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
On 5 November, the Government decided to propose an exceptional procedure for covering COVID-19 vaccination related injuries. In Finland, medicine and vaccination related injuries a covered by a voluntary insurance system provided by the Finnish Mutual Insurance Company for Pharmaceutical Injury Indemnities (20). As a usual procedure, the Company takes out reinsurance to contains its risks. For the COVID-19 vaccinations, the Government propose granting state collateral guarantee for the Company particularly in case the reinsurance is not obtainable with reasonable conditions (2).
On 17 November, the National Advisory Committee on Vaccines (KRAR) gave a recommendation on the priority order of administering COVID-19 vaccination. According to the recommendation, vaccination should first be provided for 1) health care personnel attending COVID-19 patients and staff working at nursing homes, 2) the elderly, and 3) persons who have conditions predisposing to severe COVID-19 disease. While the vaccination will be delivered to Finland in several batches, the priority vaccination order within these groups will be defined later based on detail information on the protective power and safety of the vaccinations in different target groups (3).
On 10th December, the Government approved the COVID-19 vaccination strategy prepared by the MSAH. The aim of the strategy is to provide protection against COVID-19 to the whole population and vaccines will be offered free of charge to anyone who does not have contraindications on health grounds. Municipalities are responsible of organising the vaccinations in their areas. They are recommended to co-operate with hospital districts in the logistics and also with occupational health care units and private sector in the actual administration of the vaccines. Hospital districts coordinate the vaccination arrangements for the social and health care personnel. THL guides the hospital districts concerning the logistic of the vaccination. The strategy confirmed the previously mentioned priority order of vaccine administration, that is based on a medical risk evaluation and it will be revised after the vaccines are available. The current plan is to vaccinate first social and health care personnel during February and March 2021, since the first available vaccine will most likely be the vaccine of BioNTech-Pfizer, that requires special cold chain arrangements which can be provided in large social and health care facilities. The order and arrangements to vaccinate the next priority groups will be specified after other vaccine options and more information is available. (4)
Physicians are responsible for the vaccination operations planning and implementation. Health professionals, such as physicians, and nurses, public health nurses and midwives who have received the adequate vaccination training, are tasked with administrating jabs. (14) THL has determined the qualifications for health care professionals to be able to administer vaccinations and maintains a national online vaccination training that is often included in the education of health care professionals. (15) In addition, THL organized a free online training for health care professionals on COVID-19 vaccines on December 16, 2020 and a recording of the training is available afterwards. The training deals with researched information on COVID-19 vaccines, vaccination orders, distribution of vaccines, mRNA vaccine, implementation of vaccination, the recording of vaccinations and the transfer of information. (5)
The vaccinations began on 27 of December. According to the vaccination strategy, the vaccine is first provided to the health care staff treating COVID-19 patients and to the personnel working in nursing homes. On 12 of January THL announced that the health care personnel treating COVID-19 patients and other health care professionals that have a high risk of providing care to infected patients have been vaccinated extensively. The vaccinations have now been extended to the nursing homes and are given both to personnel and residents. There has been a lot of public debate around the slow start of vaccinations in comparison to other comparable countries (e.g. Denmark). The officials have stated that delays are due to the pace of importing the vaccines being slower than predicted. THL also noted that the data on the number of people vaccinated are not entirely up to date because of slow reporting by the organisations responsible for implementing the vaccination programme. To speed up the vaccinations, THL changed its recommendation on storing vaccines for the second dose and now recommends that all doses are distributed as quickly as possible.
