3 A Resilient Health Emergency Preparedness

The concept of resilience is broad. It involves society’s ability to withstand and manage major events, restore important functions after events have occurred, and if necessary, adapt to changed conditions. The resilience of civil society is crucial in the face of cross-sectoral challenges related to such elements as security of supply, foreign direct investments, digital infrastructure, disinformation and influence operations. These challenges are relevant to society as a whole, but also to the health and care sector.

Resilient health emergency preparedness requires efforts for good public health, robust health and care services and the capacity to adjust and scale up and down, as needed. It is also crucial that national authorities and our public health and care services have the trust of the population. High levels of trust in society and good health and care services were key reasons why Norway was largely successful in its national pandemic management. The Norwegian Government shall continue to work for good public health, good health and care services and minimising inequality in the population. This Report must therefore be viewed in the context of the Norwegian Government’s comprehensive health policy. It includes, among other things, the Public Health Report, which is the Norwegian Government’s strategy to reduce social health differences and ensure good health in the population through cross-sectoral efforts, and the upcoming National Health and Collaboration Plan, which will provide direction for our common health and care services.

Norway shall have a resilient health emergency preparedness, nationwide. Our vast country, with its varying geographical population density, sets the premises for emergency preparedness. The strategic significance of the High North is increasing. The Norwegian Government believes that our health emergency preparedness should take this development into account. Svalbard’s distinctive characteristics make it impractical to structure the health service in the same manner as on the mainland. In 2024, the Norwegian Government will put forward a separate Report to the Storting on Svalbard, which will include a section on health emergency preparedness.

3.1 Flexible health and care services

Our common health and care services are key to resilient health emergency preparedness. Norway’s health and care services are its greatest emergency preparedness resource, employing more than 430,000 people.1 A well-functioning health emergency preparedness system presupposes access to a sufficient number of personnel with the right competence, organisational flexibility, prioritisations and adaptation, good collaboration across service levels, and the opportunity to mobilise reserve personnel. Health and care services shall facilitate good health and care services in all parts of the crisis spectrum, and they are crucial for the overall resilience of our society. In the most extreme scenario, the health and care services shall be able to deal with a war situation. This would require extraordinary efforts and prioritisations in our health and care services.

General emergency preparedness in the health and care services

Health and care services must be able to handle both small and large crises, and they must deliver equal health and care services throughout the country, including in crisis situations. Factors such as the size of the municipality, the demographic development involving an increasing proportion of elderly persons in the population, access to personnel and relevant competence, as well as the centralisation of settlement in Norway, all pose challenges. The health and care services must therefore plan better for this challenge. This includes the need for an increased demand for emergency preparedness in various situations, including the relocation of larger parts of the services in the event of a loss of infrastructure. Emergency preparedness must be given greater attention in both the planning and organisation of enterprises. A well-functioning everyday life is essential for good emergency preparedness during crises, as good emergency preparedness is based on everyday solutions and capacity across the health sector.

Zoom in on image

Photo: Bergen Hospital Trust.

Robust municipal health and care services that safeguard core tasks is essential for good health emergency preparedness, and crucial for reducing the consequences of crises. Municipal health and care services must become more resilient. Full-time and permanent positions, the flexible use of personnel, appropriate use of employee competence, well-integrated services in the municipality and good collaboration across service levels must be facilitated. Furthermore, systems to identify and reach out to vulnerable groups in the population are necessary.

The specialist health service consists of four regional health authorities with subordinate hospital trusts and also has agreements and close cooperation with private and non-profit institutions. It is essential for the specialist health service to have emergency preparedness plans in place for various scenarios, and that these are regularly updated. The increased use of simulation and other types of training exercises provide valuable experience and a basis for improvements. Emergency preparedness plans must include systems for flexibility for various scenarios related to, among other things, the need for reallocation and increasing the number of hospital beds, personnel and spaces, flexible use of personnel, competence and spaces, as well as medical countermeasures, home care, and cooperation across health trusts and health authorities.

The emergency medical services are a key component of health emergency preparedness. This relates to the handling of the consequences of acts of terrorism and fighting resulting in mass casualties, burns, medical evacuation – both domestically and abroad, disease outbreaks and pandemics, and incidents involving radioactive and nuclear agents and other chemicals (CBRNE). The health trusts and municipalities are responsible for the emergency medical services. The emergency medical services outside of hospitals consist of a medical emergency reporting service (Emergency Medical Communication Centres and Local Emergency Medical Communication Centres), ambulance services (car, boat and air ambulance services) and municipal emergency assistance services and other 24-hour emergency services. Cooperation with other emergency services, voluntary organisations and the population’s first aid knowledge are also important for overall emergency preparedness.

Norway has excellent emergency medical services. There have been major technical developments in these services and the opportunities for providing advanced treatment are constantly improving as a result of new and improved technology. The Norwegian Government will determine the direction for the future development of these services in a separate Report to the Storting on emergency medical services.

Strengthened collaboration

Collaboration has been challenging, both internally within the individual municipalities and the hospital trusts, between municipalities, between hospital trusts, and between municipalities and hospital trusts. Differences in organisation and funding, as well as differences in tasks and competence all have impact collaboration and cooperation. The Coronavirus Commission2 notes that cooperation between hospitals and municipalities during the pandemic was of significant value, and that this should be maintained and further developed. Municipalities and hospital trusts have shown that this frequent contact strengthened the cooperative relationships.

Zoom in on image

Photo: Getty.

The purpose of the 19 medical communities is as follows: good and sustainable health and care services for patients with major and complex needs and better joint planning. The medical communities shall prioritise planning and developing services for vulnerable groups who are particularly reliant on good collaboration. Better joint planning between municipalities and hospital trusts is essential to ensure that the overall services meet the needs of residents. In emergency preparedness planning and crisis management, both municipalities and the regional health authorities must to a greater extent plan collaboration across levels.

Planning for prioritisation in crises

There is broad political and professional agreement on the national prioritisation principles (benefit, severity and use of resources) that the Storting adopted through the consideration of Report to the Storting No. 34 (2015–2016) Verdier i pasientens helsetjeneste – Melding om prioritering [Values in patient health services – Report on prioritisation] and Report to the Storting No. 38 (2020–2021) Nytte, ressurs og alvorlighet – Prioritering i helse- og omsorgstjenesten [Benefit, resources and severity – Prioritisation in the health and care services]. The Norwegian Government aims to put forward a new report to the Storting on prioritisation.

