2 A strengthened system for health emergency preparedness

Health emergency preparedness shall protect lives and health in extraordinary events of varying nature and duration and ensure the provision of essential health services during times of crisis and war. Health emergency preparedness is far more than the emergency medical activities that take place in everyday life within the municipal health and care services and specialist health services. For instance, the Norwegian Food Safety Authority, the Norwegian Institute of Public Health, the Norwegian Radiation and Nuclear Safety Authority and the municipalities are tasked with protecting us against health threats from food and the environment and also manage incidents in these areas. A broad range of agencies and service providers is therefore essential for good health emergency preparedness.

Evaluation reports following major crises in Norway have repeatedly found that the health and care sector has largely handled crises well. The health sector’s handling of the terrorist attacks against the Government Quarter and Utøya on 22 July 2011, and its handling of the COVID-19 pandemic are examples of this.1 It has been emphasised that the capacity for prioritisation, flexibility and adaptation is crucial for the success of the health sector. In part two of its report, the Coronavirus Commission writes as follows: “Cooperation, flexibility, adaptability and the ability to act were crucial to achieving good results.” Saving lives, protecting health and caring for each individual are fundamental parts of the health service. These services are accustomed to taking action and finding creative ways to achieve their objectives.

Good systems in everyday life enable us to also function well in a crisis. This is why we must be cognisant of security and emergency preparedness on a daily basis. Emergency preparedness must be integrated into all parts of the health sector in the broadest sense and included in everyday work. It is crucial to develop and maintain a health emergency preparedness system that is sufficiently resilient and flexible in the face of both major and minor crises. In the revision of the national health emergency preparedness plan2, the Ministry will emphasise the importance of strengthening cooperation in crises that could affect the health sector. The importance of a stronger ability to act, prioritise, adapt and be flexible in the sector’s emergency preparedness planning and handling of extraordinary events will also be emphasised.

No matter how thorough our emergency preparedness efforts, we cannot predict or eliminate all risk. This is something we must help the population to accept. At the same time, we must develop resilience against both known and unforeseen threats through robust and flexible systems. Health emergency preparedness involves setting priorities both in everyday life and during times of crisis. What scenarios we choose to base our emergency preparedness on is a matter of prioritisation. Thus, it is a policy matter. Ensuring compliance with the requirements for emergency preparedness is also a political responsibility. In the healthcare service, priorities must be made every day. A crisis such as COVID-19 tests the health service and requires strict prioritisation. In major crises, consideration for the individual will be weighed against considerations for the community. This also includes weighing costs and benefits across sectors.

Good cross-sectoral cooperation

The pandemic demonstrated that measures taken to control an incident or threat can have broad societal consequences and require coordination between multiple sectors. The Coronavirus Commission and the Coronavirus Special Committee highlighted the weaknesses of cross-sectoral cooperation, not least in connection with comprehensive assessments. This applied, in particular, to assessments of risk and vulnerability, and to the consequences of cross-sectoral measures. The health sector’s crisis management requires cooperation with other sectors and is part of the system for cross-sectoral crisis management. Incidents primarily occurring in the health sector can have serious consequences for multiple sectors, simultaneously.

The basis for good cross-sectoral coordination in a crisis is formed through good structures for cooperation on a daily basis. Through the measures presented in this report, the Norwegian Government will strengthen both health emergency preparedness efforts within its own sector and contribute to better cross-sectoral coordination. The Norwegian Government will also present a Report to the Storting on total preparedness in 2024, where cross-sectoral work will be key.

Emergency preparedness principles

Civil protection measures are based on the four emergency preparedness principles of responsibility, similarity, proximity and collaboration. The principle of responsibility entails that the organisation with responsibility for an area during normalcy will retain this responsibility during a crisis. The principle of similarity entails that organisation in crises should be as similar as possible to the normal organisation. The principle of proximity entails that crises shall be organisationally managed at the lowest possible level. The principle of collaboration entails that authorities, enterprises and agencies each have an independent responsibility for ensuring that they collaborate with relevant actors and enterprises on prevention, planning and crisis management. The Norwegian Government will apply these four principles for future health emergency preparedness in Norway.

Relationship with the Parliament

The rapid and efficient handling of health crises can be decisive for the protection of lives and health and for the maintenance of critical societal functions. Time criticality implies that in such crises, it may be necessary to introduce measures through the Norwegian Government’s power to issue provisions. It should be assessed how the Parliament (Storting) can be involved in such situations after the Norwegian Government has introduced intrusive measures. The Norwegian Government will conduct a review of legislation related to infection control and health emergency preparedness and aims to submit proposals for legislative amendments in the spring of 2025.

The Norwegian Government will regularly inform the Storting of efforts to strengthen health emergency preparedness, preferably in the context of the Report to the Storting on total preparedness and the long-term plan for the defence sector. The Norwegian Government will also provide an account of the status of emergency preparedness work in the health and care sector and respond about measures and follow-up points.

2.1 Organisation of civil protection efforts

The Norwegian Government has the ultimate responsibility for emergency preparedness in Norway, including the overall political responsibility for managing and handling crises. The Norwegian Government shall provide good strategic management, balancing various societal interests. Cross-sectoral coordination will be crucial, and it will often be necessary to make decisions quickly. The Norwegian Government’s Security Committee is the highest body for the consideration of matters of a security policy or emergency preparedness nature.

