Public Health Measures Enacted by the Norwegian Political Leadership to Protect the Elderly in Response to the SARS-CoV-2 Pandemic Crisis

SARS-CoV-2, the causative agent of the COVID-19 pandemic, carries a disproportionate risk of infection, disease, morbidity and higher mortality rates in the elderly because of the direct risks caused by their increased vulnerability when considering their latent or indirect risks from sociocultural and demographic factors (Khan et al., 2020; D’Cruz & Banerjee, 2020). Public health measures (such as mask covering, social distancing, vaccination, the duration of quarantine and lockdown, the approach to and frequency for testing, hospital and long-term care visitor policies) and concrete interventions are necessary for reducing fatal consequences for all citizens, including the elderly. Williamson et al. (2021) state that the elderly are clearly among the groups most at risk of serious illness and death from COVID-19. The pandemic and responses to it limit the extent to which the elderly’s voices are heard and restrict the considerable contributions they can make to our global response and recovery.

During the pandemic, it was very important to disseminate the information about public health measures in a comprehensible manner to the entire public. As an example, when Norway enforced a lockdown, 5.4 million text message alerts were sent to its citizens and to 300,000 foreign visitors to inform them about lockdown restrictions (NIPH, 2020); these messages were written in all the local and minority languages. Additionally, all the relevant information about health measures was published online in 44 languages, along with short animated films and picture posters, by the Norwegian Institute of Public Health. The country continued to maintain the lockdown, and every Friday, political leaders, standing a significant distance apart and wearing face masks, held open conferences in professional, clear and calm voices and shared the importance of compliance with the public health measures. In this way, the political leadership of Norway was an example of ‘good practice’ for their citizens. The SARS-CoV-2 pandemic has brought structural and social issues to light, including the erosion of public trust in government and expert advice, which was compounded by a wave of mis- and disinformation (OECD, 2022). As a result of a pandemic’s dynamic nature, complete transparency concerning the potential risks was – and still is – necessary to ensure a clear definition of, and the quality of, the resulting societal and political response (Nicola, 2020). Additionally, Aasland and Braut (2022) stressed that the collaboration and the method and delivery of communication are crucial factors in handling crises such as the SARS-CoV-2 pandemic.

Haslam et al. (2021) focussed on how political leaders mobilise the population and disseminate public health measures. They used the identity leadership approach to explain how leaders can represent and advance the shared interests of group members and create and embed a sense of shared social identity among them. Several researchers emphasised that the states with female governors who issued early stay-at-home orders had fewer SARS-CoV-2-related deaths than those with male governors who issued the same orders. Subsequent qualitative analyses revealed that female governors cultivated more empathy and confidence through their SARS-CoV-2-related briefings than male governors; for example, the female governors forged deeper connections with their constituents by exhibiting empathy and showing compassion in expressions of concern and care for citizens’ welfare (Sergent & Stajkovic, 2020; Aldrich & Lotito, 2020; Bruce et al. 2022). The principal executive authorities at the national level in Norway during the SARS-CoV-2 pandemic crisis were the Ministry of Health and Care Services (national responsibility for health preparedness; declares a health crisis, thus activating roles of other authorities), the Directorate of Health (coordinates mitigation efforts and implements infection control measures) and the Institute of Public Health (monitors the pandemic situation and supervises and advises state and local authorities on infection control). Many of the political leaders in important positions were female – Prime Minister Erna Solberg and the head of the Norwegian Institute of Public Health Camilla Stoltenberg, together with the Divisional Director of Public Health and Prevention by Norwegian Directorate of Health Linda Granlund. Each leader had an important role and responsibility to convey health measures to citizens. As Boin et al. (2013) explained, the leader’s success in crisis situations depends to a great extent on exercising good judgment; further, Sturm et al. (2017, p. 350) stressed that having sound judgment is an important aspect of effective leadership. Norway’s Directorate of Health was given responsibility for coordinating the health-sector response which started on 31st January 2020, and it kept this role into 2021. When the pandemic crisis turned into a full-blown crisis in March 2020, the Directorate temporarily had extraordinarily extensive decision-making responsibilities due to emergency procedures in the Infection Control Act. Out of convenience, 12^th March lockdown decisions were formally enacted by the Directorate, even though the Prime Minister, other government ministers and the Ministry of Health were actively involved in the decision-making process (Askim & Bergström, 2022).

