Implementation of recommendations – Preparations for the nationwide roll-out of the Covid-19 vaccine

10 March 2022

Dr Liz Craig
Chairperson, Health Committee
Parliament Buildings
Wellington

Tēnā koe Dr Craig

IMPLEMENTATION OF RECOMMENDATIONS – PREPARATIONS FOR THE NATIONWIDE ROLL-OUT OF THE COVID-19 VACCINE

In May 2021, my report Preparations for the nationwide roll-out of the Covid-19 Vaccine was presented to Parliament. This was the first phase of our vaccine work. The Health Committee (the Committee) subsequently considered the report and provided its own report to Parliament in November 2021.

In May, I indicated that I intended to carry out a second phase of work on the Covid-19 Immunisation Programme (the programme). That follow-up work focused on the actions that the Ministry of Health (the Ministry) has taken to respond to the recommendations we made in our May 2021 performance audit. We also made some observations on the Ministry’s progress towards achieving the programme’s equity objectives.

The programme has evolved since our initial work. The Covid-19 vaccine is now being rolled out to 5 to 15-year-olds, and booster shots are also being administered. Our follow-up work focused on the period leading up to the end of 2021 and has not looked in detail at how these subsequent parts of the programme have been managed.

However, we consider that it is likely the recommendations in our original report will be relevant to more recent phases of the vaccination programme. We encourage the Ministry to continue to focus on transparency and public awareness, maintaining good contingency plans, and progressing equity objectives.

Given the level of public interest in, and discussion about, the extent to which the vaccination programme has achieved its equity objectives, we did look at this as part of our follow-up work. Ensuring that there is equitable access to vaccinations is also likely to be the focus of a third phase of our work on the programme. We plan on carrying out this work in 2022.

Findings and recommendations from our May 2021 performance audit

At the time of our May 2021 performance audit, the Government had secured enough supply to vaccinate New Zealanders and several other Pacific countries against Covid-19. Our report described the scale and complexity of the programme that was being developed. We found that, in developing and implementing the programme, the Ministry had drawn on substantial expertise and taken care to ensure that public safety was a primary consideration.

However, we also observed that there was a risk that not all aspects of the programme would fall into place quickly enough to reach the levels of vaccination needed for the Government to meet its overall goal.1

We made six recommendations that aimed to assist the Ministry to strengthen aspects of the programme and public confidence in the roll-out. These recommendations reflected the Ministry’s role in developing the programme’s overall approach and in co-ordinating activity across the health system. Our recommendations also recognised that it was the district health boards and other healthcare providers that would deliver vaccination services.

We recommended that the Ministry:

  1. continue to be transparent in its public communications about supply risks and the potential impact on the roll-out schedule;
  2. complete contingency plans for major risks, for example, vaccine doses do not arrive in New Zealand at the scheduled time or in the expected quantities, adequate workforce is not able to be secured, key systems are not ready on time, or a community outbreak of Covid-19;
  3. continue to improve guidance to district health boards about the scenarios in which it is acceptable to depart from the sequencing framework and make this transparent to the public;
  4. continue to work with district health boards and Māori, Pasifika, and disability health care providers to make sure equity considerations are fully embedded in delivery plans;
  5. provide more clarity to primary health care providers (including general practitioners) about their role in the wider roll-out to ensure that they have adequate time to prepare; and
  6. continue to strengthen efforts to raise public awareness of the programme in a way that:
    • ensures that communications are co-ordinated with key vaccination events;
    • encourages uptake of the vaccine; and
    • is tailored to different audiences, in particular Māori, Pasifika, people with disabilities, and harder-to-reach communities.

To inform our assessment of the progress the Ministry has made against these recommendations, we asked the Ministry to complete a self-assessment. We also asked the Ministry about its work to support equity of access to vaccinations.

The Ministry carried out a comprehensive review of its work and provided us with a significant amount of information setting out its progress against our recommendations. We acknowledge the effort that the Ministry has put into responding to our request and the ongoing focus on continuous improvement that is evident in the Ministry’s response.

We have considered the Ministry’s response and assessed its progress. Our assessment is based on information the Ministry provided, discussions with a limited number of stakeholders, and publicly available information. We reviewed selected documents and data that the Ministry provided, information on the Ministry’s website, media articles, and submissions to the Health Committee. We have also spoken with a district health board representative, the Disability Rights Commissioner, and some Ministry staff working on disability issues. However, we have not carried out a further full performance audit.

Since we made our recommendations in May 2021, the Ministry and the wider health sector have made substantial progress in rolling out the programme. In Attachment 1, we summarise our assessment of the Ministry’s progress in responding to our recommendations. In Attachment 2, we set out what the Ministry told us about its progress and provide our assessment.

