Social Science & Medicine 321 (2023) 115783
Available online 16 February 2023
0277-9536/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Power and politics in a pandemic: Insights from Finnish health system leaders during COVID-19
Laura Kihlstr ¨ om
a,b,*, Lea Siemes
c,d, Moona Huhtakangas
d, Ilmo Keskim ¨ aki
d,e, Liina-Kaisa Tynkkynen
d,eaCultural, Behavioral, and Media Insights Centre, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00300, Helsinki, Finland
bDepartment of Anthropology, University of South Florida, 4202 E Fowler Avenue, Tampa, FL, 33602, United States
cMaastricht University, Minderbroedersberg 4-6, 6211, LK Maastricht, Netherlands
dWelfare State Research and Reform, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00300, Helsinki, Finland
eFaculty of Social Sciences, Tampere University, Kalevantie 4, 33100, Tampere, Finland
A R T I C L E I N F O Keywords:
Power Politics COVID-19
Health systems and policy research Governance
A B S T R A C T
Power and politics are both critical concepts to engage with in health systems and policy research, as they impact actions, processes, and outcomes at all levels in health systems. Building on the conceptualization of health systems as social systems, we investigate how power and politics manifested in the Finnish health system during COVID-19, posing the following research question: in what ways did health system leaders and experts experi- ence issues of power and politics during COVID-19, and how did power and politics impact health system governance? We completed online interviews with health system leaders and experts (n =53) at the local, regional, and national level in Finland from March 2021 to February 2022. The analysis followed an iterative thematic analysis process in which the data guided the codebook. The results demonstrate that power and politics affected health system governance in Finland during COVID-19 in a multitude of ways. These can be summarized through the themes of credit and blame, frame contestation, and transparency and trust. Overall, political leaders at the national level were heavily involved in the governance of COVID-19 in Finland, which was perceived as having both negative and positive impacts. The politicization of the pandemic took health officials and civil servants by surprise, and events during the first year of COVID-19 in Finland reflect recurring vertical and horizontal power dynamics between local, regional, and national actors. The paper contributes to the growing call for power-focused health systems and policy research. The results suggest that analyses of pandemic governance and lessons learned are likely to leave out critical factors if left absent of an explicit analysis of power and politics, and that such analyses are needed to ensure accountability in health systems.
1. Introduction
What do crises reveal and to whom? This question is at the core of anthropological takes on crises, which assert that how we define crises, use language around crises, act in crises, and how inequalities manifest during crises, reveal a great deal of social structures, governance, eco- nomics, and politics (Closser et al., 2022; Manderson & Levine, 2020;
Team & Manderson, 2020; Barrios, 2017). Responses to the COVID-19 pandemic have revealed how power and politics are fundamentally intertwined with health system governance and policy (Bozorghmehr et al., 2022; Stoeva, 2022). “COVID-19 politics” around the world have
demonstrated that the various responses and reactions of national gov- ernments, including centralization of power, use of emergency powers, implementation of various non-pharmaceutical interventions, such as so-called lockdowns, school closures, and border closures, were un- precedented in their scale (Greer et al., 2021 p. 673; Manderson &
Levine, 2020). The pandemic has made the political nature of health highly visible, highlighting that both the unequal impacts as well as the differing responses to the pandemic could to a large degree be traced to political determinants and issues of power (Greer et al., 2021; Man- derson & Levine, 2020; Vampa, 2021).
Power-focused health systems and policy research is a growing area
* Corresponding author. Cultural, Behavioral, and Media Insights Centre, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00300, Helsinki, Finland.
E-mail addresses: laura.kihlstrom@thl.fi (L. Kihlstr¨om), lea.siemes@student.maastrichtuniversity.nl (L. Siemes), moona.huhtakangas@thl.fi (M. Huhtakangas), ilmo.keskimaki@thl.fi (I. Keskim¨aki), liina-kaisa.tynkkynen@thl.fi (L.-K. Tynkkynen).
Contents lists available at ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
https://doi.org/10.1016/j.socscimed.2023.115783
Received 4 November 2022; Received in revised form 13 February 2023; Accepted 14 February 2023
of study which is focused on investigating how relationships of power
“shape societies and, in turn, health policies, services, outcomes, and health systems” (Topp et al., 2021, p.1). This line of research builds upon literature particularly from social sciences and the humanities, including the tradition of post-politics which asserts that the inherent and ingrained political aspects of (health) governance are rarely visible in the public sphere and are instead replaced in public discourse by techno-managerial or professional vocabulary (Fafard et al., 2022;
Mouffe, 2006). Feminist-informed theories and anthropological takes on health systems have also highlighted human relations and power in re- lationships as key to understanding aspects of health system (Closser et al., 2022; Storeng & Mishra, 2014; Mishra, 2014; Nichter, 1995;
Janzen, 1978; Topp et al., 2021). Thus, by placing an emphasis on the social dynamics, relationships, and actors in health systems, power-focused health systems and policy research highlights gover- nance as a useful entry point for understanding how power, politics, power dynamics, and the agency of health system actors shape the process(es) of responding to a pandemic.
While there is a rich literature on health systems from the viewpoint of health service delivery, studies with an explicit focus on governance are much less commonplace (Bozorghmehr et al., 2022). When health system governance is studied, this is frequently done by utilizing sec- ondary data sources such as government documents, legislative docu- ments, and press releases (Greer et al., 2021; Smaggus et al., 2022).