The right to necessary healthcare is fundamental to the Norwegian health service, and it is expected that health services are equal, nationwide. In a short-term crisis, prioritisations in the health service are made automatically. During long-term crises, this becomes more complicated and more difficult for the health and care services. We must be prepared for situations that may arise where there will be a need to adapt the frameworks for prioritisations to the situation that health and care services are actually in during a crisis. One example is that many elective operations and other treatments during the COVID-19 pandemic were postponed, and patients in need of immediate assistance were prioritised. The health service must plan for such prioritisations. The population must also, to a greater extent, be aware that priorities must be made during a crisis that may affect the provision of health services according to where the country finds itself in the crisis spectrum. Openness about prioritisation and how the authorities and the health service communicate this is crucial for maintaining public trust in a crisis.

Organisational flexibility, adaptation and training exercises

Norway is one of the countries with the highest use of resources in the health and care services in Europe. We have a large share of the employees and are one of the countries that spends the highest share of public funds on these services, relatively speaking.3 In some countries in the EEA, informal family care remains prevalent, while labour market participation among women is relatively low. In these countries, the provision of public care services is smaller than in Norway. While the use of resources in Norway is high, there has been noticeably greater pressure on access to personnel in the health and care sector in recent years. It is not sustainable to simply hire more staff to manage all the challenges that the health and care services will be facing.4

The specialist health service must have established and known plans for the allocation and reallocation of its own personnel, both internally within its own operations, between hospital trusts in the same region, and between the regional health authorities. The regional health authorities have the necessary legal authority to order personnel to perform more specifically assigned work. Highly specialised personnel are a scarce resource. The regional health authorities are responsible for determining how these resources can best be used. Nevertheless, the plans must take into consideration the necessary flexibility and adaptations for the use of available resources, and employees must be informed of these plans.

In principle, the municipal health and care services do not have the same structures for coordinating human resources as the specialist health service. Nevertheless, the municipalities have the opportunity, pursuant to legislation, to reallocate their own personnel within their own operations. Such reallocation, which facilitates flexibility, must be part of the municipal plans, and the employees must be informed of these plans. A municipality can order personnel to perform tasks in a different municipality if the latter requires assistance as a result of accidents or other acute situations that may result in an extraordinary influx of patients. Several municipalities have also entered into agreements on mutual personnel assistance.

Both the specialist health service and the municipal health and care services must engage in regular and systematic training exercises to ensure that personnel develop the competence needed to practice necessary flexibility in emergency preparedness situations. Employers must have an overview of the composition of competence among their employees and facilitate competence measures and training programs that are aimed at such situations. All actors involved must practice and have knowledge of the overall plans, as well as their own roles in such plans. This applies to municipalities, county authorities, county governors and hospital trusts, as well as GPs, contract specialists, and both non-profit and private actors.

Experiences from the pandemic illustrated that the opportunities for flexibility in the legislation were not utilised to the fullest extent. The Coronavirus Commission’s second report provides a good description of the complex reasons for this.

Specialist health services are competence intensive. Necessary flexibility within certain areas that require highly specialised competence requires regular training. Knowledge and competence must be maintained and used correctly. Regular and systematic work is needed to ensure the necessary flexibility. The Norwegian Government expects the plans to be implemented in the specialist health service to facilitate increased organisational flexibility.

Zoom in on image

Photo: Birthe Havnes, Østfold Hospital Trust.

The regional health authorities have been tasked with initiating regionally structured work to promote the correct division of tasks between personnel and a more efficient organisation by assessing and systematising the need for competence in various work processes. They will also work together to establish a suitable arena for sharing experiences from these efforts. The Norwegian National Health and Collaboration Plan will include elements that support the Norwegian Government’s policy for increased flexibility and adaptability.

Intensive-care capacity and intensive care emergency preparedness

The Norwegian Government’s aim is for Norway to have an intensive-care emergency preparedness system that can cope with natural variations, so that hospitals can quickly scale up their capacity during major crises. Intensive care is highly resource intensive, and the need for intensive care beds will vary. Therefore, it is particularly important to ensure flexibility so that the capacity is adapted to the at all times actual need and that it can be rapidly scaled up.

Part two of the Coronavirus Commission’s report recommends increasing the basic capacity in the intensive care and monitoring units somewhat, and that additional intensive care nurses be trained to increase hospital capacity during ordinary operations and to strengthen emergency preparedness. This is supported by the Holden Committee’s fourth report, which recommended that the healthcare system’s capacity to manage a pandemic should be strengthened, but that socioeconomic assessments “…indicate that the isolated benefit of greater permanent capacity during major pandemics and similar crisis situations is clearly less than the costs of establishing a higher permanent capacity. If permanent capacity is to be increased, this must primarily be justified by the fact that it is desirable based on need and cost-benefit assessments in more normal times and because it may be necessary to support the establishment of a variable emergency preparedness capacity”.5 The Commission further recommends that hospitals use additional personnel groups in intensive care units to a greater extent than today. At the same time, the Commission noted that an increase in the basic capacity of intensive care and monitoring units cannot be considered a substitute for infection control measures in the event of a pandemic as serious and protracted as the COVID-19 pandemic. The regional health authorities have been tasked with following up the Commission’s recommendations and have commenced this work.

The greatest challenge for intensive care capacity has been access to sufficient personnel with the right competence. The Norwegian Government has increased the number of study programme places in the university and university college sector. The same applies to the number of training positions in intensive care units in the health regions. Organisational flexibility, competence-enhancing measures and new training opportunities will contribute to ensuring that more hospital employees can contribute to the work in intensive care units. Increased educational capacity, including more training positions for relevant groups of physicians, will continue to be relevant measures prioritised by the Norwegian Government.

During the pandemic, the manner in which the number of intensive care beds were counted among the hospital trusts varied. There was no consensus on what would constitute an intensive care bed. This led to uncertainty about the number of intensive care beds, and, thus, the actual capacity. In June 2022, a joint report was submitted by the regional health authorities with common definitions of various bed and emergency preparedness categories, which will make it easier to monitor capacity. Intensive care emergency preparedness is a particularly important part of health emergency preparedness. As a basis for assessing the need for further measures, the Norwegian Government will request regular and updated statements of intensive care capacity during both normal operations and in emergency preparedness situations.

