Auditor-General’s overview

Ministry of Health: Management of personal protective equipment in response to Covid-19.

E ngā mana, e ngā reo, e ngā karangarangatanga maha o te motu, tēnā koutou.

Along with the rest of the world, New Zealand has been grappling with Covid-19, a pandemic that has needed an unprecedented response and affected the lives of every New Zealander. Our health and disability sector has borne much of the burden of that response.

New Zealanders should, quite rightly, expect our health system to be capable of rapidly and competently responding to a foreseeable emergency, including a pandemic. Part of that response includes the need to ensure access to enough appropriate personal protective equipment (PPE) to keep those who need it and those they are caring for safe.

After the H5N1 bird flu outbreak in 2005 and the outbreak of SARS (Severe Acute Respiratory Syndrome) in 2006, the Ministry of Health (the Ministry) and district health boards (DHBs) planned how the health and disability sector would respond to, and co-ordinate in, an emergency. They also set up the national reserve of PPE to ensure access to critical supplies during a pandemic.1 The Ministry and DHBs hold these supplies.

Covid-19 has been the first real test of this pandemic preparedness. The size, scale, and speed of the pandemic required the Ministry to play a strong and decisive leadership role in a largely devolved sector. This has tested the planning and processes that were in place. There have been several epidemics and a pandemic in recent times. However, these did not trigger such high domestic or international demand for PPE as we have seen with the Covid-19 pandemic. Covid-19 has affected global supply chains to multiple sectors, including health and disability providers.

To date, New Zealand’s health response to the Covid-19 pandemic has been highly effective. The country has contained a disease that has already caused hundreds of thousands of deaths worldwide.

However, during the early stages of the response, health professionals, community-based health and disability providers, and those they were providing care for questioned whether PPE was getting to where it was needed, when it was needed.

Public reassurance about the availability of PPE appears to have led to confusion about who should have access to PPE and in what circumstances. PPE supply has caused deep concern for some vulnerable groups and the carers who work with them.

In times of crisis, people need to have trust and confidence in the systems and arrangements set up to support them. I decided that it was important to take an independent look at how the Ministry has been managing both the national reserve of PPE, and the supply of PPE during the pandemic.

In April 2020, I agreed with the Ministry to independently review the Ministry’s management of PPE during the early stages of the country’s response to Covid-19.2 We chose to do a relatively rapid review given the currency of the issues and the high level of public interest in PPE.

This has meant that we have carefully targeted the scope of our work. We were also aware that the agencies we were reviewing needed to prioritise their resources on the Covid-19 response rather than on our review.

I will want to consider other matters about the Government’s response to Covid-19 in the future, and I will report on these separately.

What we found

The Ministry and DHBs had planned for a national health emergency. The Ministry and DHBs maintain a strategic national supply of critical clinical items, including PPE, to ensure health services have continued access to them during large or prolonged emergencies that generate unusual demands on normal stocks or supply chains. However, there were gaps in the planning about how PPE would be procured and distributed to mitigate the risk of shortages.

The Ministry did not regularly review DHBs’ plans to ensure that they were kept current and that they were well aligned with the Ministry’s overall plans. We found some misalignment in the plans about roles and responsibilities for both planning for, and providing PPE in a pandemic, which led to confusion.

The gaps in the planning also meant that the Ministry was not well positioned to ensure that PPE was available in enough quantities throughout the country to meet the demand caused by the pandemic.

The health and disability system is semi-devolved, with distributed responsibilities and often complex arrangements between the Ministry, DHBs, and other organisations. The Ministry is responsible for monitoring and forecasting usage of the national reserve of PPE, and prioritising and allocating supplies when needed.

However, in early February 2020, the Ministry did not know what PPE stock the DHBs held in their reserve supplies or have a system to forecast demand. The devolved system of managing and distributing PPE stock for operational use was not able to manage the increased flow of stock needed during the Covid-19 response, and DHBs identified that some of the national reserve stock DHBs held had expired.

Before Covid-19, DHBs mostly procured stock, including PPE, individually or regionally. Not surprisingly this system did not lend itself to effective procurement in a competitive and internationally constrained market for PPE in the midst of a pandemic.

Guidelines about who should use what PPE and in what circumstances evolved during the response, and communications about those guidelines caused confusion. The changes in guidelines also challenged assumptions about the amounts of PPE that would be needed.

Despite the challenging position the Ministry was in, the Ministry and DHBs worked hard to adapt the processes during the “lockdown” phases of the country’s response to Covid-19.

The Ministry moved quickly to set up a new centralised system for procuring, prioritising, and distributing PPE stock. Ideally, that system would have been better planned for and tested as part of the health sector’s emergency readiness.

To be sufficiently prepared in the future, the health and disability sector needs a clear understanding of what PPE is held where, who it should be provided to, a way of forecasting demand, and a scalable system for procuring and distributing stock. This will provide some assurance that the right PPE is available and that it is getting to the right people at the right place at the right time.

In my view, Covid-19 would have challenged any public health and disability system. Although New Zealand has been successful in limiting its deadly effects so far, the national lock-down meant our health system has not been tested on a scale that other nations’ systems have been tested.

It is important to note that we are not out of the woods yet – there is still a risk that Covid-19 will re-emerge or another pandemic occur. However, much has been learned through this response. I consider that my recommendations will contribute to strengthening the resilience of the systems that support the supply of PPE and assist the Ministry and wider health system to prepare for similar threats that could emerge at any time.

I thank the many people who co-operated with, and contributed to, this report and took the time to talk to us while they were managing a national health emergency. I also thank those people and organisations who approached us with information about the management of PPE.

And I, along with the rest of New Zealand, acknowledge and thank the frontline health and disability workers and Ministry and DHB staff who have worked tirelessly to respond to the pandemic and protect the health of New Zealanders in difficult circumstances.

Nāku noa, nā

Signature - JR

John Ryan
Controller and Auditor-General

15 June 2020

1: Ministry of Health (2017), New Zealand Influenza Pandemic Plan, page 13. Ministry of Health, National Health Emergency Plan National Reserve Supplies Management and Usage Policies, pages 1-3.

2: For the purposes of this report, when we talk about PPE, we mean masks (standard surgical and N95 masks), goggles, face shields, gowns, aprons, and gloves.