Qualitative research, such as in-depth interviews, then, can further pinpoint to the processes and choices through which health system leaders make sense of and construct meaning during crises such as pandemics (Cassola et al., 2022). Given the central role that governance and leadership play as one of the building blocks of health systems, this line of research of studying up can potentially expand our analysis and theoretical development of power and politics in health systems (Dawes, 2020; Gore & Parker, 2019; Nader, 1972; World Health, 2010). Finally, understanding who has been responsible for decisions during the pandemic is important because it can help strengthen accountability mechanisms in health systems (Greer et al., 2022a).
This article focuses on the empirical study of power and politics in the context of the COVID-19 pandemic. We do this by conceptualizing our work through the empirical site of actor relationships and networks (Topp et al., 2021). We use two key concepts frequent in power-focused health systems and policy research. We define power as “the ability or capacity to do something or act in a particular way” and as an ability to
“direct or influence the behavior of others or the course of events’”
(Topp et al., 2021, p. 1). We define politics as “the political activity or process of making collective decisions” as well as the “continuous struggle for power among competing interests” (Bernier and Clavier, 2011, p. 111; Kickbusch, 2015, p. 1). Finally, we place these concepts in conversation with governance, summarized as “the implicit and explicit rules and institutions that shape power, relationships between actors, and the actions of these actors” (Blanchet et al., 2017, p. 431). Against this background, the question guiding this research is: In what ways did Finnish health system leaders and experts experience issues of power and/or politics during COVID-19, and how did power and politics impact health system governance?
The objectives of this article are twofold: we both seek to advance empirical research on power focused health systems and policy research, as well as connect our findings to broader implications on how we think about accountability in health systems. A focus on the process of how different health system actors made decisions and the factors that affected those decisions can provide insights into how health systems preparedness can be improved for similar future events (Greer et al., 2022b).
2. Materials and methods 2.1. Study context
The context for the study is Finland, where the health system is mainly based on public financing and provision. Finland’s health care system is currently being reformed towards a central government fun- ded system with services provided by regional authorities. During the study period, however, health as well as public health services, including the control of infectious diseases at the local level, were under the responsibility of municipalities and municipal joint authorities.
However, the system was hierarchical given that 20 hospital districts responsible for specialized health services also provide advice on con- trolling infectious diseases at the regional level. Additionally, six Regional State Administrative Agencies (Regional State Administrative Agencies) coordinate and supervise infection control and make decisions on regional control measures. At the national level, the Ministry of So- cial Affairs and Health is responsible for the general planning, steering and supervising of infection control. The Finnish Institute for Health and Welfare operates under the Ministry as a state agency for epidemiolog- ical surveillance and advising on infection control for the central gov- ernment, and regional and local authorities.
The study focuses on the events during the first year of COVID-19 in Finland. Key regulatory frameworks include the National Pandemic Preparedness Plan, local and regional preparedness plans, and the Communicable Diseases Act, which emphasize the role of local and regional actors in pandemic governance, providing municipalities and Regional State Administrative Agencies main decision-making powers in terms of non-pharmaceutical interventions and other restrictive mea- sures (e.g. closures of schools and public premises) (Ministry of Social Affairs and Health, 2012a,b; Finlex. Tartuntatautilaki, 2016). The na- tional government and the Ministry of Social Affairs and Health are responsible for resource steering and information steering through soft law. During the first year (spring 2020–2021) of COVID-19 in Finland, there were various shifts in centralization and decentralization of power (Tiirinki et al., 2020). In March 2020, the government declared a state of emergency and used the Emergency Powers Act which centralized certain powers to the national level (e.g. closure of schools, public premises and restaurants, travel restrictions in and out of the county of Uusimaa). Towards summer 2020, the governance model was decen- tralized and, thus, aligned with the existing pandemic governance framework. In fall 2020, the government introduced the “hybrid-- strategy” which emphasized local epidemic control based on the Communicable Diseases Act and effective test-trace-isolate -system (Finnish Government, 2020). The state of emergency was declared again in March 2021, but it did not centralize the decision-making power as largely as in the spring 2020. It can be thus said, that after the early months of pandemic governance, the decision-making powers have been based on the Communicable Diseases Act in which municipalities and Regional State Administrative Agencies play a key role.
2.2. Study participants
The study draws on in-depth interviews collected from local, regional, and national leaders in the Finnish health system during the first year of COVID-19. Study participants (n =53) were sampled using purposive and snowball sampling according to their role in crisis man- agement within the Finnish health system. Participants were approached via email. One declined due to conflicting schedules and five did not respond to the emails. Participants represented leadership (political and civil service) in the Finnish health system at the local (n = 9), regional (n =23) and national (n =21) level. At the local level, study participants represented municipal managers and municipalities’ social and healthcare services. Regional level study participants represented joint municipal authorities, hospital districts, and Regional State Administrative Agencies. Local and regional level study participants
were recruited from four different regions to gain comprehensive data geographically, and from two integrated and two non-integrated social and healthcare systems. National level study participants included rep- resentatives from the Ministry of Social Affairs and Health, the Finnish Institute for Health and Welfare, the Parliament, Finnish Medicines Agency, National Emergency Supply Agency, Finnish Border Guard, and the National Supervisory Authority for Welfare and Health. When this article mentions or discusses political leaders, these refer to national level participants.
2.3. Study tool
Our study tool was a flexible interview guide which was structured around three key domains: preparedness to, governance and leadership of, and learning from the pandemic. The interview guide had sub- questions under each main domain, and the data presented in this article come mainly from the domain of governance and leadership. In this domain, participants were asked questions such as: “Could you describe what cooperation was like between different actors (national, regional, local) in the health system during COVID-19”, “What were the main difficulties and challenges, and how were they resolved or dealt with during the pandemic?“, “What worked particularly well in coop- eration between different actors?“, “What kind of values impacted the governing of the pandemic in Finland?“, and “In what ways has pandemic governance been affected by politics and politicization?“As the interviews were semi-structured, they allowed for follow-up ques- tions to be asked depending on the participants’ answers. Taken together, the interviews gave participants an opportunity to reflect upon their experiences of being a leader in the health system and part of health system governance during a pandemic. These reflections allowed us to explore forms and sources of power (Erasmus & Gilson, 2008).