The government ministries that are responsible for a sector during normalcy will also be responsible for emergency preparedness planning and measures during a crisis situation. In the event of a crisis, the government ministries shall coordinate with one another, in particular the government ministry designated as lead ministry.

The Crisis Council is the highest administrative coordinating body at the government ministry level. The Crisis Council’s main function is to conduct strategic assessments, ensure the coordination of measures in various sectors, and make sure that issues requiring political clarification are quickly presented to the ministries’ political leadership or the Norwegian Government. The Crisis Council is a key participant in the discussion and anchoring of overall emergency preparedness and crisis management challenges and in the review of relevant incidents and exercises.

The Lead Ministry is responsible for coordinating crisis management at the government ministry level. The Ministry of Justice and Public Security is the permanent lead ministry for national civil crises, unless otherwise determined.

The Crisis Support Unit shall provide support to the lead ministry and the Crisis Council in its crisis management, as needed. The Crisis Support Unit is the secretariat for the Crisis Council. The Crisis Support Unit also supports the coordinating role of the Ministry of Justice and Public Security in the area of civil protection.

County governors are responsible under the Local Government Act for coordinating state supervision of municipalities and county authorities. The county governor is the link between the local and national levels, with responsibility for coordinating civil protection and emergency preparedness, including health emergency preparedness, in the county. The county governor shall, through facilitation and guidance, contribute to ensuring that regional and local agencies establish plans as part of a coordinated planning system.

Under the Regulations on municipal emergency preparedness duty, municipalities are responsible for ensuring that they are prepared to manage undesirable events, and to provide assistance in the event of accidents or other emergency situations. Furthermore, based on a comprehensive risk and vulnerability analysis, each municipality shall prepare an overall emergency preparedness plan which shall be practiced every two years.

2.2 Organisation of health emergency preparedness

The Ministry of Health and Care Services has the national responsibility for health emergency preparedness. The Ministry is responsible for regulating municipal, state and private activities through legislation, supervision, budget and grant administration, management and organisation, as well as through managing the public administration and regional health authorities. The safeguarding of critical societal functions is a prerequisite for good civil protection. Responsibility for these functions is divided between the government ministries.

The Ministry of Health and Care Services is responsible for the critical societal functions of heath and care and water. With respect to national security, the Ministry is also responsible for the basic national functions of health emergency preparedness and the secure supply of safe drinking water, as well as the Ministry of Health and Care Services’ activities, room for maneuver and decision-making capability.3 The Ministry also coordinates measures and communication with other government ministries concerned.

A number of subordinate agencies have comprehensive and important health emergency preparedness tasks, both on a daily basis and during crises. The key agencies are the Norwegian Directorate of Health, the Norwegian Institute of Public Health, the Norwegian Radiation and Nuclear Safety Authority, the Norwegian Pharmaceutical Agency (Medical Products Agency from 1 January 2024), the Norwegian Food Safety Authority, the Norwegian Health Network and the four state-owned regional health authorities. The organisation of the central health administration will change in some areas from 1 January 2024, cf. Proposition to the Storting No. 1 (2023–2024) Ministry of Health and Care Services. In keeping with the principles of emergency preparedness, the organisation will make corresponding adjustments to the health emergency preparedness tasks for these agencies.

The four state-owned regional health authorities and the municipalities must ensure that the population is offered specialist health services and municipal health and care services, respectively, both during normalcy and in crises. They shall prepare emergency preparedness plans for the services they are responsible for, including plans for input factors and critical infrastructure needed for providing such services on a daily basis and during crises.

Zoom in on image

Source: Ministry of Health and Care Services.

The national health emergency preparedness plan provides a comprehensive account of the organisation of health emergency preparedness, including the tasks and responsibilities of various agencies and enterprises.4 The national health emergency preparedness plan will be revised following the Storting’s consideration of this Report.

2.2.1 New health emergency preparedness model

Experiences from the pandemic, and increasingly complex and demanding risk and threats, necessitate changes to the organisation of health emergency preparedness. Well-functioning health emergency preparedness and crisis management require unambiguous and clarified lines of responsibility and reporting. As a rule, general responsibilities will form the basis for responsibilities during a crisis. The organisation of activities and responsibilities during crises should be as similar as possible to everyday organisation.

To ensure better strategic management and coordination in the health sector’s work on security, emergency preparedness and crisis management, the Norwegian Government is establishing a new model for health emergency preparedness work on a daily basis and during crises. This will not alter established systems across sectors. Rather, it shall improve work within the health and care sector. The purpose of the model is to strengthen compliance with the requirements for the government ministries’ work on civil protection as set out in the Civil Protection Instructions, section IV.5

The new health emergency preparedness model reflects the Minister of Health and Care Service’s constitutional responsibility. This model will not alter authority and reporting lines. The Ministry of Health and Care Services will lead the sector’s emergency preparedness work through ordinary agency and corporate governance. Through agency governance, the Ministry shall ensure that the authority of subordinate agencies is clearly specified. This will be reflected in a revised version of the national health emergency preparedness plan. The model is based on the emergency preparedness principles. Incidents shall be managed in accordance with the principles of responsibility, proximity, similarity and collaboration. Matters of significance shall be considered by the King in Council, cf. Article 28 of the Norwegian Constitution.