The present article aims to describe the response of the Norwegian political leadership with a focus on the public health measures enacted to protect the elderly during the SARS-CoV-2 pandemic crisis during 2020 and 2021. The following research question was investigated: How did the Norwegian political leadership respond to the SARS-CoV-2 pandemic crisis in protecting the elderly? This research study chose a conceptual framework to contribute to the construction of a theoretical body for the analysis of the character of the political leadership response and the instruments and measures that were used in crisis management.

For a description of Norwegian policy responses, researchers in this study were inspired by and used one part of the Framework for Evaluating COVID-19 Responses according to the OECD Recommendation of the Council on the Governance of Critical Risks (2014). There are three main policy responses that correspond to the major phases of the risk management cycle: (i) pandemic preparedness, (ii) crisis management and (iii) response and recovery (Figure 1.)

Fig. 1:

Before declaring SARS-CoV-2 a pandemic, many countries were assessed via the Global Health Security Index (GHSI) for their preparedness for pandemics (Bell & Nuzzo, 2021). According to a WHO report (2020), the United States of America (US) and the United Kingdom (UK) were identified as the most prepared countries in terms of pandemic preparedness. Prior assessments of countries such as Norway (16th on the GHS Index) are inconsistent with the actual performance during this pandemic. Crisis management is the next major phase in the framework for evaluating; this involves the policies and actions that governments deployed to deal with the crisis once it materialised. Crisis management entails responding appropriately, at the right time and in a coordinated manner across the government. Crisis management also requires clear communication with the public and transparency in decision-making, particularly as large-scale crises can critically impact people’s trust in government (OECD, 2022). Finally, response and recovery policies are aimed at mitigating the impacts of the pandemic and economic crisis on citizens and businesses, additionally supporting economic recovery and reducing welfare losses. These policies include lockdowns and restrictions, e.g., general measures taken in order to limit the spread of the virus, economic and financial support to households, businesses and markets to lessen the impact of the economic downturn, health measures aimed at protecting and treating the population, and social policies aimed at protecting the most vulnerable populations (OECD, 2022). As an example of the differences in health measures instigated to protect citizens during the pandemic crisis, it is useful to point out the mixed messages that arose regarding face coverings; while many countries urged people to use coverings or respirators, the Norwegian Institute of Public Health (NIPH, 2020) did not recommend doing so. This split messaging led to uncertainty and sparked fears regarding which precautions should be implemented.

This study characterises as a descriptive qualitative research design with the aim of communicating and producing organised information concerning the subject investigated. The methods employed here involved bibliographic survey, analysis of public health policy documents, national statistics, international reports and documents from government agencies in Norway. Public health policy documents are defined in this research as written online documents that contain strategies and priorities, define goals and objectives, and are issued by the part of the public administration responsible for the protection of public health against the SARS-CoV-2 pandemic, with a focus on the elderly population. Although several public health documents are aimed at the general population, these health measures were also analysed because they included the elderly population.

According to Bowen (2009), document analysis is a systematic research technique which uses both printed and electronic materials as the source, analysing them in-depth to extract information and indications relative to the study objective. It is important to note that document analysis is a process involving skimming (superficial examination), reading (thorough examination), and interpretation of the content to provide answers to research questions. The data obtained (e.g., excerpts, quotations or passages) were organised into major themes through thematic analysis to develop empirical knowledge (Green & Thorogood, 2018). Data gathering and analysis were conceptually driven and based on the framework illustrated in Figure 2.

Fig. 2:

All data analysed in this report are publicly available; therefore, no ethical approval was required.

This section presents the contingency plan for dealing with the SARS-CoV-2 pandemic. Furthermore, the represented public health measures for residential care services and brief descriptions of the facts about mortality rates in the country concerning the elderly population are reported. It is important to highlight that the structure of the health system is directly connected with the Norwegian public health response to the SARS-CoV-2 pandemic, since the unified public health system contributes to the better emplacement of public health policies in an equitable way. This phenomenon is clearly demonstrated by the epidemiological data concerning the mortality rates of the elderly population.

