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
Mainland Finland is divided into 20 hospital districts, which run 15 regional hospitals and five university-owned teaching hospitals (Helsinki, Turku, Tampere, Kuopio and Oulu). The five university hospital districts are legally obliged to plan and coordinate care in their catchment areas, while all hospital districts are responsible for epidemic preparedness and management in their respective geographical areas (see also section 5).
The number of ICU beds has been estimated at 300 and the number of intensive surveillance beds is about 150-200. After the declaration of the Emergency Powers Act on March 17th, the MSAH instructed all emergency care services to streamline their activities and hospitals to increase their capacity.(1) Capacity increase has been done by converting operation theatres and recovery areas into intensive care units. Authorities have estimated that the capacity can be doubled if needed. The Helsinki-Uusimaa hospital district has evaluated that it currently has 84 ICU beds that can be dedicated to COVID-19 patients. This could be further increased to 150 beds and even 220 beds if needed. (9) Helsinki University Central Hospital has also dedicated one of its buildings to COVID-19 patients, with most existing surgical hospital functions transferred elsewhere from 8th April (2,3) (see Section 3.1). According to the hospital’s CEO interviews, there are currently 280 ventilators in Helsinki and Uusimaa area. According to MSAH, the total number of ventilators in Finland is about 1000.
On April 15th 2020, a statement was issued on the evaluation of the sufficiency of ICU capacity outside Helsinki-Uusimaa region. The evaluation was done by contrasting the current, increased capacity of ICU and the models provided by THL and Helsinki University Hospital. It was stated that based on the current understanding of the development of the epidemic the capacity should be sufficient to meet the needs of COVID-19 patients across the country. (9.)
On 14th March, Kela reported issues with availability of pharmaceuticals (4) and on 16th March the Finnish Medicine Agency (Fimea) advised against overstocking of medicines.(5) On 18th March, the government restricted the sale of medicines, goods and services used in healthcare services. The aim was to ensure the availability of medicinal products and essential medical supplies as well as the functioning of the distribution chain in Finland in the exceptional conditions caused by the coronavirus. This restriction has been extended twice and they are currently proposed to be in force until the end of June 2020.
On March 23rd, MSAH decided that emergency conditions justify taking into use the medical supplies and protective equipment stored in the state emergency stockpiling .(6) The aim is was to ensure that there is enough protection for healthcare and social welfare professionals throughout the country if the epidemic expands. Protective equipment primarily means personal protective equipment (PPE) for healthcare personnel caring for patients with confirmed or possible SARS-CoV-2 infection, such as face masks and shields, respiratory protective devices, surgical masks, medical gowns, etc.
Equipment in state emergency stockpiling are stored both regionally and in emergency stocks. The distribution to the five university hospital districts was carried out by the National Emergency Supply Agency (NESA) and the districts coordinate the decentralisation and use of supplies in their own catchment areas based on needs. The NESA is responsible for supplementing the emergency stockpiling which is implemented through purchases from international markets. The National Pandemic Preparedness plan includes that in addition to the NESA, every health care facility in Finland should have a 3-6 month stock of protective equipment for normal use. It Is not clear whether all health care facilities have followed this guidance. Finland has signed the European Commission Joint Procurement Agreement on March 27th 2020 (7).
The emergency reserve of the NESA was opened and materials within it distributed across the country from 23rd March. This equipment, however, was not sufficient for the duration of the crisis also because partly the stock was outdated and could not be used and the guidance in terms of who needed a mask was updated to include a wide range of actors within social and healthcare, also elderly home care services. The equipment therefore only bought time to buy new stock. MSAH has issued five support requests to NESA during February 12- April 6 2020 (10).
The NESA has reported difficulties in acquiring sufficient amounts of PPE from the market which has, according to the NESA, led it to deviate from their normal purchasing practices and purchasing equipment also from parties that would not been considered under normal circumstances. For instance, the NESA entered into agreements with LDN Legal Partners Ltd and The Look Medical Care Oü in order to procure protective equipment. However, it appeared that there have been a qualitative and quantitative discrepancies in the delivery that arrived in Helsinki on 7 April 2020. The NESA has taken measures to partially rescind the contract / trade and is now demanding a refund for the undelivered goods and a price reduction for the erroneous items. Furthermore, the NESA has requested the police to investigate the matter. (8.) By April 23, the police has made two arrests and confiscated property for value of 2.7 million euro in relation to NESA trade (16).
Given the challenges in obtaining protective equipment from the free market, starting up local production of PPE was sped up, with safety visor production already started by 7th April (11). Requirements for protective gear are less extensive than for medical devices. Where necessary and where this can be done without compromising safety, it is possible to apply exceptional circumstances for faster approval and authorisation.
Finland signed the EU joint procurement agreement on medical countermeasures on March 27 (12), but lost the chance to participate in the four procurement calls made under the agreement so far. While Finland missed signing the agreement for a number of years, the debates have now focussed on slow action in 2020 to join to the agreement and missing initial calls and lack of communication of this to the Minister leading to – reportedly – an internal inquiry in MSAH (14). This internal inquiry was finished quickly with modest findings that there was no one to blame and that as the issue had not been urgent before the lack of clarity on the issue had not come up (17). Due to expectations of availability of products from NESA and complacency in PPE sufficiency, the very high needs of PPE in the COVID-19 epidemic have resulted in reports by TEHY trade union of nurses that between April 17-20 72% of their respondents reported of lack of PPE (15).
On 27 May 2020 Minister of Employment and Minister of Economic Affairs gave a joint overview of the current situation concerning the production of PPE in Finland and announced that three companies have launched the production of surgical mouth-nose masks and face coverings. Production of medical gowns and aprons began earlier. (18)
On 27 August MSAH announced that Finland was part of joint EU-level vaccine purchases. In addition, Finland has expressed interest in the COVAC initiative, driving equality across the world in vaccine access (19).