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
Supply and distribution of face masks
Germany’s Federal Ministry of Health is preparing to distribute 290 million masks to nursing professionals and patients and their visitors. The roughly 33,000 residential care facilities and ambulatory long-term care providers throughout the country will receive nearly 100,000 packages, each containing 1,000 FFP2 masks for self-protection as of November 10, 2020. These masks are from the federal government’s stocks, which were beefed up in reaction to the first phase of COVID-19. The deliveries start on November 10 and will continue through Christmas 2020.
Due to continuously high infection rates, the Federal Minister of Health announced to distribute FFP2 masks to vulnerable populations, which are all persons above 60 years and risk groups including their relatives. Roughly 27 million people are eligible and will be able to pick up the first three masks free of charge in pharmacies upon proof of identification as of mid-December until end of December 2020. A further 12 masks can be obtained through coupons coming in 2021 that can also be redeemed at pharmacies. Insured persons are to pay a cost of EUR 2 per coupon which entitles to two masks. An initial EUR 491.4 million will be transferred from Social Security funds to cover costs and in total the federal government expects to spend up to EUR 2.5 billion for distribution and billing expenditures.
Supply and distribution of rapid antigen tests
The federal government secured nine million rapid antigen tests for November via purchase guarantees that the federal states and institutions can officially purchase and distribute according to need. The Federal Ministry of Health plans to increase the monthly quota up to 22 million rapid tests in January 2021. Some of the federal states have already begun using the tests and ordinances of the Federal Ministry of Health have encouraged states and facilities to develop testing concepts (see also Section 1.5 Transition measures: Testing). On November 11, the Ministries of Health and Economic Affairs jointly announced a plan to boost domestic production of COVID-19 antigen rapid tests. Up to EUR 200 million will be made available and aims to strengthen medical supply chains within Germany. On December 16, this funding for domestic production of rapid COVID-19 tests came into effect.
Stock of medical equipment
On November 30, the Federal Government’s Corona Cabinet announced to establish a national health reserve for critical materials for Germany’s health care system. The reserve should have enough to meet the requirements around the country for one month, with an emphasis on stocking materials that have been domestically produced. Masks, respirators and medication are all priorities for the reserve and EUR 1 billion has been set aside in the federal budget for building it up in 2021. The reserve will be distributed across 19 storage locations throughout Germany.
The Minister of Health announced on January 24 that the federal government had purchased a new antibody-based drug (200,000 doses for EUR 400 million) to fight the coronavirus. Administering these antibodies in the early stages can help high-risk patients avoid a more serious progression. However, as of 12 March 2021, only approximately 620 vials of bamlanivimab and 190 units of casirivimab/imdevimab have been dispensed due to logistical problems. The antibody-based help patients especially in the early phase of the disease, i.e. outpatients, but the drugs are currently only delivered to hospitals. The few doses that have been used so far have only been used to treat patients who have been in hospital for other reasons, for example on an oncology ward, and who have been diagnosed with a SARS-CoV-2 infection there.
For 2022 onwards, the federal government is aiming for Germany to be able to supply itself with vaccine through own production capacities.
In early June, the state of Bavaria has started to dismantle auxiliary hospitals that were set up in anticipation of high stress on existing facilities. Many still remain on stand-by should an outbreak necessitate their use throughout the state’s different regions (for example Middle Franconia, Lower Bavaria and the Upper Palatinate), but the state’s focus has shifted to ramping up testing capacities. There are already 124 testing centers in Bavaria and state Health Minister dressed the need to boost testing for target groups (risk groups and workers in critical infrastructure).
On July 8, the federal government passed an ordinance to increase the supply of medicine for intensive hospital care. The ordinance applies to medicine with the a defined list of active ingredients including adrenalin, amiodaron, argatroban, clonidin, esmolol, heparine, meropenem, midazolam, morphin, noradrenalin, novaminsulfon, piperazillin/tazobactam, propofol and sufentanil. These active ingredients must be sufficiently available in hospital pharmacies as of October 31, 2020. The stock must meet the average need of medicine of three weeks of the intensive care department of the respective hospital.