2.4. Data collection
We conducted in-depth interviews with the study participants from March 2021 toFebruary 2022, a timeline which was allowed to be more relaxed due to the key roles that some of the interviewees played in governing the pandemic in Finland. We conducted all interviews remotely through Microsoft Teams and in Finnish. The research was completed in accordance with ethical guidelines of the Finnish National Board on Research Integrity of research completed with human partic- ipants (Finnish National Board on Research Integrity, 2021). All study participants were informed about the study and provided their verbal informed consent at the beginning of the interview. The duration of the interviews ranged from 60 to 90 min. All interviews were recorded and transcribed verbatim.
2.5. Data analysis
Two researchers first coded the data using an iterative process. At first, the two researchers read through all 53 transcripts to sort “big ideas” from the data. This step was followed by a more careful read to list emerging topics and themes from the data. These were then used to create an initial codebook which was reviewed by both researchers, and the contents for each proposed code was explained and reviewed. This initial codebook was then used to test code a sample transcript by both researchers independently, after which the two researchers discussed discrepancies, differences in interpretation, or potential additions or deletions from the proposed codebook to ensure inter-coder reliability.
A final codebook was used for the entire data set of 53 interviews, with the interviews shared between the two researchers. Coding was done on Atlas.TI version 9.1. This article is mainly based on the segments of the data coded under the category “power and politics” totaling 160 seg- ments. The lead author of this paper frequently re-read the original in- terviews to understand the quotes in the context of the entire interview.
This sort of deep reading of the transcript was also essential for grasping
the chronological order of key events and acts of governance in Finland during COVID-19.
In the final stage of coding, the lead author of this paper reviewed the segments under “power and politics” and summarized the quotations appearing in it. This process meant going through each quotation and creating a brief statement about what was being said. These summaries formed the initial list of findings, which were further clustered into the themes presented in this article. The process of clustering as well as the naming of the three main themes was done in tandem with re-reading and revisiting literature on power and politics in health systems, particularly research conceptualizations in this area of inquiry as laid out by Topp et al. (2021) as well as earlier literature published on COVID-19 (Greenhalgh & Engebretsen, 2022; Greer et al., 2021). Fig. 1 provides a more detailed description of how the data were clustered and what type of questions the data in each theme answer to.
The findings presented in the next section summarize three core themes from the data: credit and blame, frame contestation, and trans- parency and trust. The themes are presented in a narrative format with key quotations included. The analysis was completed in Finnish, and the quotations used in this research paper have been translated by the lead author from Finnish to English. In some cases, the quotes have been shortened, however, their original meaning and content has not been modified or taken out of context. For each quote, we provide informa- tion about the participant’s organization and level of governance rep- resented in the Finnish health system. The participant id, consisting of a letter and a number, indicates the level of governance (N =national level participant, R =regional or local level participant) as well as the order (number) in which participant was interviewed in the study.
3. Findings 3.1. Credit and blame
The narratives stated by study participants bring forward the shifts between centralization and decentralization of power particularly dur- ing the first year of COVID-19. These shifts are accompanied in the data with recurring instances and dynamics of credit and blame, where at times power is viewed as beneficial (credit), while at other times power is avoided or placed on someone else (blame). The theme of credit and blame in our data is best understood by utilizing a chronological list of events early in the pandemic. The weeks and months following mid- March 2020 are described in the interviews as a period of heavy participation by political leaders, during which political leaders had strong support from Finnish citizens. Our data suggest that although political leaders in Finland were eventually heavily involved, this was not the case in January and February 2020 when a potential threat regarding a new pandemic started emerging. According to one inter- viewee representing the Finnish Institute for Health and Welfare, po- litical leaders were uninterested in reacting to the information regarding a potential pandemic, and they describe particularly February 2020 as a period of “mandate allergy”:
Political leaders wanted nothing to do with this at first. Rather, they communicated that they would like us to take charge of all com- munications and knowledge-sharing regarding COVID-19. And yet, when we did take on some of this communication, they would tell us not to communicate like that. For example, if we published models or scenarios to the wider public, the political side got worried that people would be too scared. –Interviewee, The Finnish Institute for Health and Welfare (Participant id: N7)
This view was contrasted by an interviewee at the national level, who describes that health system experts’ views regarding the pandemic were ambiguous during the first two months of 2020 and thus were difficult to react upon:
The expert views from the Finnish Institute for Health and Welfare were very ambiguous. I have been present in many meetings and the Finnish Institute for Health and Welfare has also taken the view that the World Health Organization overreacted with this, that we are not in an international emergency. -Interviewee, Ministry of Social Af- fairs and Health (Participant id: N29)
There is no single event that can be detected from our data as the pivotal turning point during which COVID-19 gained political traction in Finland, however, several instances are mentioned, including growing pressure from the public, the first COVID-19 cases in Finland, and growing fears of economic repercussions (such as other EU countries ordering export bans). As crisis awareness among political leaders grew, they also started demanding more information regarding the potential steps ahead. According to one interviewee from the Prime Minister’s Office, health officials and civil servants at this point were “unable to produce solutions” particularly for operational activities and thus relied heavily on support from the political side. This statement is corroborated in the interviews by some who describe the heavy involvement of po- litical leaders as necessary because they were able to make difficult decisions during an uncertain situation. Others present an opposing view: they state that the decisions made by political leaders were
“panicky” and resembling those of authoritarian societies (e.g., border closures, closure of the South Finland region). One interviewee sum- marized that it seemed that politicians were constantly gauging public opinion in terms of their actions, recommending “opening up society when it is favorable” and “closing it again when that becomes favorable”.
