Nordic responses to Covid-19: Governance and policy measures in the early phases of the pandemic

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Health policy

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Nordic responses to Covid-19: Governance and policy measures in the early phases of the pandemic

Ingrid Sperre Saunes

, Karsten Vrangbæk

, Haldor Byrkjeflot

, Signe Smith Jervelund

, Hans Okkels Birk

, Liina-Kaisa Tynkkynen

, Ilmo Keskimäki

, Sigurbjörg Sigurgeirsdóttir

, Nils Janlöv

, Joakim Ramsberg

, Cristina Hernández-Quevedo

, Sherry Merkur

,

Anna Sagan

, Marina Karanikolos

aNorwegian Institute of Public Health, Postboks 222 Skøyen, 0213 Oslo, Norway

bDepartment of Political Science, University of Copenhagen, Oester Farimandsgade 5A, DK-1014 Copenhagen K, Denmark

cDepartment of Public Health, Section for Health Services Research, University of Copenhagen, Oester Farimagsgade 5A, DK-1014 Copenhagen K, Denmark

dDepartment of Sociology and Human Geography, University of Oslo, Postboks 1096, Blindern, 0317 Oslo, Norway

eDepartment of Management, Politics and Philosophy, Copenhagen Business School, Porcelænshven 18B, DK 20 0 0 Frederiksberg, Denmark

fFaculty of Social Sciences, Tampere University, FI-33014, Finland

gFinnish Institute for Health and Welfare, P.O. Box 30, FI-00271 Helsinki, Finland

hDepartment of Political Science, University of Iceland, Iceland

iThe Swedish Agency for Health and Care Services Analysis (Myndigheten för vård- och omsorgsanalys), Box 6070, 102 31 Stockholm, Sweden

jEuropean Observatory on Health Systems and Policies, COW.4.05 London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK

kEuropean Observatory on Health Systems and Policies, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK

a rt i c l e i nf o

Article history:

Received 11 February 2021 Revised 19 June 2021 Accepted 30 August 2021 Available online xxx Keywords:

Health policy and administration Public health

Comparative Research Governance System level

influence legislation and key principles of governance in the Nordic countries

a b s t r a c t

ThispaperexploresandcompareshealthsystemresponsestotheCOVID-19pandemicinDenmark,Fin- land,Iceland,NorwayandSweden,inthecontextofexistinggovernancefeatures. Contentcompiledin theCovid-19HealthSystemResponseMonitorcombinedwithotherpubliclyavailablecountryinforma- tionserve as the foundation forthisanalysis. Theanalysis mainly coversearly response until August 2020,butincludessomekeypolicyandepidemiologicaldevelopmentsupuntilDecember2020.

Ourfindingssuggestthatdespitethemanysimilaritiesinadoptedpolicymeasures,thefivecountries display differencesinimplementationas wellas outcomes.Declarationofstateofemergencyhas dif- feredintheNordicregion,whereastheemphasisonspecialistadvisoryagenciesinthedecision-making processisacommonfeature.Theremaybedifferencesinhowrespectivepopulationscompliedwiththe recommendedmeasures,and wesuggestthatotherstructural andcircumstantial factorsmay havean importantrole invariationsinoutcomes acrosstheNordiccountries.The highincidenceratesamong migrant populationsand temporarymigrant workers,aswell asdifferencesinworkingconditions are importantfactorstoexplorefurther.AnimportantquestionforfutureresearchishowtheCOVID-19epi- demicwillinfluencelegislationandkeyprinciplesofgovernanceintheNordiccountries.

© 2021TheAuthors.PublishedbyElsevierB.V.

ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/)

∗Corresponding author.

E-mail addresses: ingrid.saunes@fhi.no (I.S. Saunes), kavr@sund.ku.dk (K.

Vrangbæk), haldor.byrkjeflot@sosgeo.uio.no (H. Byrkjeflot), ssj@sund.ku.dk (S.S.

Jervelund), hob@sund.ku.dk (H.O. Birk), liina-kaisa.tynkkynen@tuni.fi (L.-K.

Tynkkynen), ilmo.keskimaki@thl.fi (I. Keskimäki), silla@hi.is (S. Sigurgeirsdóttir), Nils.Janlov@vardanalys.se (N. Janlöv), Joakim.Ramsberg@vardanalys.se (J. Ramsberg), C.Hernandez-Quevedo@lse.ac.uk (C. Hernández-Quevedo), S.M.Merkur@lse.ac.uk (S. Merkur), A.Sagan@lse.ac.uk (A. Sagan), Marina.Karanikolos@lshtm.ac.uk (M.

Karanikolos).

Introduction

The healthsystems inDenmark, Finland,Iceland, Norwayand Sweden share a number ofcommon features. Theyare predom- inantly tax financed and provide universal coverage to all resi- dents.Healthcareisapublicresponsibilityandthereisahighde- greeofdecentralizedmanagementthroughregionalandlocallevel governments. The decentralized governance takes place within a frameworkofnationallegislationandnegotiatedagreementstoco- ordinatestrategicpolicyaims.

https://doi.org/10.1016/j.healthpol.2021.08.011

0168-8510/© 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )

Please citethisarticleas:I.S.Saunes, K.Vrangbæk,H.Byrkjeflotetal.,NordicresponsestoCovid-19:Governanceandpolicymeasures

The outbreak ofthe COVID-19 pandemic calledforrapidpub- lic health responses toavoid spreadof theinfection andprevent COVID-19 related deaths, and the Nordic region was not an ex- ception.TheepidemiologicalsituationhasvariedacrosstheNordic countries, whichmayreflect differentpolicyresponses aswell as institutionalstructures. Differences mayalsoreflectthe resilience ofhealthsystems.

In the past, the structural commonalitieshave inspired many observers to argue that there is a distinct “Nordic model” of healthcare,sometimeslabelledasan“integratedpubliccorporatist model”[1]oramoredecentralizedversion oftheNHSintheUK [2].Recently,thecountrieshavechosensomewhatdivergingpaths withregardstothelevelofcentralizationordecentralizationinthe financingandprovisionofhealthservices[3].