Better overview and use of human resources

The need for an overview of the composition of competence, as well as plans for competence enhancement are important elements in the health and care sector’s emergency preparedness work.6 Plans that have the necessary flexibility require an assessment of competence and an overview of health personnel who can provide services within the frameworks of the health and care sector. A comprehensive overview and an efficient use of resources includes, among other things, cooperation with the municipalities, hospital trusts, GPs and contract specialists. Access to and use of other types of personnel such as dentists and veterinarians should also be included in these plans.

The pandemic highlighted the extensive use of temporary hiring of health personnel in several hospital trusts and municipalities, both in central and rural areas. Temporary hiring of personnel from other Nordic countries was particularly widespread, including temporary-hired personnel with intensive care competence. Emergency preparedness planning that involves the temporary hiring of health personnel represents a significant vulnerability. This particularly applies to the temporary hiring of personnel from abroad, but also within Norway. Full-time and permanent positions in the health and care services should therefore be facilitated. The Norwegian Government will take the initiative for a Nordic cooperation that sets out the principles between the Nordic countries regarding the temporary hiring of health personnel in crises.

The municipalities have rarely involved GPs in the emergency preparedness planning work. GPs have a fairly weak organisational connection to municipal emergency preparedness work. They have central and local agreements that do not sufficiently ensure municipal needs for resources during crises and disasters. Arrangements should be made so that the municipalities can use their GP resources for emergency preparedness work. Agreements should therefore ensure that GPs can be included in the overall municipal plans.

Contract specialists will also be a resource in emergency preparedness. They provide healthcare on behalf of the regional health authorities in accordance with the agreement between the parties. It should be clarified whether the existing framework agreements are sufficient, or whether they should be amended to ensure that these resources can be more easily activated in a crisis.

Physicians and other health personnel who provide privately funded services are, like other health personnel, covered by the provisions of the Health Preparedness Act. However, the threshold for using these groups in emergency preparedness work is probably higher than for contract specialists. Nevertheless, the Ministry of Health and Care Services will assess how this personnel group can be used more effectively in emergency preparedness situations. The same applies to veterinarians and other animal health personnel who are not covered by the provisions of the Health Preparedness Act, but who possess competence that can contribute to strengthening the overall emergency preparedness.

According to the Health Personnel Act, health personnel can delegate certain tasks to other personnel if it is justifiable based on the nature of the task, the personnel’s qualifications and the supervision provided. Those who are assigned such tasks are considered health personnel assistants. Many tasks can be performed by personnel without health-related qualifications, as long as the requirement for responsible conduct is ensured. Assistants will be particularly relevant in municipalities as a means of building sufficient capacity, and must be included in the plans.

Mobilisation of reserve personnel

Reserve personnel include students in health-related study programmes, health personnel who do not work in public health and care services and retired health personnel. Mobilisation of these groups and the use of assistants and voluntary organisations can help ensure access to sufficient and necessary personnel with and without health-related competence. However, experiences from the pandemic indicate that the health and care services should be more predictable and systematic with respect to how reserve personnel can be made available. The Norwegian Government will assess how it facilitates effective mobilisation of human resources and reserve personnel with health-related competence who do not have an employment relationship or other formal connections to the health and care services. The Norwegian Government will design a model that involves the collection and use of information from relevant enterprises, existing registers or other sources to provide an overview of:

• Health personnel who have previously worked in the health and care services, such as pensioners or personnel who now work outside such services.

• Health personnel who have not worked in public health and care services but who have health-related qualifications and experience from abroad or the private sector.

For crisis management, there may also be a need to mobilise more students in health-related studies as reserve personnel for the health and care services, in addition to medicine and pharmacy students who are currently granted student licenses after a certain progression in their studies. During the pandemic, students, pupils and apprentices taking health and social welfare studies were given the opportunity to be granted a student license in their final academic year. During the revision of the Health Preparedness Act, the Norwegian Government will assess whether this should be made a permanent scheme. The scheme offers the benefit of quick utilisation and mobilisation of students, as well as an overview of this labour reserve.

In crises, emphasis should be placed on facilitating the completion of practicums and periods of training to promote study progression and ensure recruitment to the services. During the pandemic, a national hub group was established to coordinate the cooperation between the education sector and the health and care services. During the revision of the Health Preparedness Act, the Norwegian Government will consider whether this should become a permanent scheme that can be implemented in crises.

The design of the pension schemes for the public sector has offered weak incentives to remain in the workforce. Among other things, they have contributed to earlier retirement and weaker financial incentives to accept new employment following retirement. This has diminished the effect of voluntary mobilisation of pensioners for crisis management, and special rules for handling the pandemic were therefore introduced. New pension schemes in the public sector for those born in 1963 or later provide better incentives to continue working longer and the opportunity to combine work and pension without a reduction in pension. However, for groups with special age limits, there are supplementary rules, in accordance with the agreement between the Norwegian Government and public sector parties from August 2023, that contribute to weaker incentives to continue working and where certain pension elements are reduced in relation to earned income, but to a lesser extent than in the old rules. The Storting has recently adopted changes to the pension legislation7 and at the same time requested the Norwegian Government to, among other things, facilitate good incentives for retired nurses to work in part-time positions in the public sector. The Norwegian Government will follow up on this proposal.

Students who receive loans and grants from the Norwegian State Educational Loan Fund may, through mobilisation, have their grants reduced when their income exceeds the income limits. During the revision of the Health Preparedness Act, the Norwegian Government will assess whether there is a need for more flexible mechanisms for mobilising students and pensioners, so that they can more effectively be made available in future crises.

The Norwegian Government will:

• ensure that emergency preparedness planning in the municipal health and care services and in the specialist health service is, in general, based on personnel who have employment relationships or other contractual connection to the health and care service

• to a greater extent accommodate necessary flexibility, adaptation, reallocation and training for use of available resources in emergency preparedness planning in the health and care service

• ensure a better overview of reserve personnel who can be mobilised for future crises

3.2 Trust and competence in the population

In Norway, there is generally a high level of trust in society, including for the authorities. This is of great significance in crises. It increases society’s resilience and capacity for flexibility and adaptation. However, trust cannot be taken for granted. Trust is developed on daily basis through open, knowledge-based and accountable decision-making processes. In order to maintain trust, it is important that decisions are based on fundamental principles such as due process and democracy. Decisions of major societal importance must be rooted in the population and have a clear political basis.

