Policy responses for Greece - HSRM

Greece


Policy responses for Greece

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

This epidemic has proven to expedite the need for swift reactions towards long lasting systematic deficiencies, endemic to the structure of the Greek Healthcare system.  The rapid and focused response has in turn improved the overall system’s service capacity and potential: delivery to those most vulnerable, effectiveness in mobilization and maintenance of essential services.

To date, there are 13 COVID-19 reference hospitals across the country, and 4 hospitals dedicated solely to COVID-19 patients. Isolation wards have also been designated, and in each Regional Health Authority (there are 7 in total which encompass both primary and secondary health services across the country) there is at least one reference hospital with a negative pressure isolation chamber.

Public-private partnerships to purchase ICU services from the private sector have been established to be utilized whenever deemed necessary to cater for possible future COVID-19 hospitalization needs. Private hospitals will be reimbursed by the EOPYY (the national purchasing agency). The compensation cost amounts to €800 per existing bed and €1600 per bed, only for the additional ICU beds that private clinics have been asked to develop (40% capacity increase) to cater for possible future COVID-19 hospitalization needs. Patients who will be hospitalized in private hospitals will not be subjected to any co-payments.

A contingency plan is in place should the COVID-19 cases increase dramatically, which entails the requisition of private clinics (facilities, personal protective equipment, pharmaceutical products and staff).

On November 19, the Greek government proceeded with the requisition of two private clinics in Thessaloniki, where transmission has been particularly widespread, following private hospitals’ refusal to provide 200 beds to the public health system for the treatment of COVID-19 patients. Public hospitals in Thessaloniki and other parts of northern Greece have been struggling to cope with the influx of COVID-19 patients, despite the fact that, within a month, COVID-dedicated ICU beds in the city almost increased fivefold (from 43 on 23.10.2020 to 201 on 23.11.2020) and COVID-dedicated hospital beds almost tripled (from 498 on 23.10.2020 to1,420 on 23.11.2020), in response to the increasing needs. The decision to enlist the two hospitals for two weeks in the national health system means that the state is undertaking the administrative management of the entire premises of the facilities, including all the beds of the private clinics, in addition to the administrative supervision of the staff, which will offer their services to the general public.

For the first time, on November 26, three COVID-19 patients from northern Greece were airlifted to hospitals in Athens, in light of excess pressure on hospitals and ICU capacity. The patients were transferred in isolation capsules with a C-130 from the Greek Air Force.


Measures for Primary Health Care

In an effort to strengthen primary care contribution to the management of the epidemic, five health centres in Attiki (Capital Region) have dedicated their operation to COVID-19 patients, with potential expansion to rural health centers. A tele-counseling network for COVID-19 patients, operating through Health Centres has been under construction from March and was planned to be introduced within April. It envisaged medical for coordinators to undertake daily phone checks with patients, especially the vulnerable ones, for the provision of counselling and support. The network, however, is still not operational in December 2020. Once established, the COVID-19 telehealth services will be available to self-isolated/ home-isolated patients (self and distance monitoring), patients with mild cases (distance monitoring and treatment) and patients after discharge (follow-ups). In this context, an electronic registry has been created to monitor patients diagnosed with COVID-19 and ensure continuity of care.

Despite the fact that primary health care in Greece has not yet been developed to its full potential, and problems of access, continuity of care and coordination are being reported, its role has been strengthened during the management of the pandemic through the following actions:
● Early detection and management of possible COVID-19 cases (with mild symptoms not requiring hospitalization) in dedicated primary health care centres.
● Referral from primary to specialist care of those needing hospitalization.
● Assistance to patients with chronic conditions or acute illnesses not related to COVID-19 in the remaining (non-COVID-19) primary care facilities.
● Risk minimization of exposure of patients and medical staff to SARS-CoV-2 in health care facilities.

The Action Plan, announced on April 3rd, entailed 2 main objectives:
1. The operation of designated COVID-19 health centres on a 24-hour basis exclusively for the screening and management of COVID-19 patients that do not require hospital referral.
2. The transformation of certain health centres to 24-hour health centres dedicated to care for non-COVD-19 patients with chronic diseases, management of emergencies and communication with registered patients who are in home isolation.


In the beginning of October, the Ministry of Health announced the operational expansion of185 Health Centres and 42 Regional Clinics, to include case management of citizens with coronavirus symptoms. The activation of Primary Health Care in the battle against the pandemic is expected to decongest to a large extent Hospitals, especially the COVID-19 reference Hospitals.

