National health governance, science and the media: drivers of COVID-19 responses in Germany, Sweden and the UK in 2020

Claudia Hanson, Susanne Luedtke, Neil Spicer, Jens Stilhoff Sörensen, Susannah Mayhew, Sandra Mounier-Jack

Original research

To cite: Hanson C, Luedtke S, Spicer N, et al. National health governance, science and the media: drivers of COVID-19 responses in Germany, Sweden and the UK in 2020. BMJ Global Health 2021; 6:e006691. doi:10.1136/bmjgh-2021-006691

Handling editor Seye Abimbola

Additional supplemental material is published online only. To view, please visit the journal online.

Received 22 June 2021 Accepted 17 October 2021 For numbered affiliations see end of article.

Correspondence to Dr Claudia Hanson.

ABSTRACT

The COVID-19 pandemic is an unprecedented global crisis in which governments had to act in a situation of rapid change and substantial uncertainty. The governments of Germany, Sweden and the UK have taken different paths allowing learning for future pandemic preparedness. To help inform discussions on preparedness, inspired by resilience frameworks, this paper reviews governance structures, and the role of science and the media in the COVID-19 response of Germany, Sweden and the UK in 2020. We mapped legitimacy, interdependence, knowledge generation and the capacity to deal with uncertainty. Our analysis revealed stark differences which were linked to pre-existing governing structures, the traditional role of academia, experience of crisis management and the communication of uncertainty—all of which impacted on how much people trusted their government. Germany leveraged diversity and inclusiveness, a ‘patchwork quilt’, for which it was heavily criticised during the second wave. The Swedish approach avoided plurality and largely excluded academia, while in the UK’s academia played an important role in knowledge generation and in forcing the government to review its strategies. However, the vivant debate left the public with confusing and rapidly changing public health messages. Uncertainty and the lack of evidence on how best to manage the COVID-19 pandemic—the main feature during the first wave—was only communicated explicitly in Germany. All country governments lost trust of their populations during the epidemic due to a mix of communication and transparency failures, and increased questioning of government legitimacy and technical capacity by the public.

INTRODUCTION

The COVID-19 pandemic is an unprecedented global crisis. Reported cumulative global cases and deaths were 83 and 1.8 million, respectively, at the end of 2020, and Europe accounts for around one-third of global cases and deaths. European countries were insufficiently prepared when a large COVID-19 outbreak in northern Italy first became evident. Governments were forced to respond to a crisis characterised by many uncertainties, especially relating to levels of presymptomatic transmission and infection-fatality rates. Interventions to address the epidemic were

WHAT IS ALREADY KNOWN?

Governments in Europe reacted in different ways to the COVID-19 crisis; the Swedish exception has raised debate.
Little is known, however, how differences in the pandemic handling related to government structures, the role of academia and the communication with the public.

WHAT ARE THE NEW FINDINGS?

Germany, Sweden and the UK responded in a very different way in line with the (i) pre-existing societal and academic culture, (ii) the existence of trusted academic advisory boards and (iii) the ability to manage and leverage diversity allowing broad academic involvement and societal debate.
Germany leveraged diversity and inclusiveness and allowed a broad societal debate, but this overwhelmed the population in the second wave.
Sweden feared different views: the government instead delegated the handling of the pandemic to the Public Health Agency.
The UK leveraged its strong academic structures, but the public was left with confusing and rapidly changing public health messages.

WHAT DO THE NEW FINDINGS IMPLY?

Pandemic preparedness will need to go beyond traditional approaches to preparedness within the health sector and state emergency function.
Strong pre-existing, trusted and functional academic and public advisory bodies that can support decision-making, evidence creation as well as communication with and engagement of the public may increase resilience—but these structures can only be fully leveraged if politicians and the media are able to provide them space.