In addition, MSAH gave further guidance to the local authorities on organising the vaccinations and emphasized the immediate administration of the vaccines after their arrival to the local regions and the importance of entering the information of given vaccines in the electronic medical record system according to the national guidelines in order for THL to be able monitor the implementation of vaccinations (6) As of Jan 18, 2021, THL reports daily on the progress of the vaccination. Progress is reported by hospital districts, municipalities (from 1.2.2021 forward) and age group as well as publishing the cumulative number of vaccines by date of vaccination. (8) THL administrates the national vaccination registry that is used to monitor the progress, effectiveness and safety of the vaccinations(4). Finnish Medicine Agency (FIMEA) publishes information on the suspected adverse effects of the COVID-19 vaccines.(20)
The public are informed about the practical arrangements of the vaccinations in the municipality’s and hospital district’s web pages and often also in several medias such as newspapers and social media. Different channels of communication, such as letters, phone calls, sms messages, are used as appropriate to inform individuals of the vaccination schedule to ensure that vaccinations are offered to everyone. Vaccinations are given by appointment which can be made either electronically or by phone. (18,19) The Helsinki-Uusimaa Hospital District has launched a self-service reservation system for the vaccinations, and it is implemented in the Uusimaa region. In the mid-January the system was introduced for health and social care professionals to make appointments. It is aimed to be open for the rest of the region’s population at the end of January, when the vaccinations for the elderly and those at risk begin. (7) Also several other regions have self-service reservation systems.
Vaccinations are administrated in social and health care facilities and also in homes for the customers of home care. In addition, several regions are prepared for mass vaccinations. Espoo and Vantaa will start mass vaccinations during the week 4 and Helsinki during the week 5 (9). City of Tampere has announced as well that mass vaccinations will start in February in one facility with the capacity to vaccinate 10 000 local residents in a week (10).
Older people are vaccinated with the mRNA-vaccines and vaccinations are offered from the oldest age groups to the youngest. The vaccination of the persons aged over 80 years has started in January and in many municipalities also the vaccination of the persons aged between 75 to 79 years of age start in the middle of February. The vaccinations for older people living in care homes are expected to be completed during February. (13) The Moderna vaccines are often offered to older persons living in remote areas due to the less demanding storage conditions compared to the BioNtech-Pfizer vaccines. (16,17)
On 3rd February, the National Advisory Committee on Vaccines (KRAR) gave a recommendation to prolong the interval between coronavirus vaccine doses to 12 weeks due the prevailing epidemic situation. Also, the use of the AstraZeneca vaccine is recommended for now to be restricted to those under the age of 70. (11) Due to the recommendation those under the age of 70 with comorbidities that put them in higher risk of COVID-19 complications are vaccinated alongside older age groups.(13) On 10th March 2021, the National Advisory Committee on Vaccines stated that the AstraZeneca coronavirus vaccine can be administrated also to people 70 years of age and older (21). On 13th March, Fimea and THL recommended continuing the national corona vaccination program with all marketed corona vaccines, including AstraZeneca's vaccine, for the time being. THL and Fimea monitor the situation closely and investigate the possible connection between the thrombosis risk and the corona vaccination. (22) On 20th March, 2021, THL suspended the use of the AstraZeneca vaccine after Fimea reported two cases of cerebral venous sinus thrombosis within 4-10 days of receiving the AstraZeneca vaccines. (26) THL decided to resume the use on March 29, limiting it to those aged 65 and over and continue the investigations of the possible causal pathway between the vaccination and the disease. (27)
THL published a priority sequence for risk groups for coronavirus vaccinations to determine the order in which vaccines are offered to persons under the age of 70 with different underlying illnesses. The decisions are based on Finnish research material on COVID-19 patients in Finland. Risk groups are divided into two:
Group 1: Persons with an illness or condition that poses an extremely high risk of severe coronavirus disease.
- Organ transplant or stem cell transplant
- Cancer under active treatment
- A severe disturbance of the body's defence system
- A serious chronic renal illness
- A serious chronic pulmonary illness
- Type 2 diabetes involving drug therapy
- Down syndrome (adults)
Group 2: Persons with an illness or condition that poses a risk of severe coronavirus disease.