Supply and distribution of face masks
Starting in September 2020, Germany should be able to manufacture an additional 2.5 billion masks within one year, as announced on July 8 by the Federal Ministry of Economics. The masks, which include FFP2, FFP3 and medical face masks, should bump Germany’s total mask production up to seven billion annually. The Ministry of Economics plans to invest EUR 60 million in subsidies and funding for plants that produce masks and filters.
Initially, medical testing was performed either at office-based medical practices or at the hospital. With the rapidly evolving situation, testing takes place at an increasing number of facilities. In many cities, testing pods have been rapidly set up close to hospitals or other areas to protect others using the hospitals who may have vulnerable immune systems as well as to allow general medical practices to ensure basic medical service provision and protect staff and patients. In some federal states, drive-through test stations have been set up (e.g. in Munich, Oberhausen, Bochum, Rhein-Neckar-Kreis and Kreis Esslingen). Other communities send staff home to patients to take a test at the apartment door. On April 1, the Federal Association of SHI Physicians reported that in total 400 test centres have been set up in Germany of which some also perform drive-in tests. Until 31 March, about half of all COVID-19 tests were performed in practices of SHI-accredited physicians.
Already on 15 March 167,000 tests (2023.3 tests per 1,000,000 population) were performed. Until 17 March, there were about 100 000 tests performed in the ambulatory sector. However, the capacity to test everybody with mild symptoms is currently not sufficient given the limited availability of medical laboratories. Long waiting times for testing results occur in many locations reaching up to 7 days in Bavaria and Saarland. The Professional Association of German Laboratory Doctors warns of bottlenecks of SARS-CoV-2-tests in particular due to shortages of laboratory supplies (e.g. extraction material, testing swabs, RT-PCR reagents and PPE). However, German laboratories adapted quickly by doubling staff in order at least to prevent human resource shortages. In addition, an increasing number of facilities rearranged their services, for example the laboratory of the DKMS stem cell donor registry at the University Hospital Carl Gustav Carus in Dresden and public chemical and veterinary investigations offices in some federal states started to provide laboratory testing for COVID-19.
According to the Federal Institute for Drugs and Medical Devices (BfArM) the supply of pharmaceuticals is not affected in regions that are particularly affected by COVID-19. Still, the Federal Institute (BfArM) released instructions to pharmaceutical companies and pharmaceutical wholesalers regarding storage and adequate supply of pharmaceuticals.
Personal protective equipment (PPE)
Regional associations of SHI physicians have reported that medical practices, especially GP offices, are facing shortages of personal protective equipment (PPE) without being able to purchase more protective material. Also hospitals, long-term care facilities and ambulatory long-term care providers report insufficient resources of PPE and disinfecting agent and are awaiting supply from the procurement of the federal government. The lack of PPE (especially masks) led hospitals to re-use disposable masks. The insufficient PPE supply is raising serious concern among health care professionals, which is reflected in urgent letters to politicians. The purchasing is now centrally handled by the Ministry of Health (see section 2.1), and first deliveries have arrived . On March 04, the Ministry of Health started central procurement of personal protective equipment (PPE) for medical practices, hospitals, nursing homes, ambulatory care and federal agencies. In the meantime, companies have donated PPE, if available. Export of PPE abroad is prohibited, except under very stringent conditions such as concerted international aid campaigns.
On March 13, the RKI provided recommendations on resource-efficient use of face masks in health care facilities due to shortages. Several alcohol manufacturers have started to deliver disinfectants or alcohol to pharmacies and hospitals. Since early March, pharmacists are allowed to produce certain hand sanitizers.
