3. Providing health services effectively
The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.
3.1 Planning services
The initial vaccine strategy was approved by the government on December 7. It defined three stages of building a vaccination infrastructure. In the first stage, only designated vaccination centers, generally located in the big hospitals, would provide immunizations. Other hospitals would be included in the vaccination network in the second stage, with general practitioners being incorporated for the third and final stage.
People aged above 65, chronically ill patients, health and social care workers, and critical infrastructure employees were expected to be provided the vaccination in the first stage. However, the first vaccines to arrive may not be enough to provide for all interested people from these defined groups; the strategy did not specify the prioritisation within the initial groups in detail. The vaccination will be voluntary and covered from SHI funds. In total, the government said ten million vaccine doses have been ordered (December 21).
In mid-December, experts worried the current vaccination plan had deficiencies and if not strengthened only 40% of the available vaccine doses would be used upon their arrival to the CZ, resulting in a slower vaccination process than otherwise possible.
Vaccination strategy redefined in January
In late December, the government proposed an updated version of the vaccination strategy, which was approved on January 13. Regional governments are responsible for implementing the strategy, including organization of the vaccination processes in their regions and setting up the vaccination centres. 30 vaccine distribution centres are planned around the country, with each of them required to operate at least one mobile vaccination team. Mobile vaccination teams can be also established by other vaccine centres in regions.
Prior to its official presentation in early January, the Prime Minister continually declared the vaccination strategy and priority rules by parts, bringing the new vaccination algorithm into use before the updated strategy was finalized and approved on January 13. The immunization started on December 27, with health care workers having absolute priority, followed by selected seniors. While waiting for the strategy at the national level, some regions started to develop their own vaccination strategies, particularly regarding building high-capacity immunization centres and planning logistics (8,9).
With the updated vaccination strategy, priority groups were redefined (11), with healthcare, hospital and senior homes’ workers and people aged 80 years and older being in the priority 1A group (approximately 7.5% of the total population). Priority group 1B to be immunized following group 1A’s immunization contains approx. 37% of the total population and includes the rest of healthcare and social care workers, teachers, people aged over 65 and other high-risk groups of patients (defined chronically ill patients, including the obese with BMIs higher than 35), police and firefighters and critical state infrastructure employees. Everyone else is in group 2 and will get vaccinated after groups 1A and 1B have been immunized.
The immunizations should be reported into the Infectious Disease Information System registry. The distribution and administration of vaccine doses are covered by SHI funds, while the state budget pays for the vaccine doses themselves. Before the end of the year, a new law (no. 569/2020 Coll.) was passed allowing distribution of the vaccines by private distributors, with the state being the vaccines’ owner. Also, though the vaccines are paid for by the central government via the agreement with the European Commission, the final vaccine bill will be settled by the health insurance funds who will reimburse the central state budget for all administered doses (i.e. not only for the administering itself as was previously intended).
The reservation system for the priority group aged 80+ opened on January 15. This system works in a two-step manner: in the first step, there is a registration system only (43% of seniors aged 80 or older had registered for vaccination as of January 25). In the second step, a reservation time slot is made with a selected vaccination centre. As of January 25, 18.2% of the 80+ group have a vaccination time slot reserved and 12.4% of them have been provided the first dose (10).
On January 26, the MoH recommended vaccination centres to interrupt the first-dose vaccination to ensure having enough doses for the second-dose vaccination. On January 27, the Prime Minister denied this recommendation, saying it was a misunderstanding. Nevertheless, the MoH recommendation from mid-January to postpone the second-dose administration until day 28 has been generally observed.
On January 26, the reservation system opened for the healthcare workers who have not yet been immunized. The opening of the reservation system for rest of the population has been postponed indefinitely.
Challenges to observing group prioritisation emerged due to unclarity in dealing with leftover vaccine doses at the end of the day. This has led to many controversies, attracting high media attention and has even lead to the removal of some leading officials (the head of the State Health Institute, the Deputy Health Minister and a hospital head).
Data from the central vaccination registry on the numbers of vaccinated people, sorted by priority groups and by the number of doses administered (first or second) are newly published (end of January) at https://onemocneni-aktualne.mzcr.cz/api/v2/covid-19.
