2. Ensuring sufficient physical infrastructure and workforce capacity
ENSURING SUFFICIENT PHYSICAL INFRASTRUCTURE AND WORKFORCE CAPACITY is crucial for dealing with the COVID-19 outbreak, as there may be both a surge in demand and a decreased availability of health workers. The section considers the physical infrastructure available in a country and where there are shortages, it describes any measures being implemented or planned to address them. It also considers the health workforce, including what countries are doing to maintain or enhance capacity, the responsibilities and skill-mix of the workforce, and any initiatives to train or otherwise support health workers.
2.1 Physical infrastructure
Overall hospital capacity
Hospitals have been assessing their current and maximum capacity to treat patients with COVID-19. Patient pathways and roles of different hospitals have been agreed with the Health Board. Regional hubs are set up to coordinate care among hospitals
In case of increased need, patients can be relocated to spas and hotels.
Estonia has 193 second stage intensive care beds and 157 third stage intensive care beds. When accounting for the average bed occupancy of 49%, Estonia has 80 third stage intensive care beds for COVID-19 patients. Although it is possible to equip second stage intensive care beds with ventilators and trained medical staff, these beds do not have the option for isolating patients. Therefore, only 50 second stage intensive care beds could be used for COVID-19 patients. In sum, Estonia has 80 third stage and 50 second stage intensive care beds for a total of 130 beds for COVID-19 patients in intensive care units. It is possible to increase the capacity by restructuring post-surgery wakeup rooms and day surgery rooms by providing ventilators, but this would require training doctors and nurses from other specialities because there is currently not enough trained medical personnel.
There are 239 ventilators in intensive care units in hospitals. 50 ventilators are in reserve and can expand intensive care capacity. An additional 75 ventilators have been ordered. On 25 March, the government decided to order 150 more ventilators. Once the ordered ventilators are delivered, Estonia will have just over 500 ventilators for its 1,3 million population.
Personal protective equipment (PPE) and disinfectants
The Health Board is responsible for managing the necessary emergency stock for PPE.
Estonia has a low amount of PPE and disinfectants in the country. The government has assessed that an additional 10 million masks will be required and they have placed an order though the embassy of China to order different PPEs. Estonia also participates in the joint procurement of PPEs in the EU. Meanwhile, providers themselves also negotiate with manufacturers in order to have necessary equipment available.
Hospitals, PHC and ambulance care providers have made efforts to increase their operational stockpile of PPE, but there are still shortages. The Health Board has used the national operational stockpile and the Defence Forces have shared their stockpile with health authorities.
There are no large PPE manufacturers in Estonia, but the government has requested companies to reorganize their standard work to help with the lack of PPEs and disinfectants, if at all possible. In Estonia, there is only one small manufacturer of masks located in Sillamäe, which wants to increase its production capacity.
The Government Office signed an agreement with an Estonian company in Sillamäe that guarantees the state 50,000 FFP3 type respirators per week for half a year starting in mid-April. The company is preparing to double production to produce up to 100,000 masks per week for the state. The value of the half-year contract is up to 10 million euros.
The first shipment of centrally procured PPEs from China arrived in Estonia on the 2nd of April. The order was placed by the North-Estonian Regional Hospital and the Ministry of Social Affairs, though the central procurement process is the responsibility of the Ministry of Finance.
The PPEs will be distributed to institutions where the critical stock needs to be replenished. This includes health care institutions (including family doctors and ambulances), nursing homes and state and local government agencies. The procured PPEs include:
• 1.5 million surgical masks, of which 672,000 masks were distributed between healthcare institutions, 500,000 masks among care homes and family doctors, and 244,000 masks to state and local government agencies (such as the Defense Forces, Omniva (national postal service), border checkpoints and ports);
• 30,000 FFP2 respirators were distributed among GPs, ambulances and care facilities;
• 20,000 gowns and 5,000 pairs of goggles were directed to health care;
• 500,000 pairs of gloves were distributed among ambulances, nursing homes and GPs.
Separate emphasis has also been placed on Saaremaa having enough PPEs.
