IN PRACTICE

 

The Ministerial Advisory Committees and 3 years of COVID-19 expertise - is the Department of Health's model for information-sharing pandemic-ready?

 

 

M Richter^I; Y Nokhepheyi^II

^ILLM, PhD; School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa, and African Centre for Migration and Society, University of the Witwatersrand, Johannesburg, South Africa. Former researcher at the Health Justice Initiative, Cape Town, South Africa
^IIBCom, MSc; Former researcher at the Health Justice Initiative, Cape Town, South Africa

Correspondence

 

 

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ABSTRACT

Effective pandemic decision-making depends on scientific expert evidence, transparency about public health policy decision-making, its rationales and the evidence on which it is based. The South African government laudably committed its COVID-19 response to be guided by science and evidence. Yet, the expert advice that it received was not always readily made available to the public. This submission analyses the time elapsed between the submission of COVID-19 Ministerial Advisory Committees memoranda to the Minister of Health, and the Department of Health's subsequent publication of these for the period August 2020 - January 2024. It also summarises the outcomes of the Health Justice Initiative's access to information legal action against the department on expert advice and government decision-making during the pandemic.

Keywords: pandemic decision-making, access to information, COVID-19, expert advice, transparency

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The COVID-19 pandemic had a devastating impact on South Africa (SA). It resulted in at least 102 595 COVID-19 deaths from January 2020 to January 2024, with some authors estimating that the number of 'excess deaths' is likely to be several times higher.^[1] It caused immense economic disruptions, with an estimated 3 million jobs lost in the first few months of lockdown alone.^[2] More than half a million children dropped out of school, and ~2,8 million households with 10.6 million residents were affected by hunger in the last 7 days in April/May 2021.^[3] There has been both praise and criticism of the SA government's response during this period.

Since the beginning of the COVID-19 pandemic, the SA government stated that its response will be rooted in science and evidence.^[4] In April 2020, President Cyril Ramaphosa remarked that the World Health Organization (WHO) had commended SA for its 'rapid response to the 'COVID-19] pandemic' because it 'followed scientific advice'. He also assured the public that government's risk-adjusted strategy (or lockdown levels) 'is guided by the advice from scientists'.^[5] A month later, he stated that 'our considerations 'for Lockdown Level 41 are based on empirical evidence, scientific and economic data and international best practice'.^[6]

This laudable approach is substantially different from the government's initial handling of the AIDS crisis in the late 1990s to mid-2000s. The latter was characterised by state-supported AIDS denialism and pseudo-science^[7,8] that led to >330 000 preventable deaths because an antiretrovial programme was not initially implemented when the evidence for it was unequivocal.^[9]

History and expert consensus are clear: the management of public health threats requires scientific and evidence-based policy formation. In turn, transparency about policy decision-making, its rationales, and the evidence on which it is based (what evidence was used, who were the experts providing the evidence, and did they have any conflict of interest) increases the public's confidence in and support of the public health measures implemented. During a global pandemic, timely information-sharing, and making expert scientific advice publicly available, are even more critical, as they help mitigate opposition to often far-reaching public health measures that can keep people safe. Ultimately, the public's trust in government's pandemic decision-making depends on transparency, democratic accountability, evidence - as well as autonomous advice to government.^[10,11] In fact, access to information, transparency and accountability have emerged internationally as central to pandemic preparedness, and some of these aspects are included in the May 2024 draft of the WHO Pandemic Agreement.^[12,13]

How open, then, was the SA government about the expert advice it received to inform the management of SA's COVID-19 pandemic, and how long did it take to share this expert advice with the public?

 

Methodology of time analysis

In an earlier editorial,^[14] we analysed the time between expert committees submitting COVID-19 advice to the Minister of Health, and the National Department of Health (NDoH)'s publication of their memoranda.^'151 We focused on advisories by the Ministerial Advisory Committee on COVID-19 (C-19 MAC), the Vaccine Ministerial Advisory Committee (VMAC) and the Chair MAC Social and Behavioural Change (SBC MAC) between August 2020 and August 2021 to assess the timely publication of evidence related to key decisions in the country's COVID-19 vaccine programme. We also provided an overview of a Health Justice Initiative (HJI)'s access to information request to the NDoH for all MAC advisories, the names of experts providing the NDoH with advice and the NDoH's decision-making on COVID-19 vaccine selection and prioritisation. The HJI is a health equity non-governmental organisation.

Here we update the initial analysis^[14] by extending the date range to January 2024 and by summarising new information that has since come to light through HJI's legal action on access-to-information requests.

