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
At the end of April rationing has been lifted for certain pharmaceuticals related to the treatment of diabetes (types 1 and 2).
On 8 May the Norwegian Medicines Agency (NoMA) announced new measures to ensure access to generic pharmaceuticals during the pandemic. Distributors of generic pharmaceuticals may now apply to the NoMA for permission to import and sell pharmaceuticals which do not have packaging intended for the Norwegian market (i.e. lack labels and leaflets in Norwegian).
On the same day, the Norwegian Health Authorities decided to increase prices of all generic drugs covered by the Norwegian Health Economics Administration (Helfo) by 15% for the period from 15 May to 15 August in order to secure supplies. The implementation of this measures is dependent on the wholesalers agreeing to the change in prices as they hold contracts with the producers. From 15 August 2020 all previously stepped-up prices will return to the same level as before 15 May 2020. For some drugs, there will be changes for the maximum price per pack.
On 19 May the NoMA lifted rationing for oxazepam, which is used for the treatment of anxiety and insomnia.
On 25 May dentist were allowed to reopen for regular businesses as long as they adhere to guidelines for infection control.
On 15 June the NoMA lifted rationing of azitromycin (antibiotics), prednisolone (inflammatory conditions) and hydroksyklorokin (treatment of malaria), the rationing of over-the-counter medicine was also lifted.
From 17 June NoMA introduced rationing as well as limitation on the export of dexamethasone (anti-inflammatory medication).
On 22 September infection control guidelines were updated for oral healthcare. Patients in quarantine who require health care may seek help at designated preparedness facilities. Dentist offices are essentially back to regular activity.
On 23 September the NIPH published new guidelines for rationing the yearly vaccination against seasonal flu. Before 1 December only patients above 65 years of age, patients in residential or nursing homes, patients with chronic conditions, healthcare personnel who come into direct patient contact and the next of kin of immunosuppressive patients are eligible for vaccination.
On 24 September it was announced that the temporary national system for reporting, allocation and distribution of PPE will not be prolonged into 2021. The responsibility of procurement and distribution of PPE will go back to the municipalities from 1 January.
The total number of hospital beds in the country is approximately 17,000 (2018 data) and bed occupancy is high. Specialist care is concentrated in urban areas, with a relatively low number of acute hospital beds (3.2 per 100,000 inhabitants in 2017). The national capacity for intensive care unit (ICU) beds is 289 beds but according to pandemic preparedness plans this can be increased to 742 and even to 925 beds in extreme situations. Concerns about hospital capacity resulted in the government requesting that the hospitals postpone non-urgent elective treatment, and redeploy personnel to work with COVID-19 patients.
According to estimates from the Norwegian Institute of Public Health (NIPH), a peak in the second wave of infections could require about 1,200 ICU beds, and the Regional Health Authorities (RHAs) were therefore asked to prepare for such a scenario. On April 15th the RHAs provided detailed contingency plans on how to increase the ICU capacity to 1,200 beds, but underlined that such a capacity only can be sustained for a short period of time. The main limitations were the availability of ventilators and ICU staff (https://www.helse-sorost.no/arrangementer/ekstraordinert-styremote-15-april-2020-2020-04-15).
The peak of hospital admissions was reached 1 April with a total of 325 patients admitted to hospitals on that day, whereof 99 were admitted into ICU. On 21 October the total number of COVID-19 patients admitted to hospitals was 36, whereof 2 were admitted into ICU
(https://www.helsedirektoratet.no/statistikk/antall-innlagte-pasienter-pa-sykehus-med-pavist-covid-19). In the period from 8 March until 4 June the number of hospitalized patients was updated 7 days a week. From 5 June it has been updated on working days only (thus excluding Saturdays and Sundays).
In Oslo, where the infection rate is the highest in the country, on 23-27 March, seven so-called ‘fever clinics’ were opened. They may receive patients referred by the GPs or by the emergency out-of-hours clinics.
Norway has a network of 21 clinical microbiology labs. The majority of these labs are responsible for the clinical–microbiology diagnostics for both primary and specialist care in their vicinity. Of these labs, five are regional labs (two are in the South-Eastern RHA and there is one is in each of the other RHAs). The regional labs are responsible for coordinating the 15 public labs in their region, which are all located at hospitals. In addition, there are two private labs contracted by the RHA’s, Unilab and Fürst, whereof Fürst is the largest. More remote areas that are located further away from laboratories report on delays in the handling of tests.
Two Cobas-6800 testing machines were acquired and have been operating since mid-March (see Section 1.5). Also in mid-March, the Norwegian Institute of Public Health (NIPH) reported an improved access to reagents, which was initially limited. However, it also reported uncertainty regarding future access to personal protective kits and test-taking equipment. In April, a new testing method was launched (see Section 1.5) and preparations for large scale testing have been initiated.
The Directorate of Health (DoH) has also reported a serious deficiency in the availability of personal protective equipment (PPE) in many municipalities as increased demand combined with a decline in supply have resulted in shortages. This has been especially worrisome for personnel working in the emergency rooms who triage patients and for personnel in the intensive care units who require special, high quality face masks (P2/P3 masks). On 3 March the government reached out to the national industry with a request to produce pharmaceuticals and protective gear. There has been a national call for PPE, reaching out to dentists, veterinarians, and other industries to share their equipment.
A national system for reporting, allocation and distribution of PPE has been established to help ensure sufficient access in all municipalities and hospitals. All PPE imported to Norway must undergo testing and needs an approval by the Norwegian Defence Research Establishment (FFI) before it is distributed to the health services. EEA countries, including Norway, have joined the EUs voluntary Joint Procurement Agreement which enables the joint purchase of medical equipment and supplies. Some import restrictions have been lifted to ensure continuity of supply of personal protective equipment (PPE) as well as other potential shortages of healthcare equipment. At the end of April, PPE continues to be rationed at the national level as a precaution to ensure future supply.
These challenges were already on the horizon of the Ministry as the Norwegian Directorate for Civil Protection (DSB) and featured in their 2018 yearly report. In mid-February, the DoH requested a national overview on the protective gear, but few details are available to the public, beside an acknowledgement of serious deficiency of PPE.
A national report on pharmaceutical preparedness from June 2019 also spoke about the challenges and advised on remedial actions (some of which have been implemented). The Norwegian Medicines Agency (NoMA) has reported a shortage of critical pharmaceuticals, including antibiotics and pharmaceuticals to treat COVID-19 in intensive care. There has been hoarding of pharmaceuticals and pharmacies have reported deficiencies (which may necessitate rationing of medicines). In March, the NoMA introduced rationing for several pharmaceuticals.
On 26 March the NoMA signed agreements with the three largest pharmaceutical wholesalers regarding increasing their stocks and requested that they stock up medicines that are critical for the public health service.
The Agency for Hospital Procurement Services and the South-Eastern RHA have been given special mandate to coordinate procurement of personal infection control kits as well as pharmaceuticals.