A second shipment of centrally procured PPEs arrived in Estonia on 7 April. With this delivery, 740,000 surgical masks, 350,000 FFP2 protective masks and 12,100 protective coats arrived in Estonia. The protective equipment will be distributed to hospitals, nursing homes, and family doctors, as well as local government social workers, border crossings and other people working on the front lines.
On 5 April, 2.5 million protective masks went on sale in pharmacies (previously they were out of stock). The masks for sale are individual hygiene products, not surgical masks. A private company supplied the masks to private wholesale companies, which have distributed the masks to pharmacies. As the masks are not a medical device, the state has not considered it necessary to implement a national sales restriction. However, wholesale companies have recommended pharmacies should sell no more than one box or 50 masks with one purchase.
On 21 April, the state introduced a digital solution for monitoring the stocks and forecasts of PPEs. This digital solution was initiated as a result of a hackathon organized by Garage48 and Accelerate Estonia (see section 1.1).
The application consolidates the supply of and demand for PPEs and can help decision-making by providing more accurate and timely data. The new platform simplifies the collection of data on PPE supply, demand and forecasts. The system enables user-friendly data collection across Estonia and provides visualized results. It is expected to help faster decision-making on both allocation plans and new procurements.
Previously the hospitals and ambulance service providers uploaded their supply and demand information to an online platform on daily basis. Estonia’s social security agency gathered the PPE requirements from elderly care facilities and social service providers every week. The Ministry of Finance gathered the PPE requirements for the state services like police, schools, local municipalities etc.
The private development team will support the management of the platform during the first week, while the state will take over further user support for the agencies. Although it is assumed that it may take weeks to get used to the new way of collecting data, the tool may be able to help to forecast the stock requirements according to the situation. For example, when opening planned care requires more resources, it will be immediately reflected in the requirements for medical institutions.
The Government Emergency Committee decided to allocate additional funding to secure stocks of state PPEs for health care providers, welfare and state institutions and local governments until the end of June. After that, these bodies and organizations can raise funds by participating in a national framework contract. The State Support Services Centre will prepare a centralized open tender. It is expected that using joint procurements may lower the prices of PPEs.
In total 7.4 million of the 16.2 million masks (surgical masks, FFP2 and FFP3 respirators) ordered by the state have been distributed so far and the rest will arrive in the near future. PPE purchased by the state has gone primarily to the health and social care sector. In total, contracts have been signed for the supply of various PPE for additional EUR 15.2 million. In addition to masks, the state has procured gloves, goggles, protective suits, disposable gowns, shoe covers and other equipment.
However, in order to gradually open up various services, the state will provide additional PPE for an estimated EUR 11.7 million in order to ensure a reserve that will last until the end of June. In order to organize state exams and restore limited education in schools, there is a need for about one million surgical masks and about half a million pairs of gloves. The medical facilities would need about 2 million surgical masks to distribute to patients to open services. The total cost to cover the needs of these two areas is about EUR 1.8 million.
The government decided to extend the duties of the Minister of Public Administration as the central contracting authority for personal protective equipment until 31 December 2020. The Ministry is responsible for procuring personal protective equipment, organizing its storage and distributing it throughout the country.
A large shipment of centrally procured PPEs arrived from China by plane, although the total order was not fulfilled. This is particularly the case with FFP3 masks: less than five percent of these orders have been received. Only one in five of gloves and gowns and less than half of the surgical masks have arrived. However, all goggles and aprons were delivered. Now that the basic necessary supplies were delivered by plane and present in Estonia, the government decided that in order to cut costs, the further deliveries will be made by train. It is estimated that the state will save about 1.5 million EUR with the change of transportation means.
The Government has agreed to adopt a new PPE rule in autumn in order to prepare for the second wave. The rule will require all nursing care homes, hospitals and other relevant institutions to stock PPEs themselves for at least for one month, and another month will be provided by the state if necessary.
The government allocated 2.5 million Euros from the central government budget to increase the national stock of personal protective equipment (PPE) in the social field. This aims to cover the PPE requirements for two additional weeks for welfare institutions. In total the central stock of PPEs now should last for at least six weeks. The national stock is intended to be used primarily in crisis situations to provide additional public support to social service providers. For daily needs and, if necessary, to react quickly in the event of an outbreak, it is recommended that social service providers acquire and keep a stock of at least one month’s supply of PPE on site.
