Attachment 2: What the Ministry told us about its work and our assessment of the progress made with each of our recommendations

Recommendation 1: Be transparent about supply risks

We recommended that the Ministry continue to be transparent in its public communications about supply risks and the potential impact on the roll-out schedule.

What the Ministry told us

The Ministry’s approach has been to keep vaccine supply considerations at the forefront of communications relating to the Programme rollout. Since OAG’s [May 2021] audit was completed, the Ministry has routinely published key data about the rollout including weekly data setting out the volume of doses on hand.

The Ministry has used several communications activities and channels to explain vaccine supply constraints to the public including updates in the 1pm media stand-ups on supply expectations and how this informs our programme planning. The Ministry has also explained vaccine logistics challenges and constraints to media and wider public including creating general information to explain the complexity of the vaccine supply chain.

Recent interactions with the public about COVID-19 vaccine supply include:

sourcing additional doses from Spain and Denmark when the Delta outbreak in August 2021 significantly increased demand;
availability of alternative approved COVID-19 vaccines;
‘booster’ shots;
securing paediatric doses of the Pfizer vaccine – if approved and required – for vaccinations of 5–11-year-olds.

Our assessment of the progress made

The Ministry and Ministers have communicated with the public about the supply risks and the steps taken to manage those risks – in particular, boosting short-term supply through procurement from other countries and incorporating additional vaccines into the programme.

Recommendation 2: Complete contingency planning

We recommended that the Ministry 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.

What the Ministry told us

Considerable contingency planning took place subsequent to the initial fieldwork by the OAG audit team, and plans were developed to describe how programme functions would respond in a number of scenarios, including: community outbreak (for example, the development of the drive-through service delivery model and the establishment of incident management processes to be implemented in the event); disruption to supply of vaccines, PPE and consumables; disruption to the availability of vaccinator or administrator workforce; significant IT outage; serious clinical safety risk; and serious privacy and security breaches.

Plans broadly cover points such as critical resource requirements, key activities, communications, and key contacts. Integration points across the COVID-19 Response system, including at the Ministry and DHBs, were also identified.

Community outbreak

The contingency plans prepared for a community outbreak were implemented in August 2021 when Delta was found in New Zealand, including standing up a seven-day a week incident management team within the Ministry and DHB programmes, introducing required infection protection controls at Alert Level 4, and deploying drive-through and other appropriate service delivery models.

As a result, the programme was able to accelerate vaccination uptake through the Delta outbreak, rather than being derailed by it. In the days and weeks following the discovery of new positive COVID-19 cases in New Zealand the vaccine programme lifted daily vaccination rates to some of the highest seen in any developed country.

Vaccine supply

Close management of vaccine supply has been essential to managing the risk of supply uncertainty. Tracking of stock on hand and future supply from Pfizer against current and projected vaccine utilisation has been introduced as part of routine monitoring in order to identify possible supply constraints as early as possible. An updated Inventory Portal has also been rolled out that provides clearer visibility of vaccine stock on hand at vaccination sites. A hub and spoke supply model has been co-designed with DHBs to build local contingency supply at DHB hubs to mitigate acute supply issues (for example weather events, road delay). The risk of acute supply issues is also being addressed by encouraging all vaccination facilities to hold additional stock on hand.

Since the OAG report was published, Medsafe has granted provisional approval for the use of two further COVID-19 vaccines (Janssen and AstraZeneca) within New Zealand. While New Zealand’s vaccination programme will primarily be rolled out using the Pfizer vaccine, the possibility of incorporating these vaccines into the Programme provides an additional level of flexibility to the Programme.

Workforce

A number of initiatives have been put in place to ensure sufficient workforce for the Programme including:

Registered health professionals outside of the regular vaccination workforce of general practitioners, nurses and pharmacists are able to train to deliver vaccinations
A surge workforce database (Hands Up) was put in place to provide a pipeline of potential resources to assist DHBs in the COVID-19 Vaccination Programme rollout and/or other supporting functions in managing COVID-19. An update to the database at the end of May included the registration form translated into Te Reo Māori, Samoan and Tongan to encourage increased participation by Māori and Pacific people. There were over 60 new registrations within 48 hours of this launch. Contracted Māori health providers and pharmacies have access to the database. By early October, Hands Up had more than 16,900 registrations of interest, and 359 candidates had been employed by the DHBs and Ministry.
In May the Ministry created a new class of vaccinator, the COVID-19 Vaccinator who could vaccinate while working under supervision. There are 119 authorised COVID-19 Vaccinators working under supervision and over 563 COVID-19 Vaccinators currently in training. There is increasing representation of Māori and Pacific peoples in the COVID-19 vaccinator workforce. Approximately 48 percent of people in training identify as Māori, and 11 percent identify as Pacific. There is 9 percent representation of Māori and Pacific within the wider vaccination workforce.
A contingent workforce was recruited using LifeCare and other occupational health providers to provide trained resources into areas of immediate need for DHB and commissioned providers
Development of options for additional workforce if required in Alert Level 3 and 4

