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
The country is working hard now to ensure its hospitalization surge capacity with the necessary personnel is in place, in case of larger community-based transmission. The National Infectious Disease Clinic (Clinic for Infectious Diseases and Febrile States) in Skopje is the designated reference and referral clinic for care of patients with COVID-19. If needed, the whole capacity of the National Infectious Disease Clinic (beds and human resources) will be shifted to COVID-19, although nurses will need specific training to work in intensive care units and management of severe cases. There are other infectious disease wards in the hospitals of Debar, Kumanovo, Shtip and Gostivar. On 30 March, the Ministry of Health began working with the military to establish a mobile hospital, increasing capacity by an additional 130 beds. This field hospital with 130 beds is being set up next to the Infectious Diseases Clinic in Skopje and is meant to be used if the coronavirus epidemic escalates. Military teams helped clear out the area and will help set up the hospital. North Macedonia has now over 200 diagnosed patients, several dozens of patients require constant assisted care.
Assisted ventilation is available in the ICU of the National Infectious Disease Clinic with only 6 assisted ventilators, but additional capacities will be needed in case of an increased number of COVID-19 cases.
The Minister of Health announced that there are 120 ventilators in the country, 90 of which are in facilities in Skopje. Not all ventilators however would be compatible with COVID19 case management of Severe Respiratory Distress Syndrome.
The government has turned to the private sector to reinforce its medical response capacity. The private health care institutions having intensive care and treatment units will provide such services for COVID-19 patients upon request by the Ministry of Health. For this purpose, the Health Insurance Fund will conclude agreements with these institutions, which will determine the scope and type of services that these private health care institutions will be providing for the duration of the state of emergency.
Since 29 March, the Ministry of Health is working with the military support to raise a mobile hospital increasing the capacity with additional 130 beds. This field hospital with 130 beds is being set up next to the Infectious Diseases Clinic in Skopje, meant to be used as the coronavirus epidemic escalates. Military teams helped clear out the area and will help set up the hospital.
On 30 March 2020, the Minister of Health announced the procurement of 25 ventilators by UNOPS with Norway funds as well as 30 ventilators by UNDP with EU funds. It is estimated that at least 50 more ventilators would be needed during the crisis. He announced the arrival soon of 500,000 masks and 20,000 lab tests. WHO is additionally procuring 5000 lab kits.
On 3 April 2020, the Government adopted the Decree for the emergency procurement of 200 ventilators.
As of 5 April 2020, two new COVID-19 treatment centres had been established in the 8th September hospital in Skopje and in the hospital in Bitola, increasing overall hospitalization capacity.
With WHO/USAID support, the health emergency operations room at the Ministry of Health is now equipped and functional with new premises, refurbishing and IT equipment.
On 14 April 2020, the health authorities announced that the procurement procedure for respirators has been completed. Part of the respirators will arrive in the country over the next 7 days and the rest in the next 30 days.
As of 24 April 2020 WHO had donated PPE equipment to two specialized university clinics in Skopje – the Clinic for Mxillofacial surgery, and the Clinic for Dentistry.
The government has annulled the procurement for 31 mechanical ventilators, after the contracted companies notified that they cannot deliver the ventilators by the required deadline. The contract is being rescinded and a new attempt at procurement will be made. North Macedonia tried to purchase the respirators from Brazil, Turkey and Italy but all those attempts failed, given the global situation with respirators available and the EU exports ban – 27 April 2020.
Ventilators are an important part of the care response to severe COVID19 and MOH is working on their procurement announcing the cost of 750,000 EUROs for 31 respirators to be delivered within one month, from Japan and Germany. The company "DTU Sonics Anastasia DOOEL" is the winner of the tender and should deliver 6 respirators within 10 days. Earlier procurement of 14 respirators is delayed and still awaited by end of the month. This is in addition to EU assistance promise to deliver 12 respirators and 5,000 protective masks, which are intended for the Clinic for Infectious Diseases and the hospital "September 8".
The country has secured 50 respirators through the World Bank loan, which have been provided by UNDP at the most favourable prices. The respirators are expected to arrive in June. A total of 70 respirators has been secured, including the respirators from the EU. According to the Ministry of Health’s assessment, the total number of respirators that the country would have at its disposal in June would be sufficient for the needs of the clinics.
The modular hospital next to the Clinic for Infectious Diseases has been set up, doubling the capacities of the Clinic. With support from the Swiss Embassy, the Ministry of Health has procured and installed “prefabricated modules” that accommodate hospital beds, outpatients and triage area, staff rooms, wardrobes and meeting rooms. The whole structure is connected with the Clinic for Infectious Diseases and it will be equipped with the necessary non-medical equipment.
A new road has been opened between the Surgical Clinic and the Dental Clinic.
Two new entrances of the Clinical Centre have also been opened, one new one which will lead directly to the Emergency Surgery Centre and another entrance and exit at the Clinic for Infectious Diseases where the mobile hospital is located.
A new modular hospital was set up next to the Clinic for Infectious Diseases (CID) as of 7 May 2020, with financial support from the Swiss Embassy. This allows doubling the capacities of the Clinic for COVID-19. It took two weeks to set it up as a COVID-19 centre and in the future it will be used as the Clinic’s emergency centre, where patients will undergo a triage and be referred to services according to their health condition. It is a facility of more than 1000 square metres with day care, emergency, and triage rooms that are functionally organized according to specific protocols and paths for the personnel and the patients.