In the health and care sector, there has been a practice of delegating the national coordination of the health sector’s efforts during crises and for implementing the necessary measures at the state level to the Norwegian Directorate of Health. Such delegation has entailed that, during crises, the Directorate has been authorised to coordinate the health sector and carry out tasks it does not have during normalcy. One example of this is the task of coordinating the specialist health service, the governance of which is not the Directorate’s responsibility.

The new health emergency preparedness model replaces the current practice of delegating authority to the Norwegian Directorate of Health. This means that it is the Ministry of Health and Care Services, and not the Norwegian Directorate of Health that shall coordinate the sector’s management of major, sector-wide and cross-sectoral crises. Decisions will be made along the ordinary line according to the principles of responsibility and proximity and based on recommendations from agencies and specialist environments, where relevant.

In the revision of the health emergency preparedness and infection control legislation, the Norwegian Government will assess whether the roles and responsibilities of the various agencies and organisations are clearly and appropriately defined. The pandemic demonstrated, among other things, that the legislation did not sufficiently take into consideration events that could develop into long-term national crises.

The new model shall:

• ensure and strengthen the strategic management of security and emergency preparedness on a daily basis and during crises

• clarify leadership

• facilitate increased cooperation within and across sectors

The model involves the establishment of structures that shall support the government ministry, agencies and enterprises in crisis management, as well as in everyday follow-up of risk and vulnerability assessments, the implementation of exercises, and the coordination of planning and other civil protection work. The following shall be established:

• A Health Emergency Preparedness Council

• A Health Emergency Preparedness Secretariat

• An Advisory Expert Committee for Health Crises

• Committees for Prioritised Risk Areas

The Health Emergency Preparedness Council6

Over time, the Norwegian Government has assumed a stronger and clearer management of crises, and the Ministry of Health and Care Services has elevated crisis management in the health sector to the ministerial level. Developments towards an increasingly complex society with growing national and international dependencies reinforce the need for stronger political governance. This means that the Ministry, to a greater extent than before, must assume a stronger political and strategic management of health emergency preparedness through greater overall involvement in the day-to-day work.

In order to strengthen the strategic management of security and emergency preparedness work in the health and care sector, the Ministry of Health and Care Services is establishing the Health Emergency Preparedness Council. The Health Emergency Preparedness Council is an emergency preparedness and crisis management tool for the Ministry of Health and Care Services, which will also chair the Council. The Council shall facilitate better safeguarding of cross-sectoral and interdisciplinary perspectives in health emergency preparedness work. The Ministry of Health and Care Services will use the Health Emergency Preparedness Council in its strategic management of security and emergency preparedness work in the health sector on a daily basis and during crises. The establishment of the Health Emergency Preparedness Council will not involve changes to the ordinary crisis management system at the central level, cf. the Civil Protection Instructions. The Ministry of Health and Care Services will continue to ensure coordination with the lead ministry and other ministries.

The Health Emergency Preparedness Council on a daily basis and during crises

On a daily basis, the Ministry of Health and Care Services will use the Health Emergency Preparedness Council in its work to establish systems and frameworks for security and emergency preparedness work in the sector. This particularly involves work on risk and vulnerability assessments, measures to reduce vulnerabilities and to prevent and secure basic assets, crisis scenarios, competence and exercise plans, and follow-up of lessons learned. The Ministry of Health and Care Services will use the Health Emergency Preparedness Council to ensure common planning assumptions and priorities, contribute to cohesive plans for the sector, and clarify roles and responsibilities in the health sector’s work on security, emergency preparedness and crisis management. As needed, and at least once every four years, there shall be a comprehensive risk and vulnerability assessment and emergency preparedness analyses for health emergency preparedness where the various risk areas are viewed in context.

Scenarios shall be prepared on the basis of identified risks and vulnerabilities. Analyses and scenarios are the starting point for assessing current preventive and risk-reducing measures, and for planning the need for handling of residual risks. According to the Civil Protection Instructions, the Ministry of Health and Care Services is responsible for creating a comprehensive analysis for its own sector, and on this basis, assess the revision of common planning requirements for health emergency preparedness. Overall planning assumptions and criteria for acceptable risk will be discussed in the Health Emergency Preparedness Council. Decisions will be made by the Ministry of Health and Care Services or by the Norwegian Government through ordinary decision-making processes and in dialogue with other government ministries. Expectations and requirements that affect multiple sectors, such as pandemics and nuclear emergency preparedness, will be coordinated with other government ministries and reviewed by the Norwegian Government.

The Health Emergency Preparedness Council shall actively use exercises and training to enhance competence and strengthen crisis management skills. The Ministry of Health and Care Services will determine a multi-year, strategic training exercise plan for national health emergency preparedness exercises to ensure predictability, participation and targeting. This training exercise plan shall complement and be coordinated with the exercise plans of other government ministries. The Ministry will ensure the preparation of a targeted competence enhancement for health emergency preparedness in the health and care sector. The purpose of the competence enhancement is to increase competence within the area of health emergency preparedness at the state and municipal levels. Arrangements shall be made for cross-sectoral participation.

