Every month for 20 years, Sister Patricia Watts* vaccinated up to 500 babies at her private clinic in the Eastern Cape city of Port Elizabeth.

Her clientele, however, more closely resemble those of a public health centre.

Most of the mothers who came to her clinic didn’t drive there in their own cars or push their babies along in prams – they travelled by taxi and walked through the clinic doors with their babies tied to their backs.

Few, if any, belonged to a medical aid and consequently weren’t strangers to overcrowded, under-resourced public health facilities. But for years they experienced the benefits of private healthcare when immunising their children at Watts’s clinic, where the hours are flexible and queues nonexistent.

This all came to a stop in April when the provincial health department decided not to renew the memorandum of understanding that allowed Watts to use government vaccines, free of charge, to immunise state patients in her private clinic. She charged mothers a R100 administration fee.

Today, the once bustling clinic stands empty.

“I’ve been through hell these last few months,” says Watts, a qualified midwife, whose primary source of income comes from the antenatal classes and postnatal home visits she gives to middle-class mothers.

“I’ve had to turn so many people away who can’t take a day off work to sit in a clinic queue or else they won’t get paid – and of course they can’t afford it privately,” she says.

A parent vaccinating his or her child privately can expect to pay between R8 500 and R11 000 for an average of six vaccination visits by the time the child is 18 months old, according Shabir Madhi, director for the National Institute of Communicable Diseases (NICD).

Says Watts: “Public clinics are packed to capacity and don’t have enough nurses – seeing moms at my clinic was supposed to help with those issues. I don’t understand why they would stop it. It doesn’t cost them anything and my patients are happy with the service.”

Watts used to fetch the state vaccinations from the provincial depot herself and provided monthly reports on her usage. She wasn’t allowed to charge patients for the vaccines, only for her service.

“But now the provincial health department has told me they are concerned about the R100 fee I charge. Perhaps they think it’s too high?”

Port Elizabeth pharmacist Clive Stanton also provided state-sponsored immunisation at his pharmacy in Walmer Mall for an administration fee of R25 – a quarter of the fee Watts charged. But his contract has also not been renewed.

With South Africa lagging behind its immunisation targets, according to its own data as well as international estimates by the World Health Organisation (WHO), experts are looking for different ways to increase access to vaccination. In a 2011 report in the journal Vaccine, immunisation is regarded as “one of the most cost-effective and successful public health interventions in the history of mankind”.

‘Public service is sufficient’

According to Watts, the arrangement she had with the provincial health department was a “win-win” partnership. Patients enjoyed the efficiencies of the private sector and the provincial health department benefited by increasing people’s access to vaccinations and a reduced burden on public clinics.

But, according to Sizwe Kupelo, spokesperson for the Eastern Cape health department, the public service alone is “sufficient” to meet the needs of citizens. Kupelo did not want to comment on the issue of private providers’ administration fees.

“We are satisfied with our coverage for childhood vaccines, which is 84% for the province. If people want to use the private sector they can do so at their own cost [and pay for the vaccines],” he says.

Yet the province falls short of the national health department’s target of “at least 90% [coverage] at national level and 80% in all districts by the year 2015”, as stipulated in the immunisation programme’s latest “vaccinator’s manual” published in 2012 and used by health workers across the country.

It’s not just the Eastern Cape that is struggling to get children vaccinated. At a national rate of 84.4%, South Africa as a whole lags behind its immunisation targets for the seven vaccines that are part of the state immunisation schedule, according to the Health Systems Trust’s latest district health barometer.

Madhi says reaching the national target will prevent most outbreaks of vaccine-preventable diseases.

In 2011 the WHO set a goal to eliminate measles in Africa by 2020, with elimination defined as having less than one case per million a year. But repeated outbreaks of the disease in recent years have made this goal seem unrealistic.

As recently as December last year, the NICD issued a measles outbreak alert and confirmed 62 reported cases in 2014, compared with six the previous year.

“We were lucky as this was a localised outbreak mainly affecting areas in the Northern Cape and it burnt itself out quite quickly,” says Madhi.

Five years ago, in 2009, the country experienced a much more severe measles outbreak with more than 20 000 diagnosed cases.

But, according to Madhi, many cases were probably not diagnosed and the actual number of measles cases could have been up to three times the official figure.

To effectively protect against measles – a highly contagious viral disease spread through the air – a national coverage rate for the vaccine specifically should be between 95% and 98%, according to Madhi. “Even though our coverage estimates are problematic because we haven’t had a national immunisation survey for over 10 years, we know we are way below that.”

Stopping babies from being immunised at private facilities with state-sponsored vaccines means parents without a medical aid must queue at public facilities.

Targets are not being met

With our “suboptimal” coverage Madhi says measles outbreaks are predicted to occur every five to six years, “which means we are on the cusp of another one”.

There is little information about why the coverage rates are lower than targets but globally, in settings similar to ours, “children in the poorest quintile are almost half as likely to be vaccinated than those in the uppermost quintile”, says Madhi.

“This relates to vaccine education and awareness but also to difficult or limited access to immunisation facilities.”

A 2011 study published in the Journal of Health and Population Nutrition identified “physical access, financial access, availability of services and performance of health worker” as the biggest barriers for mothers in rural Eastern Cape being able to use health services for their children.

In a few cases, these mothers delayed going to a clinic, which resulted in the deaths of some babies.