The Defence Commission writes that in order to “safeguard due process, democracy and human rights, we must not initiate measures at the expense of values we are seeking to protect. Therefore, it is necessary to more closely examine measures that promote openness”.8

The population’s physical and mental health, knowledge of how to safeguard your own and your family’s health, as well as self-preparedness are also key parts of health emergency preparedness and society’s resilience. Equality and diversity in the population must be taken care of. Complex threats increase the importance of psychosocial resilience. Awareness of influence operations and what influence operations may entail will contribute to reducing the effect of such operations.

Health in the population is unequally distributed. It is important to take this into consideration, especially to safeguard vulnerable groups. Crises affect the mental health of the population. This has not been sufficiently emphasised in emergency preparedness planning and crisis management. Good psychosocial emergency preparedness provides better general emergency preparedness.

Communication in crises

Good crisis communication is essential for the authorities to succeed in crisis management. One element of a crisis is the experience of that the situation is unclear, and uncertainty about what is happening.

During the COVID-19 pandemic, it became evident that fact-based information could be rapidly spread globally with the aid of social media. The term infodemic was used by the World Health Organization to describe the enormous flow of information resulting from the pandemic. However, this also included misinformation, disinformation and conspiracy theories. A 2020 survey by the Norwegian Media Authority indicated that nearly five out of ten Norwegians encountered fake news about the COVID-19 virus during the first week of national comprehensive measures related to the pandemic. Four out of ten came across such fake news on social media. Conspiracy theories and fake news gained a particularly strong foothold during the pandemic in countries where there was generally a low level of trust in the authorities.9

The key to good crisis communication is to follow the same principles during crises as in normal situation. According to the Civil Protection Instructions, the Ministry of Justice and Public Security shall facilitate comprehensive and coordinated communication about prevention, emergency preparedness and crisis management between authorities and to the population. This does not alter the requirements placed on each individual government ministry within the relevant area. The Ministry of Justice and Public Security shall annually update a joint plan for how the government ministries will coordinate their crisis communication. The principles of the State’s communication policy are the basis for the communication work within the government ministries and in the subordinate enterprises. These are:

• Openness: The State shall be open, clear and accessible.

• Participation: The State shall consult affected residents and involve them.

• Reaching everyone: The State shall ensure that relevant information reaches all affected parties.

• Active: The State shall actively and in a timely manner inform the public of rights, duties and opportunities.

• Coherency: State communication shall be perceived as uniform and coordinated.

Dialogue with the population shall take place through familiar channels and in familiar ways, such as websites, editor-controlled media and social media. A meta-study by the World Health Organization in 2022 on infodemics emphasised that improving the population’s health literacy and the communication of health matters are the most important countermeasures.10 Regjeringen.no publishes key information for the population during crises, while helsenorge.no is the health sector’s primary channel for the population in a crisis. It may be necessary for several participants in the health administration to collaborate on the content, for instance by creating joint editorial boards.

Regular press conferences with the Norwegian Government and the leadership of relevant agencies contribute to legitimacy and credibility to decisions. In prolonged crises, regular population surveys should be conducted to monitor whether the authorities’ measures and decisions resonate with the public. Communication must also contain advice on how psychosocial health can be safeguarded if a crisis is serious or expected to be prolonged.

Communication between the authorities and the public must take the diversity of society into consideration. The majority of the population will receive the authorities’ information through live press conferences, from websites and in the media. During the pandemic, it was evident that some information from the authorities did not always reach certain target groups, including immigrants who do not speak Norwegian, even if the information is translated into relevant languages.

In order to communicate information to immigrant groups and vulnerable groups, the authorities must be familiar with arenas and channels for dialogue. This includes plans for how key actors can quickly communicate information to these groups in the event of a crisis. This also applies to the Sámi population. The Norwegian Government will continue or establish new arenas for dialogue with representatives of immigrant groups and vulnerable groups and create channels for communication with these groups. The Norwegian Directorate for Integration and Diversity has produced a guide for how the public sector can communicate information to immigrants. This guide is published on the Directorate’s website.

Protection of vulnerable groups

Special consideration must be given to children and young people when considering measures in the event of a crisis, such as school closures, restrictions on recreational activities, etc. We need more knowledge of how various measures affect children and young people, such as in terms of security, opportunities for contact and learning. When considering measures, there must be particular emphasis on the needs of children and young people, with a focus on the best interests of the child. The participation of children and young people shall also be facilitated.

Monitoring and analysis of data shall ensure that we are able to see how the crisis and measures affect vulnerable groups and health equity. Plans and measures shall consistently be implemented to ensure that vulnerable groups receive special protection. For instance, groups with a higher risk of illness and death shall be protected from additional health risks, at the same time as psychosocial needs and other basic needs are met. Persons with non-communicable diseases such as diabetes, cancer, cardiovascular disease and mental health disorders were impacted by the consequences of reduced health services during the pandemic, as resources were reprioritised. This resulted in many postponed check-ups and treatments, diagnostic and screening delays, as well as fewer preventive activities and rehabilitation services. In sum, this entailed a risk of developing more serious illnesses. A generally good public health improves possibilities to ensure services for those who need them, and it provides better possibilities for health and care services to adapt to managing crises of varying duration.

The number of residents over the age of 70 will increase significantly in the coming decades, and this group will be vulnerable to physical illnesses, loneliness, mental health problems and disorders. To maintain the emergency preparedness resources that a healthy population entails, the Norwegian Government will develop the public health efforts to better support population groups who may be vulnerable terms of mental and physical health. In March 2023, the Norwegian Government presented its Public Health Report,11 which must be viewed in the context of this report on health emergency preparedness.

Health literacy and self-preparedness

Health literacy is the ability of a person to find, understand, assess and apply healthcare information to make evidence-based decisions concerning their own health. This applies to decisions related to lifestyle choices, measures for preventing illness, coping with illness, and use of health and care services. Health literacy is also important in times of crisis. The population have an individual responsibility to take care of themselves. However, public services must step in when needed. As part of health literacy, the Norwegian Government will contribute to increased knowledge about how the population can strengthen self-preparedness and ensure good mental health.