Thereareconstitutionaldifferencesanddivergenceinthetradi- tions ofinteraction betweennationalgovernments,stateagencies, anddecentralizedauthoritiesacrossthefivecountrieswhichinflu- encetherangeofpoliciesadoptedinapublichealthcrisis.Institu- tionalstructures settheboundariesfordecision-makingandlimit the range of likelyand possible choices. Institutionalveto points andstandardoperation proceduresmayontheonehandindicate that radical changes are rare and require substantial external or internalshocktoopenthepoliticalwindowforaction.Inmorere- cent contributions to thesocial science it has,however, beenar- gued thattransformationsmayalsobetheoutcomeofmoreevo- lutionary developments [4,5]. When studying the impact of the Covid-19crisisforthehealthcaresystemsitisthereforenecessary tounderstandthecontextwithineachsystem.

The Swedish response to the COVID-19 pandemic has in par- ticular beenthesubject ofan intense academic,aswell aspolit- ical debate [6]. In contrast to most of the EU countries and the Nordicneighbors,theinitiallackofmorestringentpolicymeasures madeSweden an outlierintermsofboththe pandemicresponse aswell astheinitial impactonpopulation health,withmortality ratesmarkedlyhigherthaninotherNordiccountries[7].

The overall aim of this paper is to explore and compare the Nordichealthsystems’responsestotheCOVID-19pandemicinthe contextofgovernancefeaturesandprovideinsightintodifferences andsimilaritiesintermsofpolicy responses totheepidemiologi- cal situation.Thisoverviewnotonlycontributeswithcomparable informationonimplementationofpolicymeasuresandoutcomes, butanalysestheroleofgovernancemechanismsandthechalleng- ing balancebetweenhealthpolicy adviceandgovernmental deci- sions.

Methods

This analysis builds on the methodology and content com- piled in the Covid-19 Health System Response Monitor (HSRM).

TheHSRMwasestablished inMarch2020anddesignedtocollect anddisseminateup-to-dateinformationonhowcountries,mainly in the WHO European Region, are responding to the crisis (see www.covid19healthsystem.org). The HSRM content is structured around standard healthsystemfunctions[8],capturing policyre- sponses relatedtogovernance,resourcegeneration,financing,and servicedelivery,aswellasmeasurestopreventtransmissionofthe virus.Theinformationiscollectedandregularlyupdated,enabling broadcomparisonsacrosscountries.

Thepolicy insightsemergingfromtheNordiccountries– Den- mark,Finland,Iceland,NorwayandSweden,isfocusedonthegov- ernanceandlegislation,aswellasselectedmeasuresofpreventing transmission.

The identification of key policy insights from country experi- ences followed a deliberative process that included extensivere- view oftheHSRMmaterials andstructureddiscussionsamongar- ticleco-authors,Observatoryeditors,andotherexperts.Whererel-

evant, other country material, key documents and literature are usedtoinformthepaper[9–13].

The aim was not to definitively answer why some countries have dealt better with the pandemic than others, but rather to draw out interesting patterns, key contrasts, and innovative ap- proaches in policy responses aimed at addressing commonchal- lengesacrosscountries.Indeed,attributinganycausallinkbetween policy response andpandemic outcome is fraught with method- ologicalchallenges. Rather,theanalysisintended todescribe gov- ernanceandassesspolicyresponsesanddrawout criticallessons.

In turn, this can serve as a basis from which to begin discus- sions that eventually lead to an understanding ofwhat seems to work, what does not work, andwhy. The analysis also intended tothrowintorelief currentgapsinpolicyknowledgei.e.whatwe still need to know,which can open up areas forfuture research.

Ultimately,thisanalysisaimedtoprovidepolicymakerswithpolicy optionsasthey designtheir ownresponses tocurrentandfuture crises.

TheanalysiscoversmainlytheperiodfromFebruary2020until August2020,butalsocommentsonsomekeypolicyandepidemi- ologicaldevelopmentsupuntiltheendofDecember2020.

Results

Currentpoliticsandpoliticalbackground

Denmark, Finland, Iceland, Norway and Sweden share many cultural,historical,socialandwelfarestructurecharacteristics,and well-established political cooperation in the form of the Nordic CouncilandtheNordicCouncilofMinisters[14].

The Nordic countries, witha total population of 27.4 million, areallrepresentativedemocracies,oftenledbyminoritycoalitions.

Over thecourse of2020, Iceland andFinland hadmajoritycoali- tions, whereas Norway and Sweden had minority coalitions and Denmarkwasgovernedbyaminorityparty.Ideologicallythegov- ernmentsvariedfromconservative(Norway),social-democraticin Denmark,andleft-greenwithsupportofthecenterpartiesinFin- landandSwedenandcenter-rightpartiesinIceland.

All governments hadbroad support for their initial responses tothepandemicintheir respectiveparliamentsaswell asamong thepublic.Criticism andpoliticaldebateemerged inallcountries inthelatespring,withtheeasingoftherestrictionmeasures.

ThedevelopmentofthepandemicintheNordiccountriesandthe initialpolicyresponses

BythelastweekofFebruary2020,allfiveNordiccountrieshad registeredtheirfirstCOVID-cases.Bymid-MarchDenmark,Finland, Iceland and Norway had implemented a number of strict policy measures such as closure of borders and schools, restriction on social gatherings and accessto restaurants etc., whereas Sweden calledforcautionandremainedopen.Theburdenofthepandemic expressedinthenumberofcasesanddeathshasnotbeenuniform acrosstheregion(Fig.1).

Data limitationsintermsofcomparability oftestingandmor- talitycodingnotwithstanding [15,16], Swedenappeared tobe the outlier in terms of the high incidences rates and the number of COVID-19 deaths in 2020. In the end of July and until early September,thepatternsintheNordiccountriesbecamemoresim- ilarwithrelativelylowincidencerates,beforetheyincreasedwith varyingdegreeinthebeginningofautumn.SwedenandDenmark bothexperiencedrapidincreaseinincidentrateswhichtheyman- agedtocurbinDecember2020.

