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
HOW ARE VACCINES DISTRIBUTED AND ADMINISTERED?
The National Committee for Coordination of Vaccination against SARS-CoV-2 was established in November 2020. It is an inter-ministerial body that is subordinated to the government and managed by a president appointed by the Prime Minister. Its role is to develop the national vaccination strategy and action plan, to organize and coordinate vaccination services, including monitoring of adverse reactions. The vaccination strategy describes the general principles, sets responsibilities, modes of communication, the stages and population categories included, the supply chain and stocks management, vaccine administration and adverse events monitoring.
The responsibility for ensuring the logistics, stocking, supply and human resources is shared by the Ministry of Health, the Ministry of National Defence and the Ministry of Internal Affairs. The Special Telecommunication Service is responsible for the development and maintenance of an electronic platform for online vaccine appointments (https://vaccinare-covid.gov.ro/). Eligible persons may schedule their vaccination appointments either directly or through their family doctors, employers, or via a phone line. They can choose the vaccination centre and the preferred appointment date, but not the vaccine type. The appointment for the 2nd dose is provided automatically through the electronic system. Each vaccination centre notifies the district public health authority about the number of vaccines that are needed for the following three days, based on the vaccination schedules. District public health authorities collate the data from all vaccination centres in their catchment area and submit it to the regional centre responsible for vaccine stocking. From there, the vaccines are distributed to the district public health authorities and then supplied to the local vaccination centres.
The central and regional vaccine stocking centres are able to ensure the required cold chain for each type of vaccine (from -800C to 2-80C). Vaccines requiring storage at -800C are transported to the regional vaccine stocking centres in dry-ice boxes, using GPS and monitoring the temperature during transport. They are distributed in small quantities and stored at standard conditions for a very short time. Vaccines requiring storage at -200C are transported in refrigerator cars, using GPS and monitoring the temperature during transport, to the regional vaccine stocking centres but also directly to the vaccination centres. Vaccines requiring storage at 2-80C are transported with standard methods for transporting bio-pharmaceutical products (refrigerator cars, boxes, etc), with temperature monitoring, to the regional vaccine stocking centres and the vaccination centres or directly to the family physicians. All vaccination centres monitor vaccines utilization, including the number of lost doses.
Vaccination centres are mainly located in hospitals, medical facilities or other available places (sports halls, exhibition areas, etc.) where it is possible to ensure compliance with physical distancing rules. A ministerial order has been issued specifying the organization, functioning and authorization of vaccination centres. There are also mobile vaccination centres and mobile vaccination teams. The legislation also allows for drive-through vaccination centres and vaccination centres to be set up within family physician offices, but these are not functional yet. The order establishes the type and quantity of resources to be used (logistic, medical, administrative), sets guidelines for organizing the flow of people from the entrance area to the post vaccination area where people are observed for immediate adverse events. All needed materials for vaccine administration and first aid devices for managing adverse effects (i.e. special syringes, epinephrine auto injectors) are centrally procured through the National Office for Centralized Procurement. The procurement procedure started even before the delivery of the vaccines. Late adverse events can be reported online on the website of the National Agency for Medicines and Medical Devices. An emergency ordinance provides the legal basis for the payment of re-deployed or newly hired human resources: epidemiologists, family physicians, school physicians, nurses, residents, students.
A special COVID-19 module was created in the National Electronic Vaccination Registry (NEVR) managed by the National Institute of Public Health. Through NEVR, the vaccine stocks, their distribution and utilization (including the number of lost doses), the number of vaccinated persons and the adverse events are monitored. After the vaccine has been administered, the person who received it is issued a vaccination certificate.
Vaccination is financed and conducted solely within the public sector. Vaccination is planned in three stages:
• Stage 1: covering the workforce in the health and social sectors, both public and private; this stage started on 27 December 2020;
• Stage 2: covering the population at high risk (older people, patients with chronic diseases, people with disabilities, the homeless) and the essential services workforce (police, defence, transport, economy, administration, etc); this stage started on 15 January 2021;
• Stage 3: general population.
Due to a measure that was taken following a second fire in one of the COVID-19 hospitals and that was aimed at reducing admissions (see Section 3.2. Managing cases), Stage 2 vaccination of populations outside of the high risk categories was postponed. In order to provide access to vaccines for the essential workers, mobile vaccination teams have been used to reach people in health settings, residential care homes and private homes. In addition, since part of the students returned to face-to-face learning, there are plans to organize vaccination campaigns in schools and on university campuses.