The contingency plan for dealing with the SARS-CoV-2 pandemic

The Norwegian health system is a decentralised universal health system with a free-of-choice provider financed by taxes, with a predominantly public production of services covering the population in Norway. Physicians are publicly salaried employees. The state is responsible for the provision of specialised care through four regional health authorities, which further control the provision of specialised health services by 27 health enterprises (Martinussen, 2022). The municipal level organises and finances primary healthcare services according to local demand. The central government has overall managerial and financial responsibility for the hospital sector.

The power distribution of these organisations is divided into two levels: a central one and a local and regional one. The central level, or centralised system level, is composed of a government body, represented by the Ministry of Health and Care. This level directs the Norwegian healthcare services through comprehensive legislation, annual budgetary allocations and various governmental institutions such as the Norwegian Directorate of Health and the Norwegian Institute of Public Health. The regional and local level (or the decentralised system level) is represented by the regional and local authorities in the municipalities across the country. This level has the responsibility for primary care in terms of nursing facilities, residential care homes, home care, ambulatory care and general practitioners. In addition, the regional level takes control over the implementation of the national health policies, including the setup, planning, organisation, governance and coordination of all subordinated local health trusts (hospitals) in their region. This way, all the levels are interconnected and work in an interdependent way, and all have the freedom to emplace more specific measures considering the epidemiological, sociocultural and special needs of each region (Øyri & Wiig, 2022).

From the central level perspective, the government’s goals for dealing with the pandemic were to safeguard life and health while keeping society open and allowing the economy to function as normally as possible. Moreover, the government and the public health agencies focussed on maintaining the population’s immunity, keeping the disease burden low, protecting vulnerable groups and prioritising children and young people. These measures were to prepare society in case the situation deteriorated, and in order to maintain this level of preparedness, the government and public health agencies only utilised information and data that are knowledge-based and open in a targeted and coordinated manner. In addition to these internal actions, one of the priority goals going forward is that Norway should further cooperate with global efforts to mitigate the consequences of the pandemic (HOD, 2022). The Norwegian government has also prepared itself for any future pandemic waves until 2023. The government is prepared to decide on the precise steps to be taken based on an overall assessment at the necessary time and when the development of a situation indicates a need for national measures. Decisions must take into consideration the positive and negative societal effects of the pandemic’s development in addition to infection control measures, including health, economic and welfare consequences. As far as possible, affected parties will be given the opportunity to comment on the measures. The assessments behind the decisions are to be published. The plan includes a course of action in the case of a serious new virus variant, which would necessitate prioritising the reduction of infection numbers. In the case of a less serious virus variant, health considerations may indicate extensive infection control measures, while other societal considerations could indicate that very burdensome infection control measures need not be implemented.

According to the documents analysed when assessing measures, the duration of any course of action needs to be considered. The Ministry of Health and Care Services has produced a flow chart for mapping the effects of two alternative strategies in the face of a SARS-CoV-2 pandemic – one strategy using infection control measures to control or kill the infection and the other letting the infection spread through the population. If the costs of infection control measures are greater than the gain, the avoided loss of health by fewer people would deem it economically unprofitable to introduce measures. The most important benefits of introducing the measures are first and foremost the costs avoided, including the societal cost. The flow chart is presented in Figure 3.

Fig. 3:

Assessment of disease burden constitutes a baseline in the assessment of risk as a starting point as to whether measures should be implemented. At this point, the local and regional levels have more freedom to access the data and implement measures recommended by the central level, based on epidemiological criteria. For the assessment of disease burden, there is a need for an overview of the national and local situation, as the assessment must include treatment capacity in both the specialist health service and the municipalities. The capacity of the municipalities can be overwhelmed before the capacity of the specialist health service. Municipalities are responsible for primary care and public health, including general practitioners (GPs), immunisation centres, and long-term care and social services. The vulnerable population evaluated in this article – elderly people – live in their own homes or in nursing facilities and residential care homes throughout the various municipalities. Prevention measures for these citizens, according to the ‘Strategy and Contingency Plan for Handling the COVID-19 Pandemic’ (HOD, 2021), use the following specific management indicators as a basis for assessing risk and the need, if necessary, to implement measures: –

The number of new hospital admissions and number of concurrently admitted patients (total occupancy)

–

The occupancy rate in intensive care units

–

The age distribution of the inpatients

–

The processing capacity in the municipalities (HOD, 2021, p. 19)

The assessment of risk must also be seen in connection with other burdens on the services, such as influenza and other respiratory infections. It must be based on a comprehensive assessment of the total burden on the health service at that time and the development of the epidemic.

