The GOVERNANCE of the health system with regard to COVID-19 relates to pandemic response plans and the steering of the health system to ensure its continued functioning. It includes emergency response mechanisms, as well as how information is being communicated, and the regulation of health service provision to patients affected by the virus.
The Netherlands had a national pandemic response plan in place before the COVID-19 outbreak. The plan describes the general actions in case of an infectious disease crisis and is directed towards the Public Health Services. It describes which measures should be taken in which phase of the crisis and who is responsible for determining the phase of the crisis. It also describes how the organisation of the Public Health Service should be modified to deal with the crisis. The phases are the following: (1) after reporting the first case: direct measures including treatment of the patient, testing, contact tracing, and lab diagnostics; (2) scaling up including cooperation with other parties, information provision, type of measures for scaling up, ensuring continuation of usual care; further measures including social distancing, refining contact tracing and diagnostics, hygiene measures, medical supervision, isolation and quarantine, vaccination and prophylaxis; (3) downscaling including cancelling the crisis organisation, after care, evaluation, reporting (https://lci.rivm.nl/draaiboeken/generiek-draaiboek).
Furthermore, the National Association of ICU physicians has a specific pandemic action plan for ICUs, which uses colour codes from green to orange to red to black. As of 30 March, the Netherlands is in the red area. (https://nvic.nl/sites/nvic.nl/files/20200316%20Draaiboek%20Pandemie%20deel%201%20versie1.3_1.pdf).
No emergency legislation related to the health system has been issued, other than relaxing to some extent the registration requirements for healthcare personnel involved in COVID-19 care (see Section 3.1).
At first, the response was at the regional level in the province of Noord-Brabant, as is described in the national pandemic outbreak plan. The mayors of the three large cities in the province were responsible. When the outbreak became more severe, it was scaled up to national level. The coordination is in the hands of the National Institute for Public Health and the Environment (RIVM). An Outbreak Management Team has been set up, hosted by the RIVM and consisting of the relevant medical specialists, virologists, medical micro-biologists and representatives of the national references lab. The Outbreak Management Team advises the Prime Minister and his Cabinet on necessary measures to be taken. As the situation in hospitals seems to be manageable at the end of April, and emphasis is shifting towards relaxing restrictions, the Outbreak Management Team has been criticized for only having experts with a medical background and some are suggesting that social scientists should be added to the team (https://www.volkskrant.nl/nieuws-achtergrond/komen-we-met-alleen-medische-experts-door-de-coronacrisis~b1996436).
Testing and reporting cases is coordinated by the National Institute for Public Health and the Environment (RIVM). There are two reference labs: one at the RIVM and one at Erasmus Medical Centre (for more details, please see Section 1.5 – Testing).
People who do not observe the rules, for example on physical distance or gatherings of people, can be fined. This is regulated through ‘noodverordeningen’ (emergency decrees), taken by municipal authorities that work together in ’veiligheidsregio’s’ (safety regions). For example, the veiligheidsregio Utrecht established an emergency decree on 27 March (https://www.vru.nl/nieuws/1168-noodverordening-veiligheidsregio-utrecht-27-maart-2020).
The Outbreak Management Team suggested that intensified contact tracing should be one of the conditions for relaxing COVID-19 restrictions (see section 1.1). The Public Health Services are responsible for contact tracing, but they lack the capacity. Following this recommendation, the government studied the idea of a COVID-19 app for mobile phones. A tender was issued and 7 apps were evaluated, but after an initial assessment none of these appeared to meet the privacy criteria. At present, the government itself is developing such an app with a group of experts and with the prerequisite that the app has to be open source in order to show the population that their privacy will be protected. (https://nos.nl/artikel/2330914-overheid-presenteert-zeven-corona-apps-maar-nog-veel-zorgen.html; https://www.nrc.nl/nieuws/2020/04/21/kabinet-houdt-vast-aan-app-in-strijd-tegen-covid-19-a3997460).
The regional Public Health Services are responsible for organising the testing and tracing of citizens (for more details, please see Section 1.5 – Testing).