Specific measures have been taken to raise awareness about the benefits of the vaccination. The Ministry of Health published a brochure for family physicians with information on vaccine safety, efficiency, contraindications and adverse effects and the College of Physicians organized a national conference that was broadcast on the national television. Information about vaccines is also communicated via the electronic platform for vaccination scheduling and through meetings of the National Committee for Coordination of Vaccination with representatives of specific groups (e.g. representatives of religious communities).
Any delays in the vaccination campaign so far were due to insufficient availability of vaccines and late deliveries of stocks from the vaccine producers.
VACCINE COVERAGE AND ACCESS
Vaccines are free at the point of care. They are free for everybody, irrespective of whether they are enrolled in the statutory health insurance system and the area of residence. The only conditions for obtaining vaccination are meeting the criteria set out in the vaccination stages (see above) and getting an online appointment. The latter may constitute an access barrier for some people, either because of excessive number of persons trying to make an appointment at the same time or because they are not able to use the internet. For the latter group, appointments can also be done by their family physician, their employer or through a telephone line.
MEASURES INTRODUCED IN 2020
On March 23, all admissions of non-acute cases were banned and medical units were urged to discharge non-acute cases within 48 hours. A week later, the Ministry of Health issued an Order on the Action plan for preparing the hospitals for managing COVID-19 cases. According to this plan:
• Hospitals reduce planned admissions by 80% and outpatient visits by 50% during the State of Emergency; exemptions are made for chronic patients and pregnant women whose survival could be affected by the postponement of necessary treatment or investigation. After the end of the State of Emergency, planned admissions and interventions, and outpatient visits can be performed depending on the local epidemiological situation; hospitals (both public and private) must provide daily reports on the bed occupancy, number of ICU beds and number of beds equipped with functional oxygen/compressed air to the electronic centralized operational coordinating centre of the Ministry of Health (see Section 2.1.);
• Hospitals treating COVID-19 cases were designated as phase I or phase II hospitals. Phase I hospitals are infectious disease hospitals that treat COVID-19 symptomatic patients. Phase II hospitals are other hospitals with intensive care units and ventilation capacity, which will admit COVID-19 patients after capacity at infection disease hospitals has been exceeded;
• Infectious diseases hospitals have a support hospital network coordinated by the district public health authority and district committees for special emergencies. This includes 57 hospitals (full hospitals or separate wards of hospitals), 44 maternities and maternity wards and 60 dialysis centres that will take over the COVID-19 patients who also need other treatments or interventions. In addition, the Nephrology Commission of the Ministry of Health developed a specific treatment methodology for the COVID-19 patients that need dialysis. Some of the support hospitals will take over severe COVID-19 cases when their number will be over the ICU departments of infectious diseases hospitals capacity; depending on the local epidemiological situation, hospitals dealing with COVID-19 cases may also treat non-COVID-19 patients, if they have separate pathways in place for such patients and an approval from the district public health authority; in addition, facilities for isolating asymptomatic patients, or for patients with mild symptoms with no risk factors have been included within the support hospital network - the list of these units in provided by each district public health authority;
• The infectious diseases hospitals and their support hospital network will prepare for treating COVID-19 cases by procuring medical equipment, pharmaceuticals, and PPE, ensuring the workforce availability and training the personnel on the optimal and effective use of PPE and on other measures of limiting COVID-19 transmission; in addition, they have to comply with specific rules regarding pathways and patient flow guidelines, especially with respect to the maternities and dialysis centres.
During the state of emergency, the hospitals administrated by local authorities will be coordinated by the Ministry of Health.
Measures were taken to support vulnerable persons in home isolation, focusing on persons in low socio-economic groups, persons at risk of disease, especially those living in rural areas and Roma ethnic groups. The measures include provision of healthcare services in the community and a food allowance of approximately 7 euros per day. Besides access to regular healthcare services, a community health nurse or a Roma mediator provides services that are aimed at limiting the transmission of COVID-19, including:
• Checking compliance with the isolation measures;
• Monitoring health status, especially for persons not registered with a family doctor;
• Identifying persons who travelled abroad and reporting this to district public health authorities;
• Food and medicine supply;
• Post-discharge healthcare;
• Information and awareness rising on limiting COVID-19 transmission measures.
In June-July, the Ministry of Health has procured 115 million masks to be distributed free of charge to disadvantaged people: families that receive social benefits, pensioners with incomes under the minimum guaranteed pension (146 euros), people with disabilities. It is estimated that 2,300,000 people will benefit from this.
To ensure a sound scientific basis for further planning of services and surveillance measures, the Ministry of Health allocated 1.6 million lei (approx. 330 thousand euros) to fund a serology testing study to be implemented nationwide between June and September 2020 by the National Institute of Public Health.