All events and exercises shall be evaluated. Lessons learned from events and exercises are important for improving the capacity to manage future events. Evaluation and implementation of lessons learned is an important part of the systematic and comprehensive emergency preparedness work. The Health Emergency Preparedness Council shall ensure that lessons learned have been registered, and that they contribute to the sharing of experiences and learning in each sector and with relevant actors in other sectors.

In crises that affect the sector, the Health Emergency Preparedness Council’s main tasks will, among other things, be to ensure a common understanding of the situation in the health and care sector, and to ensure the rapid and coordinated implementation of measures in its own sector. The Council shall help to clarify the correct decision-making level when needed, identify challenges or bottlenecks, contribute to coordination and joint prioritisation, and ensure the mobilisation and efficient utilisation of resources in the sector. The Council shall discuss strategy and crisis management and assess the need for adjustments along the way by providing advice in ordinary decision-making processes.

Composition and decision-making structure

In addition to the Ministry, the Council’s permanent members shall consist of the heads of the subordinate agencies, which include the Norwegian Directorate of Health, the Norwegian Institute of Public Health, the Norwegian Radiation and Nuclear Safety Authority, the Norwegian Pharmaceuticals Agency (Directorate for Medical Products from 1 January 2024), the Norwegian Food Safety Authority, as well as the Norwegian Health Network and the four state-owned regional health authorities.

Such a structuring is in line with how the Ministry of Health and Care Services in practice coordinated the pandemic management within its own sector at the state level, and how it leads emergency preparedness activities in the health sector related to the war in Ukraine. County governors shall participate in the Council with one representative to ensure that the municipality perspective is taken into account.

The establishment of the Health Emergency Preparedness Council shall ensure clear and predictable coordination in the sector. In addition to the permanent members, the composition of the Health Emergency Preparedness Council shall be flexible based on needs, both in everyday life and during crises. Other agencies, municipalities and organisations may be invited to participate, as needed. It is the responsibility of the various participants in the Health Emergency Preparedness Council to ensure that the municipal perspective is included in the Council’s work.

The Health Emergency Preparedness Council shall facilitate a comprehensive approach across agencies, health authorities and specialist areas in the health sector, and will provide a better overview and utilisation of the overall resources in the sector than the current model.

Relevant decisions shall be made by the responsible authority. In accordance with Article 28 of the Norwegian Constitution, matters of significance are referred to the King in Council. Decisions are made in line with the emergency preparedness principles and management lines during normalcy. Similar to the practices during the pandemic, it is the Ministry of Health and Care Services that makes decisions on nationally determined infection control measures based on the Infection Control Act It shall continue to be the government ministry that brings before the King in Council matters that trigger the government authorisation provisions of the Health Preparedness Act, and then makes decisions on any application of the government authorisation provisions.

Establishment of the Health Emergency Preparedness Council for the health and care sector does not entail changes to the responsibilities of the agencies in the health administration. Participating enterprises shall continue to perform their duties and make decisions in line with their authorities in accordance with legislation and regulations, or as described in relevant plans.

The Health Emergency Preparedness Secretariat

In order to strengthen the work on national coordination and interaction in health emergency preparedness, the Ministry of Health and Care Services will establish a Health Emergency Preparedness Secretariat. The Secretariat shall provide secretariat functions for the Health Emergency Preparedness Council, in addition to secretariat functions for the Advisory Expert Committee for Health Crises, cf. the section on an advisory expert committee. The Secretariat will be operational during normalcy and in crises.

The Ministry shall chair the Secretariat and will have staff seconded from the subordinate agencies. In times of crisis, underlying agencies will also have liaisons in the Secretariat. Having subordinate agencies participate in the Secretariat ensures involvement and coordination and prevents the distance between the Ministry and subordinate agencies from becoming too wide. Relevant ministries may also be invited to participate in the Secretariat in everyday work and during crises. Such participation will contribute to strengthening cross-sectoral cooperation at the ministry level. The Ministry of Health and Care Services, in close cooperation with the lead ministry and other affected ministries, will ensure good coordination between the Health Emergency Preparedness Secretariat, the Crisis Support Unit and other affected actors, depending on the nature of the crisis and the needs that arise.

Six committees at the agency level

There is a need for cooperation and coordination at the agency and health authority levels, both on a daily basis and during crises. The various risk areas that the health and care sector faces will affect different parts of the health administration and health and care services and, to varying extents, agencies in other sectors. In some areas, such as cross-sectoral nuclear and radiological emergency preparedness, civil-military cooperation and the secure supply of safe drinking water, there is a formal responsibility also outside the Minister of Health and Care Services’ constitutional responsibility that must be ensured.

The Ministry of Health and Care Services will establish a committee for the particular risk areas that have been identified for health emergency preparedness within the Minister of Health and Care Services’ constitutional area of responsibility. For some of the risk areas, corresponding committees have already been established, such as the Crisis Committee for Nuclear Preparedness, the Committee for Civil-Military Health Emergency Preparedness Cooperation7 and the Preparedness Committee for Biological Incidents. The mandate of the Crisis Committee for Nuclear Emergency Preparedness is established by Royal Decree and will be reviewed in consultation with the government ministries concerned, cf. Chapter 4.6. This Committee will therefore not be described in greater detail here. The Ministry of Health and Care Services, in cooperation with the relevant ministries and subordinate agencies, will establish mandates for the other committees that elaborate and specify roles and responsibilities. The relationship with, and delimitation in relation to the coordination mandates of the Ministry of Justice and Public Security and the Norwegian Directorate for Civil Protection, instructions for the county governors’ and the Governor of Svalbard’s work on civil protection, emergency preparedness and crisis management, as well as the Regulations on municipal emergency preparedness duty, shall be taken into consideration in the preparation of the mandate.