During a crisis, there may be many people who need help. Health literacy and self-preparedness will ensure that those who need it most will be given help quickly. The five-year national first aid campaign Sammen redder vi liv (Together, we save lives) is a good example of how we can develop health literacy and resilience in the population, while at the same time strengthen our overall emergency preparedness in a tripartite collaboration between the public sector, voluntary organisations and the private sector.

Psychosocial emergency preparedness

Psychosocial emergency preparedness is about promoting good mental health in the population, and about the ability of the population and the services to attend to psychological and social needs when various crises arise. Examples of events with major psychosocial consequences are the Alexander Kielland accident in 1980, the tsunami disaster in 2004, the terrorist attack on 22 July 2011, the shooting in Oslo in 2022 and the COVID-19 pandemic.

Psychosocial consequences of measures implemented to manage crises shall be taken into consideration when considering measures, to the extent this is possible. Management of the pandemic is an example of fast and effective justified decisions on infection control measures, although the potential psychosocial consequences were not adequately assessed.

Knowledge about the psychosocial consequences of measures is still under development. Updated knowledge must be used as a basis for reviewing plans and emergency preparedness analyses. Measures that will clearly have psychosocial consequences, such as the closure of schools and recreational programmes, bans on visiting nursing homes and other measures that limit people’s opportunities for social interaction must, to the extent possible, be followed by measures to limit adverse consequences in general and for vulnerable groups, in particular.

Individuals and groups who are directly affected by a crisis, such as the injured and their family members, shall be ensured follow-up in order to manage the acute phase, maintain social functioning and help reduce adverse responses and symptoms. The aim is to manage the crisis situation itself, prevent future health problems and/or social problems, and contribute to a good quality of life in the long run. Offering support early is essential. Many who are affected by crises will find that their adverse reactions diminish over time. For some, however, these reactions will persist. Diagnostics and treatment of long-term reactions and disorders will usually be managed by the ordinary health service. Psychosocial crisis teams have an important role in identifying those who need help and ensuring that they are referred for appropriate care.12 Experiences from major crisis events indicate that the capacity of the health service to attend to the population’s need for psychosocial support can quickly be exceeded. In the escalation plan for mental health, the Government states that it will support municipalities in their work on psychosocial preparedness and follow-up. This includes establishing a framework agreement for psychosocial assistance for municipal health and care services.13

Emergency preparedness plans should also include a clear plan for the psychosocial care of helpers. Both professional actors such as the police, fire services, the Norwegian Armed Forces and health and care services, as well as voluntary helpers may require and should be offered the necessary care. Psychological and social factors shall be included in the planning of various scenarios in all relevant crisis plans and exercises.

The Norwegian Government will:

• ensure that decision-making processes are open and knowledge-based, and that the consequences of various options are considered

• safeguard vulnerable groups such as children and young people in the work on health emergency preparedness

3.3 Civil society and volunteering – an important emergency preparedness resource

The Total Preparedness Commission highlights the role of civil society and volunteers in emergency preparedness work as a cornerstone of Norwegian society.14 In Norway, voluntary organisations have longstanding traditions of providing various social functions. Voluntary organisations participate in activities such as search and rescue, assisting the health and care services with transport and communication, and relieving the health service. Voluntary organisations also play an important role in providing care through contact with vulnerable groups, creating social arenas in crises and reaching out with information and measures to groups that are more difficult to reach, including certain minorities. The 22 July Commission writes as follows:

Community volunteer efforts, such as what we experienced on 22 July, will therefore be an essential resource also in later crisis situations. The professional system must be aware of this resource, value it and use it in the best possible manner. […] the emergency preparedness plans should include how volunteer efforts can best be used in a disaster situation.

The Commission emphasises the need for coordinated efforts between various authorities and voluntary organisations in emergency situations. The Coronavirus Commission’s investigation nine years later found that there was no emergency preparedness or plan in place for how the municipalities were to use various parts of the voluntary sector in an emergency situation. The Coronavirus Commission writes: “[.] a lot seems to have happened randomly and has been based on fairly random personal relationships”.15 The Commission believes there is a need for a review of the interface between the public administration and the voluntary sector at all administrative levels.

The Norwegian Government will facilitate a better integration of the voluntary sector in the health emergency preparedness system through regulations, in agreements, in plans and exercises. This means, among other things, that municipalities, regional health authorities, hospital trusts and the national health administration have considered volunteers as a resource for health emergency preparedness, that volunteer personnel must receive follow-up when needed, and that consequences for volunteers must be considered when assessing measures. The Norwegian Government will ensure closer dialogue with voluntary organisations through the establishment of an annual dialogue meeting between the Ministry of Health and Care Services and voluntary organisations. The committees in the new health emergency preparedness model shall have a mandate to ensure contact and cooperation with voluntary organisations, where relevant.

Zoom in on image

Photo: Id Skrivarhaug, Norwegian Red Cross.

At the same time, volunteering is first and foremost voluntary. Cooperation must therefore be based on reciprocity and trust. The public sector has strong executive powers during crises, but a clear distinction must be made between circumstances where the public sector exercises its authority and where it is a cooperative effort. Volunteering is often led by individuals or groups who are committed to a cause. This is a strength, but also a vulnerability in terms of continuity. Public emergency preparedness cannot rely too heavily on voluntary efforts in its key functions. A number of key tasks can be performed by voluntary organisations, including dialogue with minorities. Nevertheless, public bodies with formal responsibility must have the competence and capacity to assist voluntary organisations or be able to take over the tasks. Volunteering is an important supplement to public health emergency preparedness.

During the pandemic, many volunteers were themselves adversely affected by the measures. Many of the social arenas provided by volunteers were impacted, and the social benefits provided by the volunteers were thereby diminished. Nevertheless, voluntary organisations contributed to innovative thinking and played a key role in establishing measures that helped reduce the adverse consequences for vulnerable groups of the infection control measures. Integrating volunteers into planning and crisis management can prevent certain adverse consequences and reinforce the positive consequences for volunteers and society. Among other things, voluntary work and the consequences of the loss thereof must be considered when designing and implementing measures during crises.

