The GOVERNANCE of the health system with regard to COVID-19 relates to pandemic response plans and the steering of the health system to ensure its continued functioning. It includes emergency response mechanisms, as well as how information is being communicated, and the regulation of health service provision to patients affected by the virus.
On 22 April, the Government Emergency Committee publicly published its draft exit strategy. The strategy will be presented to the Parliament and partners for feedback and comments. The government is expected to approve it after the deliberations next week. The committee will start to review the measures with scientists and experts once a week.
The exit strategy is divided into three stages: escalation of outbreak, stabilisation, and return to normalcy. Estonia seems to be at the stabilisation phase according to the epidemiological criteria. In this phase, the measures can be gradually relaxed after certain requirements are fulfilled. The third phase is the returning to the normalcy, which requires among other things being prepared for the potential outbreak. The measures are arranged according to priority. The document presents and assesses the impact of the measures to the potential spread of infection. The first steps, aside from the already initiated opening up of elective care since 21 April, would be to open museums, extracurricular and open air sports activities, and allow small weddings and funerals. The next phase would be to open stores and some services within shopping centres, although these have remained open so far. If the indicators allow, the high schools will open from 15 May for exam preparations.
Key indicators of exit strategy:
1. Number of infected persons per day and the ratio of all tested persons, number of infected persons in the age group 50+.
2. Number of COVID-19 patients in hospital care.
3. Use of intensive care facilities due to COVID-19 (number of beds, per 24h).
4. Access to health care.
5. Preparedness of the population to follow government guidelines and measures.
6. General health of the economy.
7. Ability to implement confidence measures.
8. Epidemiological situation and COVID-19 countermeasures in the region, EU Member States and third countries.
On 15 May, the President of Estonia announced the legislative amendments approved by the parliament. The parliament introduced these amendments to the main acts regulating health care preparedness - State of Emergency Act, Communicable Diseases Prevention and Control Act, Health Services Organisation Act and the Health Insurance Act. The aim of these legislative amendments was to improve legal clarity, in particular by clarifying the roles and responsibilities of different actors in a situation of emergency, in order to ensure an operative and coordinated response. For example, the amendments clarify the definitions and provisions with regard to the quarantine and enforcement measures.
In the Health Services Organisation Act, the amendments specify provisions with regard to temporary reorganisation and limitations of activities of the health care providers. For the amendments to the Communicable Diseases Prevention and Control Act, the Health Board was granted the legal certainty and clarity after the end of the state of emergency to manage the crisis situations and to ensure effective containment of infection transmission. Through these amendments, the Health Board was granted the right to implement the necessary measures to control the virus within their competencies and power.
The emergency situation in Estonia ended on 17 May at midnight. This repealed the respective orders issued by the Government and prime minister. The restrictions imposed during the emergency situation will be gradually eased. The remaining restrictions are re-established by new government regulations, approved May 17th. The most important movement restriction, the 2+2 rule, remains in force. After the end of the state of emergency situation, the health care emergency remains in force in Estonia. The main reason for ending the emergency situation was the continued decline of the rate of the spread of SARS-CoV-2 in Estonia, as confirmed by the Scientific Advisory Group, the Government Emergency Committee, and the Health Board.
The regulatory acts related to restrictions are available here: https://www.riigiteataja.ee/index.html
On 28 May, Prime Minister Ratas introduced a plan to establish an Expert Advisory Group under the Governmental Commission on Economic Development (established in April 2017 and led by Prime Minister) to the government. The task of the Expert Advisory Group will be to provide advice to the government during the current crisis on the matters related to the recovery of the economy as well on ways to improve people’s livelihoods and economic competitiveness. The Commission on Economic Development will approve the composition of the group and the Government Office will provide the secretarial services for the committee.
On 9 June, the Health Board - the agency responsible for managing the COVID-19 crisis - lowered the level of preparedness from health care related emergency (effective since 13 March) to the risk of health care related emergency. The reason for this change was the significant reduction in COVID-19 numbers in both Estonia and Europe.
The Government decided to allocate an additional 1.016 million euros in 2020 to strengthen the Health Board in order to increase the Board's capacity to prevent the spread of the coronavirus. In order to increase preparedness for health crises, it is planned to create 27 new positions at the Health Board and to recruit up to 44 people to enhance network cooperation and sectoral counseling, including 20 people for monitoring close contacts. The amount includes earmarked funding for IT developments such as the information system for the Health Board laboratories and the information system MEDSITREP, which provides the Health Board with overviews of the patient flow and treatment capacity of hospitals.
The main legislative act in the area of communicable diseases is the Communicable Diseases Prevention and Control Act, which provides the legal provisions for the prevention of epidemic spread of communicable diseases, including for quarantine.