Each individual committee will be chaired by the responsible agency, and each agency is responsible for cross-sectoral anchoring. Participating sectors and agencies in the committees shall be reflected in the mandates. Arrangements shall be made for cross-sectoral participation. Municipalities and county governors shall be able to appropriately contribute and participate.

The committees shall facilitate more systematic and coordinated work on analyses, scenarios and planning – both internally in the health administration and across sectors. In addition to management at a strategic level, it will be necessary to ensure meeting places where specific work is carried out on designing scenarios as a basis for preventive security and emergency preparedness planning.

The committees shall contribute to ensuring that different sectors gain a common understanding of risk, and that the different sectors contribute the emergency preparedness analyses and coordinate the various sector plans. Participation in committees implies an expectation for the participating enterprises to coordinate prevention and emergency preparedness. This will facilitate emergency preparedness and coordination efforts by the authorities, various specialised bodies, the voluntary sector and the business sector, as the cooperation enables actors and resources to find one another and jointly solve the tasks. The model shall be flexible and reflect the current vulnerability and risk assessment. This means that the structure and composition of committees can be adjusted as needed.

The establishment of these committees will not entail any changes to the responsibilities of the agencies, nor will it alter the coordination functions that have already been established for national crisis management. The purpose of the committees is to strengthen cooperation and coordination in preventive and operational emergency preparedness efforts. Participating agencies and enterprises shall continue to perform their duties and make decisions in line with their authorities in accordance with legislation and regulations, or as described in relevant plans.

The committees on a daily basis

A key task for the committees on a daily basis will be to contribute to the updating and coordination of the emergency preparedness plans, and to account for the prerequisites for plans that will apply to each risk area. Important tasks will be linked to risk and vulnerability analyses, contributions to the preparation of scenarios, emergency preparedness analyses and joint prerequisites for plans, as well as the implementation of exercises.

Committee leadership shall be determined along ordinary management lines. The Ministry of Health and Care Services will task the affected agencies with establishing committees for the particular risk areas that have been identified for health emergency preparedness. Each responsible agency will report to the Ministry of Health and Care Services. The Health Emergency Preparedness Council will be the arena for coordinating the work in the committees to ensure a common framework as a basis for prerequisites for plans, scenario definitions and emergency preparedness and exercise plans.

The committees during crises

The committees can play a role during crises by contributing to good cross-sectoral assessments of measures and consequences in different sectors, ensuring good resource utilisation across crises, and by contributing to good decision making at the correct level in the responsible sectors in the established coordination mechanisms. The committees can help to systematise the competence and work with socioeconomic assessments and ensure a broader cross-sectoral basis for assessments and priorities in emergency preparedness and crisis management efforts. In the event of a crisis, the committees will be able to function as a coordinating body between the agencies and contribute to the coordination of risk assessments and advice the government ministries. The committees shall support the responsibilities of the individual enterprise to assess the effects of measures beyond their own enterprise and be prepared for the possibility that plans must be made in a crisis situation that take social impact into account.

The committees:

• The Committee for Civil-Military Health Emergency Preparedness Cooperation will build on the current committee, cf. point 4.1. This Committee will continue to be chaired by the Norwegian Directorate of Health, with the Norwegian Armed Forces as permanent deputy chair.

• The Committee for Cyber Security will be a newly established committee chaired by the Norwegian Directorate of Health, cf. section 4.2.

• The Committee for Security of supply of Medical Products will be a further development of the National Pharmaceutical Emergency Preparedness Council, where medical devices must also be ensured, cf. section 4.3. This Committee will be chaired by the Medical Products Agency.

• The Committee for Infection Control builds on and will be a development of the current Emergency Preparedness Committee for Biological Incidents, cf. section 4.4. This Committee will continue to be chaired by the Norwegian Directorate of Health.

• The Committee for safe Water Supply will be a newly established committee led by the Norwegian Food Safety Authority, cf. section 4.5.

• The Crisis Committee for Nuclear Emergency Preparedness chaired by the Norwegian Radiation and Nuclear Safety Authority is continued, cf. the discussion on nuclear emergency preparedness in Chapter 4.6.

Advisory Expert Committee for Health Crises

Interdisciplinary expert assessments that assess strategies and crisis management are crucial in order to achieve comprehensive assessments where broader societal considerations are safeguarded. The responsibility for comprehensive assessments of societal and cross-sectoral consequences rests with the decision-making authority. These assessments often require interdisciplinary competence, including socioeconomic and legal assessments in addition to health-related competence and competence in the area affected by the measure.

The COVID-19 pandemic showed how intrusive measures, in what was initially a health crisis, can have major and adverse consequences for most areas of society. During the pandemic, an Expert Committee was established for socioeconomic assessments of infection control measures to investigate how the adverse economic consequences of current infection control measures could be reduced through better targeting of the measures. The Advisory Expert Committee issued a total of four reports.8 The Committee’s analyses and reports formed part of the Norwegian Government’s decision-making basis when assessing the introduction of measures, and when selecting between different measures.