- Asthma requiring continuous medication
- Severe cardiac disease, including insufficiency (but not hypertension)
- Stroke or other neurological illness
- Respiratory conditions
- Pharmaceutical treatment for autoimmune disease that weakens immune defences
- Severe chronic liver disease
- Type 1 diabetes or adrenal insufficiency
- Severe sleep apnoea
- Morbid obesity (body mass index 40 or more) (12)
In the beginning of March 2021 vaccinations have proceeded to the vaccination of adult population in the risk group 1 in several areas. By 17th March, 75 % of the population aged over 80 years and 11,4 % of the whole population had received first dose of the vaccine. (23)
On 10th March 2021, MSAH issued a recommendation for municipal health authorities to administer COVID-19 vaccinations for persons without residence right in Finland. In addition to EU and EEA and Swiss residents the recommendation also includes students from third countries, diplomats, asylum seekers and undocumented migrants. The recommendation is in line with the earlier MSAH recommendations on free COVID-19 testing and necessary care for persons without Finnish residence right issued on August 26, 2020. (24, 25)
THL published first preliminary results on the effectiveness of coronavirus vaccines. The results are based on a register study conducted by THL. According to the results the vaccination reduced the number of severe coronavirus diseases that require hospital treatment by an average of 74% in the elderly and 84 % in the risk groups. Findings are in line with international results. (28) By April 12th, 2020, 20 % of the whole population of Finland has received the first dose of the vaccine and 1,7 % has received the second dose of the vaccine. (29)
On April 16, 2021, the Government amended the decree on voluntary COVID-19 vaccinations. The amendment specifies the current order of priority for the vaccinations and expands the group of people authorized to administer the vaccines. After the main priority groups have had an opportunity to receive the vaccine, the vaccines will be administrated to the rest of the population by age group in descending order starting from 60-69-year-olds to 50-59-year-olds and so forth. In addition, a temporary amendment in force until May 31, 2021, enables the vaccines to be targeted by region. More vaccines will be distributed to those hospital districts where at least 100 new cases per 100 000 inhabitants have been reported in the 14 days preceding the distribution of the vaccine batches. Further allocation of the vaccines to these hospital districts will be based on the size of the district population, the number of COVID-19 cases in the previous 14 days and the number of patients in specialized health care in the previous 14 days. This allocation is possible if all people over 70 years of age and those belonging to a risk group in the region have had the opportunity to receive their first dose of the vaccine. Moreover, the targeted allocation should not prevent a person from receiving their second dose of the vaccine. Furthermore, the amendment expanded the authority to administer the vaccines to dentists, and also to medical/nursing students under the supervision. (30)
On April 21st THL stated that in future, the mRNa vaccines may also be given to persons aged between 65 to 69 years upon requests if majority of the population belonging to the risk groups have received their vaccine. Until now, this age group has mainly received AstraZeneca vaccine. People aged below 65 years of age and who have received the AstraZeneca as their first dose of corona vaccine, will receive a mRNA vaccine as their second dose (31).
On April 23rd THL made an adjustment to the instructions guiding the corona vaccination order of social and health care personnel, to ensure the patient’s statutory right to access urgent care. The adjustment concerns personnel working in acute care, in example acute psychiatry units, on-call child protection units, emergency units, labor wards, and units providing emergency operations. A limited number of this personnel can be vaccinated according to the assessment of the region. So far over 25% of the population of Finland have received their first corona vaccine dose. (32)
In May 2021, vaccinations have proceeded to the population aged 45 years of age and older in many regions and 35% of the whole population has received their first dose and 4% have received their second vaccine dose by May 11th (33). THL started publishing the information on the number of given vaccines by product from May 5th forward (34). THL also informed that the vaccinations have been targeted regionally according to the epidemic situation for the first time and extra batches of the Moderna vaccines have been distributed to the hospital district of Päijät-Häme where the incidence is currently 108 infections per 100,000 inhabitants(35).
The Ministry of Social Affairs and Health has estimated that hospital districts will have to reallocate a significant proportion of their resources to the treatment of patients infected with the coronavirus. Some hospital districts have already announced that they have decreased the capacity of non-acute care (e.g. deferrals of elective surgeries) to increase the capacity for the treatment of COVID19-patients.
The Helsinki-Uusimaa hospital district has announced that it is ready to establish a special pandemic hospital if needed. It has reallocated services so that most corona patients are treated in the previous Surgical hospital. Some municipalities plan to use school and old nursing home premises to treat patients. Large cities such as Helsinki and Tampere and others have established a special coronavirus health clinic in which they only treat patients with respiratory symptoms. Some smaller cities have set separate consultation times in the health centres for suspected COVID-19 patients and other patients if it is not feasible or yet needed to arrange separate facilities.
Video and telephone consultations have increased in several service providers in the public and private sector. The Helsinki-Uusimaa hospital district has announced that it will start digital consultations (via either the phone or computer) for all appointments that can be handled remotely.(1)