Twenty monitors, 25,000 N95 masks, 100,000 surgical masks, 750,000 pairs of gloves, 10,000 goggles, which are part of the EU assistance, have arrived in the country.
Reorganization of the medical campus in Skopje:
A separate entrance for the emergency medical service to the Clinical Center is now functional and the parking capacity has been tripled as of 20 May 2020. This is meant to reduce traffic congestion and to provide for easier movement of patients and vehicles.
It was announced on 20 May 2020 that the mobile hospital that was recently installed at the Infectious Diseases Clinic in Skopje will be dismantled and located in the Ilinden barracks, since the number of COVID-19 patients did not exceed the capacity of the Clinic. The mobile hospital was donated by Norway, has a capacity of 130 beds and complete equipment, but no patients were accommodated in it. Since the beginning of the epidemic in the country, the existing hospital facilities for the hospitalization of patients with COVID-19 have been filled only to 10%.
The Institute of Transfusion Medicine acquired new equipment for the separation of plasma and platelets, which is also used for the treatment by COVID-19 convalescent plasma from healthy donors who recovered from Coronavirus.
Despite the increase of COVID-19 cases, there are enough beds in health facilities, as only 14% of COVID-19 patients are hospitalized and 86% are asymptomatic or have a mild clinical manifestation. As of 16 June 2020, a total of 318 COVID-19 patients were hospitalized in the infectious departments throughout the country.
As of 16 June 2020, the installed hospital right next to the Clinic for Infectious Diseases had 70 beds, none of which were occupied, the 8 September Hospital had 113 occupied beds out of 400 and at the Clinic for Infectious Diseases 95 patients were hospitalized, and no new patients were hospitalized in the past 24 hours. The Clinical Hospital in Bitola was fully occupied, one-third of the Ohrid Hospital and half of the capacities in Clinical Hospitals in Tetovo and Shtip were occupied. The Kavadarci Hospital was completely available, and it can be used as a regional COVID-19 center.
As of 16 June 2020, at the Clinic for Infectious Diseases, 37 patients were on oxygen support and no patients were on respirators. At 8 September Hospital, 10 patients were on respirators and 21 patients had severe clinical manifestations.
The Government adopted a Decree allowing the private hospitals to hospitalize and treat COVID-19 patients. The private hospitals “Zan Mitrev”, “Sistina” and “Remedika” will be involved in the treatment of COVID-19 patients.
The installed hospital next to the Clinic for Infectious Disease is operational – as of 23 June 2020, 3 patients were hospitalized there. The hospital has a capacity of 75 beds in total.
The Prilep General Hospital has received new equipment, the gynecology-obstetrics department and the first aid stations have been refurbished, and an emergency department has opened.
As of 23 June it is reported that the Institute of Respiratory Diseases in Children-Kozle is admitting adult COVID-19 patients. The hospital has about 60 beds to treat adult COVID-19 patients and 15 beds for children with suspected or confirmed COVID-19. Patients with mild and moderate infection are to be admitted. Internist and infectious disease teams, doctors, and nurses from both the Clinic for Infectious Diseases and other hospitals in the country will be engaged in the hospital. Since the start of pandemic in the country, the Institute of Respiratory Diseases in Children-Kozle has been designated to treat children with suspected or confirmed COVID-19.
The increasing number of diagnosed and hospitalized COVID-19 patients has delayed the return to normal functioning of the public health facilities. However, only non-urgent operations are delayed: emergency operations are being conducted.
COVID-19 Hospital Admissions: During 22-23 June, 9 patients are admitted to the Clinic for Infectious Diseases where a total of 109 patients are hospitalized – of which 46 are on oxygen support and no patients are on a ventilator. 13 patients are hospitalized in the installed hospital and one adult and 2 children patients in the Kozle Hospital. In the 8 September Hospital, 13 patients are admitted and a total of 127 patients are hospitalized there – of which 7 patients are on a respirator. 31 patients are hospitalized in the Clinical Hospital in Bitola and 20 patients in Shtip. 85 confirmed and suspect patients are hospitalized in the hospitals in Tetovo, Ohrid, Veles, Kumanovo and Prilep. Additional patients could potentially be hospitalized in Bitola (5 beds and potentially more floors could be designated for COVID-19 patients), Ohrid (9 beds), Kumanovo (9 beds), Gostivar (9 beds) and Shtip (12 beds).
An oxygen support system is being installed in the new clinic next to the Clinic for Infectious Disease, and will be ready by 2 July 2020.
COVID-19 Hospital Admissions: As of 20 June 2020, 92 patients are hospitalized at the Clinic for Infectious Diseases of which 45 are on oxygen support and no patients are on a respirator. There are 20 adult COVID-19 patients, 2 children COVID-19 patients and 4 with COVID-19 symptoms hospitalized in Kozle Hospital. There are 136 patients hospitalized in 8 September Hospital of which 11 are on respirators. There are also 41 patients hospitalized in the Hospital in Bitola, and 32 in Shtip. In total 78 patients (confirmed and suspect cases) are hospitalized at the infectious diseases department in Tetovo, Ohrid, Veles, Kumanovo and Prilep.
Supplies and equipment: WHO has organized supply lists for the Ministry of Health covering 4 institutions dealing with COVID-19 to be submitted with the MOH to partners for funding through the secretariat for European Union Accession.