To ensure a better knowledge base for managing crises that broadly affect society, and especially where comprehensive interdisciplinary assessments are necessary, the Ministry will establish a mechanism for the establishment of an Advisory Expert Committee for Health Crises.

The Expert Committee will not have continuous tasks in everyday emergency preparedness work but will instead be established as needed in crisis situations. The need to activate the Expert Committee will be assessed by the Ministry of Health and Care Services in consultation with the Health Emergency Preparedness Council, the lead ministry and other affected ministries, potentially upon clarification by the Norwegian Government. The composition of, and the reporting lines to one or more expert committees will be determined by the affected ministries and, if necessary, by the Norwegian Government. The Ministry assumes that activation of the Expert Committee will be relevant in the management of national infection control incidents, but also for other extraordinary incidents of a certain scope and duration.

The Expert Committee has been included in the model for health emergency preparedness. This mechanism shall be linked with the overall work on civil protection for which the Ministry of Justice and Public Security is constitutionally responsible. There must be flexibility to ensure that composition and reporting procedures are in accordance with the overall civil preparedness efforts.

Appointment of the Expert Committee, including which areas of expertise will be represented, will depend on the specific crisis that has arisen. The Ministry of Health and Care Services will use the Health Emergency Preparedness Secretariat to facilitate a rapid establishment of the Expert Committee. Competence that may be important to the Committee includes medical, health economic, socioeconomic, legal and ethical competence. In its work, the Expert Committee should also obtain assessments from county governors, municipalities, the Norwegian Association of Local and Regional Authorities (KS), specialist health services, non-profit actors, voluntary organisations and the business sector, which can describe how the crisis affects various sectors and assess the consequences of relevant measures.

The Expert Committee will ensure greater access to knowledge resources and contribute to a broader knowledge base in crises, including socioeconomic assessments of current infection control and emergency preparedness measures. The Expert Committee will be useful for highlighting uncertainty and disagreements related to various measures.

The main tasks of the Expert Committee in crisis management are as follows:

• Investigate and perform comprehensive assessments for a broader knowledge base for the strategy and management of crises that fall within the Minister of Health and Care Services’ constitutional area of responsibility.

• Maintain contact with knowledge environments to draw on broader competence and greater resources for analyses.

• Conduct socioeconomic analyses of infection control and emergency preparedness measures and investigate how adverse consequences of measures can be reduced through better targeting of the measures.

• If necessary, set up specific thematic groups to cover the key needs for knowledge (for example, modelling groups).

2.3 Municipalities and county governors

The municipalities’ work on emergency preparedness and protection against health threats

Strong municipal health and care services are the basis for sound health emergency preparedness and therefore crucial in reducing the adverse consequences of such crises. The municipalities are responsible for protecting their residents against health threats, and ensuring that municipal residents are offered the necessary health and care services, including in crises.

Common planning assumptions that form the basis for comprehensive health emergency preparedness also apply to the municipal sector. According to the Health Preparedness Act, municipalities are responsible for developing emergency preparedness plans for health and care services and tasks covered by the Public Health Act’s provision on environmental health care. In the upcoming revision of the Health Emergency Act and the Infection Control Act, the rules relating to requirements for emergency preparedness plans will also be considered. The Regulations relating to health emergency preparedness stipulate that actors’ emergency preparedness plans shall be based on assumptions for planning issued by the Ministry of Health and Care Services. The Norwegian Government will facilitate specialist support for the municipalities’ work on health emergency preparedness and ensure that municipal perspectives are taken into consideration in the development and determination of common planning assumptions. The committees shall facilitate that the municipalities’ experiences and perspectives are included in the work on risk areas, cf. the discussion on committees at the agency level in section 2.2.1.

In order to facilitate common frameworks and an understanding of any national measures in the event of a health crisis, the Minister of Health and Care Services will arrange regular dialogue meetings with county governors and the municipalities on the status of the health emergency preparedness work. This dialogue is intended to build a foundation for cooperation during crises that affect health.

Health emergency preparedness in Norway has an advantage in that much of the responsibilities, competence and means are at the municipal level. Knowledge of local conditions provides a more targeted and adjusted management of incidents and crises close to those who are affected, as well as the opportunity for flexibility and adaptability in the response. During the COVID-19 pandemic, the municipalities exerted an exceptional ability to mobilise resources for, among other things, contact tracing, vaccination and adjustment of activities and services to limit infection and safeguard residents. In the development of health emergency preparedness, it is important to ensure the role of the municipalities.

Textbox 2.2 Municipal chief medical officers were crucial in the management of the pandemic

During the COVID-19 pandemic, initiatives were adopted both nationally and locally by the country’s municipalities. Municipal chief medical officers had a key role in communicating and implementing national measures in the municipalities, and in assessing, recommending and following up local measures. Both local knowledge and community medicine competence were utilised in this effort.

Part 2 of the Coronavirus Commission’s report emphasised the decisive role that municipal chief medical officers had in managing the pandemic.

Zoom in on image

Photo: Bjørn Lønnum Andreassen, Frøya.no.

