Sweden country snapshot: public health agencies and services in the response to COVID-19

Peter Allebaeck and Bo Burström

Introduction

This snapshot explores the role of public health agencies and services in responding to the COVID-19 pandemic in Sweden, using a sub-set of public health functions to serve as ‘tracers’ of how far public health was engaged in different aspects of the response to the pandemic. The report covers the role of public health agencies and services in the following areas: pandemic planning, overall governance of the pandemic response, guidance on non-pharmaceutical interventions, communication, testing and tracing, and vaccination. It draws from various governmental policy reports, webpage material from authorities, and scientific articles referred to below. Three interviews were undertaken and the results integrated into the text, to illustrate stakeholders’ views. The interviewees included one member of the Swedish Association of Local Authorities and Regions (below referred to as the SALAR representative), one member of the disease control agency of the Stockholm Region (below referred to as the SR representative), and one strategic leader of the West Gotaland Region (below referred to as the VG representative). The regions of Stockholm and West Gotaland are the two regions in Sweden with the greatest population size, covering in total around 3.5 million inhabitants.

Pandemic planning

In Sweden, most decision-making is delegated to national authorities that, despite being governmental institutions, operate independently. This governance structure means that during the first wave of the COVID-19 pandemic, the government left major decisions to national authorities. The Public Health Authority (PHA) in particular has played a major role throughout the COVID-19 pandemic as the motor that drove the response to COVID-19 in Sweden. Key decisions were taken by the PHA, in dialogue with the government. The PHA also issued recommendations and communicated with the general public.

During the pandemic, three governmental authorities acted in coordination with each other:

1. the PHA, which had a role in general pandemic monitoring and planning;
2. the National Board of Health and Welfare (NBHW), which was responsible for health services; and
3. the Swedish Civil Contingency Agency (SCCA), which had a limited role in addressing general aspects of pandemic preparedness and public communication

At the beginning of the pandemic, the PHA and the state epidemiologist developed a strong reputation, being also well-known outside of Sweden, for implementing policies that slightly diverged from those implemented in other countries. Daily press conferences with the three authorities mentioned above, later reduced to twice weekly, kept the public informed and engaged in the response planning. Groups living in marginalised communities with a large immigrant population were more difficult to reach. However, in spring 2020 greater efforts were made at municipal level to reach these groups and provide information in several languages.

The PHA coordinated pandemic measures at the national level, but most health care in Sweden, including public health services, is to a large extent a regional competency. This was especially salient with regards to monitoring and testing policy. The PHA urged for more testing, which was further subsidized by the government (otherwise paid for by the regions), however a lack of prioritisation, coordination and staffing at local level severely delayed testing and contact tracing. This occurred despite Sweden’s extensive history in controlling diseases such as sexually transmitted infections.

During the first wave, Swedish law did not allow for limitation of movement, hence the PHA and the government jointly disseminated strong recommendations about refraining from unnecessary shopping or unnecessary travel, limiting restaurants to table service only, maintaining distance between persons and working from home whenever possible. Cultural and sport activities were placed on hold.  The SR representative stated that labour policies required changes in the law to allow restrictions to be implemented, and that this was the role of the government. The SALAR representative pointed out that the existing law for disease control was not set up for a pandemic, therefore a new pandemic law had to be created and voted upon by the Swedish Parliament.

Among the factors favouring public compliance with these strong recommendations during the first wave was a sense of seriousness and faith in the public authorities’ messages and recommendations. The main problem during this period was municipalities’ role in the residential care of older people. Recommendations and guidelines on distancing and wearing of protective devices were poorly disseminated across the municipalities’ health and social care services. Consequently, a high disease incidence was observed in homes for older people and a high mortality was seen among this group. All interviewees confirmed that adequate care of the older population was a major challenge and that it was difficult to give appropriate instructions and protective devices to staff in all municipalities that were responsible for care of older people.

Even before the pandemic, the situation around care of older people in Sweden has been criticised for unequal and often poor management, as well a lack of coordination between health and social care services and between regions and municipalities. This lack of coordination was even more apparent during the pandemic, and ongoing debate intensified, with demands to review the system of care of older people and the division of responsibilities between the state, the regions and the municipalities.

