng provincial lead

24-Feb-23

Dr Priscilla Kgarebe

DGMT

Free State provincial lead

7-Mar-23

Dr Giovanni Perez

Western Cape Health

Chief director, Metro Health Services

29-Mar-23

Prof. Hassan Mohomed

Western Cape Health

WC Health

6-Apr-23

Dr Mpho Shabangu

Gauteng Health

Tshwane district

13-Apr-23

Dr Mzobe

Gauteng Health

West Rand district

4-Apr-23

Mr Mndebele

KZN Health

Chief director in charge of districts and vaccine

13-Apr-23

Pauline Maketa

COVID Comms Partnership

Civil society mobiliser in DATT

15-Mar-23

Pulane Baloyi

SACC

Senior

15-Mar-23

Skye Grove

Right to Care

Director

24-Apr-23

Martin Kingston

BLSA/B4SA

Senior

29-Mar-23

Matthew Parks

COSATU

Parliamentary coordinator

2-Mar-23

Andy Searle

BPESA

Senior

28-Feb-23

Odetta Mgwenya

KeReady

Mobile health nurse

13-Apr-23

Ramona Azagsiba

KeReady

Mobile health nurse

13-Apr-23

Waarisa Fareed

DGMT

Outreach project driver

11-Apr-23

Bridget Dube

Genesis

SASSA project

30-Mar-23

Appendix 1: List of key informant interviews continues...

Interviewee

Organisation

Position/role in CDS

Date

Alex Haw and Bronwyn Macauley

Massmart and Clicks

SASSA outreach private sector

30-Mar-23

Brendan Seery

Citizen Newspaper

COVID content

16-Mar-23

David Lydell

COVID Comms Partnership

Samantha Allen

Lean Institute Africa

Director

27-Mar-23

Siven Maslamoney

Yellowwoods

DATT

20-Mar-23

Abraham (Abey) Daniels

COSATU

DATT

6-Mar-23

Adrian Williams

COSATU

DATT

9-Mar-23

Lettie Dube

DGMT

Radio DATT

24-Mar-23

Timothy Schultz

B4SA

Communications lead

15-Mar-23

Wendy Tlou

Solidarity Fund

Pillar lead

23-Mar-23

6-Mar-23