The data suggest that political leaders in Finland, particularly key ministers in the government, spent extensive periods of time in March and April 2020 on decisions regarding how to govern the pandemic. As a result, political leaders spent hours a day learning about the virus and making decisions even about minor details, such as safe distances in social gatherings. This was unusual:
It is correct to say that the government took on quite a big role. It took on an active role. That happened kind of naturally because of the Emergency Powers Act, because that required a public announcement by the government about a state of emergency. The president was involved, and the government plays a key role in coordinating the state of emergency. I guess this mode of involve- ment has sort of stuck with them. This has been quite an exceptional period regarding the role that the government has played. – Inter- viewee, Ministry of Social Affairs and Health (Participant id: N8) While political leaders were heavily invested from March 2020 on- wards, both in their commitment and in their unity, according to the
interviews this level of involvement started to shift during summer 2020 and as the municipal elections in Finland started approaching.
At first, there was an almost national defense type of consensus among political leaders. The opposition did not raise any issues. At least we did not hear about any major political disagreements from within the government. Of course, those disagreements most likely existed, but the beginning was characterized by this sort of apolitical operational mode. But normal politics caught on, and COVID-19 became a pawn in political decision-making just like any other issue. That’s pretty normal, this is how it goes in a democracy.
–Interviewee, The Finnish Institute for Health and Welfare (Partici- pant id: N7)
By fall 2020, Finland’s strategy in governing the pandemic shifted – at least this was publicly announced - from the heavily centralized model to the hybrid strategy. Interviewees representing local and regional health system leaders, however, describe that despite this shift to a more decentralized model, political leaders as well as other actors at the na- tional level were reluctant to fully grant power to local and regional actors, and still attempted to micromanage operational actions:
And so came the fall of 2020 and the plan was that regions should lead. But the government very quickly lost its trust in regions. I don’t think it was the Finnish Institute for Health and Welfare who told them they could not trust the regions. Maybe they had their own perceptions, and they were influenced by the Ministry of Social Af- fairs and Health which is politically steered in many ways. Well, in any case, the Prime Minister started this power play with the regions.
They had no need to do this. Maybe they did not realize they were just opening a can of worms by doing that. And that sort of power play has been going on since. Well, I guess that can of worms would have been opened at some point regardless. Then the government and the Ministry of Health wanted to take charge again. However, they had no mandate for doing so. And so, we ended up in these very comic situations where we had different solutions for the same problem in different parts of the country. Some bent under the phone calls of the Minister of Health. Others did not. –Interviewee, social and health care, joint municipal authority (Participant id: R7) Thus, while power was de jure granted to local areas and regions, the interviewees representing them in our data were taken aback by the de facto “politicization” and the continued imbalance in power dynamics.
Some described themselves as “wanting to stay out of politics”. Yet, this strategy of opting out of politics did not always work, at least during the first year of COVID-19, as interviewees described being thrown into a politicized crisis, with disagreements and power struggles often publicly displayed and sensationalized by national media. Local level leaders Fig. 1. Clustering segments from research interviews based on types of questions answered by the data.
described being publicly blamed in media by political leaders and gov- ernment officials for not following recommendations, such as closing schools, while there was no clear legislative basis for enforcing that decision at the local level. This made it seem to some local and regional leaders as if political leaders wanted credit in the eyes of the public by seemingly providing strong guidance, and then blaming local and regional officials for not taking proper action. This perception was echoed by one interviewee:
I found it absolutely unfathomable that during this pandemic, the Ministry of Social Affairs and Health threw us (Regional State Administrative Agencies) under the bus. They made it (governance of COVID-19) seem like something it was not, and they did not discuss it with us. I understand that those at the Ministry of Social Affairs and Health were under political pressure, and that politicians say all kinds of things. But the Ministry of Social Affairs and Health should have some class in how they handle this. We are part of state governance. We work together. The Ministry of Social Affairs and Health should not publicly go against one of its own. -Interviewee, Regional State Administrative Agencies (Participant id: N5) One interviewee described that political leaders and national level actors could “easily blame” local health officials because politicians themselves would not be investigated similarly under the rule of law in case of misconduct. According to one study participant, the “losers” in the constant dynamics of credit and blame were citizens who had to follow public quarrelling between political leaders, scientific experts, and health officials, and another wondered why these quarrels had to be had publicly. Another study participant remarked that trust was further weakened by the spectacle-like aspects of politics.
Local and regional actors were not without agency amidst these power struggles, and the politics of credit and blame were said to also have positive effects at the local level. Local cooperation was described by interviewees as having improved during the pandemic and resulted in various instances of mutual aid. For example, during a severe shortage of masks, in one municipality different actors from the public, private and NGO sector came together to find solutions. Another interviewee described how several municipalities decided to stick together during a hectic time in the governance of the pandemic, when “swiftly changing”
instructions and recommendations arrived from the national level.