To give the coronavirus measures a legal basis, an Act (the Corona Act) was sent to parliament on 13 July, 2020. This Act should replace the emergency measures that have been regulating the policies around the coronavirus, since the emergency measures are meant to regulate a crisis for a short period of time. The Act should have a validity of six months, with the option to extend this by three months. New measures should be approved by parliament before they can be implemented. The Act has been open for consultation among a wide range of stakeholders. As a result of this consultation, for instance, the initial plan to enable enforcement of measures “behind the front door” (in the homes of people) was deleted. (https://www.rijksoverheid.nl/actueel/nieuws/2020/07/13/coronawet-ingediend-bij-tweede-kamer ).The Act will be discussed in parliament after the summer break.
The government organized an evaluation of the coronavirus measures so far (up to 1 September 2020), with over 100 experts from various backgrounds sharing their advice on the preventive measures. The government summarised the advice in three broad lessons learned:
1) Have a good overview: large scale testing and tracing helps with detecting outbreaks. Test capacity should be increased and the corona dashboard should improve its comprehensiveness by including local and regional information.
2) Targeted measures: as more is known about where the virus outbreaks are and what the source of the outbreak is, more targeted measures can be taken. This will help limit the negative economic and societal effects of the pandemic by taking measures only where the virus outbreaks are found. Special attention should be paid to clearly explaining the differences in regional measures.
3) Stamina, together: attention should focus on vulnerable groups, care professionals and the work force who are affected by the measures. Understandable communication of the measures targeted to different groups (also those who do not visit mainstream media) remains necessary. People should be informed that they can go to regular medical care and do not have to avoid this in the fear of contracting the virus or overburdening the care sector (https://www.rijksoverheid.nl/onderwerpen/coronavirus-covid-19/documenten/kamerstukken/2020/09/01/kamerbrief-over-lessons-learned-covid-19).
As of 25 September, some tasks have shifted from the Minister of Health to the Secretaries of State. As a result, the Minister of Health will have more available time to combat COVID-19 without compromising the attention towards ongoing health issues. One of the Secretaries of State will take over the policy areas of care for the disabled, administrative pressures and workforce issues in healthcare. The other one will take over youth healthcare and child abuse. In addition to the coronavirus, the Minister will remain responsible for care for the elderly, informal care, home nursing care, medical-ethical issues and procurement in the social domain. The shift of tasks will remain valid until the end of the mandate of the government (spring next year) (https://www.rijksoverheid.nl/actueel/nieuws/2020/09/25/herschikking-takenpakket-bewindspersonen-ministerie-van-vws).
In mid-October 2020, the Government published a guideline on which measures would be applicable for which infection rate level. (https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/publicaties/2020/10/15/risiconiveaus-en-maatregelen-covid-19-engels/RoutekrtPubliek_EN_03.pdf). The measures at present (October 2020) are somewhere in between those of risk level “severe” and “lock down”
From 1 December 2020, the temporary Act Measures COVID-19 will come into force. The Act can be prolonged by three months whenever deemed necessary (the parliament has to agree with the prolongation) and can be stopped at any moment if no longer necessary. The Act will replace the regional “emergency decrees” with a national regulation. The Act operates via Ministerial Decisions. For the introduction of a new measure, first several societal organisations will be consulted, such as the police, the Public Prosecution Department and several umbrella organisations, such as those of education, sports and health care. After this consultation, the Cabinet will make a decision. The parliament will have a week to discuss the measure and may vote if deemed necessary. All the basic measures that apply now, such as keeping 1.5 meter distance, are included in the Act (https://www.rijksoverheid.nl/onderwerpen/coronavirus-covid-19/documenten/regelingen/2020/10/28/tijdelijke-regeling-maatregelen-covid-19).
Challenges for the government with regard to the vaccination rollout
The data system of the public health services that is used for making appointments for testing appeared to be not compliant with GDPR. Public health services personnel could download lists with personal data, including the social security number, of Dutch inhabitants and sell the data. People have been arrested for this and the public health services are working on a system with a higher security level. This was reported in January 2021, but insiders told the newspapers that the situation was known to be unsafe already for months.
Furthermore, the limited availability of vaccines prompted the government to adjust the vaccination scheme several times and they had to deal with pressure from representatives from the healthcare sector and other groups in society (such as teachers) that requested priority in vaccination (for more details, please see Section 3.1).