Fig. 1. Weekly number of COVID-19 cases per 10 0,0 0 0 population (a) and deaths per one million population (b) in the Nordic countries in the period March-December 2020.

NationallegislationunderpinningtheCOVID-19response

Even though the legal systems in the Nordic countries share manycommonalities,thedegreetowhichneworpre-existingleg- islationallowimplementationofstrictmeasuresvaries.Legislative provisionsforinfectiousdiseasecontrolcanbeusedtoimposefar- reaching restrictions on the citizens in order to prevent further spread of diseases. COVID-19 was listed asa communicable dis- easeintherespectiveinfectiousdiseaseactsby governmentalde- crees early in2020inall theNordic countries.Likewise, national disaster or preparedness acts, when invoked, give the national governments extended emergency powers and the right to im- posestrict emergencyregulations ontheir respective populations (Table1).

Iceland,FinlandandNorwayinvokednationalpreparednessacts inMarch2020.Thisempoweredthegovernmenttomakecountry- widedecisionsonseveralrestrictions.However,mostofthemea- sureswere takenin thecontext ofordinary legislation givingre- gional/local authoritiessufficient powers, such asissuing quaran- tineorclosingpublicspaces.Additionally,NorwayissuedaCoron- avirusAct(2020),authorisingthegovernmenttocarryoutrestric- tivemeasurestoaddresstheeffectsofCOVID-19.

NeitherDenmarknorSweden invokedastateofemergencyin thespring2020. ForSweden, thelegalframework doesnot allow adeclarationofa stateofemergencyduetoa pandemic,butthe Parliamenthasthepowertoinstitutenewlawsveryrapidlyincase ofemergencies.DenmarkandSwedenbothimposed newpolicies duringtheCOVID-19by amendingexistinglegislation.TheDanish

Table 1

Important legislation and pandemic plans underpinning initial COVID-19 response in the Nordic countries.

Actsand

regulations Denmark Finland Iceland Norway Sweden

National Preparedness Acts

1992 Emergency Management Act Not activated

2011 The Emergency Powers Act (Activated

March 2020)

1994 the Health Protection Act

2008 Civil Protection Act Activated March 2020

1950 Emergency preparedness Act 2000 Emergency Health Preparedness Act Activated March 2020

2003 Civil Protection Act (on municipal responsibility)

EpidemicActs 2009 The Danish Epidemic Act Revised March 2020 (sunset clause March 2021)

2016 The Communicable Diseases Act

Revised several times 2020

1997 Act on Health Security and

Communicable Diseases

The Act Relating to the Control of Communicable Diseases.

Activated February 2020

Revised several times 2020

2004 Communicable Diseases Act Revised April 2020 (sunset clause June 2020)

COVID-Acts Enforced

27 March

(Sunset clause 27 May) National

Emergency Plans

The National Emergency Management Plan 2015

Regional contingency planning, coordinated at ministerial level

The general contingency plan

National health preparedness plan 2018

Pandemic Plans

The Pandemic Plan 2013

National preparedness plan for an influenza pandemic 2013

Pandemic and Influenza Preparedness Plan Updated 2020

National plan control communicable diseases 2019

21 regional plans 2019

EpidemicAct(2019)allowsthegovernmenttotemporarilysuspend specific rightsandobligationsoutlined byother legislation,when it is necessaryto prevent orcontain adangerous contagiousdis- easeortomaintainheathcarecapacitytoprovidehealthcareser- vices to citizens.In Sweden,a temporarylegislation (amendment to CommunicableDiseasesAct) wasinvokedfrommid-Apriluntil the endof June, empowering the government to impose restric- tions on restaurants,bars,shopping malls,transportations,etc.in ordertocontain thespread.Thiswasnotutilized,butan amend- ment tothepublicorder actwasusedtoregulate thenumberof peoplepermittedtogatherinpublicspaces.

ANordicPublicHealthPreparednessAgreement(2002)requires thecountriestoshareinformationonmeasuresthatmayinfluence the cooperation between the countries. This extends to relevant legislativemeasures,aswellastheobligationtofacilitateexchange of experiences, cooperation and competencebuilding. The World Health Organisation’s International Health Regulation (IHR) from 2005 is incorporated in the national legislation in all the Nordic countries[17]

Governanceapproachesinpractice

DuringtheCOVID-19response,theNordiccountrieshavebeen guidedbythefollowingprinciplesintermsofemergencymanage- ment,whichareincorporatedinnationallegislation[18]:

• sectorresponsibilityremainsinthesectorduringcrises;

• emergencymanagementshouldreflectstandardprocedures;

• emergencymanagementshould behandledatlowest effective organisationallevelpossible;and

• authorities are responsible for cooperation and coordination witheachotherintermsofplanningandmanagement.

Formal responsibility forthe developmentof policy responses to COVID-19 lies with the respective governments, while any change to the legislation mustbe adopted by the parliaments in all fiveNordiccountries,includinginanemergencysituation.The MinistersofHealthareallheadsoftheministerialdepartments(in thecaseofFinlandtherearetwoministersofHealth),andNational agencies,subordinatetotheMinistries ofHealth, actindependent

oftheirnationalgovernments.Theministriesmaysteerthemindi- rectlythroughinstructions,missionsandfinancing.

In Denmark, Finland, Norway, andSweden the regulatory re- sponsibility of advice on communicable diseases are located in the agencies responsible for monitoring and assessing the situa- tiontogetherwithECDCandWHO.InIceland,theChiefEpidemi- ologist, advisingand preparing recommendationsto the Minister of Health, operates within the Directorate of Health, while the decision-makingauthorityinresponsetopandemicsiscentralised andrestswiththeMinisterofHealth.

InNorway,theDirectorateofHealthisincharge ofoverallco- ordinationofthehealth andcaresector’s effortsandimplements thenecessarymeasuresduringanemergencysituation.InSweden, thePublicHealthAgency(SPHA)withtheChiefEpidemiologist,as inIceland,isresponsibleforapplyingtheinfectioncontrollegisla- tionatthenationallevel.InDenmark,The DanishHealthAuthor- ityandStatensSerumInstitute(SSI)areresponsibleformonitoring andprovidingrecommendationstotheMinister ofHealth.InFin- land,thenationalexpertagencyistheFinnishInstituteforHealth andWelfare(THL).