first based on practices used to curb common influenza epidemics including handwashing. The use of masks was adopted, but only hesitantly at first. When the second wave hit Europe in autumn 2020, uncertainty was substantially reduced. In early November, consensus emerged on infection-fatality rates, with estimates ranging from 0.4% to 0.8% across European countries, confirming higher levels than in typical influenza epidemics. There was broad consensus at that time on the importance of transmission through smaller airborne droplets (aerosols), the importance of presymptomatic and asymptomatic infection transmission and more clarity about the role of infection and transmission in children. In the midst of the second wave, news about the imminent availability of effective vaccines was released. Soon after, new mutations discovered in the UK and South Africa curtailed hopes that the pandemic could be tackled within a few months; again this raised uncertainty. Government decision-making in such a crisis, particularly when scientific uncertainty is high, demands capacity and legitimacy to protect citizens as well as health systems. Concepts of health systems resilience—the capacity to adapt and respond to shocks—have been discussed and framed in recent years. This includes critical consideration in reducing the negative and often unequal effects on health that can result from crises. Discussions about system resilience emerged during and after the 2013–2016 West Africa Ebola outbreak. That time evidence was created—although often ignored—on the importance of health systems being adaptable to sudden crises, contributing to thinking on how systems could also adapt to longer-term challenges such as climate change. Subsequently, a larger body of evidence has been gathered to better conceptualise and refine the concept of health system resilience, and studies are beginning to use this concept to analyse systems responses to outbreaks. Few have applied resilience as a lens for the analysis of governance and government decision-making in crises to review the relevance of the domains. Yet, the COVID-19 crisis highlights the importance of governance of the health systems and health. The importance of assessing processes, including communication, building legitimacy and creating knowledge in the population, in addition to focussing on outcomes such as morbidity and mortality, cannot be overemphasised. After over 1 year into the COVID-19 pandemic, several scholars have started to rank country performance. Within Europe large differences in excess mortality has been described for 2020. The Bloomberg Resilience Score takes a more holistic approach and includes in addition to mortality also social freedom, vaccination and other indicators describing the ability to go back to normality. The ranking of better and worse performers raises the question of factors and processes which made countries to be more or less successful. Those countries, including Sweden and the UK, which scored highest on Global Health Security Index—a six-category score encompassing aspects of detection and reporting, rapid response and health systems readiness—did not demonstrate an effective response, raising questions about aspects of crisis readiness that were missed in the score. To support the further conceptualisation of potential factors which increase epidemic preparedness and increase societal and health systems resilience we use the Blanchet et al resilience framework to better understand the COVID-19 response and particularly governance and leadership, the link to science, and how this shaped communication with populations leading to enhanced or damaged inclusion and trust. Further, we aimed to contribute to theoretical reflections on governance and resilience and how to better frame necessary processes and decision-making to strengthen future crisis management and pandemic preparedness. We selected the three countries on the European continent of Germany, Sweden and the UK because the (i) were being hit at virtually the same time in 2020 but (ii) adopted very distinct approaches to the first and second wave. Germany was early characterised as well-performing. The Swedish exceptionalism was unique in Europe and has raised much international debate. The UK has a strong academic public health tradition and UK based researchers were publishing important background papers, yet COVID-19 mortality rates were high and its response to the first wave was heavily criticised. COVID-19 mortality rates differ strongly between the three countries in the first and second wave and differences are still seen.

METHODS AND CONCEPTUAL FRAMING

We analysed governance, policies and communication of the governments of Germany, Sweden and the UK, informed by the resilience framework of Blanchet et al with additional adjustments relating to cross-cutting dimensions as hypothesised by Hanefeld et al. The domains within our framework are supported by governance scholarship and are particularly relevant for thinking about health crisis management, and hence for conceptualising key issues that have arisen during the COVID-19 pandemic. In particular the framework reflects the importance of (i) legitimacy of governance and decision-making, (ii) knowledge creation and communication, particularly when there is scientific uncertainty and (iii) collaboration with as well as interdependence between the community and other actors including scientists and the media. We populated the original elements with information from the three countries. Specifically, we mapped legitimacy, interdependence, knowledge generation and the capacity to deal with uncertainty. Our analysis describes the capacity of these countries to manage the crisis in 2020. The paper is based on a systematic document and policy analysis. However, while we sought to directly compare the three countries, in practice it was necessary and appropriate to adopt a flexible approach when identifying the documents that we drew on. This was because the sources of information on COVID-19 varied substantially between the countries. Also, the nature of the pandemic, the policy resources and sources of information changed very rapidly throughout 2020. Much of the information we used was drawn from government and public health Agency websites of countries’ public health agencies and governments: the Robert Koch Institute, Germany, the Public Health Agency (PHA), Sweden, and the Coronavirus (COVID-19) page of the UK government (Gov.UK). We also included mass media websites. A list of websites searched and keywords used is provided in online supplemental web annex 1. We analysed the policies of the countries in relation to each domain of our framework. Information was cross-checked with already published work and carefully referenced to ensure transparency. We reconstructed the timeline of events and interventions from government websites and mass media and extracted data on the 14-day rolling average of cases, deaths and SARS-CoV-2 testing from the European Centre for Disease Prevention and Control (ECDC) except for the UK testing data for which we extracted data from the government homepage of England, Wales, Scotland and Northern Ireland and calculated weekly rates per population. We used the COVID-19 Government Response Stringency Index, to assess the strength of the government intervention in each country. We used the YouGov COVID-19 tracker to summarise levels of trust by plotting the answers to the question of whether respondents agree that the government handled the coronavirus ‘very’ and ‘somewhat well’. We imputed missing data points using the impute command in Stata V. 16.

RESULTS Timeline of the pandemic and the response

All three countries detected their first cases of SARS-CoV-2 in January 2020 which triggered their first responses, but they only started to act more decisively when community transmission became apparent in the three countries in early March. Both Germany and the UK responded on 23 March with national restrictions, although of different intensity. Educational, leisure and cultural facilities were closed in both countries. The UK instituted strict ‘stay-at-home’ orders, while Germany allowed people to meet outside. In contrast, Sweden’s public life remained less interrupted. Schools remained open, although the last three grades moved to distance learning. Also, large events were banned. Given the fast and more restrictive reaction of other Nordic countries, the PHA’s strategy came in for early criticism by some. Cases started to decline in mid-April in Germany and the UK at which point measures were relaxed and public life partly restored, and schools were reopened. In contrast, there were only minimal changes in Sweden where less stringent measures remained including ban of larger events. Germany and the UK had very low numbers of cases of just 6 (Germany) and 12 (UK) over a 14-day rolling average per 100 000 population in June and July 2020, while in Sweden cases were never reduced below 25 infections in 14-days