Due to new knowledge, the MoH has published a recommendation for those in 80+ priority group that their GP should assess their health status prior to vaccine administration. However, this has not been made a necessary condition for getting vaccinated in a vaccination centre.
The somewhat slow start of vaccination for each particular vaccine, especially relevant for AstraZeneca in February, is partly due to the fact that the MoH starts public procurement for its distributor only when a vaccine is already approved and arrives in the country (except for the Pfizer/BioNTech vaccine, which contracts distributors on its own). Thus, the official AstraZeneca distributor was only chosen on February 19. The state-chosen distributer is responsible for distribution from a central repository to the 14 regional repositories; the regions (regional vaccination coordinators, one per region) decide on further disbursement of vaccines (whether and to which vaccination centres, hospitals, mobile teams, or GPs).
Vaccine administration is done by healthcare providers only in designated areas. Regional governments and hospitals are responsible for securing enough stock of necessary material, including syringes for vaccination centres. The same applies to GPs (allowed to provide vaccination in their offices to their registered patients since March 1, see below). For GP offices, the jabs are administered by the GP. In the large-capacity vaccination centres, the jabs are done by qualified nurses under a physician’s supervision (i.e. one physician on site for multiple nurses). Mobile vaccination teams always have a physician and a nurse and the jabs are more likely to be administered by the physicians themselves. Neither paramedics nor medical students are allowed (by legislation) to vaccinate.
Mobile vaccination teams can be organized at different levels of government, not just regionally. For instance, mobile vaccination teams in the city of Brno for immobile residents aged 80+ include a physician, a nurse and an administrator, emergency rescue toolkits and oxygen bottles.
On February 27, 2021, registration for vaccinations was opened for teachers of elementary, secondary, and preschools (within few hours, 90 000 out of 330 000 eligible people had already registered for an appointment); teachers’ priority registration closed on March 28.
On March 1, 2021, registration opened for all people aged 70+.
On March 24, 2021, registration for vaccinations in large-capacity centres opened for defined groups of chronically ill people (those below 70 years). To register, patients are given a special code by their outpatient specialist; the code will be valid only until April 30, 2021 (13). In addition, patients at the vaccination centre must present medical records from their physician confirming they are suffering a chronic condition. Prior to this date, vaccinations of younger chronically ill patients were only carried out in some specialized healthcare facilities to their own patients, or through their GP (see below).
On March 1, GPs could begin vaccinating registered chronically ill and senior (aged 70+) patients. However, this was conditional upon receiving vaccine doses. In mid-March, most GPs had not yet received any vaccines and complained about the fact that they had no information on when any vaccine would actually arrive (12, 14). Whereas the MoH claims to have allowed GPs to get some vaccines (AstraZeneca) directly from distributors, regional governments have actually been tasked with determining how many of these vaccines are made available to GPs and most regions have opted to supply the big vaccination centres first. Prior to March 1, only a small number of GPs were vaccinating based on supply from an individual region (for example in senior homes with vaccines provided by the reginal distribution centres). 4000 out of 5000 GPs declared ready to start vaccination in their offices once they receive vaccine doses in mid-March.
To get vaccinated in a GP office, a person should NOT register for vaccination through the central registration system, as the GPs have to register their interested patients into the central information system themselves (in order to claim vaccine doses). The registration system thus serves only for appointments in vaccination centres; it automatically schedules the appointment for the 2nd dose. The GP is instead responsible to schedule the appointment for the 2nd dose for patients vaccinated in her/his office. The central registration system is open to all insured people including all Czech citizens, people with permanent residence and foreign nationals (from 3rd countries) employed by Czech-based employers.