The German armed forces provide support in different ways. Its medical units - comprising around 20 000 soldiers - are preparing the military's five hospitals for the general public. German armed forces have also started to provide food, camp beds and mobile doctors' facilities and they are storing medical goods in their barracks. The military also started to mobilize reservists to augment Germany's military services and to help with medical duties. In addition, the military's procurement office now has EUR 241 million allocated to find medical protective gear on the global market, which the Health Ministry is to distribute among clinics and doctors' offices across Germany. Within 24 hours the procurement office could contract the delivery of 300,000 eye protections and protective masks of type FFP-2.
Even though the number of hospitals decreased over the last years, Germany has the highest number of hospital beds per population in Europe (8.0 hospital beds per 1 000 population). In addition, the German hospital sector is highly decentralized resulting in a very good accessibility. In 2017, there were 28 031 ICU beds provided by 1,160 hospitals resulting in 33.7 ICU beds per 100,000 population which is a relatively high density compared to other countries. According to the Ministry of Health, currently 25,000 ICU beds have ventilation capacity. The occupancy rate of ICU beds was 79.0% in 2017. The Government and the federal states released a statement on a Hospital Emergency Plan which aims to double ICU bed capacities through use of provisional facilities (e.g. rehabilitation facilities, hotels, public halls). In many hospitals, capacities are shifted from planned and elective procedures to increase general and ICU bed capacity (see sections 3.1 and 3.3).
Developments in chronological order
On April 1, the German Hospital Federation reported that since the government’s guideline to free up capacity for coronavirus patients the number of ICU beds has increased by 12,000 to about 40,000. The head of the German Hospital Federation further states that now 30,000 of the 40,000 ICU beds are equipped with respirators (see also Section 3.1). However, according to the intensive care register (DIVI) the actual ICU capacity was lower: for example mid-May the DIVI register reported about 32,500 ICU beds of which about 37% were not occupied. Early July, there were still 32,700 ICU beds and a occupancy rate of 66%.
On April 2, the crisis management of the federal government decided that protective face masks (FFP2 and FFP3) may be reused under certain circumstances by medical personal in health care facilities and residential facilities. Face masks may be reused if there is a temporary shortage of protective material. The reuse requires appropriate handling in regard to personalization, collection and decontamination.
Until April 5, the federal government delivered an important stock of protective equipment to the federal states according to the Minister of Health which included 8 million FFP2-masks and 400,000 FFP3-masks, as well as 25.5 million mouth-nose protection masks and 22.5 million gloves. The federal states are responsible for allocating and distributing the material to health care providers.
On April 8, the Ministry of Health released further regulation regarding procurement of medical devices and PPE. Internationally operating companies that procure medical devices and PPE are exempt from liability risks as contractual partners of the federal government. This means that the federal government itself imports medical devices and PPE. Allocation of medical devices and PPE to certain population groups lies within the responsibility of the Ministry of Health from now, while usual sales channels are prohibited.
Since April 9, a new digital marketplace of disinfectants has been launched (https://notfalldesinfektion.vci.de/) by the German Chemical Industry Association (VCI). The new platform was created as a temporary platform to coordinate applications from health institutions and support measures from the chemical and pharmaceutical industry during the Corona crisis. Health care facilities such as hospitals, care homes and medical practices that are in an emergency situation and all companies or institutions that want to contribute to solving the problem can register immediately. In this way the digital marketplace aims help improve the supply of disinfectants.
On April 21, the Minister of Health announced that his Ministry will receive additional funding of EUR 7.8 billion from the federal government for the procurement of masks, gloves and other protective gear for medical practices and hospitals during the pandemic. Part of the funding will be reimbursed by the federal states and SHI funds. The federal government has decided to centrally procure more equipment and additional respirators for hospital intensive care units (see above). Approximately EUR 5 billion had already been approved for this.
Until May 5, the federal government has procured roughly 114 million additional masks for hospitals, care homes and medical practices in recent weeks in response to PPE shortages worldwide. 92 million surgical masks, 20 million FFP2 masks and almost two million FFP3 masks, plus 46 million gloves were distributed by the federal states and the Regional Associations of SHI Physicians.