Close involvement in a health crisis can be challenging, and there are varying degrees of professional follow-up by organisations and individuals who participate. Studies show that those who volunteered during and after the terrorist attacks on 22 July 2011 were more vulnerable to long-term effects than the healthcare workers.16 Such aspects must be taken into consideration in emergency preparedness planning.

The Norwegian Government will:

• facilitate better integration of the voluntary sector into health emergency preparedness, through regulations, agreements, plans and exercises

• ensure a closer dialogue with voluntary organisations through an annual dialogue meeting between the Ministry of Health and Care Services and voluntary organisations

• ensure that the committees in the new health emergency preparedness model maintain contact and cooperation with voluntary organisations, where relevant

3.4 Cooperation and dialogue with the private sector

Crises affect society as a whole and are best resolved through joint efforts. It is society’s ability to bring people together that determines how well we will manage a crisis and how much it impacts us. Through good cooperation, the public sector and the private sector can contribute to a successful and robust health emergency preparedness. Our common health service will be a sector that is prepared in the face of crises and disasters. The private sector also plays an important role in its contributions to emergency preparedness.

The efficient mobilisation of the private sector in a crisis requires established cooperative relationships. As part of the health emergency preparedness system, the Norwegian Government will facilitate strategic interaction and dialogue with the private sector and emergency preparedness actors. A shared understanding of the situation is important to ensure good cooperation. In connection with the Norwegian Government’s work on a new strategy and emergency preparedness plan for managing the COVID-19 pandemic in the spring of 2022, sectors impacted by infection control measures, including external actors, were asked to provide further comments on the design of infection control measures. The various actors have the knowledge and experience to assess opportunities and propose the design of measures, which can then be assessed by the infection control environment and the authorities. The Coronavirus Commission noted that “their main impression was that the work to adjust the strategy [the spring of 2022] was more systematic and more similar to anchoring and consultation processes that are carried out in a normal situation”.17 The mandate of the committees in the new health emergency preparedness model will be to ensure contact and cooperation with relevant parts of the private sector in relevant risk areas, as needed.

A robust and flexible healthcare industry

According to figures from Menon Economics, the Norwegian healthcare industry accounted for a total revenue of NOK 65 billion in 2021 (not included the distribution link), of which approx. NOK 22 billion were export revenue.18

A competitive private sector can have positive ripple effects on emergency preparedness and form part of society’s resilience in a crisis. This concerns the efficient use of society’s total resources. Adaptation and flexibility in the manufacturing of items such as hand sanitizer and face masks made a good contribution to the management of the pandemic. During the pandemic, a number of solutions and technologies were also adopted, such as video consultations, contact tracing systems, testing equipment and logistics solutions. A competent and adaptable private sector can thereby help meet the needs that arise in a crisis.

In 2023, the Norwegian Government presented its Road map for the healthcare industry. The roadmap presents the breadth of the Norwegian Government’s policy to promote and strengthen the Norwegian healthcare industry. Many aspects of the healthcare industry are characterised by lengthy research and development that requires access to advanced infrastructure and production capacity. Development pathways are strictly regulated, and access to patients and data from public health and care services is often required. This entails a need for good cooperation between the public and private sectors. In its follow-up of the road map for the healthcare industry, the Norwegian Government will establish an arena for strategic dialogue with the healthcare industry. The Norwegian Government’s ambitions with the roadmap can also result in positive ripple effects for health emergency preparedness, including opportunities for the development and manufacturing of pharmaceuticals and medical devices in Norway.

The Norwegian Government will establish a national initiative for pharmaceutical manufacturing and study how the healthcare industry can benefit more from the catapult scheme, including whether a separate catapult centre should be established for the healthcare industry, or whether adaptations or expansions should be made to other centres. The catapult scheme supports multipurpose centres for testing, simulation and piloting of new products and processes. This could contribute to an infrastructure that stimulates Norwegian pharmaceutical and vaccine manufacturing.

European initiatives for increased resilience

In recent years, the EU has placed an increasing emphasis on developing open strategic autonomy. This is about reducing dependencies and vulnerabilities in supply lines in strategically important areas for society and the economy. It has been proposed to implement measures in a number of policy areas to diversify access to raw materials, increase domestic production capacity and ensure a well-functioning internal market for future crises. This work also entails strengthening the European healthcare industry.

Among the measures used to strengthen the EU’s resilience in business areas experiencing market failure was the more active use of Important Projects of Common European Interest (IPCEI) from 2014. IPCEI is an alternative scheme under state aid law, which allows national authorities to provide increased funding for projects that are considered to be of common European interest. IPCEI projects shall be highly ambitious and contribute to achieving strategic EU goals. It is a requirement that the projects involve several countries and create spillover effects throughout the EEA, and that recipients of funding also have private funding for the projects. Such projects have been established in areas such as microelectronics, hydrogen technology and battery technology. In 2022, IPCEI was also launched in the area of health. To date, Norwegian actors are participating in IPCEI hydrogen and microelectronics projects, and a process has been initiated to connect Norwegian projects to the IPCEI cooperation on batteries. The Norwegian Government will monitor the IPCEI scheme for health and will consider Norwegian participation further.

Norway’s participation in EU programmes provides excellent opportunities for cooperation and funding for Norwegian actors, including in the healthcare industry. The EU’s research programme Horizon Europe, the EU’s EU4Health programme and the DIGITAL capacity building program are the most important arenas for the healthcare industry. There is considerable potential for the Norwegian healthcare industry in achieving EU funding in the near future. Horizon Europe’s overarching goals are to increase European industrial competitiveness, boost economic growth and solve major societal challenges. Through EU4Health, the EU funds and facilitates development initiatives, projects and cooperation between countries in Europe. EU4Health has four priority areas: health emergency preparedness, disease prevention, healthcare systems and digitalisation. Cancer is also a priority in all areas. DIGITAL is Europe’s most important tool for developing digital capacity and infrastructure, and ensuring advanced digital skills in six areas: supercomputing, artificial intelligence and data, cybersecurity, advanced digital competence, ensuring the wide use of the technologies, and dedicated commitment to semiconductor manufacturing (European Chips Act).

