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
MEASURES INTRODUCED IN 2021
COVID-19 vaccination is part of the national vaccination programme in Norway. National guidelines for COVID-19 vaccination are published by the NIPH and have been available online since December 7 (https://www.fhi.no/nettpub/koronavaksinasjonsveilederen-for-kommuner-og-helseforetak/). The guidelines provide information on the overall strategy, the COVID-19 vaccination programme (English version available here https://www.fhi.no/en/id/vaccines/coronavirus-immunisation-programme/), information on the various roles and responsibilities for all stakeholders (national agencies, regions, municipalities etc.), distribution of vaccines, monitoring of vaccination as well as reporting of adverse events. COVID-19 vaccinations are administered either by the municipalities (general population) or by the hospitals (employees).
How is Norway distributing and administering vaccines?
The Directorate of Health is responsible for distribution of necessary material/equipment to all the municipalities, including what is necessary for transport (incl. transport of vaccine coolers) and storage (incl. in the municipalities). Information on equipment, use and user manuals for coolers are available in the National COVID guidelines issued by the Directorate
The Norwegian Institute of Health is responsible for receiving, stocking and distribution of the vaccines. Vaccines are distributed to one site in each municipality. Municipalities are responsible for the distribution within its geographical area and are free to decide on the organisation of vaccination locally, incl. the partners they will involve. Responsibilities of the municipalities with regards to the vaccination planning are described in detail in the COVID-19 vaccination guidelines.
The municipalities have to organise and plan the administration of vaccines in much detail, as vaccines expire after only 3-5 days after delivery. The municipalities are responsible for offering coronavirus vaccination to high risk residents. GPs (private practitioners contracted by the municipalities) are central in identifying people in the risk groups eligible for vaccination and may also partake in the administration of the vaccines. Private providers administering vaccines are contracted by the municipalities.
Administration of vaccines to patients (jabs) are regulated by the Act of Health Personnel. Physicians and nurses are deemed competent to perform vaccinations. They might delegate it to other health personnel with sufficient training. The ultimate responsibility remains with the health personnel in charge.
Vaccination of the Norwegian population started the second week of January. Due to limited supply of vaccines, the NIPH gave priority to ensure everybody who received a vaccine would receive their second dose. The vaccination strategy is expected to be a bit slower in the beginning, but more controlled and would ensure a better overall result. As the level of COVID is fairly low it was deemed a safe approach.
Higher risks groups are vaccinated first, with the order of priority set as follows:
1. Residents in nursing homes
2. People aged 85 years and above
3. People aged 75-84 years
4. People aged 65-74 years; people between 18 and 64 years with diseases/conditions at high risk of a severe disease course (marked with * in the list below); adolescents 16-17 years (the risk of severe COVID-19 in this age group is low, even with chronic underlying diseases; however, it is still possible for prioritise vaccination of adolescents who have a high risk of severe disease course - they can be offered the BioNTech and Pfizer vaccine, which is approved for use from the age of 16 years.)
5. People aged 55-64 years with underlying diseases/conditions (marked with * in the list of risk groups below)
6. People aged 45-54 years with underlying diseases/conditions
7. People aged 18-44 years with underlying diseases/conditions
8. People aged 55-64 years
9. People aged 45-54 years
People with the following diseases/conditions are defined as medical risk groups: Organ transplant*,
Immunodeficiency*; Hematologic (blood) cancer in the last 5 years*; Other active cancer, ongoing or recently finished treatment for cancer (especially immunosuppressive therapy, radiation therapy to the lungs or chemotherapy)*; Neurological or muscular disease with impaired coughing strength or lung function (e.g., ALS, Downs Syndrome)*; Chronic kidney disease or significantly impaired renal function; Chronic liver disease or significantly impaired liver function; Immunosuppressive therapy, e.g. with autoimmune diseases; Diabetes; Chronic lung disease, including cystic fibrosis and severe asthma that has required the use of high-dose inhaled steroids or steroid tablets during the last year; Obesity with body mass index (BMI) of ≥ 35 kg/m2 or higher; Dementia; Chronic cardiovascular disease (except high blood pressure); Stroke. Other serious and / or chronic diseases not mentioned in the list above may also increase the risk of serious illness and death from COVID-19. This should be assessed individually by a doctor. Diseases/ conditions marked with * can give a high risk for a severe disease course and death among younger people.
The initial prioritisation included only people/patients in the risk group, not health personnel, but within a very short time it was extended to include some health personnel. Municipalities may use up until 20% of their available vaccines for vaccinating health personnel in the primary health service and can vaccinate them in parallel with the various medical priority categories. Selection of health personnel is made according to the same criteria that were defined in January 2021: health personnel providing essential health services, which are critical for the health facility where they work and are difficult to replace/substitute, and health personnel working with patients. In addition, a total of 30,000 doses, which is enough to fully vaccinate 15,000 health workers, have been prioritized for the specialist health service.