The municipalities require sufficient community medical competence, as well as additional competence on infection control, environmental health protection and radiation protection, in order to protect residents against health threats. Capacity and competence for planning and management are also required. There is considerable variation in the size of municipalities in Norway. It can be challenging for individual municipalities to ensure sufficient capacity and competence to prevent and manage health threats.

The situation of the municipalities and municipal chief medical officers was separately assessed by the Coronavirus Commission in part 2 of their report.9 In their Public Health Report, the Government announced that it will considered how the municipalities’ community medical responsibilities can be ensured through inter-municipal solutions, as well as measures to strengthen the community medical expertise of municipal chief medical officers.10 In accordance with the recommendations from the Coronavirus Commission, the Norwegian Government will clarify the capacity, availability and tasks related to the municipal chief medical officer’s role. There must be plans for continuous staffing and for scaling up community medicine capacity for events that require greater resources over time. The Ministry of Health and Care Services has ordered the Norwegian Directorate of Health to develop a national guide for the community medicine tasks of the municipalities and for the tasks and role of the municipal chief medical officer. This will also apply in the event of other threats to life and health. This guide will contribute to clarifying the expectations of municipalities in this area.

Municipal infection control efforts require measures that may impact many sectors of a municipality. Infection control and emergency preparedness for other health threats shall be better integrated into the municipality’s cross-sectoral public health work and emergency preparedness than it is today. Among other things, the need for amendments to relevant legislation including the Health Preparedness Act, the Infection Control Act and the Public Health Act will have to be considered.

The municipal chief medical officer’s function is described in more detail in the white paper on Public Health.11

The county governor as a link and coordinator in health emergency preparedness

The county governor shall contribute to coordinating, simplifying and streamlining state activities in the county. County governors shall take the initiative for coordination in the county in relation to other state enterprises and other actors where relevant, to ensure that national goals are achieved across levels and sectors, and to ensure the coordination of the state’s governance of the municipalities.12

County governors shall contribute to implementing national policies in the area of health emergency preparedness. This involves, among other things, informing municipalities and other actors of what regional planning prerequisites that have been established, which set the premises for municipal health emergency preparedness. Furthermore, county governors shall provide the municipalities with professional support and contribute to ensuring that the municipal sector and central authorities are coordinated in the work on protection against health threats and crisis management.

The pandemic highlighted the central role of county governors as a link between central authorities and the municipal sector. This applied to the collection and coordination of information on the management and challenges of the pandemic in the municipalities, as well as the dissemination of information from central authorities on implemented measures and the coordination between the county’s municipalities. In the work on health emergency preparedness, the Norwegian Government believes it is important to strengthen and further develop the county governor’s role as an initiator and link between the state and municipality. This shall be done by including a representative among the county governors in the Health Emergency Preparedness Council. Furthermore, an annual health emergency preparedness meeting will be arranged between the Ministry of Health and Care Services and the county governors, which is intended as an arena for the mutual exchange of information.

County governors are assigned a coordinating role between state authorities and the municipal sector in health emergency preparedness efforts. It will therefore be essential for them to understand and familiarise themselves with the municipalities’ situations, challenges and needs. Furthermore, all participants in the Health Emergency Preparedness Council shall ensure that the municipal perspective is included in their work. As a coordinating body in the emergency preparedness efforts, it is essential that county governors ensure that the flow of information and involvement is of such a nature that it is perceived as mutual. It is emphasised that county governors have a particular responsibility to ensure that the challenges faced by municipalities reach the central authorities, including the different perspectives emanating from the diversity of municipalities in Norway.

2.4 Strengthening our knowledge and knowledge-based management during crises

Good emergency preparedness requires strong professional environments and effective systems for monitoring, analyses and risk assessments as a basis for scenarios, planning work, crisis management and learning. In its first report, the Coronavirus Commission described the need to strengthen health emergency preparedness through improved infrastructure for sharing information and better capacity for monitoring and knowledge production. Insufficient information flow between digital solutions during the pandemic contributed to additional work, inefficient processes and manual processing. The Holden IV Committee also highlighted the need for quick and precise information as a basis for crisis management.

The Norwegian Government is working to establish an effective knowledge system with a focus on structures that are used in everyday life, and that are flexible and can be scaled up in a crisis. This includes comprehensive and efficient systems for collecting data, such as registers, population surveys, measuring equipment, laboratories, national common components and international reporting systems, etc. This also applies to technological systems for the linking and delivery of data, such as common platforms, standards etc. Legal clarifications of what can be linked, both in everyday life and during crises, are essential. Increased digitalisation and automation, as well as the use of previously collected data in various registries and databases, will improve monitoring and reduce the need for manual processes.

Knowledge during crisis management

Another important lesson from the pandemic was the significance of a flexible and quick response adapted to changes in the situation. This offers a better opportunity to maintain control of the crisis, thereby minimising adverse societal impacts. If we had lost control of infection rates, more extensive measures would be required until control was regained. Measures to contain a crisis must be proportionate so that the adverse consequences of the measures are not greater than the consequences of the crisis, in addition to the fact that it must be practical and feasible in terms of resources to implement the measures. This requires a continuous assessment of the crisis, knowledge of effective measures and knowledge of the consequences. At the same time, it is important to be able to implement the measures in time if the situation is very uncertain. Late, imprecise or exceedingly comprehensive measures could have substantial human and societal costs.