3.2. Frame contestation
Another important finding from the data regarding power and poli- tics is the issue of frame contestation. An overarching concern among the interviewees was that the pandemic was not only a biomedical event but rather a crisis which touched all sectors of society. Despite of this notion, the interviews demonstrate that the pandemic was predomi- nantly framed from the perspective of health system functioning and -security, reflected by the most dominantly followed indicators which were also published daily by national media (intensive care unit (ICU) capacity and the number of COVID cases in the population). According to health system leaders at the municipal level, this reflected the power that hospital district leaders and specialized care have in the health system:
What one has to remember is that everyone looks at this from the viewpoint of their own organization. Hospitals look at this from the viewpoint of intensive care, particularly the availability of intensive care. In a way, they do not have to care about other issues, while municipal leaders or the prime minister, for example, have to ponder the economic and social impact, as well as many other dimensions regarding health. They have to seek balance. This sort of balance thinking does not fit well with the operational logics of intensive care. So, this easily leads to taking action just in case, and we have seen the same logic with the Ministry of Social Affairs and Health,
closing everything just in case. -Manager, municipality (Participant id: R21)
The data suggest that the framing of the pandemic from a dominantly biomedical perspective, as well as the indicators used to monitor it, stemmed at least partly from how power was allocated in the early months of 2020: first through the declaration of a state of emergency (which centralized power to the national level) and then through the allocation of power to one sectoral ministry. The declaration of a state of emergency signaled to the public the severity of the situation and could have allowed for stricter measures to mandate health workforce to be deployed, however, this option was not used. In our data, there is also critique against the declaration of a state of emergency. For example, one interviewee states that there was no national data available on the availability of health workforce, and thus the decision lacked adequate evidence-base. One interviewee stated that the state of emergency was a
“political move” which was followed by drastic measures, including restrictions at the border. The latter is described by one interviewee as a
“wholly political decision”, given that there was no legislative basis or possibility to close the border from Finnish citizens returning abroad, which eventually did occur. Study participants disagree regarding this issue, however, as others critiqued those in power, particularly the Ministry of Social Affairs and Health, for being too slow in their actions at the borders.
Rather than promoting a whole-of-government approach from the get-go, in Finland most of the coordination of pandemic governance was centralized from the Prime Minister’s Office to the Ministry of Social Affairs and Health. This decision was justified by an interviewee from the Prime Minister’s Office as being “a natural solution,” given that the legislation which was central for the pandemic (Infectious Disease Act) fell under the jurisdiction of the Ministry of Social Affairs and Health.
However, interviewees in our study from the Ministry of Social Affairs and Health largely disagreed with this notion, highlighting that the pandemic was a multifaceted crisis, and that the overall coordination of a state of emergency should have fallen under the Prime Minister’s Of- fice rather than under the Ministry of Social Affairs and Health. In- terviewees at the Ministry of Social Affairs and Health described being understaffed and under-resourced for taking on the coordinating role, particularly related to legislation, and that the help they received from other Ministries (at least during the first year) was only scant, although the pandemic touched upon issues under the jurisdiction of those Min- istries as well. The lack of cooperation between sectoral ministries was said to have been made more difficult by news articles in the media which blew some of the debates out of proportion. Having to bear the brunt of the responsibility for governing the pandemic led to frustration at the Ministry of Social Affairs and Health, and an interviewee pointed out that political leaders had been crucial for the governance of COVID- 19.
I think the problem is that many politicians are not personally responsible for governing the pandemic. The ministers at the Min- istry of Social Affairs and Health have this responsibility. A lot of politicians have been keen to talk about how we open society back up. But when it comes to governing the epidemic, the Minister at the Ministry of Social Affairs and Health has been completely alone.
Politicians like to share good news to their own people and this tendency got stronger in the spring (of 2020). But one of the reasons why Finland has so fared so well in the pandemic is that COVID-19 has been politically steered. -Interviewee, Ministry of Social Affairs and Health (Participant id: N1)
That power was allocated to the Ministry of Social Affairs and Health and that the pandemic was framed from a dominantly biomedical perspective was said to have tangible impacts on decisions taken during the first year. While interviewees from the Ministry of Social Affairs and Health stated that decisions were made based on the goal of protecting health and well-being, this view was also challenged in the data. For
example, a senior expert from the Finnish Institute for Health and Welfare stated that the Ministry of Social Affairs and Health chose to vaccinate the older adult population first for political reasons, while it could have prioritized vaccinating the communities with the most out- breaks. Another interviewee argued for the need to vaccinate those first who represented critical infrastructure in society (health workforce, water infrastructure, food security). Additionally, the framing of the pandemic from the viewpoint of Ministry of Social Affairs and Health was perceived among some interviewees to weaken the ability of having a comprehensive view of COVID-19. According to some interviewees, the Ministry of Social Affairs and Health relied too heavily upon the needs of hospital district leaders rather than thinking broadly about the repercussions of action taken, particularly when hospital districts do not have a legislative mandate for power in the Finnish health system. This led to minimal discussions regarding actions taken, including the implementation of non-pharmaceutical interventions, such as re- strictions on gatherings, business closures, and school closures.
We have too long a history of the Ministry of Social Affairs and Health relying upon hospital district leaders and chief medical offi- cers. It is odd that this is the model used because hospital districts represent only one third of social and health care. Of course, one can think that the situational awareness in hospital district represents the whole nation, but this is untrue. It is only one lens through which to view the world, and it is too narrow. -Interviewee, health and social care, municipality (Participant id: R1)
The framing of the pandemic from the perspective of Ministry of Social Affairs and Health, according to the interviewees, remained the dominant framing of the pandemic as long as it had the Prime Minister’s support. Once the Prime Minister’s support started wading (according to the interviewees this was towards fall 2020), challenging viewpoints started to emerge more publicly. This coincided, again, with the allo- cation of power, as the hybrid strategy granted decision-maker back to its “normal” legislative framework. Those interviewees who were closer to the local context, such as municipal leaders, were more inclined to frame the pandemic more holistically:
We have been worried about our region because many have a low socioeconomic status. We have the most single parent families, a lot of households that need income support, severe drug and alcohol abuse, different kind of issues. This whole time we have not only been worried about the acute situation with COVID-19 but about the well-being of the population in our region, particularly children and young people. We have started thinking about what our exit strategy will be, not only for the pandemic but everything that it has caused in our region. From the very beginning, we have been worried about school closures (secondary schools) because we did not want to do that. We were kind of forced to do that by the Minister but we have seriously tried to keep our young people in school. -Interviewee, joint municipal authority (Participant id: R3)
Another interviewee representing a municipality remarked that they were worried about families in their region, as during spring 2020 there had been a sharp increase in domestic violence cases. They concluded that COVID-19 was a “massive issue” and there should be a wider set of indicators used to track the impact of the pandemic and the measures taken to mitigate it, including domestic violence cases, child protection notices, and unemployment rates. Another interviewee described how framing the pandemic as solely a “health crisis” led to abandoning the rights of those in social services and disregarded other viewpoints.