Following vaccines have been approved in Norway:
Comirnaty - BioNTech & Pfizer - conditional approval 21.12.2020
Moderna - Moderna - conditional approval 06.01.2021
Vaxzevria - AstraZeneca - conditional approval 29.01.2021 paused 11.03.2021
Janssen - Jansen-Cilag International NV - conditional approval 11.03.2021 but later halted.
Vaccine coverage and access
The government has decided that the vaccines and vaccination within the Coronavirus Immunisation Programme are free for everyone in the recommended groups who lives in Norway, including foreign nationals. This does not apply to Norwegian citizens living abroad.
Due to limited availability, vaccination will be initially available to priority groups. The Government determines priority groups on the advice of the Norwegian Institute of Public Health. Older people, medical risk groups and healthcare professionals are currently given priority. The strategy is to ensure a fair geographical distribution of vaccine doses across the country. The vaccine is mainly distributed according to how many people there are in the relevant risk groups in each municipality, with a dynamic order of priority, meaning that the order can be adjusted according to the infection situation and decisions by the Government (https://www.fhi.no/en/id/vaccines/coronavirus-immunisation-programme/coronavirus-vaccine/).
As of February 15, it has not yet been decided if the coronavirus vaccine will be offered to healthy people aged 18-44 years who are not in the prioritised groups.
Several newspapers have published reports about older people not receiving information on when and how to get their first vaccines. This might be due to differences in the communication strategies across the municipalities. In some municipalities the GPs have been calling patients and giving them information on the vaccination process; in others, eligible populations have been contacted via text messages. The latter have been reported to be inefficient and alienating.
As of April 20, a total of 1,142,793 people have received the first dose of COVID-19 vaccination, and 304, 512 were fully vaccinated (two doses).
MEASURES TAKEN IN 2020
To ensure safe and sufficient access to health services a series of measures has been taken. Patients with symptoms were advised not to report at their GP office directly, but to call first. If necessary, they will be referred to a test offered in the community, outside the GP office. Follow up by the local health services has varied, with some patients being called on a daily basis, while others not receiving any follow up and calling emergency services after becoming severely ill and needing acute hospitalization. People in long-term care nursing homes were advised to be treated there and avoid being admitted to hospitals.
If hospitalization is considered necessary patients should as far as this is possible receive treatment at their local hospital. People requiring more specialist care should be referred to the appropriate level of care. A process of so-called reverse triage started on initiated 12 March. Elective care (in- and outpatient) has been reduced to an absolute minimum:
- only necessary treatment, including acute and emergency care, treatment for cancer or other conditions for which it is not considered advisable to postpone treatment, can be offered;
- elective treatment involving respiratory equipment or treatment that might require intensive care should be reconsidered and only performed if necessary;
- all cancer screenings has been postponed;
- access to intensive care must be planned locally.
Patients’ right to choose hospital has been suspended from 27 March until 27 May, with the exemption of psychiatric care, substance abuse as well as intensive rehabilitation care for children and patients already undergoing treatment in private hospitals.
Hospitals were advised to start reopening for elective care from 14 April.
According to the assessment of risk and responses to the COVID-19 pandemic of the Norwegian Institute of Public Health (NIPH) from the 5th of May, hospitals must be prepared for the full onset (stage 3) of the pandemic. The current situation in Norway on the whole is classified as stage 2 of the pandemic, whereas some areas of Norway are classified as stage 1. Municipalities and hospitals should continue to prepare for a pandemic situation that will last about a year and in stage 3 may have 1700-4500 patients hospitalised, with 600-1200 of them in intensive care units.
On 15 May the Directorate of Health (DoH) issued advice to the municipalities to maintain or reopen School Health Services and Maternity and Child Health Care Centres.
From 19 May dental care services could reopen if adherence to the guidelines for infection control in dental care is maintained. For patient with COVID-19 or with suspected infection, treatment should be postponed or referred to specific clinics with preparedness measures in place.
On 26 May the Parliament approved a temporary legislation amending the Health Preparedness Act. The stated aim of this Act was to ensure control of resources but meant limiting patient rights to choose hospital and to waiting time guarantees. Through the amendment, the Ministry has reinstated patient rights to be informed about whether they are eligible for elective care within 10 days of referral as well as the right to choose hospital for elective treatment. The legislation is valid until January 1, 2021 and supersedes previous restrictions, i.e. restrictions imposed by the Act on the control of communicable diseases and further restrictions introduced by the Coronavirus Act, which were valid until 27 May. Temporary suspension of patient rights is detailed in regulations valid until 1 October 2020. Currently there are no legally binding rights relating to the limitation of waiting time.
The Government has proposed to prolong the temporary legislation amending the Health Preparedness Act. The stated aim of this Act was to ensure control of resources but meant limiting patient rights to choose hospital and to waiting time guarantees. The temporary amendment is to be valid until the 1st of June 2021.
From 15 December the Directorate of Health has started the distribution of equipment for vaccination to all the municipalities in Norway. Vaccines will be distributed to all municipalities in a proportionate manner. The NIPH ais responsible for ensuring warehouse storage and distribution of vaccines, as well as developing national guidelines for how to distribute and prioritize vaccination. Municipalities are responsible for managing the vaccination.