The public health professionals and their mutual collaboration with political leaders play an important role in policy development and provide knowledge of health systems, including making recommendations when change is warranted and developing plans to address various societal situations in connection with public health protection. During a pandemic crisis, trust contributes to adherence to health guidelines, such as social distancing and wearing face masks, additionally reducing the spread of misinformation, fostering support for and adherence to the lockdown-encouraged vaccination, and facilitating a greater sense of community (Sibley et al., 2020; Cairney & Wellstead, 2021; Lalot et al., 2022). The main aim of each country’s political leadership during the outbreak of the SARS-CoV-2 pandemic was to bring the pandemic under control as effectively as possible with as little as possible impact on its citizens.

Public health measures for residential care services, the level of restrictions in long-term care and the composition of personnel, professional training and personal protective equipment in different countries at the start of the pandemic all varied; this is also true of the times at which the restrictions were eased and their duration. Norway’s relative success in handling the pandemic during the first year has been attributed to factors such as rapidly implemented containment measures, geographical location, low population density, high levels of trust in government and generous social welfare arrangements (OECD, 2021). Healthcare personnel are mentioned as crucial participants in the containment of the virus. Their willingness to follow and put into effect the necessary measures is crucial to encouraging individuals to implement and adopt the necessary restrictions. In Norway, researchers confirmed that having a permanent, stable staff who do not work in other locations is perhaps the most important improvement that can be made to control infection, and this could reduce mortality (Kirkevold et al. 2020).

Gautun (2022) continues that Norway and Denmark had a slower spread of infection and fewer deaths in elderly care in relation to COVID-19 than other European countries. Both these countries implemented a national lockdown quickly, which may have had some bearing on these results. This early lockdown was critical at the start of the pandemic when residential care services in many countries, such as nursing homes, lacked infection control equipment and test equipment. Askim & Bergström (2022) drew attention to the fact that Norway’s response was more influenced by gerontology-related science compared to Sweden’s response, which was more influenced from a public health perspective. The central government response in Norway included swifter and more decisive moves to restrict outsider access to elderly care institutions and a far higher presence of doctors and trained nurses in elderly care (Kvinnsland et al. 2021, p. 345).

In Norway, the mortality rates in the first and second waves of the pandemic were among the lowest in the world. The first wave of SARS-CoV-2 cases was curbed through a national lockdown introduced in mid-March 2020, and Norway was one of the first countries to start gradually reopening society in April, with no new rise in cases observed until late summer. The second wave saw less restrictive containment measures, although a rise in cases in March 2021 demanded national restrictions. In contrast to most EU countries, death rates were lower through the second wave than through the first. The SARS-CoV-2 death rates in 2020 were nearly nine times lower than the EU average, and no excess mortality was observed (OECD, 2021). By investigating the national statistics and the government communication of pandemic measures to its citizens, and especially to the nursing homes and residential care services, the analysis shows that the initial use of regulatory instruments was sufficient in the first wave. Despite the lack of preparedness in some aspects, Norway has arguably performed well in handling the pandemic quickly and effectively compared to other countries. One explanation is that the government succeeded in making the objective of crisis management ‘United We Stand’, and therefore had a successful collaboration in decision-making with health experts (Christensen & Lægreid, 2020). The Norwegian public, as is the case in other Scandinavian countries, expresses a high degree of confidence in the government, and this confidence was largely maintained during the pandemic (Christensen & Lægreid, 2020; Petrov et al. 2020; Laage-Thomsen & Frandsen, 2022). The Norwegian government actively appealed to its population to launch a collective action in the fight against the pandemic, and today we can, based on data analysis, conclude that the Norwegian government succeeded in its aim.