With the exemption of Iceland, regional or local authorities (withrespectiveChief Medicalofficers)areresponsibleforcoordi- natinglocalpoliciesandrecommendationswiththestateagencies.

Theyarealsoresponsible fornecessary precautionsagainst trans- missionofdisease,andtheChiefMedicalOfficershavethepower toenforce measures,such astestingandquarantine and/orisola- tion againstindividuals, tocounter a public healthcrisis. The re- sponsibilityforsecuringbedandICUcapacityandhandlingCOVID- 19inthehospitalsliesinregionalorganisationsinDenmark,Fin- land,Norway,andSweden,whileinIcelandtheresponsibilityisat thenationallevel.

Nationalguidelinesforhandlingtheepidemics areprovidedin all countries,butthepower ofenforcingadherence totheguide- lines varies with the status of the guidelines as either advisory ormandatory.Thisisreflectedinthenationalpreparednessplans forpandemicsinDenmark, Finland,IcelandandNorway. InSwe- den, where regions are responsible for handling the pandemic, thereisnotonenationalplan,but21regionalpreparednessplans.

Regional/local preparedness plans are also present in the other Nordiccountries,underpinnedbyanationalplan.

Table 2

Selected preventive measures adopted at population level in the Nordic countries during the first 6 months (March through August 2020).

Denmark Finland Iceland Norway Sweden

Travelrestrictions citizens/residents:

- International/EU (leisure) (X) (X) (X) (X) (X)

- Nordic (leisure) (X) (X) (X) (X) X

- Quarantine upon (re)entry from high risk area (X) X X X

Travelrestrictions EU/EEAcitizens– (entry)

-Leisure/non-essential purpose (X) (X) (X) (X) (X)

-Quarantine or negative test (X) (X) (X) (X)

-Exceptions for migrant workers and other "worthy purposes" (X) (X) (X) X

Internalmobility restrictions

-travel across municipal/regional borders (X) (X) (X) (X)

-curfew/mobility outside home Childcare andeducation:

- closure of nurseries / kindergartens - remote education in lower primary school

(X)

X (X)

(X) (X)

- remote education in middle/high schools X (X) (X) (X) (X)

- remote post-secondary education (e.g. universities) X (X) (X) (X) X

Recommendation to workfromhome

-private businesses X (X) (X) X X

-public sector (non-essential) X (X) (X) X X

Restrictingaccess forvisitors

-nursing homes and hospitals X X X X X

Closing or restrictingaccess to

-restaurants and bars (X) (X) X (X) (X)

-Retail shops (non-food) and non-essential retail services (X)

-indoor sports facilities (X) (X) (X) (X) (X)

-cultural events (concerts, theatres, museums, spectator sports etc) (X) (X) (X) (X) (X)

Maximumnumberof persons gatheredatPublic events 10 10 10 5 50

Maximumnumberof persons gatheredin Privatehomes 10 10 10 5 50

Contact tracing X X X X (X)

Self-isolation wheninfected X X X X X

Physical distancing 1 m 2 m X 1m 2m

Face mask required (X) (X) (X) (X)

() = temporary + partial, bold = mandated by law, - Regular = recommendation; Physical distancing is highly recommended, whereas wearing a face mask is only recommended when physical distancing is not possible. For gatherings of persons the number is the lowest that have been recom- mended during the early phase of the pandemic. Source: authors

During thefirst waveofthe COVID-19 pandemic,all countries reported the same broad COVID-19 policy aims: to ensure suffi- cient capacity in the health care system; to prevent deaths due to COVID-19 andto preventnew cases.Broadly, thestrategy was to contain and reduce the spread of the virus. Special consider- ations were given to protect older people and other vulnerable groups inall countries. There were also calls fromthe countries’

leaderships for solidarity to reduce the risk of infection spread and emphasison voluntary effort, asall countriescommunicated a strong reliance on the public to follow the recommendations.

Table2presentsanoverviewofthemainpolicymeasuresadopted atpopulationlevelinalltheNordiccountriesfromMarchthrough August2020.

In the spring 2020, comprehensive national measures were takeninDenmark,FinlandandNorway,wherethestrategywasto stopthespreadofthevirusbyissuingthestrictestpolicymeasures taken in times of peace. It wasenforced through restrictions on international travel, combined with reduced social interaction in thepopulation(closureofnon-essentialbusinesses,schools,public events,etc.).FinlandandNorwayalsohadrestrictionsoninternal mobilityforashortperiodoftime.Itshouldbenotedthatcurfews havenot beenimposed inanyofthe Nordiccountries, andmany educationalfacilitiesandbusinesseshaveremainedinoperationby convertingtodigitalandremotework.

Successivere-openingphasesstartedinlate April,asconcerns forbusinessesandthebroadereconomystartedtodominatepol- icydiscussions, shiftingtheaimtowards controllingthespreadof thevirus.Thegradualreopeningprioritisedtheyoungestchildren, allowing daycare centersandschoolstoresumeactivities (in Fin- land facilitiesfortheyoungestchildren remainedopenthewhole

period).School startedto open on15^th Aprilin Denmarkandon 27^th April in Norway. Finland reopened educational facilities on 13^th May. In Norway, schoolsand daycare centers were open for children ofessential healthcarepersonnel throughouttheperiod andthiswasalsothecasefordaycarecentersforessentialperson- nelinDenmark.InIceland,childcareandcompulsoryschools(from 6to 16 yearsof age)remained open,subject toinfection control measures.

Sweden and Iceland introduced international, while recom- mendingnational,restrictionsonmobility.InSweden,thestrategy wastoissuerecommendationsaimedattheentirepopulation,be- sidestargeting recommendations forpeople aged 70+ and those with an underlying disease. High schools and universities were closed and a ban issued in March 2020 on assemblies of more than 50 persons (including for sportand music events) was up- held in the entireperiod. Museums and amusement parks were alsoclosed.