On May 20, the cabinet agreed on a revision of the Foreign Trade and Payments Regulation (AWV) with the intention to better protect security-relevant businesses in the health branch better from take-overs from outside the European Union. In future any acquisition of a stake of ten per cent or more in security-relevant businesses in the health branch must be reported and can be examined. For this purpose, the cabinet has extended the list of companies for which the acquisition of a stake by a purchaser from outside the European Union can be examined. In future the list will include businesses in the health branch – with a view to the possible endangering of public order or safety. The new list includes business that develop or manufacture goods that are indispensable for the maintenance of a properly functioning health system in Germany, such as personal protective equipment (PPE), drugs and vaccines. Other factors relating to the investor per se have also been incorporated in the Foreign Trade and Payments Regulation (AWV). The examination can, for instance, take into account whether the body acquiring a stake is directly or indirectly controlled by a foreign government, including any state agency or armed forces.
On May 21, media reports revealed that 130 million masks are currently stored by the Ministry of Health without being delivered to the health facilities due to logistical problems. To ensure and speed up supply of PPE, the Ministry of Health started an open process for tenders to centrally procure of protective equipment end of March (see above). Until early May, it awarded 738 surcharges to companies of which 308 companies supplied material. To incentivize production and ensure supply, a minimum of 25,000 of delivered masks and a fixed price of EUR 4.50 per FFP-2 mask were set by the Ministry at which it would purchase the material. Although materials were delivered, distribution of PPE is still a challenge leading to lack in health care facilities (see Section 2.2. entry of May 18). Another problem, according to the Ministry, is the inadequate quality of some of the masks supplied. About 20 percent of the protective masks supplied do not meet the requirements.
The stimulus package's investments in infrastructure and equipment
On June 3, the federal government announced the agreement on a stimulus package of EUR 130 billion, which sees Germany taking on new debt to deal with the economic fallout of the pandemic (see also Sections 4.2 and 6.1). The package sets out to strengthen the health care system and improve pandemic preparedness. As part of the ‘Pact for the Public Health Service’ (ÖGD) the federal government will increase funding in programmes for digital and technical setup and equipment of public health offices. The funds can be invested in hard- and software equipment to improve reporting and crisis response, in information and communication technology and in the necessary training for employees. Common standards to ensure comprehensive communication and interoperability are agreed in a “sample equipment”. To improve and accelerate reporting of infections existing procedures will be reviewed and upgraded. The federal and state governments jointly support improved communication and concept development to strengthen the public health service (ÖGD) at all levels in e.g. revising state law regulations to strengthen the “health in all polices” approach. The necessary financial framework to implement the measures is estimated at EUR 4 billion.
Further, a ‘Hospitals of the Future Programme’ will be set up to fund necessary investments in better digital infrastructure and improved emergency care capacities (EUR 3 billion). Emergency care and digital infrastructure of hospitals will be modernized both in terms of space and equipment to improve capacities, cross-sectoral provision of care, process organisation, communication, telemedicine, robotics, high-tech medicine and documentation. In addition, investments in IT and cybersecurity and strengthening of regional health care, are to be supported by the program. Implementation takes place via the legal expansion of the Hospital Structural Fund, which was established in 2016 to improve regional inpatient care structures.
The stimulus package also aims to increase the capacities and independence in the production of PPE, active ingredients and vaccines. For this purpose, the government foresees to set up a program that promotes flexible and scalable domestic production of key medicines and medical devices. In addition, financial support of another EUR 1 billion will be granted for building up strategic reserves of PPE both at federal and state levels and in medical facilities.
Finally, the federal government is providing EUR 0.75 billion in funding to promote the development of a vaccine (e.g. contribution to new international alliance CEPI), to secure production capacities and to start production early also to improve epidemic preparedness for future events.
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