The requirement to register for an appointment online (does not apply to institutionalized people) has proven a burden to access for many older people and they have been helped by their relatives or caregivers, while some cities opened telephone lines to help with registrations. Thus, opening up the possibility of being vaccinated in a GP office without the need to register electronically was meant to resolve this issue. However, many seniors continue to wait for available vaccines (on a waiting list, as GPs are still waiting on supply even though they have priority patients by age) at their GPs office while younger people receive their vaccines at the vaccination centres,
In mid-March, regional authorities were optimistic about their vaccination capacities and declared that by July, a first dose should be available to any adult. Regions have also taken different strategies in administering vaccines. For instance, the Prague and Moravskoslezský region rely on high-capacity vaccination centres (there are already 30 such centres in the Moravskoslezský region and two more are planned). On the contrary, the Jihomoravský region plans to significantly engage GPs in vaccinations, expecting one third of its population to be vaccinated in GP offices, while the Liberecký region decided to distribute all available AstraZeneca vaccines to the GP offices (12).
In mid-March, the MoH announced plans to extend the permitted time between first and second doses of the Pfizer/BioNTech and Moderna vaccines from 21-28 days up to six weeks; beginning April all new vaccination appointments will be done with 2nd dose 42 days apart. AstraZeneca remains with 2nd dose appointment 12 weeks apart.
(11) Ministry of Health Extraordinary Measure MZDR 1595/2021-1/MIN/KAN and the Vaccination Methodological Instructions from https://www.mzcr.cz/metodicky-pokyn-kampane-ockovani-plan-provedeni/
On March 17, the MoH ordered providers to delay all planned care and non-urgent treatment to open capacity for expected COVID-19 patients (1); this measure was relaxed in the second half of April in an effort to bring care provision for non-COVID patients back to standard levels (2). The government also prohibited all medical workers to take regular leave during the state of emergency; this resolution was revoked on April 10, 2020. In general, redeployment from other specialities to deal with COVID-19 patients did not occur (for details on physical infrastructure and workforce, see section 2). A plan was prepared to transfer standard beds into ICU ones along with staff redeployment in case the epidemiological situation worsens (as of beginning of May, there were approximately 300 hospitalized COVID-positive patients in the CZ (3)). Starting on April 8, inpatient care facilities were obliged to report any change in their ICU bed capacity and occupancy on a daily basis (4). On April 29, the MoH announced plans to concentrate COVID-19 patients requiring hospitalisation to selected bigger hospitals on regional level, aiming to free smaller hospitals to focus on non-COVID patients only (5).
General Practitioners (core primary health care providers; each person should be registered with one who, however, does not have the gatekeeping role) were initially advised to treat patients by phone and only accept physical visits with appropriate PPEs (many GPs did not have this in the beginning, so many were unwilling to actually see their patients in the first weeks of the outbreak). Prevention and other care was postponed during March and April. The use of e-Prescription as well as other electronic tools (e.g. a new system to issue medical certificates for fitness to work/sick leave) increased.
Regarding distanced medical consultations: the health insurance funds widened providers’ reimbursements to include these arrangements (telemedicine, email, phone) for most outpatient specialists. General practitioners reported making a majority of contacts with their patients over phone in spring, with the average daily number of contacts for those who did not close or limit their office hours substantially being down only by less than 15% (6). According to the temporary reimbursement rules, even dentists were able to perform telemedicine consultations with their patients (see also section 4). Most of these reimbursement rules were temporary and in force till June 30 (7). In the beginning of September, health insurers introduced new code for GPs’ phone consultations to avoid confusion with spring phone consultation coding. The new code is activated by health insurers only in “crisis” times and as a temporary measure; it was activated on September 1.
Over the summer, testing strategy and laboratory network developed and was strengthened (see section 2.1); coordination across regional governments and inpatient facilities in regions was aligned with the central level. Regional intensive care coordinators (usually chief physicians of main regional hospitals’ departments of anaesthesiology and resuscitation) cooperate with appointed National Intensive Care Coordinator.
In mid-September, COVID-19 patients were primarily taken care of in university and regional hospitals. Bed capacity continued to be reported daily and closely monitored. With the rapid increase of positively detected cases, hospital beds started filling up. As of September 18, the MoH declared there was still enough capacity, while some medical experts expressed worries about it. No limit on non-urgent care was imposed from the government at that time (September 16).
With rapid increase of newly detected cases in October, planning hospital capacities became an urgent matter: On October 19, the National Inpatient Care Control Centre restored 24/24 operation. Inpatient facilities continue to be obliged to report any change in their ICU beds capacity and occupancy daily.
