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Transparency fail adds to vaccination rollout woes

Introduction by Croakey: As concerns continue to grow about the Federal Government’s troubled vaccine rollout, the Government launched two COVID-19 advertising campaigns over the weekend; one imploring Australians to “Arm Yourself” against COVID, and the other, a graphic depiction of a young woman in hospital struggling to breathe.

Both campaigns have attracted criticism, with health policy consultant Bill Bowtell calling for the “insensitive” graphic ad featuring the young woman to be “immediately taken off air”.  Others say this ad may contribute to vaccine hesitancy.

The Guardian also noted that there were many questions about the role of Lieutenant General John Frewen in the vaccine rollout – including the parameters of his role and who he reports to – but few answers.

At Inside Story, Frank Bongiorno wrote that the Federal Government’s mishandling of vaccination rollout illustrates the damage that has been done to the public sector.

“We should all be alarmed by what the Federal Government has shown it cannot do – by its incompetence in both words and deeds – as well as by what the present occupants don’t regard as any of their business,” he wrote.

In The Saturday Paper, Rick Morton said the nation’s early response to the pandemic lacked imagination and urgency, and that this extended to the role of science in public policy.

Below, Associate Professor Lesley Russell, a contributing editor and columnist at Croakey, explores the lack of transparency throughout the fraught vaccine rollout, from purchase agreements to the public health messaging.


Lesley Russell writes:

Australia’s vaccination rollout is a national scandal, but even if it was a success there is every reason for Australians to know how their tax dollars are being spent in the effort to purchase and deliver vaccines.

However, in a scenario that has come to exemplify the Morrison Government’s approach to issues of public concern, an unnecessary veil of secrecy surrounds the details of the strategy (or lack thereof) and financing of the national vaccination program.

This is highlighted by the stonewalling that the Senate Select Committee on COVID-19 consistently confronts from Cabinet Ministers and their departments (see for example the recommendations in the committee’s second interim report) and by the failure of Freedom of Information (FoI) requests from organisations such as the ABC.

I recently wrote an article on the vaccination rollout failure for Inside Story, which triggered a number of emails from people with additional information as to what was happening inside the Morrison Government.

This paper collates what I have learned from these emails, from media coverage and from my own research to summarise, to my best ability, what is known about government expenditures, contractual agreements and commitments in vaccine acquisition and vaccination rollout.

Vaccine purchases

To date, the Morrison Government has committed some $5 billion via five separate agreements to purchase 195 million doses from four manufacturers of four (or possibly five) different vaccines.

Information from the Department of Health (DoH) website shows this is made up as follows:

  • 53.8 million doses of AstraZeneca’s viral vector vaccine. Of these, 50 million doses will be manufactured in Australia by CSL and 3.8 million will come from overseas. Some of this overseas supply was held back by the European Union; it is known that 700,000 doses have arrived.
  • 40 million doses of mRNA vaccine from Pfizer. These are manufactured in Europe and the majority (around 32.6 million) of these doses are not due to arrive until the last quarter of 2021.
  • 10 million doses of mRNA vaccine and 15 million booster or variant doses from Moderna. This vaccine has yet to be approved by the Therapeutic Goods Administration (TGA). Even under the best of circumstances these doses will not arrive until late in 2021. The booster or variant doses are not due until 2022. Information about this additional purchase was only recently added, without fanfare, to the DoH website.
  • 51 million doses of a protein vaccine from Novavax. This vaccine has only recently completed Phase 3 clinical trials, so its commercial availability this year is unlikely.

This information needs to be aligned with that issued by the DoH Vaccines Allocation Horizons, which sees Moderna vaccine availability commencing by the beginning of September and the distribution of some 33 million Pfizer doses and 6 million Moderna doses by the end of the year.

The Government’s Horizon plan for July and August originally had around 2.6 million doses of AstraZeneca and 750,000 doses of Pfizer distributed nationally to state hubs and GP clinics each week.

This week, in response to requests from New South Wales, Morrison has announced additional Pfizer vaccine supplies. He was very coy in the announcement about where these additional supplies were coming from, saying: “We have had some success in recent days of accessing additional doses which I can’t go into the commercial arrangements for.”

It appears there are no new purchases, but vaccine deliveries are being brought forward to increase supplies in July and August (at the expense of supplies later in the year). It is not clear how much of this increased supply will be directed to New South Wales.

The Vaccines Allocation Horizons figures would allow for the complete vaccination of some 30 million people, so this appears to assume the vaccination of some children and perhaps some vaccine wastage.