Vaccine services and delivery

Greece has secured access to a sufficient number of vaccines to cover it’s entire population through the EU joint purchasing mechanism. The MOH prepared a National COVID-19 Vaccination Operational Plan, where vaccine distributionplayed a key role. Initial deliveries of vaccines are limited in number in line with pro-rata distribution among the Member States. As vaccine deliveries are gradual, it was deemed necessary to prioritize vaccinations in specific population groups. Therefore, the National Vaccination Committee proposed the following vaccination prioritization:

Stage 1
- Health and social services staff
- Residents and staff of nursing homes
- Residents, patients and staff of care structures for the chronically ill and rehabilitation centres
- Priority staff for critical functions of the Government

Stage 2
- People 70 years and older (regardless of medical history). Further prioritization:
• People aged 85 and over
• People aged 80 and over
• People aged 75 and over
• People aged 70 and over
- Patients at increased risk for severe COVID-19 illness, regardless of age
- Priority staff for critical functions of the State
- People 60 to 69 years old (regardless of medical history)
- People aged 18 to 59 years at increased risk for severe COVID-19 illness

Stage 3
People 18 years and older without underlying conditions

Timeline
• On 26th December 2020, Greek authorities received the first batch of the Pfizer vaccine (the initial symbolic shipment to all EU Member States).
• On 27th December 2020, the first vaccinations were performed in 5 reference hospitals in Attica. A nurse was the first to be vaccinated against Covid-19 in Greece, followed by a nursing home resident, the President of the Hellenic Republic and the Prime Minister. 
• On 28th December 2020, vaccines were further distributed to 4 Hospitals across 3 different regions in the Country, to commence the vaccination of healthcare personnel on 29th December.
• Following the vaccination of frontline healthcare workers and the most vulnerable groups, the vaccinations of the general population begun  on 16th January 2021 for citizens aged 85 and older.
• On 22nd January, vaccination commenced for citizens aged 80 to 84.
• On 15th February, vaccination commenced for citizens aged 75-79. On the same day, vaccination commenced for the age group 60-64, utilising the AstraZeneca vaccine. The National Vaccination Committee approved AstraZeneca vaccine for people younger than 65 years of age, due to the lack of data on its administration to the elderly.

Up to 20th February 2021, health authorities have conducted 693,436 vaccinations (of which 1st dose: 465,842 and 2nd dose: 227,594), covering over 4% of the country’s population. This ranked Greece in 12th place among EU countries. In the last week of February, 21,000 vaccinations on average take place on a daily basis. Over 1.3 million vaccination appointments have been scheduled already for the following months.

COVID-19 Vaccine Management Process

The Operational Plan contains detains on integrated vaccination process management, starting from the receipt of the vaccines from the producers, storage and their distribution to the Vaccination Centres.

Delivery to storage centres

Greece will gradually receive vaccines from at least 6 producers, starting with the first receipt in December 2020 from Pfizer / BioNTech. The protection of vaccines during their transport in carried out by the distributors of the vaccine producers with the support of the Greek Police. The Storage Facilities are informed about the upcoming deliveries from the Coordination Center of the Ministry of Civil Protection and Crisis Management. This information is provided through a central application developed by the Ministry of Digital Governance, specifically for the purposes of supply chain management of the COVID-19 vaccine. The in envisaged that employees of the Storage Centres are trained in ensuring storage requirements. Special equipment for receiving, storing, monitor and transporting vaccines, as well as to ensure protection of staff is planned to be done through central procurement procedures. In addition, detailed instructions were issued on:
• The necessary checks upon delivery and proper documentation;
• Vaccine management specifications upon delivery (times - temperatures) until their placement in the freezers of each Storage Centre and adequate recordkeeping documentation;
• The necessary equipment according to the respective vaccine specifications;
• The use of personal protective equipment;
• The use of the central supply chain application and pre-alarm systems.

In addition, each Storage Facility is assisted by 3 officers of the Armed Forces, who attend, monitor and support the vaccines delivery.

Storage specifications

The vaccines will be stored in 5 approved warehouses that meet the standards. More Storage Facilities can be activated in proportion to the volume and particular storage characteristics, if deemed necessary. Each Storage Facility supplies specific Vaccination Centres based on the distance between them and the time required to cover this distance, in order to minimize the time they remain in transport mode (for Pfizer / BioNTech and Moderna vaccines). Storage Facilities are equipped with a sufficient number of freezers, which meet the specifications (such as maintaining temperature of -70 to -80 °C for BioNTech/Pfizer vaccine). The freezers have a suitable temperature recording system installed in order to constantly monitor the freezing levels and the automatic update (pre-alarm) in case of temperature deviation.