Furtherrecommendationsincludedworkingfromhomeifpos- sible, and avoiding public transport, unless absolutely necessary.

Non-essential travel fromoutside the EU/EEA was restricted fol- lowing the EC recommendations. Later recommendations con- cernedbanningvisitorsincarehomes.InIceland,peopleweread- visednot totravel tocountriesdefinedashigh-riskzonesby the ChiefEpidemiologist.

The overall picture of population level measures showsmany similarities, despite the more formal differences in instruments.

The timing andenforcementof measures variesby country,such as when the limitations on visits to nursing homes were intro- duced. Internal travelrestrictions havebeen limitedinspaceand time,andlockdownshavenotbeenasstrictasinsomeotherEuro-

Table 3

Overview resources and measures for testing, tracing and isolating in the Nordic countries during the first 6 months (March through August).

Denmark Finland Iceland Norway S weden

Testing Resources

Extremely limited, Sufficient by May 2020

Testing free

Limited, sufficient by summer 2020 Public testing free

Limited, sufficient from early spring 2020

Extremely limited, Sufficient by May Testing free

Extremely limited.

Sufficient by summer 2020

Testing Local/regional/

national

Municipalities Municipalities and hospital districts Private providers

National Municipalities

Supported by NIPH

Regions

TracingApps Yes, from June 2020 Yes, from August 2020 Yes, from April 2020 Yes, from April.

Abandoned June

No

Quarantine Exposed

Mandatory Mandatory, Penalty upon violation

Mandatory Mandatory No

Isolation upon diagnosed withC-19

Mandatory

Penalty upon violation

Mandatory

Penalty upon violation

Mandatory

Penalty upon violation

Mandatory

Penalty upon violation

Mandatory

Isolation upon

diagnosed withC-19 Mandatory Self-isolation

(voluntary) Mandatory Mandatory Adviced

Support

Accessto quarantine facilitiesfree of charge

Yes Yes Yes Yes No

peancountries,especiallyonrulesforleavingthehouse.Theinter- naltravelbanwasenforcedmorestronglyinFinlandandNorway, thaninDenmark,IcelandandSweden.

In Denmark andNorway, there have been a shifttowards re- gionalorlocaldifferentiationinmeasuresbasedonthelocallevels of infection by the autumn of 2020. In Finland andSweden, re- gional differentiation isthe rule by default asit is based onthe existingregulation.

Preventingtransmissionthroughtesting,tracingandisolating

ThecommonstrategyacrossmuchofEuropeforCOVID-19 has been to ensure early diagnosis, isolation, as well asquarantining of casesin order toslow the spreadasmuch aspossible andto minimizetheburdenonhealthservices.Thisisalsoknownasthe Find-Test-Trace-Isolate-Supportstrategy(FTTIS).

Thetestingcapacitywasextremelylimitedacrossthecountries at the beginning of the pandemic. Initially,only people with se- veresymptomsandmorevulnerablegroupswerereferredtotest- ing, followedby a stricttestingpriority ofvulnerable groupsand health personnel.With different speed, startingwith Iceland, all Nordic countriesmanaged to expand their testing capacity.Once demand fortestingwasmatched,all Nordiccountrieshaverelied on incidence figures formunicipalities/regions to make informed adjustmentofpreventivepolicies.

Regulations for contact tracing differ somewhat between the countries(Table3),andhavechangedovertime.InDenmark,indi- viduals who tested positive forCOVID-19 infection were initially requested to track down their own recent contacts. From 12^th May 2020, the Danish Patient Safety Authority assumed respon- sibilityforassistanceintracing closecontacts.InFinland,Iceland andNorway, contacttracing hasbeenin placesince theonset of theepidemic.InFinlandandNorway,regional/localauthoritiesare responsible for contact tracing, and in Norway, Norwegian Insti- tute ofPublicHealth(NIPH)mayassistincontacttracingandhas the authority to obtain contactdetails about passengers in pub- lictransport. InIceland,aspecialised contacttracing teamwithin the Civil Protection Departmenthas the overall responsibility for contact tracing. Norway andFinland launched online educational coursesforstaff responsibleforcontacttracingatthelocallevel.In Sweden, SPHAabandonedthestrategy ofcontacttracing asana- tionallevelpolicy inmid-Marchduetothehighnumberofcases incertainregions. Contacttracing wasresumedasanationalpol- icyduringthesummer2020.

Mobileappsdevelopedtodetectclosecontactswereintroduced inIcelandandNorwayinApril2020,followedbyDenmarkinJune andFinlandinSeptember.IfanappuserisdiagnosedwithCOVID- 19, other users who have been close contact are informed that they mayhave beenexposed to COVID-19, without revealingthe identity oftheinitial case. Privacyissues were raisedaboutGPS- trackingandcentralstorageofdatainNorway,andtheinitialapp usewasdiscontinued.Anewapp, similarto theDanishone,was developedovertheautumn2020.

Isolation and quarantine are regulated by the infectious dis- easelegislationinalltheNordiccountries.Self-isolationisconsid- eredmandatoryforallpatientsdiagnosedwithCOVID-19,whereas quarantineisrecommendedinSwedenandmandatoryintheother Nordiccountriesforpeople whohavebeen exposed tothe virus.

Isolationcanbeenforcedinallcountriesandthepatientisentitled to benefits covering income losses. With the exemption of Swe- den, isolationisalsorequiredforthose whohavebeen travelling inspecified areaswithwidespread transmission.InSweden, only travellersfromabroadwithsymptomsofCOVID-19 areadvisedto quarantine.The Nordic countrieshave closedtheir borders toall non-essentialtravelfromcountriesoutsideEU/EEAwithsomeex- emptions.Denmark,Finland,IcelandandNorwayhaveintroduced voluntarytestingforCOVID-19forpassengersarrivingfromabroad.