Inter-ministerial review of legislation and infrastructure

The Norwegian Government has formalised and strengthened the inter-ministerial work to assess (i) legal and ethical issues related to the collection, accessibility, sharing and use of data during crises, and (ii) effective and secure infrastructure for access to, and the sharing and use of relevant statistics and data during crises. Two expert groups have been established to investigate each of the two topics.13

The expert group that assessed legal and ethical issues relating to the collection, accessibility and use of data proposed several measures to remove obstacles in the legislation. These proposals include, among other things, amendments to the Health Preparedness Act relating to the use of emergency registries, and amendments to the Health Research Act to exempt pure register studies from requirements for approval by the Regional Committees for Medical and Health Research Ethics. Furthermore, it is proposed to give the Regional Committees for Medical and Health Research Ethics the opportunity to grant exemptions from the requirement for consent from research participants if there is no risk of harm, as well as changes to the Health Register Act to ensure that health registers can always be used for research and statistical purposes if the other conditions of the Act have been met.

The Health Research Act has largely remained unchanged since it entered into force in 2009. Based on the recommendations by the expert group, and on medical, technological and organisational changes in general, the Norwegian Government will begin the work of reviewing the Health Research Act and other legislation that governs health research. Several of the expert group’s proposals will also be considered in the Ministry’s ongoing work on the revision of legislation on health emergency preparedness and infection control.

The expert group that has assessed effective and secure infrastructure for the sharing and use of data during crises emphasises that there are already objectives in place for making public data available through the sound management of metadata, the development and use of common services for easier sharing of data, and the reuse of data so that the same data would not have to be collected multiple times. The Norwegian Government will therefore monitor compliance with the expectation that the parties concerned get their house in order.14

In times of crisis, the need for updated knowledge is far greater than in normal situations. Knowledge production requires data, analytical capacity, qualified personnel and strong professional environments. Lack of available competence can be critical in a crisis. The Norwegian Government will facilitate easier access to competence and knowledge in a crisis situation by integrating the acquisition of knowledge and data processing to a greater extent in the health emergency preparedness plans.

Norway has good infection control competence, including at the Norwegian Institute of Public Health and the specialist health service. At the same time, there are varying levels of competence relating to infection control in the health and care services as a whole and in the municipalities. This vulnerability can be critical in a crisis. The Norwegian Government will work to facilitate good professional environments in the area of community medicine, including infection control, in municipalities. Any development of infection control competence in the health and care services will be assessed as part of the work to develop an action plan for better infection control. Both the health and care services and municipalities rely on a close dialogue with central authorities for professional advice in crises, which are often characterised by considerable uncertainty.

The Research Council of Norway has been asked to investigate a possible framework for how analysis capacity and infrastructure can be quickly scaled up in a crisis. This investigation will include assessments of scale-up opportunities should there be a need for greater capacity in the government ministries, in subordinate agencies and enterprises, announcements of assignments, and access to research and data infrastructure. The Research Council will present the results of the work in a report in the autumn of 2023.

The Health Preparedness Act authorises the Norwegian Institute of Public Health, the Norwegian Directorate of Health and the Norwegian Radiation and Nuclear Safety Authority to establish emergency preparedness registers containing health data to manage emergency preparedness situations. This authorisation was used during the COVID-19 pandemic to establish the Emergency preparedness registry for COVID-19 (Beredt C19)15, which was crucial for the ongoing monitoring of the pandemic and as a basis for analyses to gain more knowledge of the management of the pandemic. Experiences from Beredt C19 have been key to both expert groups.

Based on the expert group reports and other ongoing work in the government ministries, the following four areas have been identified for further work:16

• Knowledge preparedness must be more clearly specified in Norwegian emergency preparedness efforts.

• The government ministries should encourage better evaluations, including better facilitation of randomised trials and other quasi-experimental methods.17

• Rapid access to and proper use of data.

• The data flow between the administrative levels and between the municipalities should be improved.

International data sharing and analyses

Part 2 of the Coronavirus Commission’s report noted that there is considerable potential in strengthening international cooperation for monitoring, analysis and reporting of cross-border health threats. Norway must share data and knowledge internationally in order to contribute to global monitoring and knowledge production. This entails a need to participate in international projects and networks, and to develop infrastructures and legislation that support the sharing of analyses and data. Such cooperation shall be expanded, strengthened and systematised, and the reports shall be included in the analysis of the Health Emergency Preparedness Council.

The World Health Organization (WHO) strongly emphasises the need for countries to have good and robust surveillance systems to detect, report on and manage a threat that may impact other countries. Participation in international surveillance networks and warning systems is therefore an important component of health emergency preparedness.

Through the WHO’s International Health Regulation and the EU’s legislation in the area of health emergency preparedness, Norway is obliged to have systems to detect, assess, report and respond to incidents that may impact other countries. Correspondingly, cooperation has been established with the International Atomic Energy Agency (IAEA), NATO and the OECD. Norway also is also a party to the Nordic Public Health Preparedness Agreement which provides a framework for Nordic cooperation and which, among other things, includes the exchange information in crises.

The European Commission has put forward a legislative proposal on the European Health Data Space (EHDS). A European health data space will be crucial for our national efforts to simplify access to data, including in health crises. The regulation will be a basis for secure access to and use of health data, thereby strengthening our health emergency preparedness.