Researchers accessed the NDoH's official COVID-19 online resource (the portal) to search for all published MAC advisories. ^[16,17] All of these, published during the period 25 August 2020 - 31 January 2024, were downloaded and catalogued according to the date of the respective MAC chairpersons' sign-off. Website page analytic tools were employed to determine each advisory's last date of upload to the portal - this served as the proxy date of when the particular advisory was made publicly available. Only advisories in official MAC memorandum format, and signed by the chairperson, were included. This excluded additional appendices and reports.

On 21 February 2024, the NDoH announced over X (formerly Twitter) that the portal will not be updated regularly as it would be migrated to the NDoH website.^[18] At the time of publication of this article in July 2024, the portal information was not yet available on the NDoH website and no new MAC advisories had been added since the January 2024 cut-off. We assume that this article thus contains an analysis of all MAC advisories in the public domain.

Table 1 summarises the main findings of the time analysis, and appendices A - C (https://www.samedical.org/file/2269) catalogue the MAC advisories by date.

In a recent article the C-19 MAC noted that it had produced 154 advisory documents' during the period March 2020 - July 2022, and that 'only 113 of the 154 advisories provided by the MAC on COVID-19 were eventually published on the dedicated website'^[19] This confirms our analysis, while also indicating that the NDoH had failed to make available a sizable number of expert advisories. The C-19 MAC's article does not mention the topics of the 41 unpublished advisories, nor does it speculate on why this information was likely withheld.

Access to information case on MAC advisories

After March 2021, the HJI engaged the NDoH to release all MAC advisories and expert advice related to vaccine selection for SA.^[14] It became clear that the NDoH refused to share all information voluntarily. On 20 July 2021, HJI then submitted a formal request under the Promotion of Access to Information Act No. 2 of 2000 (PAIA).^[20] Within a couple of days, 26 advisories were uploaded to the Department's portal.

The NDoH did not respond formally to the PAIA request nor to the HJI's internal PAIA appeal. In April 2022, the HJI was obliged to initiate legal process against the Minister of Health and the NDoH to access this information.

The NDoH resisted. In July 2022, its deputy director-general filed an opposing affidavit.^[21] In it he claimed that much of the information was already in the public domain. Certain other information was not within the power of the NDoH but with National Treasury. And PAIA protected some under mandatory non-disclosure provisions. Some was locked in Cabinet decisions - and PAIA protects Cabinet minutes.

In Table 2, we analyse the information the NDoH's opposing affidavit provided after HJI's PAIA request, and highlight key issues not yet resolved.

 

Conclusion and recommendations

The HJI's PAIA litigation brought important new information to light. In October 2022, the HJI withdrew the challenge, after its counsel advised that protracted litigation was unlikely to produce substantially more information.

How long does it take to publish expert advice? The answer is a median of 53 and 127 days, respectively, for the C-19 MAC and VMAC. This delay is alarming. Withholding some of the advisories, and a truculent response to access to information requests, suggest that the NDoH does not pay enough heed to the public's constitutional right of access to information. Nor does it fully recognise the essential connections between robust information-sharing, reliable and consistent communication of evidence-based pandemic decision-making and building public trust during a global pandemic.

These components are pivotal not only to future pandemic readiness, but also to the new National Health Insurance scheme's advisory and benefit selection structures.^[28]

Based on these findings, we recommend that with any current and future MAC structure, or any equivalent expert advice provision, the names of all expert advisors, their listed expertise and any conflicts of interest are published and regularly updated. In addition, all pandemic advisories should be published within 72 hours of submission to the Minister. Here, the framework and best practice policies of the UK's Scientific Advisory Group for Emergencies (SAGE) are informative.^[28]

Finally, where the government has not sought independent expert advice and/or does not follow the recommendations of independent experts in making pandemic policy decisions, it should say so clearly and explain its health, ethics, economic or other rationale for doing so. This would mean that government decision-making processes that have a far-reaching impact on lives and livelihoods are transparent, accessible and accountable and, thus, more likely to inspire confidence in an anxious public.

Data availability. The data are available from the corresponding author on request.

Declaration. None.

Acknowledgements. We would like to thank Leslie London and Fatima Hassan for suggestions and advice.

Author contributions. MR and YN conceptualised the study and performed the data analysis. MR wrote the manuscript and all authors edited and approved the final manuscript.

Funding. None.

Conflicts of interest. None.

 

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Correspondence:
M Richter
marlise.richter@gmail.com

Received 13 February 2024
Accepted 22 February 2024