The Norwegian Government will:

• establish arenas for strategic interaction and dialogue with the private sector for the effective mobilisation of the private sector during crises

• establish an initiative for pharmaceutical production through the Roadmap for the Health Industry

3.5 European resilience

Russia’s war of aggression against Ukraine has strengthened the collective unity in Europe. The war has brought together allies and united democracies. The war in Ukraine has had far-reaching consequences for the European security architecture. NATO remains the bedrock of collective security in Europe. At the same time, the war in Ukraine has demonstrated that the EU also plays an important role in a cooperative and robust Europe. Together with NATO and the EU, Norway is developing increased resilience across sectors and from society to individual.

Health cooperation with the EU

Norway cooperates closely with the EU in the health field, and this cooperation is particularly important as a result of our increasingly shared vulnerabilities. The pandemic and the war in Ukraine demonstrate that Norway cannot address these vulnerabilities alone. Strategic autonomy is highlighted as a key measure based on a recognition of the need for greater control over input factors and supply chains.

Zoom in on image

Photo: Ronald Johansen.

Health emergency preparedness cooperation in the EU has developed at record speed since the COVID-19 pandemic impacted Europe. As early as September 2020, the President of the European Commission launched the ambition of the EU Health Union, which is an enhanced cooperation in the field of health to strengthen health emergency preparedness. In autumn 2021, the Health Emergency Preparedness and Response Authority (HERA) was established. By the end of 2022, four legal acts were in place. These include measures to ensure the supply of medical countermeasures during a crisis. Furthermore, European regulation of cooperation on serious cross-border health threats has been strengthened, and the European Centre for Disease Prevention and Control (ECDC) and the European Medicines Agency (EMA) have been given extended mandates.

For Norway, the COVID-19 pandemic has revealed vulnerabilities in national emergency preparedness that can only be resolved through international cooperation. Norway’s participation in the internal market through the EEA Agreement puts Norway in a special position. At the same time, the EEA Agreement did not provide Norway with access to vaccines and other medical countermeasures. Norway depended on close cooperation with key European countries, and for some time, a tweet from the President of the European Commission was the only written documentation indicating that Norway was included. Sweden’s vaccine negotiator was instrumental in finding a solution that ensured Norway access to the EU’s vaccine procurements. It was not a foregone conclusion that Norway would succeed.

Norway was largely included in the EU’s crisis response. Norway was allowed to participate in the EU Crisis Management Mechanism (IPCR), where EU Member States discussed the COVID-19 pandemic and coordinated measures. Norway also participated in frequent informal meetings of ministers of health. Participation in EU forums was an important source of knowledge for our national management. At the political level, dialogue with Nordic and European ministers of health was also important for national management.

Norway took its share of responsibility and contributed to European solidarity. In April 2020, Norway sent an Emergency Medical Team (EMT) of healthcare professionals to Bergamo, Italy, where the healthcare system was at a breaking point. Norway sent gloves to France when French stockpiles were empty and intensive care medication to Spain and Sweden.

There is no other responsible alternative for Norway than binding cooperation with the EU’s enhanced health emergency preparedness. Therefore, the Norwegian Government is working to participate in EU cooperation on health preparedness and response – on as equal terms as possible to EU Member States. The Norwegian Government is taking this step to ensure a robust and predictable Norwegian health preparedness and response, and to safeguard the Norwegian population.

Health dialogue with the EU and key countries

Systematic and strategic cooperation with key EU actors and selected countries on a day-to-day basis forms the basis for good cooperation in times of crisis. Norway must clearly and at an early stage identify national interests in order to help ensure that EU mechanisms for health emergency preparedness are developed to safeguard Norwegian interests. The Ministry of Health and Care Services prioritises close dialogue with the EU at both political and senior official levels. Furthermore, the Ministry is working to enter into structured cooperation on health emergency preparedness with selected EU countries.

The EU Civil Protection Mechanism

In principle, emergency preparedness and crisis response are part of the internal affairs of EU countries. Nevertheless, developments over time have resulted in the EU receiving a mandate to facilitate enhanced cooperation on emergency preparedness and crisis response. This is primarily done through the EU Civil Protection Mechanism (UCPM).

UCPM is a demand-driven assistance scheme. Countries can request civil assistance, and it is then at the discretion of other countries to offer what available resources they can spare. Both during the pandemic and the war in Ukraine, European countries have shared enormous quantities of medicines, vaccines and medical devices. Under the UCPM, strategic stockpiles for pharmaceuticals and medical devices are being further developed, also for CBRNE incidents in Europe. This does not replace national emergency preparedness, but is intended to function as a reserve. Emergency preparedness is costly, but it is improved and becomes less expensive when resources and expenses are shared.

NATO and Nordic cooperation

NATO is increasingly emphasising resilience, civil protection and civil-military cooperation. This is a prerequisite for the overall emergency preparedness and defence of the individual Allies, and, thus, the Alliance. Allies’ commitment to enhancing their own collective capability and capacity to withstand an armed attack is based on Article 3 of the Washington Treaty. The work is based on fundamental expectations of resilience in critical societal functions (Seven Baseline Requirements19). Continuity of government and critical government services, a resilient water supply and the ability to deal with mass casualties are expectations that fall within the health and care sector’s areas of responsibility.

NATO’s increased emphasis on civil-military cooperation and resilience in critical societal functions means that the health sector is to a greater extent integrated into the work of NATO. Active participation in relevant forums is important for safeguarding Norwegian interests in the work on resilience in NATO. The health and care sector will work systematically to meet NATO expectations. Norway has an important role in providing host nation support to Allies in connection with exercises and incidents. Norway has good systems in place for requesting assistance but needs to develop better solutions for host country support.

The increased strategic significance of the High North and the accession of Finland and Sweden to NATO give rise to new needs and opportunities for developing Nordic health emergency preparedness cooperation, including in the civil-military context. Cooperation on enhancing resilience and cooperation on emergency preparedness plans for mass casualties and serious societal crises will be especially important. In March 2022, the Nordic ministers of health adopted a declaration on health preparedness and resilience in the Nordics. The declaration states that the Nordic countries will work together to strengthen Nordic and European health emergency preparedness, resilience and crisis management.

In order to strengthen strategic Nordic cooperation, the Norwegian Government is seeking to further develop the work of the Nordic Group for Public Health Preparedness (the Svalbard Group). One important component will be how the Nordic countries can jointly contribute to good European health emergency preparedness solutions in the EU and NATO. The Norwegian Government will facilitate the preparation of and exercises pertaining to emergency preparedness plans for health emergency preparedness and medical services in cooperation with the Nordic countries and NATO.