Thewelfaresystemensuringfinancialsupportincaseofunem- ploymentorsickness hasbeenan importantfactorforadherence tothesemeasuresduringthepandemic.InDenmark,Finland,Ice- land andNorway, municipalities/health authoritiesare obliged to provideaplacetostayforthosewhoare unabletoself-isolateat home,e.g.inhotels.Finland,IcelandandNorwayhavealsodefined levelsofpenaltyinvolvedforviolationoftheisolationrules.

KnowledgebehindCOVID-19decisions

Political decisions have in general been informed by advice fromtherespectivenationalagenciesorcommittees.However,de- cisionshavealso beenmade withoutclearsupport orupon con- flicting advice from the advisory bodies. Even though access to evidence-basedknowledgeandclinicalguidelinesisan important factorinthehandlingofthepandemic,itappearsthatad-hocin- dependentcommissionsandexpertgroupshaveplayedanimpor- tantrole.Thebaseforvariousdecisionsisnotentirelyclear.

InDenmark,politicaldecisionsareinformedbyadvicefromthe DanishHealthAuthorityandSSI. Theadvice isbasedon thebest availableevidence.Insomecases,thenationalgovernmenthasim- posedharderrestrictions thanrecommendedby thehealth agen-

ciesduetopoliticalconcernsandasa“cautionaryprinciple”.This wasparticularlyseenintheearlyphases,wheretheDanishHealth Authority advised against closing borders, schools and day care facilities, since evidence pointed to limited preventive effects on transmission. Yet, the Government decided to impose lockdown measureswithsomesupportfromSSI.Thisexamplealsoillustrates occasionaldisagreementamongtheagencies,whichhavealsobeen criticizedforlackoftransparencyaboutdataandpredictionmod- els.

In Finland,it hasnot beenpossible tofully assesstheknowl- edgebaseforthedecisionsastheGovernmentandtheofficialsthe Ministries and theFinnish Institute forHealthand Welfare(THL) did not,inthe beginning,publishall epidemiologicalmodels and other relevantevidence.However,therehasbeenanaimtostrive forevidence-basedpoliciesasthegovernmenthasappointedasci- entificpanel tosupportthegenerationofevidence,aswellasas- sembleda numberofexpertgroupstosupport thegovernmental decisionmaking[19].

InIceland,policydecisionsarepublishedtogetherwiththerec- ommendations fromtheChiefEpidemiologist andarereportedto be based on the best available evidence. A governmental multi- sector steering group was established to monitor the social and economic impact ofthe public health responses tothe COVID-19 pandemic,andalsoproviderecommendationsonpolicymeasures.

Acouncilofseven expertsappointedbytheMinister ofHealthis overseeing policyandmeasurestakeninresponsetocommunica- blediseases.

InNorway,NIPHregularlypublishesrisk-responsereportswith strategic advice on handlingthe pandemic. The institute advised againsttheclosureofschoolsanddaycarefacilities,aswellasthe national travel ban imposed in the early stagesof thepandemic.

Thiswasinconflictwiththefinal advicegivenbytheDirectorate ofHealthasadvisedbytheNationalPreparednessCommission.In- formationontheagendaanddecisionsprocessesintheprepared- ness commission havenot been transparent.An independent ex- pertcommissionwasappointedtoassessthesocio-economiccon- sequencesofimplementedpolicymeasures.

The government in Sweden relaied on the principle of dele- gatedauthority(responsibilityofadviceonpandemics)whichrests within the Swedish Public Health andInfectious Disease Control Agency.

There havebeenanumberofexpertgroupsappointedtogive recommendationsandpropositionstothe government.The Prime Minister’s OfficeanddifferentMinistries havepublishedthese, for variousrestrictivemeasuressuchasuseoffacemasks.

Furthermore, Denmark, Finland, Norway and Sweden have all appointed independent national commissionsto evaluate the en- tire courseoftheCOVID-19 crisis. Thecommissionsare setupto evaluate thepreparednessforandhandlingoftheCOVID-19 pan- demicaswellastoreportontransparencyofpolicies.

Discussion

This paper presents a descriptive analysis of how the Nordic countries compared in termsof governance and policy measures inresponseto theCOVID-19pandemicatpopulationlevelmainly fromMarchuntilAugust2020.Bymappinglegislationandthena- tionalgovernance ofpandemic responses,theanalysisshowsthat theinitial useofregulatoryinstruments,aswell asingovernance ofpoliciesdiffered.TheCOVID-19pandemicposednewchallenges asitdifferssomewhat fromscenariosdescribedininfluenzapan- demicpreparednessplans.

BytheendofFebruary2020,COVID-caseswereregisteredinall the Nordiccountries.InMarch Finland,IcelandandNorwaywere in a state of national emergency. Denmark, Finland andNorway

hadissuedapartialnationallockdown,whereasSwedencalledfor cautionandremainedopen.

Governancebyrecommendationsrestonhighlevelsofsocietaltrust

All countries have strong central public administrations with agenciesprovidingoversight andrecommendationsofpandemics.

Measuresingeneralhavebeensimilaracrossthecountries(albeit withsome variation intiming)and inmostcasesthe authorities reliedonrecommendations ratherthan legislation.Recommenda- tions were used to advice on working from home, limiting pri- vateandpublicsocialgatheringsandtravelingabroad.Swedenim- posedsome of thesame measures, includingtransitionto online teachinginhighschoolsanduniversitiesandrecommendationsto workfromhomewheneverpossible.Policymeasuresintroducedin theautumnof2020broughtSweden evencloserto theapproach adoptedintheotherNordiccountries.

The extensive reliance on recommendations led to fewer for- malrestrictions in thefirst phase ofthe pandemic in theNordic countriescomparedwithmuchofthe EU/EEA.Ingeneral, there- strictionsoninternalmobilityhavebeenverylimitedintimeand area.Bansonvisitstonursinghomesandhospitalswereonlyen- forcedstrongly ina few months. There havebeen nocurfews or confinementto homes,with theexception ofisolationand quar- antine.Restrictionsonmassgatheringshavebeenimplementedin allcountriestoreducecontact.Facemasksforthepopulationhave only beenrequired inspecific places when physicaldistancing is notpossible(bars,publictransportation,hospitals,nursinghomes, etc.).

