It is sometimes said that generals tend to prepare for the last war. In the case of the coronavirus pandemic, it seems that while the "war" was of the future, preparations were few and far between. Knowing is not enough if one fails to act on that knowledge. The best early warning system is useless if it is not followed by action, Auditor General Janar Holm writes.
Now that the new head of the Health Board Üllar Lanno has taken office, we can hope that the new captain can, in addition to addressing the COVID-19 crisis, catch the fair wind and create a robust system and preparedness for solving new healthcare emergencies in the future. The task of proving the pandemic is real no longer falls on him.
This spring's coronavirus crisis constituted an accident we saw coming. The necessary warnings, many of which were pointed out by the board itself, were there but went unheeded. Different scenarios had been described but were ignored. Legislation was passed, while deadlines therein were allowed to come and go.
Despite assurances from institutions that we were ready to contain a viral outbreak, Estonia entered the crisis with preparedness that existed only on paper. Weaknesses in the healthcare system in terms of crisis readiness had been pointed out by the Government Office's healthcare organization expert group, the National Audit Office (most recently in 2018), the Ministry of Internal Affairs and the Health Board itself.
A Health Board risk analysis from seven years ago considered an epidemic infection situation likely and its consequences severe. The same conclusion was drawn in the board's 2018 risk analysis. Therefore, an extensive infectious disease of epidemic potential was not unimaginable. The only thing that could have been unexpected was that it would start in early 2020.
The Health Board's analysis was accurate also in predicting that the agency would be given tasks they could not possibly hope to accomplish if a nationwide crisis broke out. A medium-sized agency most people usually do not remember exists was suddenly in charge of it all.
The Health Board's crisis regulation management structure and work allocation were approved in 2018. This created round the clock response capacity. At the same time, the board pointed out in its reply to the National Audit Office that it would not be able to man the structure in the case of a protracted crisis.
The Health Board's summer of 2018 crisis analysis highlighted other alarming gaps in capacity. The document revealed that hospitals only had enough personal protective gear stockpiles for initial reaction. There were virtually no healthcare stockpiles, including personal protective gear. Existing supplies had largely expired and their renewal was overlooked.
Laboratories lacked equipment, reference laboratories did not exist. There was no overview of ambulance and hospital capacity, especially as concerned treating dangerous infectious diseases. Allow me to emphasize that all of these assessments came from the Health Board. The journey from having the necessary information to taking action proved too long for the state. Perhaps the problem was that early warning came too early.
It is sometimes said that generals tend to prepare for the last war. In this case, it seems that while the "war" itself was of the future, preparations were few and far between. Repeated trainings were organized and sported strikingly realistic scenarios, but it is becoming increasingly clear that lessons were not learned.
For example, an international medical exercise in Saaremaa in April of 2019 tasked the Health Board with coordinating ambulance teams. The evaluation report points out that despite repeated reminders, the Health Board did not draw up goals in the planning phase and was not aware of its role and responsibility during the exercise.
Another interagency cooperation exercise took place in September of 2019. The report reads that the Health Board's regulatory and supportive role was missed. A recommendation was made following the exercise for the board to have a clear picture of what type of emergency management centers are to be created and where, as well as how agencies involved in providing solutions would communicate on different levels. Also, in terms of the information different management levels are in charge of and need and how it will be ensured.
The problem of lack of clarity in terms of coordination and responsibility in solving healthcare emergencies went beyond the Health Board.
We drew the attention of director general of the Health Board and the health and labor minister to the necessity of creating a crisis management structure that would clearly determine, among other aspects, division of responsibility between the board and the Ministry of Social Affairs in our 2018 crisis preparedness audit.
While the director general approved the crisis management structure and work organization in April of 2018, it did not cover any aspects of cooperation with the ministry.
Our report also pointed out that the Ministry of Social Affairs' crisis work organization directive was outdated and made it impossible to determine the ministry's tasks in a crisis or how it would perform them, including as concerned persons responsible and exchange of information in an emergency. This lack of clarity as concerned the roles of the board and the ministry was visible during the crisis months in spring.
Some of the aforementioned gaps in capacity and problems required money to solve, while some were purely organizational and only needed a decision or coordinated management that, nevertheless, did not follow.
The Emergency Act required plans to be drawn up by July 1, 2019, while the deadline was allowed to come and go. The Health Board started work on plans in 2019 and by the time the crisis started, all they had was an informal work in progress version. That is why we did not have a functional crisis communication plan for emergencies and a resource plan for activities.
Let us move on to the question of stockpiles the very real fear over possible depletion of which took on cinematic proportions. Talk of Estonia lacking healthcare stockpiles to adequately react to crises has been around for years. A Government Office expert group made a proposal for healthcare service providers to have supplies to last 72 hours and the state for at least two months back in 2017.
The 2017 Emergency Act prescribes the creation of national operating stockpiles that would include state-owned or contract-ensured resources for solving emergencies.
According to the law, the government should have approved a corresponding order by July 1, 2018. The stockpiles do not only concern medica emergencies but are necessary for weathering different crises. No such order was approved in time.
The government cannot issue the order before ministers present proposals for compliance in their administrative areas. Unfortunately, the social affairs minister had failed to sum up the needs of their domain and present proposals to the government.
The Ministry of Internal Affairs had to remind the social ministry of its obligation on June 16, 2018, having read the Health Board's risk analysis and its conclusion that Estonia basically lacked medical stockpiles. The reminder was of no use.
There is still no government order for the creation of national stockpiles two years after the Emergency Act deadline. That said, the government has been addressing the problem of stockpiles intensively over the past months and is drawing up operational principles and applications for a stockpiles center. We can hope for a good systemic solution.
One can understand ministries and heads of agencies having reduced motivation to contribute resources and man-hours toward something that might never happen, especially in a situation where both are in short supply even for addressing current matters. Because crisis preparedness or matters of broad-based national defense are not priorities for ministries and seldom make the list of primary political choices, most initiatives are not funded.
What to do? One solution would be to include broad-based national defense as a package in state budget talks and make concrete political decisions annually. We have been able to do that in our preparation for military crises. Preparing for civilian and military crises is equally important, not least because one can turn into the other should unfortunate circumstances coincide.
Societies learn from their own painful experiences. However, was the first wave of the coronavirus crisis painful enough for society as a whole to warrant necessary steps for achieving crisis preparedness? The masks never completely ran out in spring, patients were not treated in hallways, shocking mortality rates that hit many European countries did not reach Estonia.
Let us hope this will not leave us complacent should an epidemic the likes of the Spanish Flu from a century ago arrive. Estonia got lucky and the new head of the Health Board has the opportunity to better prepare us. But let us not bet on luck alone as learning only from one's own mistakes would also be a mistake.
The comment was originally published on the National Audit Office blog.
Editor: Marcus Turovski