Despite Kupelo’s assertions that the Eastern Cape vaccine coverage is “sufficient”, the national health department recognises these barriers and is investigating working with people in the private sector, in a similar way to Watts’s operation, to improve access to immunisations.

The national health department’s deputy director general for maternal health and HIV, Yogan Pillay, says: “We know people don’t always find government clinics convenient, especially those who are working, and this is where the bulk of

primary health care is delivered. While we focus on how to expand services in the public sector there is a need to also think about how to use the private sector.”

Role for the private sector

The private sector is better resourced – in terms of finances and personnel and public-private partnerships have often been cited as one strategy to improve state services. The 2011 green paper on national health insurance highlighted how private general practitioners could be contracted by the state as one strategy.

Although the country’s private sector caters for less than a fifth of the population, it is responsible for just over half of all healthcare expenditure, according to the district health barometer.

A 2013 report by the business consulting firm, Econex, estimated 37% of general practitioners and 59% of specialists worked in the private sector.

While this disparity reveals unequal access to health services, the district health barometer authors note it is also “an opportunity to make better use of the high-quality capacity [of the private sector] that is available in the country”.

Pillay says a pilot project is under way in the Western Cape to assess whether providing contraceptives and childhood vaccines through the private sector will result in increased coverage but remain cost-effective.

He says 190 private providers are part of the project, all of which are administering contraceptives on behalf of the provincial government and 110 are also giving vaccines.

Watts’s case was referred to the national department after she and her patients sent hundreds of testimonies to the health minister.

The Western Cape project, coupled with the confusion and unhappiness caused by Watts’s service closing, shows there is a need to formalise the situation so that all provinces can benefit from nationally driven guidance, says Pillay.

“When we give commodities to the private sector we need to make sure they are being used for the intended purposes. This involves good-quality monitoring and evaluation processes as well as certain guidance on, for example, the appropriate administration fee private providers can charge patients so that it doesn’t become exploitative,” says Pillay.

“We will learn from the Western Cape, which will help us finalise national guidelines for working with the private sector in this area.”

A draft national guideline has been completed and, according to Pillay, it should be finalised by the end of the financial year.

Until then, lower middle-class parents in Port Elizabeth must choose between the inefficiencies of the public health system and the exorbitant prices associated with private care.

For many who are used to the convenience of Watts’s clinic, such as first-time mother Zandile Xate, who works as a lab analyst and can’t afford medical aid, it isn’t an easy choice.

Outside the busy Walmer Mall in Port Elizabeth, where she does her grocery shopping after work, she distractedly rocks her four-month-old son on her hip.

Her expression changes from confused to concerned. She’s just found out she can’t take Lolwethu to Watts’s clinic for his scheduled vaccinations in two months and must instead forfeit a day’s work to go to a public clinic or pay more than R1 000 at a private facility. Confronted with a choice she previously did not have to make, her expression changes again – this time to one of defeat.

She can’t afford the R1 000 but neither can she afford to take a day off from her new job at the laboratory.

“Having a baby is already too expensive. It isn’t fair to put us in this position,” she says.

What used to be a stress-free 30 minutes with Watts will become half a day’s wait at Kwadwesi Clinic in Ibhayi, Port Elizabeth.

“Now I’m going to have to struggle,” says Xate. “There is no good choice in front of me.”

Zandile Xate now has to take a day’s leave to ensure her son Lolwethu is vaccinated.

* The source asked not to be named so as not to jeopardise future collaboration with the Eastern Cape health department

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Declining vaccination rates linked to measles outbreaks

In January, a measles outbreak linked to two Disney theme parks in the United States made international headlines partly because the country had just recorded the highest number of cases of the disease since 2000 and partly because it intensified the already heated debate about the harm the anti-vaccination movement has caused to public health efforts.

According to the US Centres for Disease Control (CDC), a total of 668 measles cases were identified in that country during 2014 compared with 2000 when the US reached the target for measles elimination. Vaccination rates in the US have been declining since the 1998 publication of a study that linked the measles, mumps and rubella vaccine to autism. 

Published in the Lancet, the study has been discredited and retracted. A number of further studies have also been published refuting the link. The negative press about the purported link to autism resulted in a 2% drop in the country’s immunisation rates the following year, which continued to decline in following years, according to a 2012 study conducted by University of Cincinnati researchers. 

Fuelled by increased access to the internet the anti-vaccine movement has gained in popularity in most parts of the developed world where vaccination rates are falling. This is despite the CDC, the World Health Organisation and other credible and internationally relevant health bodies repeatedly emphasising the scientific evidence underpinning vaccine safety and efficacy, and the lack of science behind anti-vaccine theories. 

According to the CDC, most people affected by the latest US measles outbreak had not been vaccinated. 

In South Africa, where measles outbreaks are more common and affect more people, inadequate vaccination rates have been linked to public health constraints rather than a growing dissident movement, according to Shabir Madhi, director for the National Institute of Communicable Diseases. 

“I think there may be some problematic attitudes in a small group of people from higher socioeconomic contexts but I don’t think there is too much of a problem with negative attitudes towards vaccines in the majority of the population,” he said. 

However, a 2012 study published in the journal BMC Public Health identified both health system failures and “anti-immunisation rumours” as barriers to improving South Africa’s national vaccination coverage rate.