During the second wave it was clear that public willingness to comply with recommendations and rules was fading, so the government took on a more prominent role and communicated more visibly with the public. It also adopted firmer restrictive measures, such as introducing limitations on public gatherings; new laws regarding the number of persons that could gather in public and private places were passed. However, despite this increased political guidance, the strong communication channels established between the government and the public authorities meant that that decision-making was likely to have been less politicized in Sweden, when compared to some other countries. As one representative of the disease control agency of the Stockholm Region (SR) pointed out: “The PHA and regional disease control agencies have knowledge that the government cannot have. You cannot make a political issue of what is knowledge-based.”

Overall governance of the pandemic response

The Swedish PHA traces its origins back to an infectious disease surveillance authority which was merged into a more generally oriented PHA several years ago. Thus, on the one hand, the PHA already had a strong tradition of infectious disease control that was strengthened and became more prominent. On the other hand, the general mandate of the PHA includes other health aspects and a strong focus on health equity. This was advantageous in that the PHA was responsible both for controlling the spread of SARS-CoV-2 as well as for other health effects. The SALAR representative highlighted this as one reason why the PHA advocated against general closure of schools: it was considered more harmful for children to be locked in their homes than to keep schools open for children up to 15 years old. The interviewed SR region representative stated that the PHA as an agency was virtually unknown to the public prior to the pandemic, but afterwards went on to become the most well-known agency in Sweden.

The PHA was the leading voice during debates and communication about recommendations and guidelines, although there was some discrepancy between what was communicated and what was actually implemented. The prime minister, and even more so the minister of health, were also visible on the media. However, there was some public surprise about the strong role of the PHA compared to that of the government. Although the government took on a more prominent role during the second wave of the pandemic, and the Swedish parliament was essential to pass laws that enabled restrictive measures to be legally binding, with fines for restaurants and gatherings which did not comply, throughout the pandemic it was really the PHA that led the monitoring and issued social/behavioural guidelines, whereas the NBHW had a leading role in the management of health services. 

Guidance on non-pharmaceutical interventions

The Swedish PHA had a scientific way of determining which measures to recommend and how they were communicated. The rhetoric was very much concerned with “evidence”. Rational arguments were given on the value of e.g. school closures against side effects on health and wellbeing of children and families. Mask-wearing was much discussed, and evidence of generalized mask-wearing in public areas was considered low, whereas strong emphasis was put on physical distancing. Communication was directed to decision-makers at all levels and directly to the public through a strong media presence. A few measures were repeatedly communicated:

• Maintain good hygiene and wash hands frequently with soap and water or alcohol
• Avoid contact with people other than those you live with
• Stay at home whenever there is any sign of airway infection
• Keep at least 1.5m distance from other people
• Work from home whenever possible

A complete lockdown was never implemented. However, all persons aged 70 years and older were advised to stay at home, and arrangements were made to provide them with food and maintain contact with family and social services through digital devices whenever possible. Many grocery stores also had early opening hours dedicated to older people and other at-risk groups. The blunt age limit was criticized, but the recommendations were mostly followed, until they were lifted in March 2021. The importance of physical distancing was repeatedly communicated and mostly followed, whereas mask-wearing was primarily recommended when adequate physical distance could not be maintained, such as when accessing health services or on crowded public transport.

However, perhaps an overly scientific approach was taken regarding the wearing of masks in the community. As mentioned above, the evidence favouring wearing of masks in general was not considered to be strong by the PHA, so many public transport companies did not control or enforce mask-wearing, despite PHA recommendations when they indeed were given. Furthermore, governmental officials did not adopt an official position on wearing masks. While there was debate around this and many wanted stronger recommendations or mandates about, for example, wearing masks in shops, there was no political controversy on this. At the political level no one (not even among the opposition parties) advocated stronger restrictions. The main political criticism was against lack of testing, and poor management in homes for older people, which was not the mandate of the PHA, but the mainly the responsibility of regions and municipalities.

Secondary schools (for students aged around 16 years) and universities moved to distance learning. This transition was considered by many to have succeeded beyond expectations, although negative aspects and increased inequities in learning were also recognized. Although schools for younger children, preschools and nurseries were generally kept open, in some cases lack of staff and COVID-19 outbreaks led to temporary closures or to arrangements, such as dividing schools or classes to enable students to physically attend on alternating days.

A strategic leader of West Gotaland (WG) region said that the PHA was careful about implementing restrictions that did not show a reduced risk for spread of the coronavirus. 