Business continuity planning

DHBs were required to confirm business continuity planning had been carried out as part of providing assurance of readiness to move to scale. The Ministry has drafted COVID-19 Vaccine Operating and Planning Guidelines for DHBs and providers outlining risk mitigation and incident management processes and procedures. This is frequently updated.

Our assessment of the progress made

The Ministry told us that its contingency planning supported accelerated and ongoing vaccine delivery during the Covid-19 Delta outbreak.

Recommendation 3: Continue to improve guidance

We recommended that the Ministry 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.

What the Ministry told us

Detailed policy work has been undertaken by the Ministry to guide the vaccine sequencing framework and subsequent rollout of the vaccination programme that takes a strong equity approach and takes into consideration that Māori and Pacific people are disproportionately affected by COVID-19 and subsequent lockdowns.

The Ministry provided guidance to DHBs in regular meetings between Ministry officials and DHBs to use the Sequencing Framework as a guide and that it should not be used at the expense of the efficient delivery of the vaccine to communities (for example rural and remote communities). For example, the National Director wrote to all DHB Chief Executives and Vaccine Senior Responsible Owners on 3 May 2021 to clarify this point.

The Ministry also recommended to DHBs and providers that they respond flexibly to the needs of their local communities and to take a whānau-centred approach to the vaccination rollout in order to meet the Programme’s equity obligations.

The sequencing framework and the need to support clear pathways for priority groups resulted in updated processes and protocols, for example the establishment of the Māori and Pacific pathways as well as a dedicated Disability call centre through Whakarongorau Aotearoa.

An updated Sequencing Framework was released after OAG’s [May 2021] audit took place to provide clarity on where various categories fit within the sequencing framework. For example, additional guidance was provided relating to border workers status in quarantine free travel and included additional frontline healthcare workers within Group 2. These changes enabled clearer communication with the public, and simplified decision making for requests by organisations and volunteer support groups who had sought approval for earlier vaccination within Groups 1 to 3.

In August 2021, the framework was updated to include a new category 2c, to reflect an amendment to the Alert Level Requirements Order and support prioritisation of people working in customer/client-facing roles or supporting critical infrastructure during Alert Level 4. Following the prioritisation of this group and an Alert Level change, an operational update included extending prioritisation to people required to work in these roles during Alert Level 3.

Material was made available on the Ministry and COVID-19 websites relating to departures from the sequencing framework in order to vaccinate people wishing to travel overseas from New Zealand on compassionate grounds or for reasons of national significance (for example Olympic Games representation). The criteria were extended in August to include other reasons for travel, including business.

With the opening of vaccinations to all age bands on 1 September 2021, the sequencing framework developed to pace the vaccine roll-out to New Zealand’s population in the early part of the programme had largely completed its function.

Our assessment of the progress made

The Ministry communicated with district health boards in early May 2021, permitting some flexibility in how they applied the sequencing framework.

We were told that there was some ambiguity in the advice provided and that, to some extent, district health boards and providers made their own choices on how to balance the equity and coverage objectives of the programme in practice.

The Ministry has also communicated publicly about subsequent changes to the sequencing framework. In August 2021, the framework was updated to include a new category 2c, to reflect an amendment to the Alert Level Requirements Order and support prioritisation of people working in customer- or client-facing roles or supporting critical infrastructure during Alert Level 4.

Recommendation 4: Embed equity considerations in delivery plans

We recommended that the Ministry 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.

What the Ministry told us

To prepare for the roll-out of COVID-19 Vaccine Programme, the Ministry engaged with all DHBs to discuss and agree on their equity plans for Māori, Pacific people and Disabled people. Equity production plans focused on equitable vaccine uptake for these populations and showed the number of Māori and Pacific people DHBs intended to vaccinate for the period July to October 2021.

