Weekly Briefing, Vol. 27, No. 3 (Sl), March 2020
Covid-19 epidemics reveals the weak points of Slovenian health care system and related systems
Summary
The sudden onset of the Covid-19 pandemic in Slovenia in the beginning of March, following a large-scale epidemic in the neighbouring Italy, caused a great shock to the health care institutions and related structures, both in the private and public sector. After the initial struggle with the supply of protective gear and the scare about the lack of intensive care equipment, other positive and negative characteristics of the health care systems were revealed. The shock overtook other related systems as well, most notably the nursing homes, and caused a debate about the functioning of the health system during and after the pandemic.
Background: Onset of Coronavirus pandemic in Slovenia
After the epidemic of Covid-19 started spreading in North Italy in the second half of February, both the institutions and the general public in Slovenia started worrying about the spread of the virus over the western border with Italy, especially due to the fact that one of the worse hit regions, Veneto, is very close to Slovenia. The initial testings of suspected cases, however, were continuously negative until the beginning of March. Although the first identified case on March the 4th was a man who came back ill from an organized trip to Morocco and several other people from the same group subsequently tested positive for coronavirus, most of the early cases were linked to people who spent their winter holidays in the ski resorts of Northern Italy. Unfortunately, the winter school holidays in Slovenia overlapped with the initial phase of mostly undetected spread of SARS-CoV-2 in Italy. In the following week the first cases were identified, and although secondary infections were identified, the virus has not yet started spreading in the population. Bigger public events were forbidden (over 100 people in closed spaces, over 500 in open spaces). This period ended by March 11 (57 cases tested positive by that time), when the spread of disease was detected in schools and the closing of all school institutions was announced for the following Monday, March 16. All cultural institutions closed down as well. On Saturday March 13 a new government is sworn and makes a lot of effort to demonstrate its efforts to fight the virus with greater vigilance, changing a number of systems that were put in place by the previous government in the initial phase of the epidemic, including the way it cooperates with the National Institute for Public Health and the way it communicates to the media and general public. “Crisis Headquarters” are established (and abolished ten days later) and many strict measures put in place in the next few days, including the stopping of all public transport, closing of most of the shops, restaurants and bars on March 16 and the lockdown of public life on March 20.
Lack of protective gear and medical equipment
One of the first critical problems to address was a severe lack of protective gear and intensive care medical equipment. Already in February, but especially after the situation got worse in Italy, medical institutions started issuing warnings about insufficient supplies of medical protective gear for the medical workers, especially FFP masks, goggles and gowns, but were unable to obtain more due to the interruptions in supply chains. The demands to get the supplies from the national Agency for Commodity Reserves could only be answered when the epidemic was officially proclaimed on March 12, but it was evident that even those supplies could run out very soon. With a lot of public debate on the responsibility for both the lack of reserves and the inability to procure new supplies, the new government tried to address this issue by ordering larger supplies from several companies, but one of those, the order of 3.8 million masks, failed due to a fraud (with the details of this case still being examined). Help also came in the form of donations, many of those from Chinese companies, the biggest so far from Alibaba, negotiated through Aleksander Čeferin, Slovenian president of UEFA (Union of European Football Associations). After the epidemic spread in Slovenia, the dire need for protective medical equipment also opened space for corruption, especially due to the preventive measure according to which these could only be purchased through a Slovenia based company. One of the companies chosen for the import of masks was found to be personally linked to the Minister of Defence, another was personally linked to the Minister of Economic development (the ministry which oversees the Agency of for Commodity Reserves). Both cases are currently under the investigation of the anti-corruption commission. The situation in Italy, where intensive care units have to struggle with a lack of ventilators for treating the worst cases of Covid-19, also brought the fears about the lack of those in Slovenia. With an estimate of only 168 being available (and some also needed for other intensive care patients) this might turn out to be the greatest liability of Slovenian medical system in the time of the pandemic. Fortunately, several donations followed (by Velenje Chinese company Hisense, Telekom etc.) which will help secure the most urgent needs of the intensive care units in the country.
Spread of the pandemic into the nursing homes
The fact that the new SARS-CoV-2 is disproportionately dangerous for the elderly people, especially those over 80 years old, makes the nursing homes the most vulnerable part of the society at large. In the early phase of the epidemic, a nursing home in Metlika was infected by a medical worker who wnet back to work after returnin from holidays in Italy but then fell ill and tested positive for the virus. He was initially said to be in contact with 12 residents of the nursing home, but the disease spread quickly and eventually almost 40 residents and 10 workers fell ill and 5 of the infected passed away so far. This then developed in a local cluster in the South-East of Slovenia, where the two neighbouring municipalities of Metlika and Semič are among the worst hit areas in Slovenia (currently with 703 and 182 infected per 100,000 people respectively). Similar cases happened in other parts of Slovenia, most notably in a nursing home in Šmarje pri Jelšah, the worst hit municipality in Slovenia (currently with 1498 infected per 100,000 people). The third such cluster developed in Ljutomer, where more than a half of the residents were infected over a period of two weeks. The advice by the state authorities was to treat most of the ill in the facilities themselves, apart from those that need intensive care that the facilities could not provide. Additional advice by the ministry of health after the spread in the nursing homes started intensifying, was to cordon the residents into three groups, infected, suspected and healthy, keeping them completely apart from each other and also diving the staff that works with one of those groups only. With the spread of the disease in the nursing home continuing, these two measures were criticized by many, especially the staff of the nursing homes, who claimed that neither the staff nor the facilities were suited for such tasks and that the spreading of the disease is a result of this. Additionally, the system of cordoning the residents proved to be problematic due to the lack of frequent testing, false negative testing and the fact that the contagiousness is possible also with asymptomatic patients.
Conclusion
The spread of Covid-19 from the badly infected regions of Italy to Slovenia caught many systems in state unprepared for the epidemics of such proportions. The fear of having a system breakdown such as the one that happened in Lombardy, showed a dire need for a bigger and more stable supply of medical protective gear and intensive care instruments. The first attempts to secure those, however, also revealed some corruption weak points and resulted in several cases of alleged corruption now being investigated by the relevant state organs. On the other hand, the epidemic also showed some weaknesses in the system of nursing homes, where a number of them became clusters of the epidemic, a situation that was worsened by state regulations forcing these institutions to struggle with the spread on their own without having the sufficient equipment, resources or personnel to do so. The consequences of these two issues might hopefully be that in future the planning for such emergencies becomes more comprehensive and inclusive on the national and the regional level.