Saunes et al. (2022) emphasised that extensive reliance on giving recommendations, rather than forcing through legislation, led to fewer formal restrictions in the first phase of the pandemic in Nordic countries compared with much of the EU/EEA. In general, restrictions on internal mobility were very limited in time and area. Bans on visits to nursing homes and hospitals were only enforced strongly for a few months. Additionally, many political leaders supported the restrictions, regardless of their political standing, which helped the heads of the government remain steadfast. According to Christensen & Lægreid (2020), in March 2020, Norway invoked the National Preparedness Act, which accredited the government with the power to establish countrywide decisions on various restrictions. According to Aasland & Braut (2022), the Norwegian role of county governor has specified responsibilities during an emergency situation, including being the chairperson of the County Emergency Council (CEC). The main factor in the successful coordination of the public health response is the governors’ ability to support the municipalities and the local communities, balancing the need for independence against the need for state control. Karlsen et al. (2022) highlighted that municipal public health coordinators (PHCs) are an important ‘tool’ for providing local intersectoral public health work. The founders of the social services facilities are the municipalities, and thus, the ability of the governors to coordinate work on measures against the spreading of the pandemic had a direct impact on the protection of those placed in these facilities. Norway’s leadership communicated the importance of responsibility, nationhood, patriotism and the sense of valuing communication in the community (Christensen & Lægreid, 2020). Communication should cultivate a sense of belonging; in the case of Norway, talking about the love of their country and nationalism inspired many individuals to respond positively to the government’s requirements.

There are several limitations and strengths to this study that should be noted. The results strengthen knowledge transfer by relating the results and experiences of a country which had low death rates as a result of the SARS-CoV-2 pandemic. Our methodology is feasible and can be reliably replicated in future updated reviews, or similar comparative research in EU countries could be carried out. Norway, a European country, managed to competently take care of and protect vulnerable groups, including the elderly, and thus this country has become a good example of how to manage a pandemic or other crises. Several limitations should be considered when interpreting these results. Due to the ongoing nature of the SARS-CoV-2 pandemic, our data collection was deliberately restricted to public health websites and national statistics reports. The list of policy documents identified for this analysis is not exhaustive, and more recent documents might have been published during the submission process of this article. Other public health or government documents might also not have been identified during the research stage. A wider range of documents (e.g., research articles or annual reports) may provide additional insight as to the range of consequences of the SARS-CoV-2 pandemic. A further limitation of this study is that we relied on the cause of death from the registries for COVID-19-associated mortality, which is dependent on the registration of COVID-19 among those who died.

The public health measures enacted by the Norwegian political leadership to protect the elderly in response to the SARS-CoV-2 pandemic crisis necessitated collaboration with public health professionals when they focussed on reducing the elderly mortality rates through contingency plans for dealing with the SARS-CoV-2 pandemic. This collaboration contributed to the success in containing the crisis as it unfolded and was beneficial in drawing up the recovery policy aimed at mitigating the impacts of the pandemic situation. The results of the authorities’ actions provide decision-makers from public health policy with insights to draw upon for political discussion to further improve on the Norwegian government’s responses to crises. Further research is required to examine the experiences of the leaders of residential care services in connection with how they reflected on measures impacting the social and healthcare services and mortality rates of the elderly during the SARS-CoV-2 pandemic; such research could be performed through in-depth interviews. Furthermore, the Norwegian policy responses, such as public health measures, restrictions, the social consequences for vulnerable groups such as the elderly, and cross-government and cross-community cooperation, will all need further analysis.

Despite posing new challenges, Norwegian leadership has deployed significant efforts to respond to the SARS-CoV-2 pandemic crisis. The impact of their public health measures in protecting the elderly during the SARS-CoV-2 pandemic crisis can be a good practice example for other countries. The collaboration of the political leaders, mutual communication and the level of citizens’ trust in political leaders are fundamental preconditions for successfully preventing the spread of a contagion during a pandemic or potential pandemic. The findings of this study contribute to a better understanding of the connection between the political responses and public health measures, as well as a way to disseminate information and the impact of implemented public health measures provided by residential care services towards the elderly.