The Norwegian Government will:

• work to promote Norway’s association with the EU’s enhanced cooperation on health emergency preparedness on as equal terms as possible to EU Member States

• further develop Nordic cooperation on civil-military health emergency preparedness within the frameworks of NATO and the EU

3.6 Global resilience

Norwegian health emergency preparedness does not begin at Norway’s national borders. Even the best prepared societies and the most resilient health system will benefit from the prevention and containment of outbreaks, to avoid them becoming global crises. Generally, the most dangerous pathogens do not arise in Norway, but rather in countries and regions with far weaker health systems, where capacities to detect and contain outbreaks are weaker.

Our health emergency preparedness therefore begins locally, where an outbreak occurs. Weak health systems in other countries and weak systems for international cooperation pose a risk to Norway.

Future Norwegian health emergency preparedness depends on all countries becoming better at avoiding outbreaks, at detecting outbreaks in time and containing them effectively. It is also in Norway’s interests that those outbreaks that are not contained but which become major epidemics or global pandemics, are met by well-functioning multilateral cooperation consisting of strong institutions and effective systems.

Thus, we see that some capacities for health emergency preparedness at the national, regional and global levels benefit all countries. Future global and Norwegian health emergency preparedness should be based on such global public goods.

Evaluations of the response to the COVID-19 pandemic show that these systems are grossly underfunded. For example, the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response describes a need for annual global investments in global public goods in the amount of USD 15 billion per year over the next five years. The Independent Panel for Pandemic Preparedness and Response notes that although large amounts are needed, failure to make these investments in prevention leaves us vulnerable to crises that are many hundred times more costly.20

Traditional health development aid is an important tool for improving health conditions in the recipient countries. But if Norway and the rest of the world are to be better prepared for future crises, targeted and enhanced financing of global public goods for health preparedness is required. Such investments must be based on technical assessments of health needs and supported by dedicated funding.

In the Norwegian Government’s view, there is a clear need for as many countries as possible to invest heavily in health as a global public good. It is particularly important to increase investments in surveillance, warning and research capacity, as well as the development of countermeasures against pandemic threats. There is also a need to ensure appropriate and sustainable investments in organisations that form the backbone of multilateral health cooperation and that benefit all countries, such as the World Health Organization and the Coalition for Epidemic Preparedness Innovations (CEPI).

Countries that allocate too low a share of their national budget to ensure that all their citizens have access to basic health services should primarily increase this share. Through the Sustainable Development Goals, all countries have committed to ensuring basic health services for all by 2030. The world is behind schedule in achieving this goal.

Improved global access to countermeasures and more equal distribution

There are major global inequalities in countries’ abilities to prevent and manage health crises, such as pandemics. All countries have a moral responsibility to contribute to international solidarity and to improve equity. Contributing to a global pandemic response is also in the national interest of all countries.

Balancing national self-interest and international solidarity can be challenging, as shown by global uneven distribution of scarce resources such as vaccines and protective equipment during the COVID-19 pandemic. The cumulative effect of governments individually securing access to scarce resources for their own populations is an unacceptable uneven global distribution.

Zoom in on image

Photo: WHO, Photo Library.

The speed with which safe and effective vaccines against SARS-CoV-2 were developed, was a research and industrial revolution. For the future, we must strive for even shorter development times, even greater and more regionalised production capacity, as well as structures that ensure more equitable access. Immediately available funding is needed when outbreaks occur, as well as a significant strengthening of national health systems. Norway, together with South Africa, took global leadership responsibility for improving access to medical countermeasures during the COVID-19 pandemic, through the Access to COVID-19 Tools-Accelerator (ACT-A) partnership. Norway is therefore well placed to contribute to the further development of global cooperation in this area.

The World Health Organization, International Health Regulations and Pandemic Agreement

When major crises arise, we need predictability based on clear rules and procedures, and a willingness to engage in international cooperation. The World Health Organization, as the UN’s specialised agency for health, is the world’s leading, coordinating and normative agency in international health cooperation. The work to ensure that outbreaks are contained is led internationally by the World Health Organization, and helps prevent many epidemics from spreading to new areas. In order to protect the Norwegian population, it is also important that other countries, including low-income countries, detect and combat epidemics. We need the World Health Organization to strongly lead the global response, provide a well-functioning arena for cooperation between countries, and provide independent technical advice when a crisis occurs. Norway will continue to be a constructive and reliable supporter of the World Health Organization.

Two parallel negotiations have now been initiated at the World Health Organization to strengthen the global regime that regulates management of pandemics. Both are scheduled to be completed by May 2024.

Firstly, countries are revising the International Health Regulations (IHR). The IHRs are a binding international legal agreement which aims to prevent the international spread of disease and ensure internationally coordinated follow-up. The IHRs establish specific rules for cooperation among States Parties and the World Health Organization, and place high and specific demands on the health emergency preparedness systems of the States Parties.

Implementation of the regulations requires major domestic investments for some States Parties. The revision has been initiated due to insufficient compliance with the rules and in order for the text to best support the purpose of the regulations. Norway participates in these negotiations, among other things to help ensure that States Parties detect relevant information about possible events and outbreaks to the greatest extent possible, and are able to assess and report to the World Health Organization as quickly as possible. Norway is also working to ensure that States Parties are given greater opportunities to hold each other accountable.

Furthermore, negotiations have been initiated to develop a new, binding international agreement for the prevention and management of pandemics, which will complement the IHRs. Norway is working to ensure that the treaty, together with the IHRs and future cooperation on medical countermeasures, will contribute to improved equity in countries’ capacities to prevent and respond to pandemics. The treaty should also contribute to a strengthened value chain for the development of and access to medical countermeasures, improved exchange of information on health threats, enhanced cooperation across the human health, animal health and climate sectors, and for the strengthening of health systems.

The Norwegian Government will:

• further develop Norwegian investments in global public goods for health emergency preparedness in the development aid budget and be a driving force for other countries to do the same on the basis of the principle of fair burden-sharing

• work to strengthen multilateral cooperation in the field of health, based around the World Health Organization

• work to strengthen global access to medical countermeasures and achieve a more equitable distribution