On a daily basis, Storage Facilities conduct a quantitative inventory of the vaccine stock at the end of the day and in presence of the Armed Forces. Following the daily inventory, the Storage Facilities update the central supply chain application. The security of the Storage Facilities is ensured with the assistance of the Greek Police and Fire Brigade.

Delivery to Vaccination Centres

Vaccine delivery is based on the vaccination prioritisation plan, mentioned above, and the associated demand (i.e., the number of vaccination appointments), both in terms of volume and timing. The Coordination Centre receives information through the vaccination appointments application and schedules the necessary deliveries through the central supply chain application, the algorithm of which will initially be demand-based and then acquire a level of demand forecasting (such as expected non-attendance of vaccination appointments, etc).

The Storage Facilities receive daily information from the Coordination Centre through the central supply chain application for the upcoming needs of the Vaccination Centres in stock and liaise with distribution companies directly to ensure the uninterrupted flow of the vaccination process. The vaccines are packed in specially designed isothermal boxes, the temperature of which is monitored. The isotherm containers have been subjected to a series of tests in collaboration with the National Technical University of Athens. In addition, they have been designed in multiple sizes, which have been distributed to each Storage Facility based on multiple criteria (population distribution by region, number and size of Vaccination Centres served, etc.), in order to maximize the efficiency of the supply chain.

The Storage Facilities affix QR codes to each box, which include all the necessary information about the vaccine batch contained. The QR codes are scanned by the Vaccination Centres upon receipt, thus, automatically updating the central supply chain application, to ensure traceability throughout the route of the vaccine batch until their administration.

The isothermal boxes containing the vaccines are then delivered to the Distribution Company. During the loading, the Storage Facilities carry out driver and vehicle identification checks as well as visual checks on the vehicle with the presence of Armed Forces officials. The Distribution Company’s transport vehicles must meet the specifications of cold chain distribution and pharmaceutical products transport. A key condition during the transport to Vaccination Centres is to maintain a constant temperature in the cold rooms to ensure efficiency during administration.

Storage at Vaccination Centres

Authorized personnel of the Vaccination Centres receive the vaccine boxes and proceed to the electronic registration of their receipt in the central supply chain application. The Vaccination Centres store the boxes according to the instructions of the Producing Company and in each case adhering to the basic principle of storage FEFO (first-expired, first-out), and supply with vaccines the other units or means of vaccination (e.g. care homes, mobile health units). Vaccination Centres were established to ensure different storage conditions; ability for multiple doses to be administered within a limited time; supervision by a doctor.

Vaccination Scheduling Options

On January 11, the dedicated website, emvolio.gov.gr, for the Greek vaccination program was launched, providing information as well as access to appointment management application.

Eligibility checking (based on the vaccination phase – priority groups):
- Via the website emvolio.gov.gr, by filing a form using the Social Security Number (SSN), in combination with Last Name and Greek VAT Number, or
- By sending a text message to 13034 with the SSN and surname;
- Citizens registered to the e-prescription system will automatically receive a text message on their mobile phone from the number 13034 when they become eligible along with a pre-booked vaccination appointment (with the possibility of modification).
Citizens who do not have a SSN, are advised to visit a Citizen Service Centre to apply for one.

Appointment scheduling for eligible population groups: 
1. Via the online platform emvolio.gov.gr:
• Using TAXISnet codes (credentials for use in several Greek Government e-services, such as tax returns), and SSN to obtain access to available vaccination dates, locations and time slots to choose from;
• For two-dose vaccines, users secure both appointments;
• Appointment verification by replying to an automated text message from the dedicated line (13034).
2. Citizens who have no online access or TAXISnet credentials can schedule their vaccination appointment at pharmacies or citizens service centres (also known as KEP). This can also be done by a representative with the required documentation (SSN, Mobile phone number, and ID photocopy of the applicant).
3. Citizens registered to the e-prescription system will automatically receive a text message on their mobile phone from the number 13034 when they become eligible for vaccination.
• The text message will indicate the Appointment Number, the date & time of vaccination and the recommended vaccination centre. The closest vaccination centre is pre-selected based on the declared Postal Code in the ehealth.gov.gr platform.
• The citizen has the opportunity to confirm the pre-booked appointment within 120 hours, either by sending a text message to 13034, or via the platform using TAXISnet credentials.
• In case of no confirmation within 120 hours, the pre-booking is released and the citizen has the opportunity to later schedule a new appointment through the platform.