The Ministry has made funding available to DHBs to cover the cost of specific events planned by DHBs and providers to address the specific needs of priority populations. For example, DHBs have hosted events for disabled communities, set up to be more accessible and welcoming, and introduced specific festival-style events to encourage Pacific and Māori communities to be vaccinated.

The Ministry of Health monitors data on the number of Māori, Pacific people and disabled people vaccinated, and regional rates to assess whether the vaccine is being rolled out equitably. Data is shared regularly with DHBs and partner agencies Te Puni Kōkiri, Ministry for Pacific Peoples, Te Arawhiti, Ministry of Social Development and Ministry for Ethnic Communities to form strategies to increase vaccine uptake and successful strategies are shared between groups. Data is also shared with service providers and released on the Ministry’s website down to suburb level to support activities to lift vaccine uptake.

Regional Equity Account Managers in the Ministry have supported the DHB they’re allocated to with the development and implementation of their equity actions with a focus on the following areas:

prioritisation of accreditation and authorisation activities for workforce development;
presentations and follow-up hui and activities completed with DHBs on workforce development support systems;
regional hui with DHBs and other sector partners to develop multi-level and sectoral action plans to address equity;
working with DHBs to prioritise commissioning and resources to address equity. This has included investment in services or organisations other than the already funded Māori or Pacific health providers. This allows full flexibility to work directly with whānau with specific needs and commission agencies outside of the health sector.

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The Ministry has worked closely with the DHBs to ensure that mainstream sites are accessible and have established a range of disability specific services including pop up sites at familiar spaces such as residential services, NZSL [New Zealand Sign Language] clinics, low sensory clinics, and home vaccinations. An accessible and inclusive vaccination process, including a disability-specific helpline service run by Whakarongorau Aotearoa, booking support and Super Accessible Sites has also been developed.

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Guidance and operational plans

To increase options for access, guidance and resources have been produced for the following service delivery options:

mobile clinics – buses and vans
whānau vaccinations
vaccinating whole communities
walk-ins as well as bookings
DHBs reserving vaccination capacity for Māori
Marae vaccinations
Workplace vaccinations
School vaccinations
Festival based events
Pop-up and outreach sites
Drive through vaccination sites

Our assessment of the progress made

The Ministry appointed Regional Equity Account Managers from June 2021. Theyhave used the Ministry’s high-level strategies to regularly engage with district heath boards about their plans for vaccinating Māori and Pasifika. These discussions particularly focused on ensuring that an adequate and appropriate workforce is available, such as an appropriate percentage of Māori or Pasifika staff.

The Ministry engaged with the disability community early in the programme. It also regularly engaged with the vaccination programme disability leads in each district health board. Although the programme eventually included various initiatives to make it more accessible to disabled people (as described above), achieving this took some time.

The Ministry also produced guidance and resources for delivering the vaccine in several settings, including mobile van and bus clinics, to provide coverage in more geographically remote areas.

Despite these efforts, specific groups (in particular, Māori) have still not achieved the same level of vaccine uptake as the rest of the population. This suggests that the Ministry and the wider health sector have more work to do to meet the programme’s equity objectives. It is important that the Ministry ensures that the programme supports, and reduces any barriers to, the use of local initiatives that have been successful in reducing inequalities in vaccination rates.

As well as the differences in vaccine uptake in different groups, there are inequalities in Covid-19 hospitalisation rates (in particular, higher rates for Māori compared with other groups).

Early data indicates generally similar, or better, levels of vaccine coverage for disabled people compared to the non-disabled population, but there is some variation between the diverse groups within the disabled people population.

Recommendation 5: Provide clarity about the role of primary care

We recommended that the Ministry 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.

What the Ministry told us

Primary health care providers have a central role in vaccinating New Zealanders. Early in the COVID-19 Vaccine Programme, the sequencing framework, supply constraints, cold chain and additional administrative requirements meant COVID-19 vaccinations were predominantly delivered by DHB-run community vaccination centres.

From April 2021, a specific service delivery model appropriate for existing healthcare facilities (general practice, community pharmacies, Hauora providers, and urgent care) was developed in consultation with stakeholders, and a fee for service price for COVID-19 vaccinations had been established and was in place for the primary care sector. The Ministry provided funding directly to Māori and Pacific health providers to support their readiness. This funding allowed providers to assess what they needed to deliver a successful vaccine programme including their workforce and infrastructure needs.