Measures to prevent the spread of communicable diseases during an emergency situation will be applied in accordance with the provisions of the Emergency Act. This act provides a legal basis for all emergency situations irrespective of their origin. It covers declaration, resolution and termination of an emergency situation, crisis management, including preparing for and resolving an emergency as well as ensuring the continuity of vital services. According to the Emergency Act, the type of crisis determines which authority will take the lead. In case of infectious disease related emergencies, the responsibility lies with Health Board, who is leading a crisis coordination centre, involving authorities from different sectors. Under the Emergency Act, the Health Board was tasked with developing a plan to manage the emergency situation related to epidemics by 2019, however this document was not available among the list of all the other plans for managing emergency situation (https://www.siseministeerium.ee/et/siseturvalisuse-valdkond/kriisireguleerimine?id=10). In case the new plan does not exist then the previous plan is effective.
The government declared an emergency situation on 12 March that will remain in force until 1 May, 2020. The Prime Minister is in charge of the emergency situation. On 12 March, the government formed a commission to handle the spread of the coronavirus and to manage problems related to public health and the economy. The government commission is tasked with ensuring that situations concerning the spread of the virus are resolved, organising the cooperation between state and local government, and coordinating the use of resources and capabilities. The commission has the right to delegate tasks to the executive branch of the state authorities and to obtain information from them about the completion of tasks.
The government commission meets three times per week: on Mondays, Wednesdays, and Thursdays. On Thursdays, after the weekly formal Estonian government meeting, the work of the commission can be discussed with participation from all members of government.
The activities of the commission are headed by the Prime Minister. The commission members include: the Minister of Justice, the Minister of Economic Affairs and Infrastructure, the Minister of Finance, the Minister of Internal Affairs, the Minister of Social Affairs, the Minister of Foreign Affairs, the Minister of Education and Research, the Minister of Defence, and the Secretary of State. The commission may include additional members in its work as needed.
The current inter-agency working group, led by the Minister of Social Affairs, transferred the work to a team assisting the Government Emergency Committee, consisting of representatives of the ministries and agencies concerned.
The Health Board is responsible for the surveillance, communication, international reporting and testing, and is also the dedicated IHR focal point to report to WHO through ECDC.
On 13 March, a local crisis committee was formed in Saare municipality, which has the highest number of positive cases per capita. Task of the crisis committee is to coordinate response related activities locally.
On 20 March, the Government Emergency Committee convened a Scientific Advisory Board to gather, analyse, and report on expert information. Among other things, the advisory board will assess the impact of the restrictions currently in place on the prevention and control of the spread of the virus. Professor Irja Lutsar of the Institute of Biomedicine and Translational Medicine of the University of Tartu was approved as head of the advisory board.
Starting on 24 March, and for the duration of the emergency situation, the Health Board’s crisis team appointed the emergency situation’s medical director (Dr Arkadi Popov, Head of Emergency Centre of the North-Estonian Medical Centre) who is responsible to coordinate the organisation of work in the medical institutions across the country. The medical director has the right to give orders for rearranging the provided health care services.
On 31 March, the emergency situation’s medical director decided to divide country in to two regions - north and south. The emergency teams leading the regional emergency health system response will be centred around Tallinn (north) and Tartu (south).
The responsibilities of the regional emergency centres include:
• regionally organizing patient flow management
• advising hospitals on treatment processes and management structures
• developing treatment standards and coordinating their implementation
• developing principles for the selection of patients for intensive care and mechanical ventilation
• proposing changes in treatment standards to the crisis medical emergency manager
Tasks of the regional ambulance centres include:
• developing and applying treatment and performance standards according to the specifics of ambulance services
• monitoring the ambulance work load
• mapping, monitoring and submitting proposals to the Crisis Centre’s Chief Medical Officer for additional ambulance brigades and reducing/modifying their composition
• coordinating the transport between hospitals, including assignment of responsibility areas by region
• proposing options for rearranging the management of ambulance calls
On 27 March, a subgroup with the task of developing, coordinating, and monitoring the implementation of an exit strategy was formed under the government commission to handle the spread of the coronavirus and to manage problems related to public health and the economy. The cross-sectoral strategy will be developed with both a short and long-term framework for mitigating the impact of the emergency situation and take into account the interacting effects of different sectors. Researchers, municipalities, representatives of private sector and civil society will be involved in the planning of activities. The first draft of the strategy is planned to be presented to the government commission in mid-April.
The Government decided on 24 April to extend the state of emergency from initially planned 1 May until 17 May. The still ongoing spread of infections and discovery of new clusters calls for continued implementation of effective measures to contain the further spread.