ThepublicintheNordiccountriesgenerallyexpressahighde- greeof trusttowards fellow citizens andgovernments whichhas remainedhighduring thepandemic [20–23].All the Nordicgov- ernments actively appealed to their population for collective ac- tionto fightthepandemic,andappearto havemostlysucceeded [24,25]. Nationalmedia have beenperceived assurprisinglysup- portiveoftheirrespectivegovernmentsintheinitialphases[26].

Criticism and politicaldebate have increased asthe countries havemovedfromvariationsoflockdowntowardsgradualreopen- ing. Denmark andSweden are portrayed astwo outliers; Danish media were initially perceived to be too consensus-oriented and supportive of national governance, whereas the Swedish media questionedpoliticsandgovernance,thusfosteringmorepublicde- bate[27].ThelatterisnotsurprisinggiventhatSwedishapproach hasattractedwideinternationalattention.

Nordiccountriesvariedintheuseofstateofemergencyasalegal instrumenttocentralisepower

Declaring a state ofemergency allowed the governments’ ac- cesstolegislativeresourcestheydonotpossessundernormalcir- cumstances.Thegovernmenttemporarilygainsthelegalmeansto imposepotentiallyfar-reachingpolicymeasuresinfringingonper- sonalliberties,aswellasoverridingthedecentralisationofpower embedded in the governance of the Nordic health care systems.

TheEuropeanConventionofHumanRights(ECHR)safeguardsthe individual’srights,alsoagainstmeasures that canbe invokedun- der publichealth epidemiclegislation, suchasfreedom of move- ment between and within countries [28]. Declaring a state of emergencymaybeawaytosidesteptheserights.

ForSweden,unlikeintheotherNordiccountries,declarationof a state of emergencylimitingthe individuals’liberty is not a le- galoptioninthecaseofapandemic.ThisisincontrasttoIceland wheredeclaration ofemergencyis aprecondition inorderto in- vokethehighestlevelofresponse inthecontingency plans.Both Finland andNorway chose to declare a state of emergency early on,eventhoughitisnot clearwhetheritwasanecessarycourse

of actionto implementmeasures taken. It is,however, clearthat theuseofemergencypowershaslimitedthedecentralisedpower embeddedinthehealthcaresystems,andinfringedpatientrights such astherighttotreatment withina specifictime frame.Den- markhasrefrainedfromitsusesofar.Theuseorabuseofemer- gencypowersareincreasinglysubjectofpublicdebate.

It has been argued that Norway andFinland have beenmore preoccupied with individual rights and constitutional aspects of thechosenpolicymeasuresduringthepandemic,althoughinDen- markandSwedensuchdiscussionshavealsosurfaced.Anotherex- planation forthedifferencesinuseofemergencypowersmaylie in the democratic tradition [18,26]. Even though a stronger tra- dition for the use of legislative measures might have a stronger foothold insome countriesthan others,it is not evident whyan external shock like a pandemic triggered so different legal re- sponses. Anotherexplanation might be differences in emergency preparedness, where civilpreparedness seems to have been less prominentonthepoliticalagendainSweden.

Effortstocoordinateoperationalandcapacityissues,aswellas implementation of measures acrossgovernment levels havebeen substantial; however, there have been some ongoing challenges, reflecting the broadly decentralised nature of the Nordic health systems’ function. Denmark, Iceland and Norway have all estab- lished formal coordination commissions for emergency crisis re- sponse,whichincluderelevantnational levelauthoritiesfromdif- ferentsectorsandotherrelevantstakeholders,inlinewithexisting emergencypreparednessplans.

Specialistadvisoryagenciesandexpertgroupsplayedastrongrolein thedecision-making,althoughwithvaryingdegreeoftransparency

Strategic decisions have been made at the national level by politicians, after consultation and advice presented by agencies andcommissions,withtheexemptionofSwedenwherethePublic Health Agency has been atthe centre of strategic decisionmak- ing.InNorway,theMinistryofHealthdelegatedthepowerstothe Directorate ofHealth until April 2020. Overall strategic goals are similaracrosstheNordic,emphasizingtheneedtoprotectvulner- able groupsandhospital resources inordertomaintainuniversal accesstocare.Inadditiontherehavebeenextensiveuseofadhoc expert advisory groups andevaluations. These groups mayfunc- tion asa supplementto the existing governance structures, per- haps indicatinga moregeneraltendencytoinitiate expertadvice toinformpoliticalconsensusprocessesasatoolofsupportforthe regularadministration.

Countriesfaceddifferentconditionsforpreventingtransmission

Another important factor to consider when comparing onset and spreadof the pandemic is the changingcriteria andvolume oftestinginthecountries.Inthefirstmonths,thetestingstrategy only targeted people withobvious symptoms andhealth person- nelatrisk,whereasintheautumntestingwasavailablefornearly all. Eventhough testing strategies were similar, capacitydiffered andcautionshouldbetakenincomparisonsbeforethesummerof 2020.

Rigorouscontacttracing,followedbyself-isolationandquaran- tinehavebeenparticularlystronginIceland,NorwayandFinland duringthepandemic.Theuseofemergencypowersensuredaccess torequirehotelsasquarantinefacilities.

Anumberofpre-existingfactorsandchosenresponsesdistinguished SwedenfromotherNordiccountries

SwedenhasbeenanoutlierintheburdenofCOVID-19mortal- ityandexcessdeathscomparedto theother Nordiccountries.As

thisanalysisshows,thereare differencesinthelegislative frame- works, which did not allow Sweden to declare a state of emer- gency,leavingthegovernmentwithfewerinstrumentstouseearly on.Inaddition,responsibilityforpandemicemergencyplanningis decentralisedtothe21regions,whereasintheotherNordiccoun- triesdecentralisedplansare governedby nationalplans.Thelevel ofdecentralisationlikelycontributedtolackofconsistencyandin- tensity ofresponse. One potential explanation is that fragmenta- tionanddiluted responsibilitiesbetweenlocal,regionalandstate authoritiesleftgapsintimesofacrisis,thatthegovernmentstrug- gledfillingfastenough,asexpertiseandanalyticalcapacityarelo- catedintheagencies.