Communications strategy and communicating with the public

The communication strategy adopted during the pandemic was in line with standard governance policy, i.e. national authorities were primarily responsible for communication, while collaborating closely with the government and the regions. Therefore, the communication strategy was to a large extent led and coordinated by the PHA, NBHW and SSCA. At the governmental level, the Minister of Health was more prominent and active than the Prime Minister with regards to communication.

Although the overall governance structure was not altered, the scale of collaboration and strength of media presence developed by the authorities was new and unprecedented. According to the SR representative, the PHA had a successful communications strategy and the regions simply referred in most cases to the PHA website. However, the SALAR representative suggested that the regional disease control authorities were the ones performing decisive communications work. This discrepancy might be due to the fact that the Stockholm Region operates closely with national bodies and authorities, whereas in other parts of the country it is essential for local players to have a strong role in communication. The Stockholm region also encountered problems reaching out to suburban communities with many migrants, leading to a higher rate of COVID-19 spread in those areas. It was only later that more active measures, such as engaging community representatives and using mobile buses for testing and vaccination, were introduced. Regulations were intended to be sustainable, although by the end of May 2021 the difficulty of maintaining distancing measures was increasingly obvious. Although recommendations and regulations varied, and at times felt inconsistent, the fact that restrictions were less strong than in some countries, was thought to enable a more sustainable level of distancing than in countries where very strong lockdowns were applied, lifted, applied again, etc. The latter was the case in Norway, but a study showed that both in Norway and Sweden there was a high level of trust in authorities’ recommendations, compliance with restrictions and that the strategy applied by governments were well supported.

Testing and tracing

The implementation of testing and tracing was a key challenge due to the decentralized system in Sweden. Both the SR representative and the WG representative mentioned that it was difficult to conduct proper contract tracing because of difficulties in obtaining proper test kits and having a functional flow of processes to analyse the tests: “… but it was impossible to recruit 300 bio-analysts instantaneously” (SR representative). “It was difficult to get access to test materials, difficult to organize testing, many different paths were created, [it was] difficult for patients to navigate” (VG representative).  Capacity, resources, and even prioritization varied across regions, even though there were strong recommendations and guidelines from the PHA and the government in place. The government encouraged scaling up testing, and also provided funding for the regions to increase testing capacity (normally the financial responsibility is the regions), but is seems that funding was not the issue, but logistics and staffing.

Vaccination efforts

From the very start of the pandemic, Swedish authorities, and the general public, recognized that the preparedness for a pandemic, as well as crisis situations in general, were poor. There is a consensus that this needs to be improved.

While some players have suggested the role of the PHA has been too strong, others have asked what the alternative would have been. Swedish governments (of all political sides) are strongly dependent on expert authorities and do not seem to want to shift to more ministerial governance.

A very high death rate in the beginning of the pandemic threw the light on already poor conditions in the municipalities’ care of older people. The problem was not new, but was highlighted by the pandemic.

The strongly decentralized responsibility for health services was perceived as a problem, since the government’s and the PHA’s recommendations on testing were not implemented. A reduction of the number of regions has been proposed earlier, but there is no strong support for this.

Capacity of health services turned out to be almost above expectations, since increased capacity for intensive care was rapidly deployed, and the necessary reorganisation and re-prioritisation of health care was put in place.

While Sweden initially was considered an outlier with lesser restrictions and very high death rates, other countries did in the 3^rd and 4^th wave adopt similar policies, regarding e.g. school closures.

In recent figures on excess deaths, Sweden turns out to be at the lower level among EU countries, although neighbouring countries have much better figures. The reasons why Sweden has fared better than many other EU countries while poorer than neighbouring countries is an interesting research question, but difficult to answer.

References

Helsingen LM, Refsum E, Gjostein D. The COVID-19 pandemic in Norway and Sweden – threats, trust, and impact on daily life: a comparative survey. BMC Public Health; 2020; 20: 1597.

Ludvigsson JF. The first eight months of Sweden’s COVID-19 strategy and the key actions and actors that were involved. Acta Paediatr. 2020;109:2459-2471

Pashakanlou AH. Sweden's coronavirus strategy: The Public Health Agency and the sites of controversy. World Med Health Policy 2021; Jun 3;10.1002

Rizzi S, Søgaard J, Vaupel JW. High excess deaths in Sweden during the first wave of COVID-19: Policy deficiencies or 'dry tinder'? Scand J Public Health 2021; Jul 2; doi: 10.1177

COVID-19 - The Public Health Agency of Sweden (folkhalsomyndigheten.se)