The GOVERNANCE of the health system with regard to COVID-19 relates to pandemic response plans and the steering of the health system to ensure its continued functioning. It includes emergency response mechanisms, as well as how information is being communicated, and the regulation of health service provision to patients affected by the virus.
MEASURES INTRODUCED IN 2020
The Norwegian health care system is a semi-decentralized health system with four Regional Health Authorities (RHAs) being responsible for specialist care and municipalities responsible for primary care and social services. Over the last decade the so-called ‘coordination reform’ has established a mandatory network of governance structures encompassing health trusts and municipalities to improve coordination of specialist and primary care.
On 31 January, the Ministry of Health and Care Services delegated the responsibility to coordinate the health system’s response to the COVID-19 outbreak to the Directorate of Health (DoH), with activities coordinated with the Norwegian Institute of Public Health (NIPH) as well as other relevant stakeholders. From the 13 March the Ministry of Justice led the overall response to COVID-19, whereas the DoH continued to lead the health system related aspects. The Directorate of Civil Protection is responsible for maintaining the complete overview of risks and vulnerability in general and of the digital nationwide multi-agency public safety network. During the COVID-19 outbreak they are participating in the preparedness-group as well as supporting the work of DoH. From 7 May the responsibility to develop and implement sector specific regulations has been transferred back to the ministries responsible for each sector. The Directorate of Health and the Norwegian Institute of Public Health continue to support them by providing relevant information.
Each regional health authority (RHA) has weekly, and sometimes daily, network meetings of medical directors, head of infectious diseases, the hospital’s leading expert on infection prevention for discussion and deciding regional policies and planning activities, in relation to the national guidelines issued by the DoH and the NHIP. The intensive care specialists have daily information meetings, discussing experiences so far, and what to do further regarding all aspects of treatment, and also online meetings where the latest results from other countries are being discussed.
National preparedness plans
Norway has a legal system of national preparedness which include a National Health Preparedness Plan (NHPP) (last updated in January 2018), as well as a National Preparedness Plan for Outbreaks of Communicable Diseases (NPOCD) (last updated on 2 December 2019). The latter is the national pandemic response plan. These health preparedness plans clearly outline the lines and responsibilities of various agencies, entities and enterprises during crises. Source:
National health preparedness plan: https://www.regjeringen.no/no/dokumenter/a-verne-om-liv-og-helse/id2583172/).
The Health Preparedness Act (Act No. 56 of 23 June 2000 relating to health and social preparedness) which underwrites the NHPP requires that all health and care administration and services have preparedness plans to ensure prudent service delivery during crises and war. This applies to the specialist health service (RHAs, health trusts/hospitals) and environmental health care, as well as other health and care services in the municipalities. The preparedness plans are the basis for their crisis management and are described by the Directorate of Civil Protection.
The Control of Communicable Diseases Act (Act of 5 August 1994, No. 55), which underwrites the NPODC, aims to protect the population from communicable diseases. Health and other authorities, including RHAs and municipalities must draw up plans and implement the measures necessary to control communicable diseases, and coordinate their efforts. The legislation gives the health authorities powers to implement measures to prevent or hinder the spread of disease, e.g. by imposing quarantines, prohibiting movement into or out of specified areas and restricting travel. A number of regulations have been specified in accordance with the Control of Communicable Diseases Act. Reference is also made to the duty of health personnel to report cases and to give notification of communicable diseases.
In addition, certain Royal Decrees have used this legislation the basis for securing resources, if required. For example, the Royal decree from the King in Council dated 28 February 2020 (using provisions of the Control of Communicable Diseases Act) addresses access to necessary pharmaceuticals and medical resources while the Royal Decree from 6 March (using the provisions of the Health Preparedness Act) confirmed the responsibilities, tasks and resource allocations, as well as powers of the Ministry of Health and Care Services (e.g. to requisition private property if necessary). The Ministry determines what measures are necessary and how they will be implemented.