The following enablers were developed to support primary care providers as they moved to establish themselves as COVID-19 vaccination sites:

The Primary Care Onboarding Guide is a tool developed to provide an integrated, consolidated summary of Ministry resources for establishing and managing a COVID-19 vaccination site.
An operational review of the Ministry’s activities supporting the onboarding of new sites was undertaken. This review led to improved visibility of forecast onboarding numbers and enabled timely and appropriate interventions, where needed, to support periods of high onboarding numbers.
User training for the technology systems that support vaccination events were transitioned to a self-service e-learning model to enable greater numbers of vaccination staff to be trained per week.

The Ministry’s objective has been to provide all primary care vaccination providers with an opportunity to participate in the COVID-19 vaccination programme by the end of October 2021. Primary care providers onboarded 819 COVID-19 vaccination sites in the period July to September 2021. As at 11 October, primary care providers had delivered COVID-19 vaccinations from 1212 sites. An increasing proportion of vaccinations have been delivered through primary care with 66 percent of doses administered by primary care in the week ending 10 October 2021.

The Ministry continues to work with DHBs to encourage and support all primary care providers to onboard as COVID-19 vaccination sites. Onboarding guides and processes are reviewed monthly to identify options for fast-tracking and simplification. Two additional enablers have been developed to support sites for whom onboarding is a significant challenge:

An Onboarding Concierge service is being trialled targeted at Māori and Pacific health care providers and small general practices and community pharmacies. These sites are generally resource stretched and struggle to find time to complete onboarding activities and training. The service assists with completion of the site set-up paperwork and guides staff through the training and onboarding requirements.
General practices with a high proportion of enrolled Māori patients are being contacted by telephone to encourage onboarding as vaccination sites. When required, assistance is provided to remove or overcome the specific barriers that are preventing onboarding of that site.

The Programme continues to produce a fortnightly newsletter and host fortnightly webinars for the primary care sector, meet on a fortnightly basis with the Royal New Zealand College of General Practitioners, and attend fortnightly Primary Health Organisation (PHO) Clinical Leaders forum meetings. In addition, the Ministry communicates the important role primary care plays in achieving COVID-19 vaccination targets through relevant forums. The national IMAC [Immunisation Advisory Centre] webinar and the NZMA GP CME [continuing medical education] South conference are two examples where the need to have primary care providers onboard was reinforced, and the on-boarding process explained.

Our assessment of the progress made

At the time of our first audit in May 2021, we were concerned about the lack of clarity about the involvement of primary care in the programme and the potential for the programme to focus on volume rather than equity.

Many general practitioners, pharmacies, Hauora Māori, and Pasifika providers are now part of the programme. A significant number of primary care providers became part of the programme in June, July, and August 2021. In our view, it would have been useful to engage primary care providers earlier so that they could plan ahead better.

The Ministry has told us that the sequencing framework, supply constraints, and cold chain and administrative requirements were why vaccination centres run by district health boards rather than primary care providers were used early in the programme. We accept that, but we still consider that communication with these groups could have been better and would have assisted these groups to plan for the wider roll-out.

Some general practitioners and pharmacists have found engaging with the programme frustrating. This was because of limited availability of assessors to assess their credentials, different practices at different district health boards, the scale of the compliance work involved, and the length of time before they had enough certainty that they would be involved.

Recommendation 6: Continue to strengthen communication efforts

We recommended that the Ministry 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.

What the Ministry told us

Since OAG’s [May 2021] initial work, the communications and engagement team has grown and adapted with the Programme. The group has implemented a public information strategy and communication programme focused on two layers:

An information layer providing straightforward and accessible information about the vaccine, the rollout programme and advising groups and cohorts within those groups when and how they can be vaccinated.
An emotive layer motivating people to get vaccinated through the central proposition, “The Stronger our Immunity the Greater our Possibilities”. This campaign layer uses story-telling to reinforce that vaccination is a pathway to protect and strengthen the nation socially, culturally and economically.

A consumer research programme has been put in place to ensure barriers and motivations to vaccination are well understood, and new campaign concepts and collateral are tested with relevant audiences before launch. Research cohorts are upweighted for Māori, Pacific and disabled people. In addition, activity is informed by specific pieces of research into each of these priority groups.