Theoretically, Australia should now be set for a complete, if much slower than best practice, vaccine rollout.

But that depends on two factors: (1) that vaccines arrive in the quantities ordered within the expected timeframes and (2) that the national distribution and vaccination efforts proceed apace.

Vaccine constraints

There is a huge risk that vaccines manufactured overseas will not arrive in a timely fashion. Already an unknown number of AstraZeneca doses (possibly as many as 3 million) were refused an export licence by the European Union on the basis that they were needed in Europe.

At the beginning of May, CSL reported that it was producing “more than one million doses a week” of AstraZeneca vaccine. That may have increased further since then.

It should be noted that CSL’s commitment to the manufacture of AstraZeneca means it does not have the capacity to manufacture other coronavirus vaccines. Novavax is looking for an Australian manufacturer, but CSL says that, at the government’s behest, it will “remain fully focused on the production of the AstraZeneca vaccine”.

However, CSL expects to finish its 50 million dose production run of the AstraZeneca vaccine in the first months of 2022 and then plans to turn its focus elsewhere – but apparently not to mRNA vaccines. Surplus AstraZeneca supplies will be sent overseas under the direction of the Australian Government.

The Pfizer vaccine is manufactured in both Belgium and the United States. Recent reports suggest that the United States will limit exports and the rise of the Delta SARS-CoV-2 variant will also drive increased demand for supplies. Treasurer Josh Frydenberg said the Government is confident of receiving 2.8 million Pfizer doses this month (apparently from Europe) but so far only 300,000 have arrived.

Finance Minister Simon Birmingham recently admitted that Australia was at the “back of the queue” for Pfizer vaccines (finally giving the lie to assurances from the Prime Minister and the Health Minister that “our strategy puts Australia at the front of the queue”).

We don’t know what the contracts the Government has with vaccine manufacturers say about delivery timetables and the consequences of delivery failures.

The ABC’s 7.30 sought information about the AstraZeneca contract and the FoI request was refused on the grounds of a “real and substantial risk to national security” and damage to AstraZeneca’s commercially valuable information if the contract was released. In contrast, European countries, the United Kingdom and the United States have all released substantial parts of their AstraZeneca contracts.

The ABC estimates that the contract is likely worth more than $1 billion. That seems reasonable given that the 2020-21 Budget provided $1.7 billion for the purchase of AstraZeneca and the (now discontinued) University of Queensland/CSL vaccines.

Some international price comparisons reveal that the AstraZeneca price per dose varies from US$2.15 to US$5.25: it appears Australia is paying premium prices. When the November purchases of Novavax and additional Pfizer vaccines (worth $1.5 billion) were announced last November, an article in The Australian estimated that Australia was paying around $350 million more for these two purchases compared to deals struck by other countries that had acted earlier.

Failure to make the vaccine contracts public means there is no way to know this, or what provisions were made to cover the licensing agreement and liability issues of the manufacturers.

We do know, from the 2020-21 Budget Papers, that AstraZeneca was provided with an indemnity “covering certain liabilities that could result from the use of the vaccine”. The same indemnity was provided for Novavax and Pfizer in the 2020-21 mid-year economic and fiscal outlook. However, the indemnity details are unknown and when asked about vaccine indemnity at a press conference, Health Minister Greg Hunt waffled.

It’s worth noting that both Pfizer and Moderna are yet to receive full approval from the US Food and Drug Administration and Novavax has yet to apply to FDA for even an Emergency Administration Exemption. Australia has taken the approach of requiring full approval before COVID-19 vaccines are publicly available, so this places another time constraint on incorporation of Moderna and Novavax into the vaccine rollout.

Vaccine wastage

The issue of vaccine wastage has not been much discussed in Australia but it could consume some 20 percent of supplies. Failure to use vaccines before the expiration date, vaccines going unused at the end of the day (often because expected numbers of people do not show up), and not being able to draw every dose from multi-dose vials all contribute to wastage.

The AstraZeneca vaccine comes in an eight-to-10 dose vial and the Pfizer vaccine in a five-dose vial (Pfizer says that with the low-dead space syringes and the correct technique, a sixth dose can be drawn). In February, DoH Secretary Dr Brendan Murphy said that Australia had secured an order of low-dead space syringes, then in huge demand internationally, but he also said standard syringes were still effective.

With demand for Pfizer rising, there is no further information available about the efficient use of limited supplies. At the same time, with demand for AstraZeneca falling, there are concerns that this vaccine will go to waste in Australia (although it could be used in countries like Papua New Guinea and Fiji). There have been reports of unused AstraZeneca being thrown out in Central Australia.