OtherfactorscouldalsobeatplayinSweden.First,therehave beenreportsthatherd immunityhasbeenpursuedaspartofthe strategy ofhandlingthevirus in Sweden [23].While thegovern- mentandSPHAhasdeniedthis,herd immunitywasnevertheless seenasanoutcomeofwidesocietalspread,ratherthananofficial goal,the agency seemedto underestimate thespread ofthe dis- easeandthepotential tohaltthespreadthroughstrict measures.

Thiscould explain the authoritiesunwillingnessto seekwaysfor strongerimplementationofrestrictions,intheinitialphaseofthe pandemic.OtherNordiccountriessoughtstrictermeasuresofpre- venting the spread earlier, a more precautionary-based response of thedirect effects of the pandemic. It should be noted that in Sweden a temporary legislation passed in the spring 2020, em- poweredthegovernmenttoimposerestrictions,suchastemporary closureofshoppingmalls,butthegovernmentchosenottoinvoke it.Assuch, itwasapolitical(in)decision.Second,a largenumber ofCOVID-19fatalitiesoccurredamongresidents inlongtermcare settings,reflectingnotonlythehighinfectionratesingeneral,but alsostructural weaknessesinthis area (suchasthe highlevelof temporarystaff not eligibleforsickness benefits,larger-size insti- tutions,widespreadlackofPPEandguidanceonpossibilitytoban visitors)havehadanimpact[27].Finally,anotherearlystep,wasto abandoncontacttracinginthegeneralpopulation,whichisconsid- eredtobeanessentialtooltocontrolthespreadofthevirus[25]. Thiswasexplained by thelack ofresources to copewithtracing whentheincidencestartedrisingrapidlyinStockholmarea;how- ever,SPHAherebyputlessfocusoncontinuedtracinginotherre- gions,wherethenumberofcaseswasstilllow.

Conclusions

Therehavebeenanabundancyofresearchtryingtolinkpolicy measures and outcomes, less research on the overall governance andresilience of health systems orimpact of welfare system on theoutcome ofthe pandemic.The welfaresystems intheNordic countriesfunctionasasafetynetforthepopulation,ensuringless devastatingconsequencesandenableshighleveloftrust.

Ourfindingssuggest thatdespite themanysimilaritiesinpol- icymeasuresbetweenthefivecountries,therearealsointeresting differencesingovernanceoftheCOVID-19pandemic,andcleardif- ferencesinoutcomessofar.Thedifferencesingovernancemaybe linked to different explanatory models. Sweden and Finland dif- fer fromNorway andDenmark inthe degree of decentralization.

Iceland, Finland and Norway are relying more on the formal le- galization of measures than Denmark andSweden. This analysis ofgovernance isindicativeof morediverseresponses than antic- ipated,takenthecommonbackgroundandthecommonprepared- ness agreed upon in the Nordic council. This diversity in gover- nanceofhealthsystemsmightreflectmoregenericresponsemod- elsinstalledinthedifferentgovernments.

A commonfeature for Denmark,Finland, Icelandand Norway is the extensiveuse of expertadvice in and outsidethe special- istagenciesbythepoliticalleadersofthecountry,andrelianceon a numberofinternal coordination forabetweenministries, agen-

ciesandotherrelevantpublicauthoritiestofacilitateaconsensus- baseddevelopmentofpolicy measures.Sweden,onanotherhand, seems to have relied on technical expertise of the public health agency,withpoliticiansdistancing fromthe decision-makingpro- cess. Whileregional/localauthoritiesinDenmark,Finland,Iceland andNorway formally havethepowerto implementstricter mea- sureswhendeemednecessary,thisisusuallycoordinatedwithor evenimposedbythenationallevel.Swedishregional/localauthori- tiesinpracticehavemorediscretiontodecideandimplementpol- icymeasuresundertheguidanceofSPHA.

It also seems plausible that a numberof other structural and circumstantial factorshaveplayedan importantrole invariations in outcomes across the Nordiccountries. In particular, it is rele- vanttofurtherexploretheimportanceofhousingconditions,pop- ulation density,and behaviour inparticular populationgroups as potential explanatoryfactors.BothDenmark,Finland,Norwayand Swedenhaveseenhighincidenceratesamongmigrantpopulations andtemporarymigrantworkers.ItshouldbenotedthatbothDen- mark and Sweden managed to curb high levels of infections in thepopulationwithoutenforcingatotallockdownaftertheinitial phase.

Finally, there is a need to call forcaution for when andhow exceptionalemergencypowersareinvoked.Denmark,Finland,Nor- wayandSwedenhaveallappointednationalcommissionstoeval- uatetheentirecourseoftheCOVID-19crisis.Thecommissionsare setuptoevaluatethepreparednessforandhandlingoftheCOVID- 19pandemicaswellastoreportontransparencyofpolicies.Itisa goodtimetoquestionhowthehandlingoftheCOVID-19epidemic willinfluencefuturecommunicablediseasecontrollegislationand whetherthecurrentcrisishavealastingimpactonthekeyprinci- pleofgovernanceintheNordiccountries.

The findingsherearebased onananalysisoftheearly stages, andcautionmustbetakenintheinterpretationoftheresults.They do howeverpoint to importantfeatures of thehealth systems in theNordiccountries.ItwouldbeofinteresttocomparetheNordic countries’responsetootherwelfareorhealthsystems,suchasthe UK orGermany,the statesofNewEnglandorKaiser Permanente intheUS,thelattertwobeingmoreofacomparablesize.

Furtherresearchisnecessarytodeterminethedegreetowhich respective populations complywith the recommended measures.

Eventhoughtheavailabilityofcomparabledatawithinandacross thecountriesaregoodintermsoftesting,incidencerates,mobility andoutcomes(COVID-19-related, aswell astotalmortality),little isknownonhowcompliantthepopulationisinfollowingthead- viceandregulations.

DeclarationofCompetingInterest None.

Funding

This work waspartly supported by the European Observatory onHealthSystemsandPolicies,Brussels,Belgia.

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