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
On May 3, following the end of the State of Emergency, the Minister of Health determined that all NHS services should identify and reschedule all elective activity, which had been postponed since March 17. All health care provision should follow strict recommendations to avoid spreading the infection, including use of masks, avoiding peaks of outpatient visits, promote home visits and the use of telemedicine.
Aiming to prepare the response of the NHS during the Winter period, when it is expected that SARS-CoV-2 will circulate together with the flu and other respiratory viruses, the Ministry of Health is preparing a plan to ensure the NHS keeps its health care provision for the population, while still responding to a higher demand of health care due to the Winter season. The Plan will include the expansion of ICU beds, laboratory capacity and anticipation of flu vaccination.
The first version Plan for Fall/Winter 2020/2021 was presented on September 21. The plan lays of 3 main strategic areas (https://www.dgs.pt/documentos-e-publicacoes/plano-da-saude-para-o-outono-inverno-2020-2021-pdf.aspx):
• Response to the seasonal risk, including COVID-19
• Maintaining non-COVID-19 healthcare
• Literacy and communication.
The plan outlines a number of actions to be implemented in each area, including:
• Adapting the circuits dedicated to COVID-19 to all patients with suspected respiratory infection;
• Plan early flu vaccination;
• Strengthening public health response, particularly in dealing with outbreaks;
• Define the national testing strategy for SARS-CoV-2;
• Create a dedicated task-force to coordinate non-COVID-19 healthcare;
• Maximize responses in primary and hospital care;
• Promote ambulatory surgery;
• Define COVID-free hospitals;
• Continue to expand home hospitalization;
• Promote the use of the app StayAway COVID;
• Media dissemination of public health messages.
The Plan has been submitted to the National Health Council, the Social and Economic Council and other partners for further contributions. The consolidated version is expected to be published soon. The Plan will be reassessed regularly.
VACCINE SERVICES AN DELIVERY
The COVID-19 Vaccination Plan was publicly presented on December 3 (https://covid19estamoson.gov.pt/plano-vacinacao-covid-19/). The COVID-19 vaccines will be free and administered by the NHS in several phases, according to age, exposure and risk criteria:
Phase 1 (950,000 people):
-People aged 50 years or older with at least one of the following conditions: cardiac failure; coronary disease, renal failure; COPD or chronic respiratory disease with ventilatory support;
-Residents and workers of nursing homes and similar institutions;
-Patients and workers of long-term care units;
-Healthcare workers directly providing care to patients;
-Workers from military and police forces and critical services.
Phase 2 (1.7 million people):
-People aged 65 years or older with or without chronic conditions;
-People aged between 50 and 64 years with at least one of the following conditions: diabetes; active oncologic disease; chronic renal disease; hepatic failure; obesity (BMI > 35 kg/m2).
-Remaining population living in Portugal (more priority groups will be defined later on).
The government expects to initiate vaccination at the beginning of January 2021 and conclude Phase 2 before the end of June (3.6 million people vaccinated). A dedicated Task-Force was nominate by the Ministry of Health to define the COVID-19 Vaccination Plan and the logistics (https://dre.pt/web/guest/home/-/dre/149707171/details/2/maximized?serie=II&parte_filter=31&dreId=149707145).
COVID-19 vaccination started on December 27 with the first health care workers receiving the 1st dose of the Pfizer vaccine. Until January 25, 263,537 vaccine doses (of both Pfizer and Moderna vaccines) have been administered in Portugal to health care workers, patients and workers in long-term care and the older population and workers in nursing homes, including 31,127 2nd doses.
The COVID-19 vaccination Plan was updated in order to include all people aged 80 and over in the 1st Phase, as well as people with Trisomy 21 (age 16 and over) (https://covid19.min-saude.pt/wp-content/uploads/2021/03/i027259.pdf). On March 29, Portugal had already achieved the goal of having at least 80% of those aged 80 years and over vaccinated with at least 1 dose of the COVID-19 vaccine.
A mass vaccination of teachers (primary schools) and remaining personnel of schools and nurseries took place on the weekend of March 27-28 and will be concluded in the following days (for other school levels). Around 58,000 vaccines were administered to this group on that weekend.
Given the increasing concerns with the safety of COVID-19 Vaccine AstraZeneca®, Portugal suspended the use of the vaccine on March 15, only to restart its use on March 22 (https://covid19.min-saude.pt/wp-content/uploads/2021/03/i027257.pdf). Prior to this, Portugal has limited the use of this vaccine to people below 65 years of age, but that restriction was lifted on 10 March.
Until 28 March, more than 1.6 million doses of vaccine were administered in Portugal, including around 470 000 second doses. Phase 2 of the COVID-19 Vaccination Plan will be in place on April, with the vaccination of all people aged 65-79 years, and also people aged 50-64 years with diabetes, active cancer and chronic kidney disease.
On 16 March, the Ministry of Health determined that all NHS hospitals should postpone elective surgeries and treatments, discharge patients hospitalized for non-clinical reasons, and refer all non-urgent episodes from emergency services to primary health care units. Additionally, non-priority outpatient visits and exams should also be postponed. Primary health care units should reduce their face-to-face consultations as much as possible and be ready to expand schedules for assisting episodes of acute illness. Only immunization programmes and follow-up of pregnancies and patients with decompensated chronic conditions should be maintained as essential activities in primary care. The use of alternative ways of communication between health care workers and patients is strongly encouraged.
Aiming to strengthen human resources in the public sector, the Ministry of Health has also published legislation which simplifies the process of hiring health care workers. NHS institutions are allowed to hire new personnel for a period of four months (https://dre.pt/application/conteudo/130277343). The Directorate-General of Health has issued guidance to health services on management and procedures for several areas that needed to reconfigure services due to the pandemic, including pregnancy and birth, long-term care, patients with chronic kidney disease in need of dialysis, collection of health care waste, etc.