Vaccine deliveries

In a media release just before Christmas Day last year, Health Minister Greg Hunt announced that the Morrison Government had signed contracts with DHL and LinFox for the distribution and logistics around vaccine supplies (this work did apparently not go to tender).

This left many who work in the pharmaceutical supply area gobsmacked. The Government already has a well-established mechanism for the supply of pharmaceutical products to the most remote areas of Australia through the Community Service Obligation that is funded under the Community Pharmacy Agreement.

This supply network, for which the Government pays $200 million per year, involves a small number of pharmaceutical wholesalers with decades of experience in deliveries to pharmacy doors (and, in remote areas, medical services and doctors’ offices). It is used every year for the delivery of flu vaccines. But none of the pharmaceutical wholesalers were approached to undertake this work.

The value of the contracts signed with DHL and LinFox is not known (the 2021-22 Budget has $234 million over two years for vaccine distribution, cold storage and the purchase of consumables), but I was made aware of one pharmaceutical wholesaler that was convinced they could do it better and cheaper. There have certainly been media stories, especially early in the rollout, that vaccine supplies were late and not delivered correctly.

Contractors’ vaccination roles

The Commonwealth Government has responsibility for the vaccination of people in aged and disability care and in GP respiratory clinics and has contracts totalling $155.9 million with Aspen Medical, Health Care Australia (HCA), Sonic Healthcare and International SOS to deliver these services.

Despite the fact these companies were selected in January, only now have a majority of residents in aged care facilities been fully vaccinated. There have also been logistical problems: for example, poor planning led HCA to cancel vaccine deliveries, and thousands of doses were been thrown away after problems with temperature-controlled storage.

Meanwhile, the possibility of using nurses and nurse practitioners for these tasks has been ignored.

Parliamentary requests for details about these contracts have been ignored amid concerns that the firms involved are significant Liberal Party donors. The Government initially indicated the tender was limited but then said it conducted an “open” and “competitive” process to select the four companies.

Aged care experts advise they have calculated that these contractors are receiving around $420 for aged care vaccinations. Medicare reimburses GPs $37.75 or $30.75 (depending on rurality) for the first vaccine dose and $27.55 or $24.25 for the second dose. At that rate the contractors could deliver some two million jabs; to date it’s just over 450,000 in aged and disability care.

The Federal Government’s latest COVID-19 vaccination campaign.

Communications efforts

A significant part of the failure to date of the vaccination rollout is due to vaccine hesitancy and yet the quality of communications efforts from the Commonwealth Government is poor, the reach is inadequate and multicultural communities are ignored. In May, Morrison dismissed calls for a ramp-up in advertising to tackle any perceived vaccine hesitancy.

The Prime Minister has indicated that there is $40 million allocated (over two years) to the vaccination campaign. This funding is made up of $23.9 million included in the 2020-21 MYEFO, $6.7 million in the 2021-22 Budget, and it has been inflated by including $11.2 million specifically allocated in the 2021-22 Budget as part of the Health COVID-19 Response Package, for providing support to regional and remote Indigenous communities. This can hardly be construed as advertising funding.

Advertising industry experts believe the current campaign, launched six months ago, and under fire for being boring, unemotional and unconvincing, has spent only a fraction of this funding (the figure of $13.8 million has been quoted). Just $32,000 has been spent on digital messaging around vaccines.

major advertising campaign to encourage vaccination by young people by ad agency BMF was launched on the weekend. Based on statements from Minister Hunt it appears that the controversial young woman with COVID-19 ad may have been developed some time ago.

The advertising spend includes (merely) $1.3 million to target culturally and linguistically diverse communities in their own languages. 

In contrast, the  Government spent $7 million to promote take-up of the failed COVIDSafe app and so far this year has spent over $50 million to promote its economic policies.

Consultancies advising government

The erosion over time of the public services and the failures of the current Government to continue efforts to ensure pandemic preparedness meant the Morrison Government was always going to be slow off the mark to plan a vaccination rollout.