Summary of progress since May 2021

The Ministry has taken action to implement all of our recommendations. However, its efforts to support the programme’s equity objectives has not been wholly successful.  Supporting equitable access to vaccinations continues to be an objective of the programme and a focus for the Ministry’s work.

A large-scale immunisation programme has now been rolled out

In May 2021, about 400,000 vaccine doses had been administered and the Delta strain of the Covid-19 virus had not yet reached New Zealand.

As at 1 March 2022, 4,003,247 people had been fully vaccinated (population aged 12 and over, excluding booster shots). The reported proportion of the total eligible population that had received both doses of the vaccine was 95.1%. This compares with 94.4% in Australia (as at 1 March 2022 for those aged 16 years and over) and 85.2% in the United Kingdom (as at 2 March 2022 for those aged 12 years and over).

This is a substantial achievement. It reflects the combined efforts and hard work of many public servants, workers in the health and disability system, iwi, hapū, and other community leaders, including those in the Pasifika community, and many others.2 The vast majority of New Zealanders have chosen to get vaccinated to protect the safety of themselves, their whānau, and their communities.

It is likely that the Covid-19 Delta outbreak acted as a catalyst for people to get vaccinated. Decisions made by the Government and actions taken by the Ministry to increase the vaccination workforce, develop a new booking system, improve communications, and develop bespoke events such as the Super Saturday initiative all contributed significantly to achieving the vaccination coverage. The Ministry also took steps to boost its short-term supply of the vaccine.

The community outbreak of the Omicron strain of the Covid-19 virus might also act as a catalyst for people to get vaccinated and boostered. Some of the strategies used in the initial roll-out of the programme, such as targeted advertising, are also being used to promote uptake of the booster vaccination.

The programme has delivered a large number of vaccinations. Much of this was achieved during the Delta outbreak in Auckland, when the health system also had to increase its capacity for testing and contact tracing to manage the outbreak.

The Government announced that the programme had met the overall target of a 90% vaccination rate by the end of 2021. However, there are still geographic, ethnic, and other disparities. Some groups of people have considerably lower vaccination coverage than the population as a whole. This is why we chose to focus on the progress made towards achieving the programme’s equity objectives as part of this follow-up work.

The Ministry continues to state publicly that a key focus for the programme has been in ensuring that it is equitable across different groups of people.

The most recent publicly available information on vaccine coverage of disabled people is from 30 November 2021. At that time, the percentage of disabled people who had received at least one dose of the vaccine (90%) was higher than the percentage of the non-disabled population (83%).

Ministry information shows that, as at 1 March 2022, 95.1% of the eligible population (including 95.9% of Pacific peoples) had been fully vaccinated. However, only 87.4% of Māori had been fully vaccinated.3 Māori have also been over-represented in Covid-19 hospitalisations.

Although some groups have lower uptake than others, we saw evidence that the Ministry is working with and across the health and disability sector on a range of ways to improve uptake. The Ministry’s efforts and achievements to date should not be underestimated or go unrecognised. However, the Ministry has acknowledged that it still has work to do to fully achieve its equity objectives.

We have heard a range of views about the reasons for the lower vaccine coverage in some groups. These include that planning for vaccination of these groups started too late, that representatives of some of those groups were not involved enough in the planning, that the response was overly centralised, and that there is long-standing mistrust among Māori in the health and disability system and in the government. Although the Ministry set aside some funding early in the programme to support iwi and Māori communications organisations to work with the programme, this funding was not distributed for some time.

Regardless, it is critical that efforts to reach groups with lower vaccination rates remain a priority. The overall success of the programme depends on how well it covers these groups, including younger age groups and when delivering booster vaccinations.

Targeted funding has been committed to support Māori, Pasifika, other ethnic communities, and disabled people being vaccinated in the programme. In addition to providing this targeted funding, the Ministry has:

  • worked with a wide range of people and organisations, including those representing Māori, Pasifika, and disabled people;
  • made substantial tools and resources (such as information systems) available to the planners and providers of vaccination services;
  • supported workforce training and expanded the group of people who can work in the programme; 
  • produced operational guidance and multiple communication resources to support equity in the programme; and
  • supported a telehealth service to help people to navigate the programme.

The expanded group of people who can work in the programme includes a new “Covid-19 Vaccinator” position. This position can be filled by people who have worked in other healthcare settings (for example, a kaiāwhina or a pharmacy technician), who after receiving appropriate training can work with limited scope under the supervision of a qualified and experienced health practitioner. The Ministry has indicated that this workforce has a higher proportion of Māori and Pasifika than the broader vaccination workforce.

Initiatives with local communities where providers involve trusted members from those communities appear to have helped improve vaccination rates.