The situational awareness on the pandemic has been that of a uni- versity hospital. From their point of view, pandemic governance is going well when there are no patients in the hospital. But what about the fact that our young people are all over the streets and there are difficult situations in families. Or what happens to patients with substance abuse issues or the homeless. This is not of interest to a
university hospital. They focus on an empty hospital and that has been the core of governing the pandemic in Finland. -Interviewee, municipality (Participant id: R17)
Finally, framing also had an impact on the potential legacies of the pandemic. Study participants at the local level remarked that the framing of COVID-19 as a unique crisis, affecting particularly intensive and specialized care, had resulted in large financial support from the national level, but at the same time one municipal leader feared that similar investments would not be made in primary health care systems once the pandemic would be over.
I emphasize that critiquing the government is warranted because we have had an immense amount of money for governing the pandemic, but my fear is that as soon as we start focusing on treating other diseases in Finland, this flow of money will cease, and municipalities are left on their own. They are left to think about how to adapt and we will again be in a tricky situation. This is what I mean when I talk about the government leading the health system. It (the government) directs a lot of money to one issue and no money to another. This should not happen again, that COVID is considered a completely exceptional case. Every life should be saved in a pandemic, but this sort of thinking, that other diseases don’t matter, or that we don’t treat those diseases because of COVID, that is simply catastrophic.
-Interviewee, hospital district (Participant id: R6)
3.3. Transparency and trust
Finally, interviewees described how power and politics manifested was through a sense of lack of transparency in crisis communication and decision-making. This lack of transparency was reported to impact the level of trust between different actors in the health system. During the first and critical months of 2020, local and regional health officials in our study (particularly those representing municipalities and Regional State Administrative Agencies) remarked that they felt sidelined in crisis communication. They described watching the latest guidance on pandemic governance from the television during the Prime Minister’s info sessions, alongside with citizens, after which they (health officials) immediately started getting phone calls from journalists regarding in- structions at the local level.
I put the TV on and listened to what the Minister was saying. We did not know in advance what would be said on TV…So, while we are trying to grasp the situation, the first journalists are already calling us and asking us how we are going to deal with this. The journalists are wondering why we did not know about these instructions already. I had to ask journalists to get back to me in a couple of hours, so that we can think this through and figure out how we are going to do this and what all of this means. -Interviewee, social and health care, municipality (Participant id: R10)
According to those at the Ministry of Social Affairs and Health, this lack of transparency in crisis communication in the early months resulted from several reasons. Leaders did not want to scare commu- nities or local and regional health officials with scenarios that were considered too frightening. As a result, many of the early meetings held in February and March 2020 were deemed classified and documents including scenarios were strictly protected from leaking.
Transparency in crisis communication seems to have also partly failed because it relied upon pre-existing networks and communication.
Representatives from the Ministry of Social Affairs and Health described having a working relationship and a history of communicating with hospital districts, which, in our data, mostly described having no problems with accessing information regarding decision-making during the pandemic. The Ministry of Social Affairs and Health assumed that information from the hospital districts would trickle down to munici- palities and Regional State Administrative Agencies, but this seems to
have not happened to the most part during the early months of COVID- 19. Rather, municipalities and Regional State Administrative Agencies received official information afterwards and build their situational awareness through informal contacts and media which decreased trust between local and regional actors and national level actors. The situa- tion, however, was reported to improve as the pandemic progressed.
Study participants also described the lack of transparency as stem- ming from not knowing how and why decisions regarding non- pharmaceutical interventions were made. What sparked many discus- sions in our data regarding this issue were decisions made regarding restaurants and/or clubs and children’s hobbies and/or schools. The fact that at during certain points of COVID-19 restaurants were allowed to operate in Finland but children’s hobbies were heavily restricted led to some interviewees stating that decisions were solely political and not evidence-based, and heavily influenced by interest groups and lobbying.
One interviewee described how children were disadvantaged because they did not have a large lobbying organization backing them up.
