South Africa's Vaccine Roll-Out Failings Expose the Hollowing Out of the State

Following 17 phone calls with the CEO of the drugmaker Pfizer, Prime Minister Benjamin Netanyahu announced in January 2021 that he had secured an agreement for Israel to roll out Covid-19 vaccinations. In a deal whereby the Jewish state would serve as a “model country” for Pfizer by offering statistical data on the vaccine's effectiveness, within two months more than five million people, exceeding half of Israel's population, had been vaccinated.

Cut to South Africa where less than 0.5% of the population has been vaccinated. Instead of accepting that there was a problem, in March 2021 President Cyril Ramaphosa joined a chorus of African and other leaders criticising “vaccine apartheid”. “Vaccine apartheid must come to an end,” said Ramaphosa, criticising developed countries for hogging vaccines.

Admitting that his government “had lost a little bit of time”, by that stage South Africa's health system had failed to administer a single dose outside of vaccine trials of a drug not yet approved by its own health authorities. After months of promises of a vaccine roll-out which would require 160,000 daily doses to reach the government's own targets by the end of 2021, just more than 200,000 healthcare workers had been inoculated after the first 36 days, averaging 5,700 doses daily. At this rate, it would take more than 16 years to vaccinate 67% of the population required for so-called herd immunity.

Even though Ramaphosa and other leaders of his government were among the first in the queue to be inoculated, vaccine apartheid cannot be to blame for the lack of a workable roll-out plan and lack of transparency about where and when the vaccines would be acquired. Only in April did the government finally announce it had signed a deal to acquire 20 million doses of the Pfizer vaccine to augment its Johnson & Johnson doses.

This failure between political rhetoric and real roll-out is not unique to South Africa. Despairing at the slow movement of his government on vaccines, Hernando de Soto, the Peruvian economist running for president in the April 2021 election, has proposed a 60-day programme to deregulate state purchase of the vaccine and obtain it privately through the market. “We are not going to ask a state, which doesn't know how to organise its own commercial life, to distribute vaccines,” said De Soto, known globally for his work on the centrality of property rights to economic growth.

It has not been vaccine apartheid or poverty condemning people to death in South Africa, despite the willingness to employ the old South African trope to justify the government's inability to make good on its own rhetoric. It highlighted once more the difference between plans and action — and the pathological, systemic failure to walk the talk.

Ironically, South Africa has easily the most efficient and widespread private healthcare network in Africa, with nine million private medical aid subscribers. These companies are ready to vaccinate millions of members — and offered to vaccinate an equal number of non-members — but are dependent on the government's acquisition of the doses.

The government's desire to control the vaccination process despite its manifest inability to execute with efficiency, and its implementation of an extreme lockdown that severely damaged the economy but did little to discourage Covid-19 (South Africa has the highest number of cases and deaths in Africa) suggest it confuses power with delivery.

Stalin would have been proud of the iron will to control but perhaps a little disappointed in the plasticine inability to deliver.

Such state delinquency occurs, in part, when voters let politicians off the hook, are easily manipulated and divided and ruled, not least by identity politics, of which the term “vaccine apartheid” is a variety.

Why is it that some states are able to talk so well and walk so poorly? The explanation may be found in the world of global aid, where the gulf between what recipients say they will do with the money and its ultimate fate is yawning.

It is to be expected, perhaps, of those countries requiring dollops of external aid to fail to carry out their functions, since they exist in a perverse tautology: they would not need the money if they were well governed. But it does not entirely explain why the government is so feckless, or what can be done to improve the link of accountability between citizens and government.

The government can easily be disincentivised by aid, knowing that there is always a donor willing to come in and help, not least since the donors' own incentives are skewed in this way. As Tendai Biti recalls of the drought that gripped Zimbabwe in 2010 during his first year as finance minister in the Government of National Unity, “certain Zanu ministers would say to me, don't worry about budgeting for food imports, the WFP [World Food Programme] will come in”.

A lot rests on leadership — and this applies to countries equally, not only those requiring aid for development. And the value of this component should not be measured, observes Bishop Precious Omuku, a special adviser to the Archbishop of Canterbury, only by the extent of the sincerity of leadership, but by the management of their choices.

The answer to this aid conundrum, Biti argues, is to be more strategic. Aid should be demand-driven according to a country's own needs, rather than be determined by those of the donor. This lends itself to better coordination, where Treasury, in particular, should play an overall coordinating function, without which “there is duplication and sometimes competition and 'turfism', compounded by a lack of transparency”. While there is always an appetite to fund short-term emergencies such as droughts and pandemics, there is a need to align aid to long-term requirements, designed to create “capacity resilience and independence as opposed to dependence within the state”.

Rather than playing this important role in managing large-scale acquisitions and matching them with financial resources, South Africa's Treasury appears to be losing control of the fiscus, becoming a passive dispenser of money to programmes without measuring their efficacy. It does not take much of a leap to work out the consequences of this as demonstrated in the recent scandals over the acquisition of personal protective equipment.

A lot rests on leadership — and this applies to countries equally, not only those requiring aid for development. And the value of this component should not be measured, observes Bishop Precious Omuku, a special adviser to the Archbishop of Canterbury, only by the extent of the sincerity of leadership, but by the management of their choices.

Yet the prevalence of their failure — and the serial search for external excuses — is a reminder of the premium of leadership.

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As the UK's Chief of the Defence Staff, General Sir Nick Carter is responsible for the welfare and utility of 157,000 servicemen and women, and is well placed to identify what he sees as four key leadership roles: the need for clarity of purpose — “the what and why”; the need for prioritisation to ensure impact and the link to value; the empowerment of trusted subordinates by minimising constraints, maximising freedoms and incentivising innovation; and the need to ensure delivery by setting targets and holding people to account for delivery. Courage, intelligence, vision and its translation into policy, personal ownership, discipline, humility, and the personality to get others to follow are all essential attributes.

All this has to be matched by the health of institutional structures, including the rule of law and transparency.

“Once you define the agenda,” observes Juan Carlos Pinzón, the Colombian defence minister at the time of the country's security and economic turnaround in the 2000s, “you need to set every managing tool for decision making (with private-sector concepts) and follow up.”

You also need to establish a “team to handle the execution” from the top to the bottom. “Many times, governments,” he warns, “are determined by slow-moving bureaucracy or by political commitments that push unqualified individuals to positions of responsibility.” And external reviews are critical in both measuring progress and suggesting adjustments. This generally should involve external experts since “typically, bureaucrats will be on the defensive, trying to prove that they're right. Politicians also always are seeking for the best possible story even in the middle of failure.”

What matters to the country is not the extent of the hard work, or how the leadership looks, but the ability to transform situations. Or, as Biti notes: “Everything in Africa is a function of good leadership. Good leadership entails a vision, a strategy and a plan. Good leadership is about accountability, transparency, building institutions and capacity.”

Perhaps the last word should, fittingly, be left to Bobi Wine, the Ugandan reggae artist who took on the might of Yoweri Museveni's state in the election in 2021.

“The difference between eloquent presentations [by politicians] and delivery is accountability,” he says. “But there is an exchange of failure on both sides: citizens don't hold the government accountable and they, in turn, are not expected to behave responsibly. The solution has to come from both sides. Leaders are not going to do what's right because they are good, but rather because they are held accountable.”

“We are not,” says Wine, “going to get what we deserve, but what we demand.”

This article was originally published on Daily Maverick.