Building of new temporary facilities: A temporary hospital was built in Prague in October (500 beds), using army hospital equipment, beds from State Material Reserves, and new government-purchased beds from Czech-based bed producer Lindet. The hospital has been drafted as a backup facility for Bulovka hospital for COVID-19 patients that do not require ICU care anymore. Till November 15, its capacity has not been used yet, fortunately. Another temporary facility was established in Brno in the exhibition buildings (300 beds) in late October; this facility was turned into vaccination centre in January, but in case of need can be turned back into inpatient facility in just one day.
Other measures to increase capacity include repurposing of existing facilities, e.g. by adapting hospital wards and separating them from other wards with physical barriers to keep patients apart. On October 12, major (mostly university) hospitals agreed to repurpose their beds to increase COVID-19 patient capacity by half. Since then, many hospitals turned several wards into COVID-19 wards, with some reaching their capacity limits. The limits are, however, often determined by the staff availability, not technical capacity. In such cases (for example Zlín region – 9 COVID-19 wards in mid-November), hospitals from neighbouring regions, and Prague, take over some serious COVID-19 cases; transports are organized by the emergency service. Backup COVID-19 hospital capacity is ready also in selected spa facilities, with spas being restricted to provide care only to SHI patients since late October. On October 28, MoH ordered regions to reserve spare capacity for COVID-19 patients that do not require an intensive care anymore, but cannot yet return to their homes, mainly due to the inability to isolate these people from other social care facilities’ clients; regions with population less than 550thousands required to reserve 80 beds, bigger regions 160 beds.
Hospitals started to delay planned and non-urgent care in mid-October. On October 26, non-urgent inpatient care was restricted by the government resolution. New inpatient admissions for all elective care were suspended, including admissions to long-term health care facilities; hospitals and LTC facilities ordered to dispatch as many patients to home treatments as possible.
By the end of November, most hospitals started to (slowly) restore their operation regarding elective care. Planning of postponed treatments and surgeries took place and new non-COVID-19 patients were admitted.
By mid-December, elective care was again being delayed in many regions; in some regions elective care was fully cancelled. On December 22, with the epidemiologic situation worsening, MoH ordered all hospitals to restrict elective care and increase their COVID-19 wards’ capacity.
The non-urgent inpatient care restriction applied throughout January. Too many newly detected cases at the end of 2020 resulted in hospitals being at their capacity limits, mainly determined by the staff shortages. Transports of patients from overwhelmed hospitals to other regions were organized on an almost daily basis by the emergency services and even involved using army helicopters (Karlovarský region).
In early February 2021, the Prague Letňany temporary hospital was dissolved due to the lack of skilled personnel and high operating costs – this backup facility was not used at all for patients over the period of its existence. The MoH decided that a better strategy would be to strengthen personnel in existing hospitals instead of having a separate remote facility.
In February and March 2021, the number of COVID-19 patients requiring hospitalisation and intensive care continued to increase. It reached three times the level of what was originally thought to be the limit of COVID-19 care capacity in Czech hospitals back in spring 2020 (3000). For information on hospital capacities, patient transport among regions and international help, see section 2.1. Hospitals have downsized provision of non-COVID-19 care to emergencies only, including treatment provided in outpatient settings.
In mid-March, the number of hospitalized COVID-19 patients peaked at 9 460 with 2 065 being seriously ill. In the second half of March, the inpatient numbers began to decrease slowly.
(1) Ministry of Health Extraordinary Measures issued on March 16, 2020 (MZDR 12066/2020-1/MIN/KAN) and March 19, 2020 (MZDR 12312/2020-2/MIN/KAN)
(2) Ministry of Health recommendation for healthcare providers, issued on April 14, 2020 https://koronavirus.mzcr.cz/doporuceni-poskytovatelum-zdravotni-pece/
(4) Ministry of Health Extraordinary Measure on intensive care capacity reporting, issued on April 8, 2020 (MZDR 15190/2020-6/MIN/KAN)
(6) information provided by the CZ Association of General Practitioners