Given the importance of equity and the public funds committed to the programme’s equity initiatives to date, we anticipate that our next performance audit of the programme will look at the management and effectiveness of those initiatives in more depth.

Multiple government agencies are responsible for some of the equity-related funding initiatives, not just the Ministry. For example, the Ministry, Te Puni Kōkiri, and Te Arawhiti administer the $120 million fund to support Māori communities to fast-track vaccination efforts and prepare for the new Covid-19 Protection Framework.

Involvement and priority of Māori in the programme

There has been some public comment expressing a view that Māori have not been involved enough in aspects of the programme4 and that not enough information has been available to some organisations to support their work vaccinating Māori.5

There has also been comment on the Government’s policy decision to not directly prioritise Māori in the vaccination sequencing framework.6 It was suggested that the Government should have done so to reflect the earlier onset of morbidity and mortality within the Māori population. These factors mean that the Māori population is at higher risk of the effects of Covid-19 at an earlier age compared with other populations.

Policy decisions and rulings about the legality of a public organisation’s actions are outside of the Auditor-General’s mandate. The Waitangi Tribunal and the courts are the appropriate authorities to consider those matters, and we note they have been the subject of judicial reviews as well as an inquiry by the Tribunal.

Vaccination rate data

Vaccination rate information has been a critical component of the programme. Data has informed prioritisation and planning, and provided information about the programme’s equity performance, at the district health board and national level. The most current vaccination rate information is available on the Ministry’s website at health.govt.nz.

The Ministry has used the Health Service Users dataset to determine the eligible population when calculating vaccination rates. This dataset counts the number of people who are enrolled in a Primary Health Organisation (PHO) or who received health services in 2020.

Some uncertainties affect the completeness of this dataset. It excludes some people – for example, some visitors to New Zealand, those not enrolled in a PHO, and those who did not seek health services in 2020. It also includes some people who left New Zealand after they last used a health service.

There is also evidence that enrolment rates in PHOs are lower for younger people and Māori than for other groups.7 It is important that the Ministry continue to take these uncertainties into account when using the data to manage the programme.

Information readily available to the programme about iwi affiliation and disabled people is also limited. The Ministry has taken actions to improve this information. These include the Ministry collecting iwi affiliation during the programme and working with the Social Wellbeing Agency and others to obtain and integrate disability information from multiple sources.

Conclusion and next steps

Since we carried out our audit in May 2021, the nationwide roll-out of the Covid-19 vaccine has made substantial progress. The Ministry has made significant efforts to implement the recommendations we made in our May 2021 report. The Government has said that it has reached its target to vaccinate 90% of the eligible population.

This is a considerable achievement and one that should be recognised. It is an achievement that would not have been possible without the support and contribution of all parts of the health and disability sector, public servants, iwi and community leaders, non-government and community organisations, and the public.

Although the programme has achieved a high level of vaccination for the population as a whole, there are still differences in vaccination rates between communities serviced by different district health boards and  lower vaccination rates for Māori compared with the non-Māori population. Work on further reducing these inequalities must remain a priority for the programme. The booster programme and the vaccination of younger age groups may face the same equity challenges. The lessons learned to date need to be considered in further phases of the vaccination programme.

The Committee may wish to invite the Ministry to discuss its progress.

Because of the level of public interest in the programme, we will publish this letter on our website.

Nāku noa, nā

Signature - JR

John Ryan
Controller and Auditor-General

1: When we published our report, the goal was to vaccinate as many people aged 16 years and over as possible by the end of 2021. On 22 October 2021, the Government announced a target of vaccinating 90% of the population to move to the new Covid-19 Protection Framework.

2: In addition, the Ministry, the Ministry of Foreign Affairs and Trade, the New Zealand Defence Force, and others have supported vaccination in the Pacific, including in Tokelau, Niue, and the Cook Islands (referred to as “Realm” countries) and in other Pacific countries.

3: The proportion of population aged 12 years and over and excluding booster shots.

4: Health Select Committee, Briefing on the Government’s response to COVID-19, 29 September 2021.

5: Covid-19: Whānau Ora plans to take govt back to court over Māori data for under 12s” (19 January 2022) at rnz.co.nz.

6: “Māori largest number of new cases – ministry ‘didn’t follow the science’ ” (15 September 2021) at teaomaori.news, and “The stark inequity of the vaccine rollout” (6 September 2021) at newsroom.co.nz.

7: Irurzun-Lopez, M., Jeffreys, M., and Cumming J. (2021), “The enrolment gap: who is not enrolling with primary health organizations in Aotearoa New Zealand and what are the implications? An exploration of the 2015-2019 administrative data”, International Journal for Equity in Health, Vol. 20, No. 93.