On 21 March, 2020 the parliament adopted temporary legislation, the Coronavirus Act (Act of March 21, 2020, enacted from 27 March), that authorise the government to carry out necessary and proportionate adaptive measures for a limited period (of one month only in the first instance) to address the effects of the coronavirus. This legislation, which has been negotiated with the political parties in the parliament, provides the legal basis for necessary measures that deal with impacts not directly related to preventing infection or strengthening health services (such as limiting choice of hospital).
The original version of this act proposed to give the government powers (until 2022) to pass legislation without involving the parliament, and avoid following existing legislation, when this is necessary to “limit the disturbance of the normal functioning of the society” and “to mitigate negative effects for the population, businesses, the public sector or the society at large”. However, the original proposal was strongly criticized by the Norwegian legal experts in the media and the parliament fundamentally rewrote the proposal before passing it. The act now states that the government may not limit the jurisdiction of the courts. A new mechanism of parliamentary control over the Government was designed: there is no necessity for the parliament to meet in a formal session; the government must immediately repeal its regulations if one third of the MPs is against it and notifies the parliament (for example by email). The act remains in power until 27 May.
While the government and parliament were developing central rules and measures, many local governments enacted their own rules based on the powers to them in the Disease Prevention Act. Such powers have been used by more than 120 of the 356 municipalities in Norway (https://verfassungsblog.de/fighting-the-virus-and-the-rule-of-law-a-country-report-on-norway/).
Research and evidence gathering
The NIPH has established Live map of COVID-19 evidence. The purpose is provide an overview of scientific publications on COVID-19 categorized and divided into more specific subgroups, providing quick access to specific topic-relevant publications. As a result, the map also identifies research gaps, possibly guiding further research efforts (https://www.fhi.no/en/qk/systematic-reviews-hta/map/).
The Norwegian Research Council has announced a call for proposals on COVID-19-related research which is earmarked for health innovations, as well as economic consequences of COVID-19. The Foreign Ministry is also providing extra funding for research in the WHO.
Norway will give priority to vaccine development and distribution through the Coalition for Epidemic Preparedness Innovations (CEPI) and Gavi, the Vaccine Alliance, but will also seek to mobilise international support for cooperation to develop better treatments and testing.
The Government has initiated a series of consultations on how to prepare for a reopening of the economy, starting with an extraordinary tripartite meeting between the employers, trade unions and the Government on 20 April. The meeting was followed by a series of videoconferences, focusing on various sectors (https://www.regjeringen.no/en/aktuelt/package-of-measures-to-support-the-oil-and-gas-industry-and-the-supply-industry/id2700656/).
On 24 April, the duration of the Coronavirus Act remaining in force has been extended until 27 May (it was initially in force until 27 April). Regulations that have been passed under the Coronavirus Act will also lose legal force on 27 May but some will be re-enacted as independent regulations (two are already in the process of being re-enacted) and will as such remain in force. On the same day, a Royal Commission was set up to evaluate the preparedness for and handling of the COVID-19 pandemic in Norway. The Commission is to deliver their report to the Parliament by the end of March 2021.
From 7 May the responsibility to develop and implement sector specific regulations has been transferred back to the ministries responsible for each sector. The Directorate of Health and the Norwegian Institute of Public Health may support them by providing relevant information.
The risk and response report published by the Norwegian Institute of Public Health (NIPH) on 5 May offered strategic advice on handling the pandemic until 2023. The aim is to have a dynamic response, adjusting to the changing in pandemic stages and in the available knowledge. The NIPH advises on the following core measures: good hygiene (prevention); early detection and isolation of infected patients; contact tracing and quarantine for close contacts. Travel restrictions and restrictions on social gatherings/events should be lifted as long as their participants adhere to infection control measures.