From the 14th of September, it is obligatory to wear a mask while working in or visiting elderly homes.
Pharmacies and pharmaceuticals
Estonia does not produce any pharmaceuticals and has to rely on international trade to get necessary pharmaceuticals into the country. Many countries are closing their borders, which has a large influence on Estonian trade and also availability of pharmaceuticals. Policies adopted by some countries to discontinue the export of pharmaceuticals may have a devastating effect on the access of essential pharmaceuticals in Estonia.
Since people have started to stock up their pharmaceuticals, the government decided to implement new regulations for pharmacies and prescribing medicines. Now, doctors can only prescribe medicines for chronic diseases for two months at a time or less. Pharmacies may dispense recurring prescription medicines for no more than one prescription’s worth for no more than two months. When dispensing medicinal products, pharmacies should consider the quantities of medicinal products purchased earlier and only dispense medicinal products if the already purchased amount does not suffice for the next two months of treatment (in the case of continuous treatment) or until the end of treatment (in the case of fixed-term treatment). If the life or health of a person would be compromised if they go without the medication, the pharmacy may also dispense the medicinal product, but it must document the reason for the exceptional case. The pharmacies may dispense over-the-counter medicinal products no more than two packages per proprietary medicinal product per customer.
Exports of certain pharmaceuticals (e.g Roactemra and Pulmozyme) have stopped in order to protect stocks for the anticipated increase in ICU patients.
Starting from 4 April, the Minister of Social Affairs changed the conditions and procedures for the wholesale of medicines by creating additional obligations during the emergency. Wholesalers who maintain at least a 10% share in the pharmaceutical market must submit their stock information to the Agency of Medicines at the end of every working day. The Agency of Medicines compiles a summary report based on the submitted information within the next working day. This enables Estonia to keep track of its pharmaceutical stock.
As of 11 April, Estonia may face shortages of paracetamol due to increased stockpiling in households and difficulties of securing additional supplies due to production and logistics problems. Therefore, the Minister of Social Affairs has decided to further limit the amount of paracetamol dispensed with one purchase to the amount sufficient for a standard course of treatment for the average household. Pharmacies may dispense up to 30 tablets per buyer of medicines containing paracetamol. Other over-the-counter medicines still follow the previous restrictions, whereby pharmacies may dispense up to two packs per medicinal product per purchaser. The need for a restriction is reviewed and reassessed on a weekly basis.
At the beginning of May, the Minister of Social Affairs lifted the restrictions on prescribing and dispensing prescription medicines from pharmacies as well as on dispensing over-the-counter medicines. However, the restriction on the dispensing of medicines containing paracetamol remains at 30 tablets per purchase.
In addition, the Minister of Social Affairs and seven pharmaceutical wholesalers entered into co-operation agreements as an expression of common goodwill to ensure the availability of all essential and most commonly used medicines. The co-operation agreements cover a total of 800 different active substances and are valid until the end of the emergency.
The restriction on the dispensing of 30 tablets of paracetamol has been lifted as of 18 May.
Some restrictions on the cross-border movement of medicines will remain in place until the supply of medicines has improved security.
In July 2020, the Regulation on the Conditions for Wholesale Medicinal Products changed to oblige wholesalers of medicinal products with a larger market volume to submit weekly overviews of the stock of medicinal products in Estonia to the State Agency of Medicines. The change is necessary to prevent difficulties in the supply of medicines and to alleviate effects on patients.
During the emergency period, major wholesalers were required to submit an inventory report every working day. Usually, larger wholesalers submit inventory reports quarterly, but the amendment obliges them to submit inventory reports once a week. Additionally, if a wholesaler had a share of the medicinal product market in the previous year of at least 10%, they have an additional obligation to submit data. These wholesalers are determined by the market volume of human medicinal products according to statistics published by the State Agency of Medicines. This ensures that the majority of the market volume is represented.
The change is expected to enable implementation of necessary measures in cooperation with the Ministry of Social Affairs, pharmaceutical companies, marketing authorization holders and wholesalers to prevent shortages in supply.