Once the appointment is scheduled, citizens receive – depending on the booking method – an Appointment Number (also as a QR Code) along with the appointment details. Citizens will be notified three days ahead of their appointments via email and SMS indicating exact hour and date and including a link with preparation instructions (e.g., what to do if you have fever or feeling unwell the day of your scheduled appointment). Citizens will receive an additional three automated SMS reminders for their appointment (3 days before the appointment, 1 day before the appointment and at 7am on the day of the appointment). Appointments can be modified up to 72 hours before the planned appointment.

Vaccination programme implementation and vaccine administration

In February 2021, vaccine has been administered in 1018 vaccination centres around the country, and further 480 vaccination points (Hospitals, Health Centers, Mobile Units, etc.) are planned to be gradually activated.

Four Mega Vaccination Centres are set-up in order to greatly increase the daily vaccination capacity:
1. Thessaloniki International Fair exhibition facilities (from 15 February): 108 Vaccination Centres with capacity  for 157,248 vaccinations per month
2. HELEXPO Exhibition Centre in Athens (from 15 February): 96 Vaccination Centres with capacity for 139,776 vaccinations per month
3. TAE KWO DO Stadium in Athens (from 1 March): 64 Vaccination Centres with capacity for 93,184 vaccinations per month
4. Peristeri Exhibition Center in Athens (from March 1): 96 Vaccination Centres with capacity for 139,776 vaccinations per month

The Covid-19 vaccine is free & administered only in public structures. People are not be able to select which vaccine they receive. The process is as follows:
• The Citizen provides the appointment code-number or the QR Code and the identification documentation (identity card, passport, etc.) to the staff of the Vaccination Centres. Members of staff confirm the appointment through a dedicated application.
• Person being vaccinated is required to fill in pre-vaccination questionnaire, which includes both general and specific health-related questions depending on the vaccine to be administered.
• Based on the answers, and after the diagnostic process, the doctor makes a decision on whether to proceed with the vaccination and a prescription is issued.
• The Vaccination Centre enters the details of the vaccine packaging used in the electronic application. In this way, the process of traceability and pharmacovigilance is enhanced.
From 19th February 2021, vaccinated people can request their digital vaccination certificate. About 40,000 vaccination certificates have been issued digitally just one day after the operation of the platform through gov.gr.

4-Phase Plan for Vaccination of Greek Island Residents

The inoculation of the population on the islands has started on 11th January 2021. It is a complex scheme due to the distinctive geographical characteristics of the island regions and the actions involved. The vaccines are being distributed to islands initially by air, mainly with scheduled flights, at no cost, under the supervision of personnel of the Hellenic Armed Forces, law enforcement and the General Secretariat for Civil Protection.

The first phase includes 18 islands where the National Health System (ESY) hospitals operate. Vaccinations for health care workers started on 11th January and for residents on 18th January. The second phase includes 13 islands with a population of over 3,500 permanent residents. Vaccinations started on January 28 for residents aged over 80 years and continue with other age groups. The third phase concerns 19 islands with a population between 1,000 – 3,500 permanent residents. Vaccinations started on 10th February with the participation of all age groups – especially individuals over 60 years – and vulnerable groups. The fourth phase concerns 42 islands with a population of less than 1,000 permanent residents. Vaccinations on these small islands will be carried out with the assistance of the Ministry of Interior and local authorities, and concern all individuals over 18 years old. The procedure will require the transportation of vaccines and medical personnel by air. The vaccination scheme launched on 27th January in the small island of Kastelorizo.

Pharmacovigilance

There is a process in place to monitor post-vaccination activity, for the timely information and subsequent identification of the risk factors from the vaccine administration:
• By notifying the side effects to the National Medicines Agency through the Yellow Card scheme (usual procedure);
• By keeping a vaccination registry, through which either the supervising doctor responsible for the vaccine administration or the doctor visited by the Citizen, can note any side effects.

Communication

Communication strategy designed to ensure the timely and valid information on the vaccination plan and process reaches citizens and health professionals, as well as the act on false or misleading information, through the appropriate communication channels.