On 7 May, the government announced its long-term plan for reopening the Norwegian society and easing the COVID-19 restrictions. The aim is to allow as many businesses and activities as possible to reopen before the summer. To achieve this, the former strategy to suppress the spread of the virus is replaced by a strategy to control the spread of the virus. Reopening must therefore comply with infection control regulations.
From 27 May the Coronavirus Act is no longer in force. New temporary legislation has been enacted and will be temporarily in place for the next 4-7 months. The changes affect the Health Preparedness Act (with validity until January 1, 2021) enabling the government to enforce regulations to secure resources, (see Transition measures: planning services) and the Execution of Sentences Act (with validity until 1 November 2020) creating a legal opening for suspension of sentences, regulating visiting prisoner, etc.
On 10 June the Government released their national preparedness plan for an increased level of COIVD-19 in Norway. The plan is aligned with the Government’s reopening plans from 7 May, based on three different scenarios. The first scenario assumes a mainly controlled situation, with a limited incidence rate throughout the country, with a local variation expected but with access to health and care services in place. In this scenario, the control measures will be adjusted to the incidence rate. The second scenario assumes an elevated incidence rate where the health care system is no longer able to deliver health and care services of good quality to those in need. The third scenario assumes that international cooperation is affected in such a way that assistance (e.g. home-transport for citizens abroad) is no longer possible and international trade is disturbed (nationalization of production etc). The plan distinguishes between six categories of measures that can be taken to limit the effects of the pandemic. Those are:
1. Hygienic measures
a. Hand hygiene, cough etiquette and self-isolation (scenarios 1-3)
b. Use of face masks when physical distancing is not possible (>1 metre) (scenario 2)
2. Early detection and isolation of infected persons:
a. Detect and isolate upon clinical indicated testing (scenarios 1-3)
b. Detect and isolate asymptomatic infected without clinical evaluation (scenarios 1-3)
c. Intensify monitoring to ensure close follow up (scenarios 1-3)
3. Contact tracing and quarantine (scenarios 1-3)
4. Domestic and international travel restrictions, and quarantine
a. Restriction and quarantine on international travels (scenarios 1-3)
b. Avoid unnecessary international travels (scenarios 1-3)
c. Avoid domestic travel (scenarios 2-3)
5. Reduce point of contacts within the population. Advice and measures:
a. Keep distance (at least 1 meter) (scenarios 1-3)
b. Home-offices, digital meetings (scenarios 1-3)
c. Close childcare centres and schools (scenarios 2-3)
d. Close high schools and universities etc (scenarios 2-3)
e. Close meeting venues and events for large groups (scenarios 2-3)
f. Avoid public transport (scenarios 2-3)
g. Close restaurants/diners etc (scenarios 2-3)
h. Stay at home orders (scenarios 2-3 in extreme situations)
6. Invasive measures for patient in health care institutions and at risk population
a. Measurements for HC institutions (scenarios 1-3)
b. Advice on shielding patients at risks
The plan also identifies who is in charge and is further detailed in the local preparedness plans.
12 October: With the easing of national restrictions, a letter has been sent to all municipalities informing them on their increased responsibility to implement local measures to fight the virus. As the spread of the virus differs between the municipalities, it is necessary to adopt local measures.
The Government has proposed to prolong the amendments to The Emergency Health preparedness legislation until 1 June 2021 (see section ‘Managing cases’).
December 15: The Government prolonged and updated the long-term strategy for handling of the COVID-19 pandemic published on 7 May. An important update is relating to a system for risk assessment, with each county assessed according to a set of quantitative and qualitative indicators. The NIPH will be responsible for monitoring and reporting on the level of risk in the counties. These amendments are reflected in an update to the COVID-19 regulation.
A new risk assessment system was implemented in December, as described in the COVID-19 regulations, categorizing municipalities experiencing an outbreak into five levels. Municipalities are responsible for deciding on measures for outbreaks classed at level 1-3; local authorities are normally also responsible for measures at level 4, but national authorities may intervene if local measures are not appropriate for the given risk situation, i.e. if the local health system is no longer able to deliver health and care services of good quality to those in need, or if the outbreak affects a larger geographical area. National authorities are responsible for setting measures at risk level 5.
