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
Initial availability of physical resources
The initial availability of physical resources needed to manage the COVID-19 outbreak was satisfactory, taking into account the population size of Montenegro (circa 630,000). The total number of hospital beds in the country is 2183. The Healthcare Crisis Response Team appointed by the National Coordinating Body for Combatting Infectious Diseases issued a Strategic Operative Plan (number 00-2/1; of 26 March 2020) for the healthcare institutions functioning in Montenegro during the COVID-19 epidemic. The Plan described which hospitals were designated to treat COVID-19 patients and which hospitals were to treat other patients (for a detailed description see Section 3.1 on “Planning services”).
The initial number of hospital beds prepared for COVID-19 patients was 163 in the Clinical Center of Montenegro (the main hospital in the country) and 583 in other hospitals (for further explanation, see section 3.1). This number of beds was defined in the afore-mentioned Strategic Operative Plan issued by the Healthcare Crisis Response team. The total number of intensive care unit (ICU) beds in the country is nearly 160. All hospitals have re-organized their departments in order to create “COVID-19 zones and pathways” designated especially for these patients.
This initial number of COVID-19 beds was later reduced, in accordance with the improvement of the epidemiological situation. During the resurgence of the COVID-19 crisis in Montenegro in June/July; the total number of COVID-19 hospital beds was increased once again (see Section 3.1).
The initial number of ventilators (before the COVID-19 epidemic) in the country was 71 which was sufficient for non-COVID-19 patients in Montenegro. During the preparation for the epidemic, 90 ventilators were either purchased from the donations fund (money donated by various benefactors) or from the state budget; or were donated directly from companies and people from Montenegro or abroad. The total number of ventilators in the country at the beginning of May was 161, which includes both stationary and mobile ventilators.
After several donations (by the European Union, supported by the UNDP) as well as the Government of Norway (which occurred in May and June); the total number of ventilators in Montenegrin hospitals was 168 as of 16 July 2020 (both stationary and mobile ventilators). An additional 18 ventilators and 50 CPAP masks are currently in the process of distribution among Montenegrin hospitals. Furthermore, the EU has announced the arrival of an additional 86 ventilators in the second half of July.
The UNDP has also donated 10 digital X ray machines that were distributed to the following hospitals (based on the decision made by the Healthcare Crisis Response Team):
- the Clinical center of Montenegro (5 machines)
- the general hospitals Bar, Berane, Pljevlja and Bijelo Polje; as well as the special hospital for pulmonary disease “Jovan Bulajic” Brezovik (one machine each)
Personal protective equipment (PPE)
There were certain quantities of personal protective equipment (PPE) available before the epidemic that were distributed across health facilities. Additional quantities were secured through different channels. The Government, through the central budget, has allocated additional resources for procurement of essential commodities to respond to COVID-19. Montenegro did not have any state reserves regarding PPE. Stockpiling of medicines, equipment and personal protective equipment has been organized throughout the health system, also using aid from various individuals and donors.
PPE (surgical masks, respirators, sterile and non-sterile gloves, visors, goggles, overshoes) was donated by several international benefactors (with personal or business connections with Montenegro), and was also purchased by the Government of Montenegro (from China). It was distributed according to hospital capacities and purpose (COVID-19 or hospitals for other patients). Also, tests for SARS-CoV-2 were frequently donated or purchased, and distributed to the Institute of Public Health. All Government structures worked together in order to obtain as much international help as possible, with the involvement of UNDP, EU, NATO, diplomatic bodies etc.
The Healthcare Crisis Response Team led the distribution of PPE during the first period of the COVID-19 crisis (from the end of March through mid-May). During this period, the following amounts of PPE were distributed among healthcare institutions, as well as social services, the police and the military:
- 1,126,300 surgical masks
- 157,300 N95 masks
- 5,419 medical visors
- 304 infrared thermometers
- 16,472 protective overalls
- 2,601 protective eyeglasses.
A steady rate of PPE procurement in the entire country has resulted in a shift of distribution policy-making from the Healthcare Crisis Response Team to the Ministry of Health (as it was before the COVID-19 epidemic).
The need for antiviral drugs (lopinavir/ritonavir) and chloroquine (the shortage of which was noted in all Balkan countries) was satisfied with the donations by AbbVie (lopinavir/ritonavir) and Sandoz (chloroquine), until free purchasing was enabled near the end of April.
There was a risk of a shortage of certain drugs produced by several European pharmaceutical companies because of the temporary policy of export restriction by the Republic of Serbia (they are the “gateway” for the import of several pharmaceutical companies’ drugs to Montenegro). Fortunately, Serbia quickly changed its policy to open the export (as it was before the epidemic). The back-up plan of Montenegro was to use its diplomatic relations to purchase the drugs from other European countries.
Temporary objects (e.g. military tents) were set up in front of primary care centers and hospitals as triage spots; after which the patients would enter different pathways based on the degree of suspicion of COVID-19 (the pathways were clearly designated in all health institutions).
The increase in the outdoor temperature in June has forced the healthcare institutions to replace the triage tents with containers that allow for better cooling.
Five field hospitals were created during the preparation for the epidemic (four in sports centers: “Bemax” and “Moraca” in Podgorica; “Topolica” in Bar and “Sports center Berane” in Berane; and one in the high school in Golubovci, Zeta region (near Podgorica)). These hospitals were designated for COVID-19 patients with mild symptoms, supervised by general practitioners, internal medicine specialists and nurses. The infrastructure of these hospitals was created according to hygiene standards (modern beds and medical equipment, adequate water and electricity, bathrooms etc.). Fortunately, by 19 May 2020, no patients had been admitted to these hospitals.
The equipment for temporary triage objects (tents) as well as the hardware (including beds) for field hospitals was borrowed from the Armed Forces of Montenegro, as well as the Emergency Directorate (a segment of the Ministry of internal affairs); in order to avoid unnecessary expenses.
In May 2020, all field hospitals were temporarily closed and all the medical equipment was stored in military warehouses. The objects used for field hospitals were returned to their previous sports activities.
Due to the increase of COVID-19 hospitalized patients in June/July, initial preparations to re-open at least one field hospital in Podgorica are underway since mid-July.
Apart from several individual cases of counterfeit selling a minor amount of pharmaceutical goods (disinfectants), no significant counterfeit sale or stockpiling was observed. The aforementioned cases did not arise from any health institutions, and were dealt with by the police.