When restaurants were closed, there was practically a parliamentary hearing on the issue every week for six consecutive weeks…the entire parliament was attuned to how we could open restaurants back up. Upper secondary schools were closed for six months and there were no parliamentary hearings. Children do not have MaRa (the Finnish Hospitality Association) and the one who has the loudest voice will often find better decisions for themselves than those who do not get their voice heard. -Interviewee, The Finnish Institute for Health and Welfare (Participant id: N11)
There are other examples in the data regarding how decisions taken during the pandemic disproportionately affected marginalized pop- ulations, including people with disabilities in assisted living units. The following excerpt from a manager at the municipal level demonstrates how the Ministry of Social Affairs and Health sought to influence de- cisions at the local and regional level, but that municipalities also could have asserted their agency. It further demonstrates that the benefits and drawbacks of decisions taken at the municipal level were considered only afterwards and once the legal basis for such decisions became under scrutiny:
The Ministry of Health tried to take power which the law does not grant to it. This happened several times. The Minister tried to use such power by making phone calls regarding school closures and such. And the question was whether or not we would do what the Minister wanted us to do. If they did not have power regarding the topic at hand, then we made our own decisions. But regarding re- strictions and non-pharmaceutical interventions, there have been many unclear issues. For example, last spring we made the decision – as did others – that no visits should be allowed in assisted living units. And then during our summer holidays we read the Ombuds- man’s statement that we cannot forbid people to invite other people to their homes. -Interviewee, Joint authority for health and well- being (Participant id: R7)
Lobbying and interest groups were mentioned by several in- terviewees as affecting decisions during COVID-19. This led to a sense among some interviewees of not knowing which actors health system leaders listened to during various points, and which expertise had the most impact on political leaders and civil servants.
The government and certain ministers have just seized executive power in this matter… And they have listened to only certain ex- perts. Up until this point, this has meant that they have believed the worst-case scenario, the worst option, and non-pharmaceutical in- terventions have been based on those scenarios… There has been a lot of doing anything so that it looks like all is being done, but no critical thinking regarding what would actually be the feasible thing to do. -Interviewee, hospital district (Participant id: R6)
The problem with these steps taken, according to the interviewees,
was that little was communicated outwards and the “negotiations made in government tables” were not elaborated on. Overall, the lack of transparency and issues of trust seemed to relate to a sense of frustration of not following the legislative framework for power and responsibilities in a pandemic.
4. Discussion
The findings presented in this article reflect the viewpoints of Finnish health system leaders regarding their experiences during the first year of COVID-19. Overall, power and politics were experienced and inter- preted differently at different levels of the health system and depending on the interviewees’ positionality, i.e. their respective organization, such as municipality, agencies, university hospital, health research institute, ministry, government, or another organization. A common understanding among the participants was that governance of COVID-19 had been a political effort, and this was viewed as having both a negative and positive impact. On the one hand, politicizing the pandemic was necessary because it allowed political leaders to chime in on value-based judgments and decisions, particularly on difficult decisions during a time of uncertainty and limited information regarding a new virus (Greenhalgh & Engebretsen, 2022). On the other hand, having political leaders participate in decision-making during the pandemic made those decisions vulnerable to lobbying efforts and less inclined to be evidence-based, particularly as the pandemic progressed. Most impor- tantly, the different dimensions of power and politics – credit and blame, frame contestation, and transparency and trust– demonstrate that the topics of power and politics overall transcended the realm of political leaders. In other words, while focusing on what politicians did, and why, is an important question, this question needs to be expanded to account for how power was used and experienced by all relevant actors at different levels of the Finnish health system.
The findings point out that health system leaders representing mu- nicipalities and Regional State Administrative Agencies frequently felt either excluded or sidelined in official crisis communication (beginning of the pandemic) or micromanaged and patronized (as the pandemic progressed). The latter happened particularly at times what has been suggested as the ending of the “honeymoon period” during which po- litical leaders perceived that “visible heroism could lead to credit”
(Greer et al., 2022a, p. 409). The question then becomes, why was de jure power, which was granted to local and regional actors through legislation not sufficient in leading to de facto power? The findings suggest that this may be partly because of the power that national level actors, particularly the government, the Ministry of Social Affairs and Health, and hospital districts yielded through framing. Language around crises is key to how they are understood and perceived (Barrios, 2017). If power is understood as directing and influencing the behavior of others or the course of events, we can see in the light of our data that the course of events in Finland during COVID-19 was impacted by the decision to monitor and govern the pandemic through utilizing indicators pertinent to specialized health care, rather than monitoring the issue holistically or through a more integrated approach. Lastly, while our data do not provide sufficient information on the matter, the findings warrant further research on what role the media plays in who is perceived to have more power in pandemic decision-making (Harjuniemi, 2022;
Vuorelma, 2022).
It is also important to point out that while describing being caught up in politics, local and regional actors during COVID-19 were also constantly negotiating power themselves. For example, the findings show acts of solidarity in local and regional networks as a protest to the leadership from the national level as well as small acts of refusal to abide by national recommendations. The strength of such local and regional networks has been documented in another article published from our research data (Kihlstr¨om et al., 2022). As our study is a limited snapshot of four regions, this calls for more research on what agency and resis- tance look like from the viewpoint of various local and regional actors,
and why some followed the legislation that bound them, while others implemented the recommendations from the national level (even if not always having a justified legal base). Furthermore, the findings also call for a better understanding of how public health experts at the national level seek to influence decision-making during health crises. In our data, public health experts questioned the evidence-base of decisions taken during the pandemic. While political science literature has demon- strated that public health experts play a key role especially early on in health crises, a period during which politicians are often risk averse, public health experts themselves may also be risk averse to produce recommendations during the same period because models and pre- dictions come with a great deal of uncertainty (Greenhalgh & Enge- bretsen, 2022; Greer et al., 2022a). Solely blaming politicians for not being evidence-based may mask deeper issues, which may include public health experts’ insistency on a linear policy model (rather than addressing and engaging with the complexities of decision-making and policy), lack of engagement with political theories, and/or “opting out of politics” in fear of repercussions (Fafard et al., 2022).