A raft of consultants and consultancies appear to have been employed to work in this area. Here’s a list of what I have been able to track down:

  • In January, Accenture and PwC were described as lead consultants for the vaccine rollout. Accenture was engaged in December, 2020 to develop a software solution to enable “point in time” visibility of COVID-19 vaccines across the delivery chain, including receipt of vaccines by health services, vaccination of patients and monitoring of adverse reactions. It received at least $7.8 million as the primary digital and data contractor.  Note that a media release from Health Minister Hunt last December announced over $40 million in funding is being provided to Services Australia, the Australian Digital Health Agency and the Therapeutic Goods Administration to improve digital integration and streamline processes necessary to the approval and distribution, so the clinical information from the vaccination rollout can be assessed in real time. There is presumably some overlap or re-announcement here.
  • It is not clear if the described software solution was delivered. The Medical Software Industry Association also had/has a $300,000 contract for work in this area.
  • PwC was also engaged in December, when it was described as a “program delivery partner”. It was originally contracted to oversee “the operation, and coordinate activities of several actors working on specific functional areas, including – for instance – logistics partners DHL and Linfox”. An April article in The Guardian questioned whether PwC was still working with the DoH.
  • In April, McKinsey received a two-month contract worth $3 million to work with the Department of Health on vaccine issues. McKinsey also has a contract ($2.4 million for three months) with the Department of Prime Minister and Cabinet to look at ways “to maximise economic and social opportunities” [sic] as the vaccine rollout progresses by providing “research and analysis, project management, strategic policy advice and communications products.”
  • EY was contracted for $557,000 last November to deliver a “2020 Influenza Evaluation and Covid Vaccine System Readiness Review”. Later it was contracted for $1 million to assess vaccine system readiness and provide advice on on-shore manufacturing.
  • Former Secretary of DoH and Department of Finance Jane Halton has a $15,000-a-month contract to provide health advice to the Prime Minister and his Cabinet.

This list is almost certainly incomplete.

The military to the rescue

Despite all this “expert” – and expensive – advice, the vaccination rollout has become such a shambles and so far behind schedule that now a member of the military (Lieutenant-General  JJ Frewin) has been called in to coordinate efforts and to finally develop a national plan.

Professor Adam Kamradt-Scott, chair of global public health at the European University Institute, has outlined some good reasons and some international precedents for bringing military expertise into the vaccine rollout.

While concerns have been expressed about this, realistically the resources of the military (logistical and transport capabilities, healthcare personnel and geographical reach) should have been an integral part of planning from the beginning — although at this stage this seems to be more about the personal qualities of Lt General Frewen such as command and organisational capabilities, his understanding of the value of data and how to use it, and his ability to talk to all the stakeholders regardless of politics that seems to be what is required rather than military resources per se.

Perhaps some people are disconcerted because they see this as a marketing exercise. Morrison chose to describe this as a “completely new organisational structure for getting a whole-of-government effect on a very big problem” and highlighted this by renaming the taskforce Operation COVID Shield.

Some may be put off because the Prime Minister is overly keen on military language, “fighting the virus”, putting National Cabinet on a “war footing”, and conducting “war games”.

Others may be concerned, knowing that Morrison is always reluctant to be the person seen to make the difficult decisions, and this provides him with someone to blame if things go wrong, while still claiming credit for whatever works.

When asked why he was brought on, Frewen said the Prime Minister had asked him to take “operational control of the rollout and the messaging around the rollout”. The first part of that responsibility is certainly understandable, and all the evidence points to his initial success in this area.

The idea of a military man with no medical or epidemiological training taking control of messaging is more problematic, and this rises to the level of real concern (and inappropriateness) if he is required to publicly justify political decisions.

On the other hand, some honest, factual, straight-talking communications from someone whom the public can trust would be welcome. It is interesting that Frewen’s appointment comes at a time when the Secretary of Health Brendan Murphy appears to have lost the confidence of both Morrison and Hunt.

Conclusion

Australia’s vaccination program began on February 22. In the months before then and since, the Morrison Government has spent an unaccountable and un-counted sum on contractors and consultants, only to end up bringing in the military to rescue the vaccine rollout.

The expensive outside “experts” have contributed to what Professor Stephen Duckett called “a train wreck” and what others have described as “a mystery box of spending, wrapped in layers of ‘commercial in confidence’ provisions and opaque strategy advice that experts say cannot be justified”.

The primary task now must be to get all Australians vaccinated. That will require consensus on a national strategy and vaccination rollout plan, much better national organisation and cooperation, effective communications, and much more public accountability and transparency from the Morrison Government.

Eventually the Government must be held to account for its failures, but immediate efforts must focus on tackling the coronavirus pandemic and its impacts on individuals, communities, and the nation.

Dr Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney, and a contributing editor at Croakey. Dr Russell writes The Health Wrap column. Follow her on Twitter: @LRussellWolpe. 


See Croakey’s archive of stories about COVID-19.

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