MEASURES INTRODUCED IN 2021
Following the increasing incidence rate of the English variation of the coronavirus in some municipalities in the eastern part of Norway, the governor of the affected county approached the national health authorities to ensure a swift and coordinated response. The government decided to implement a set of stricter measures in the affected area, which they are authorised to do based on the national preparedness plan for an increased incidence of COVID-19 in Norway released in June 2020. The aim is to prevent the new variant from spreading to the rest of the country. Measures that have been decided on the national level that are only applicable to selected municipalities are called ‘regional measures’.
On January 24, the government decided to implement a two zone system – called Ring 1 and Ring 2 - which will determine which control measures will be applicable in the municipalities. The choice of measures will depend on how serious the outbreak is as determined in a risk assessment. ‘Ring 1 municipalities’ include municipalities where an outbreak has taken place, municipalities affected by the same outbreak, as well as municipalities whose inhabitants are in frequent contact with the municipality where the outbreak has taken place. ‘Ring 2 municipalities’ include municipalities that border on the ‘Ring 1 municipalities’ - they must also implement measures swiftly in response to the outbreak.
The first regional measures were implemented on January 23 and apply to the capital Oslo as well as nine other municipalities. On January 24, measures were extended to 15 neighbouring municipalities. Four municipalities further south in the region were included as Ring 1 on January 31. These regional measures were lifted on February 16.
The increasing incidence rate of the English variant in the western region of Norway, led Bergen as well as two other municipalities to request the national health authorities to implement stricter regional measures. On February 7, these municipalities were set to be included as Ring 1 areas, and neighbouring municipalities were set to be classed as Ring 2. The regional measures were lifted on February 19.
On February 21, the government decided to abandon the categorization of municipalities as Ring 1 and Ring 2, and simplify the COVID-19 regulation by reducing the number of levels from four to three, and introducing an ‘ABC’ system of risk classification. Level A means a particularly high level of measures; Level B means high level of measures; and Level C means a fairly high level of measures. This change is expected to give the municipalities more freedom to supplement national measures with local measures. Municipalities should determine whether kindergartens and schools should transition to the red level (the modified traffic light model with yellow and red lights remains in place for educational institutions). However, the government may intervene if measures are not adequate to the risk assessment.
Municipalities subject to stricter measures implemented by the national authorities are identified in a special list. Municipalities that have implemented stricter control measures out of their own initiative are not included in the list. As of March 15, the government decided that Level A measures should be implemented in the Viken region, with a total of 51 municipalities as well as 15 other municipalities (about 40% of the Norwegian population). A further nine municipalities will have to introduce Level C measures.
March 15: The government made amendments to the Level A measures to permit organised, outdoor sporting and leisure activities for children and young people under the age of 20 provided this takes place in groups of no more than 10 persons and all participants come from the same municipality. The government recommends that all activities are facilitated in a way that ensures participants can maintain distancing of two metres from each other.
Pursuant to the Control of Communicable Diseases Act municipalities may introduce local measures. As of March 15, Svalbard, as well as 60 municipalities have enacted local regulations. The local regulations vary from the use of face masks to mandatory use of home office and stricter quarantine regulations.
April 14: The National COVID-Commission released its report, which concluded that the overall governance of the COVID-pandemic has been good, largely due to the compliance with the national measures by the population. The report also stated that although the Government knew, from previous national risk assessments, that a pandemic was the most likely crisis, the outbreak of COVID-19 has found it unprepared. A scenario for a long-time duration of the pandemic was not developed. Access to personal protection equipment and pharmaceuticals was challenged, and the Government failed to ensure that emergency measures did not infringe on personal liberties as stated in the Constitution or to safeguard individual rights according to the Human Rights declaration.
April 15: The Government mandated the National COVID-Commission to continue its works.