Against this background, how power and politics affected gover- nance during COVID-19 in Finland should also be discussed within the broader framework of accountability within health systems. As McKee (2021) has argued, “leaders must take responsibility for how events unfolded, including the unintended consequences for failed policies.” For example, what has been characteristic to pandemic governance in Finland has been the lack of clarity in the soft law instruments through which national steering has been exercised (Korkea-Aho & Scheinin, 2021). These soft law instruments, such as recommendations to ban visits in residential care homes, were interpreted as binding by those who actually had the power to make decisions (i.e. municipalities and Regional State Administrative Agencies). In essence, municipalities and Regional State Administrative Agencies have made decisions based on official liability, while national level politicians (or other actors who have provided guidance for decision-making) have not had a similar responsibility regarding the decisions made during COVID-19. While the recommendations from the national level have likely been influenced by politicians who have gauged public opinion, these cases, along with several others brought out by the participants in this study, raise ques- tions about the legitimacy and accountability of pandemic governance in Finland. We highlight that the Finnish COVID-19 response should not be interpreted as a failure, as according to many comparative studies and indicators, Finland has fared well in managing the pandemic espe- cially when it comes to infection and fatality rates (COVID-19 National Preparedness Collaborators, 2022; Saunes et al., 2022). However, we highlight that taking stock of what happened, and how power was used at various points and at various level of the health system during the pandemic, is key to a more transparent and accountable way forward.
Moreover, the decentralized structure of the Finnish health system provides an interesting context for the study of pandemic governance, as the division of powers and responsibilities between different actors can both lead to avoiding responsibility and at the same time provide a possibility to use powers when it seems expedient and beneficial.
Finally, our results come with a set of limitations. First, we should be careful about not exceptionalizing the pandemic. While COVID-19 has made many issues of power and politics visible, these issues should not be discussed out of their historical, pre-pandemic context. For example, our findings point to pre-existing power dynamics in the Finnish health system. The Ministry of Social Affairs and Health had a strong existing collaboration with hospital districts which was emphasized during the pandemic. This pre-existing collaboration and trust between these actors gave hospital districts power to influence decisions and framing. Addi- tionally, due to the decentralized structure of the Finnish health system, national and local/regional are not geared towards collaborating on an everyday basis. Such pre-existing issues and dynamics should also be taken into consideration when assessing the inequities and inequalities brought forward by COVID-19. A second broad limitation is that our study focused primarily on health system leaders. A more nuanced
understanding would require an analysis of how leaders in other sectors (such as social care, social policy, business) experienced similar issues.
Finally, the data in our study came from online interviews – a type of data collection which is not necessarily best suited for capturing the nuances and subtleties of power. Thus, future research should continue exploring how methodologies such as ethnography can be utilized in the study of power in health systems and policy (Closser et al., 2022; Topp et al., 2021).
We argue based on our findings that a focus on power and politics in a pandemic has the potential to bring out themes which are not typically accounted for in system-centered conceptualizations of health systems (Closser et al., 2022). Future studies should also discuss how power and politics matter for resilience and resilient health system responses. Given the fact that many countries which were expected to be best prepared for a pandemic, at least according to health system preparedness metrics, were in fact not able to implement successful strategies during COVID-19, has resulted in calls for acknowledging politics, political capacity, governance, and conflicts regarding power and resources as key domains through which to better understand what health systems and resilience look like in practice (Bozorgmehr et al., 2022; Greer et al., 2021). Building on power-focused health systems and policy research, our results also complement the notion that treating COVID-19 as an isolated shock for health systems renders invisible the fact that shocks and disturbances also stem from and can be exacerbated by intentional choices and decisions made by health system actors at the international, national, and local level, i.e. by health system governance itself (Greer et al., 2022b; Topp, 2020).
5. Conclusion
As lessons learned are being drawn from the COVID-19 pandemic, power-focused health systems and policy research emphasizes the need to investigate why, how, and by whom decisions were made during the pandemic. This article advances empirical research on power and poli- tics in the health system by focusing on the actor relationships and networks of Finnish health system leaders with the COVID-19 pandemic as our research site. We identified three primary themes which demonstrate how power and politics manifested in pandemic gover- nance particularly during the first year of COVID-19 Finland: credit and blame, frame contestation, and transparency and trust. Taken together, these findings highlight recurring power dynamics and power imbal- ances between various health system actors, most notably between na- tional (government, Ministries) and local and regional level actors, between civil servants and political actors, as well as between those advocating for a public health approach and those highlighting the role of specialized care and/or a biomedical approach for governing COVID- 19. The results demonstrate that no health system is immune to the impacts of power and politics, rather, they are present at multiple levels of the health system, take various forms, and can have both positive and negative impacts. We conclude that public health professionals and re- searchers need a deeper engagement with the concepts of power and politics to deal with the challenges of health crises and shocks to health systems. Through understanding who has the power to influence de- cisions, to make decisions, and how these actors are connected to each other is key to building more accountable health systems and responses to health crises such as pandemics.
Author contributions
Kihlstr¨om Laura: Conceptualization, Methodology, Analysis, Writing, Reviewing, and Editing Siemes Lea: Literature review, Writing, Reviewing, and Editing Huhtakangas Moona: Conceptualization, Methodology, Analysis Keskim¨aki, Ilmo: Conceptualization, Supervi- sion, Resources, Writing, Reviewing, and Editing Tynkkynen, Liina- Kaisa: Conceptualization, Methodology, Analysis, Writing, Reviewing, and Editing, Supervision, Resources.
Data availability
The data that has been used is confidential.
Acknowledgments
This research has been funded by the Academy of Finland (grant numbers 340501 and 340503) and the Strategic Research Council (grant numbers 345300 and 345349). We want to acknowledge all the in- terviewees who participated in the study and made this research possible. From the RECPHEALS project research group we would like to acknowledge Marjaana Viita-aho, Henna Paananen, Soila Karreinen, Kristiina Janhonen, and Markku Satokangas for providing critical comments and/or participating in the data collection process.
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