This campaign has been promoting the information and emotive layers in:

A national campaign to encourage vaccination using a wide range of channels outdoors, broadcast media, digital, and social media. A new motivational campaign “It’s Our Shot NZ” was launched in September and builds on the “Possibilities” campaign with a stronger call to action. In October it was joined by “Two Shots for Summer” which is aimed at 16-29 year olds.
Targeted campaign and engagement activity for priority audiences such as Māori, Pacific people, disabled people, and younger people, which our research and vaccination data indicates have or are likely to have a lower vaccination uptake. Content includes information on the vaccine’s safety and stories of people from these communities talking about their decision to be vaccinated and their vaccination experience.

As the rollout of the Programme has progressed through all eligibility cohorts, the communications focus has shifted from communicating the sequencing framework rolling out eligibility in cohorts to running a campaign to encourage everyone aged 12 and over to vaccinate.

Detailed vaccination uptake data is also now published and regularly updated on the Ministry website, including breakdowns by ethnicity and location.

Māori, Pacific peoples, disabled people communications

Targeted campaigns and engagement activity have been designed for priority audiences and new ways of working have been designed in partnership with other government agencies and sector stakeholders to ensure that vaccination messages reach and resonate with those communities. This has included ensuring the Ministry’s own national campaign activity remains relevant, targeting priority audiences when using highly targeted digital and social campaigns, and supporting partner campaigns in those communities and through other government agencies and DHBs.

The “Super Saturday” initiative is a recent example of this multi-layered communications and engagement approach. It saw a wide range of organisations mobilise to promote vaccination supported by the Ministry, including iwi, faith-based organisations, government agencies, and businesses and NGOs.

Māori

The Ministry has developed close working relationships with the Iwi Comms Collective and Te Puni Kōkiri and have supported the development of a communications strategy for rangatahi Māori.

Collaboration with Te Puni Kōkiri includes supporting their Karawhiua campaign for Māori to ensure our campaigns are complementary, including:

Sharing research and insights.
Targeted digital and social advertising.
Featuring Māori champions and influencers throughout our mainstream communications campaigns.
Sharing media buying and funding Karawhiua media placement.
Consulting with Te Puni Kōkiri when developing our mainstream campaign content to ensure it remains relevant to Māori.
Funding for Māori organisations to develop local or regional responses in their communities.

Pacific people

A similar approach has been adopted with Pacific people, working closely with the Ministry for Pacific Peoples to support their “We’ve got your back Aotearoa” campaign. This collaboration includes:

Sharing research and insights.
Targeted digital and social advertising targeting Pacific peoples and their communities.
Featuring Pacific people influencers in our mainstream campaign.
Consulting with the Ministry of Pacific Peoples when developing our mainstream campaign content to ensure it remains relevant to Pacific peoples.
Translating content into Pacific languages.
Funding for Pacific organisations to develop local or regional responses in their communities.
Alongside the Pacific Health team within the Ministry and the metro Auckland DHBs we also work with Pacific communications specialists in Auckland.

Disabled people

A disability sector forum has been established and meets regularly to:

Advise the Ministry on how best to engage with the sector
Test proposed activity and content
Provide timely feedback from the sector.

The approach to disabled people differs from our approach to Māori and Pacific people in that the sector strongly prefers to be included in the mainstream campaign rather than in a separate campaign targeting disabled people. This has meant working with the Forum to ensure disabled people are reflected in and included in our mainstream campaign. This has included actions like:

Ensuring disabled people are featured in our mainstream campaign and storytelling.
Ensuring content is presented in accessible formats.
Creating content to support disabled people to confidently access vaccination.
Sharing content with disabled networks for distribution.
Ensuring customer service channels are accessible.
Funding disability groups to enable engagement with their communities.

Specific communications funds were established for Māori, Pacific, and disabled peoples to produce their own communications content and messaging, specific to their community and region and in their preferred formats.

Our assessment of the progress made

The Ministry has expanded its communications team and programme since we carried out our first audit in May 2021.

The Ministry has increasingly tailored its messaging to different demographic groups, introduced a consumer research programme, and regularly published vaccination rates that are disaggregated in several ways. The focus of the communications programme has changed over time from communicating the sequencing framework to encouraging everyone aged 12 and over to get vaccinated.

The Ministry has worked closely with other relevant organisations to support communications with Māori and Pasifika. These include the Iwi Communications Collective, Te Puni Kōkiri, and the Ministry for Pacific Peoples.