Meetings as an arena for coordination in crisis: The county governor's contingency coordination through the county emergency council in Norway

Bjørkquist, Catharina; Hansen, Gunnar Vold; Ramsdal, Helge Article Meetings as an arena for coordination in crisis: The county governor's contingency coordination through the county emergency council in Norway Administrative Sciences Provided in Cooperation with: MDPI – Multidisciplinary Digital Publishing Institute, Basel Suggested Citation: Bjørkquist, Catharina; Hansen, Gunnar Vold; Ramsdal, Helge (2022) : Meetings as an arena for coordination in crisis: The county governor's contingency coordination through the county emergency council in Norway, Administrative Sciences, ISSN 2076-3387, MDPI, Basel, Vol. 12, Iss. 4, pp. 1-15, https://doi.org/10.3390/admsci12040154 This Version is available at: https://hdl.handle.net/10419/275424 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. 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If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. https://creativecommons.org/licenses/by/4.0/ Citation: Bjørkquist, Catharina, Gunnar Vold Hansen, and Helge Ramsdal. 2022. Meetings as an Arena for Coordination in Crisis: The County Governor’s Contingency Coordination through the County Emergency Council in Norway. Administrative Sciences 12: 154. https://doi.org/10.3390/ admsci12040154 Received: 27 September 2022 Accepted: 27 October 2022 Published: 2 November 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). administrative sciences Article Meetings as an Arena for Coordination in Crisis: The County Governor’s Contingency Coordination through the County Emergency Council in Norway Catharina Bjørkquist * , Gunnar Vold Hansen and Helge Ramsdal Department of Welfare, Management and Organisation, Østfold University College, 1557 Halden, Norway *Correspondence: [email protected] Abstract: This article aims to study how Norwegian county governors (CGs) performed their coordination tasks shortly after the lockdown in March by emphasizing the use of the County Emergency Council (CEC) as a meeting arena for coordination in times of crisis management more generally and the challenges the CGs had to face in this particular situation. We ask (1) what kind of meeting arena is the CEC and (2) how does the CEC as a meeting arena facilitate coordination at this level of government? In order to analyze the dynamics of the CEC meetings, we will refer to two theoretical approaches, i.e., meetings science and coordination. The present study is based upon an exploratory research strategy to analyze how the CGs responded to the challenges and performed coordination through the CEC. We found that the CEC meetings could be seen as hybrids of organization, institution and network, and even a network of networks, where several CG offices established thematic networks. These smaller networks have the advantage of establishing personal relationships more easily than the larger networks; however, they may lack the comprehensive overview that is necessary in a crisis that cuts across sectors. Keywords: contingency coordination; county governor; meetings; organization; institution; networks; network of networks 1. Introduction This article analyzes meetings as a phenomenon for contingency coordination and crisis management by studying the Norwegian county governors (CGs) and how coordination took place through meetings in the County Emergency Council (CEC) 1 , potentially the most prominent meeting arena for collaboration and coordination at the regional level. Coordination may take place in meetings; meetings are commonly referred to as part of various kinds of processes, e.g., policy formulation, implementation and evaluation. According to the classical literature on organization studies, meetings have been seen as an instrument for achieving specific tasks and for division of labor (see, for instance, Simon 1997 or Scott et al. 2015). Furthermore, this might reflect a tendency towards centralization of power and hierarchical command structures, as recommended by many prominent organization experts (Kettl 2003;Peters 2005). On the other hand, meetings can serve an important role by framing public problems and highlighting policy alternatives (Tepper 2004). Furthermore, attention has been paid to how organizational structures, and thus meetings, are patterned to handle uncertainty the organization faces, including in its environment (Turner 1976). In current meeting science literature, the context of meetings and the way they are organized have been studied in empirical projects, where the focus has been on strategic orientations and what people actually do when organizing and conducting meetings. Jarzabkowski and Seidl (2008) discuss how a turn in strategy research to “practice-based theorizing” contributes to organization theory by emphasizing the importance of different meeting modes, particularly when studying the role of meetings in shaping stability and Adm. Sci. 2022,12, 154. https://doi.org/10.3390/admsci12040154 https://www.mdpi.com/journal/admsci Adm. Sci. 2022,12, 154 2 of 15 change in organization strategies. In their conclusions, they find that the way meetings are organized have different consequences due to the mode of the meeting and demonstrate how strategic meetings lead to stability and change in complex processes. Standaert et al. (2021) discuss how meeting modes are important by studying whether and how differences in virtual meeting mode effectiveness can be explained by the differing functional capabilities. They conclude their study, based upon a comprehensive survey of business meeting organizers, by stating that using shared computer screens and/or workspaces, and experiencing co-location are fundamental modes for achieving any of the business meeting objectives (p. 7). These findings are further elaborated in a discussion of when and how to meet virtually in a post-pandemic world. Here, important points are matching the appropriate communication capabilities with various meeting objectives and taking into account meeting size and duration (Standaert et al. 2022). Handling crises is handling complexity and crises can be understood as wicked problems (Lægreid and Rykkja 2015;Rittel and Webber 1973). Wicked problems involve the difficulty of having no clear standards for how they are to be solved. The COVID-19 crisis is described as a wicked problem due to its complexity, the unclear understanding of the challenges the pandemic would pose to society and the difficulty to draw on experience from previous pandemics (Schiefloe 2021;van den Oord et al. 2020). Wicked problems therefore put static organizational frameworks under pressure. The solution usually outlined for such problems is extensive use of cooperation between different actors and flexible organizational frameworks that facilitate coordination (Head and Alford 2015). Using the County Emergency Council (CEC) as a meeting arena may be regarded as a more or less explicitly formulated strategy to overcome the challenges of wicked problems (Ferlie et al. 2011;Head and Alford 2015;Blondin and Boin 2020) resting on recommendations and mutual information processes which may foster knowledge uptake and develop networks (Tepper 2004). Research has shown that networks, to some extent, should be able to handle both the scale and complexity of wicked problems, here pandemics (van den Oord et al. 2020). This article aims at studying how the CGs performed their coordination task shortly after the lockdown in March 2020—the COVID-19 pandemic stretching the coordination role to its limits, by emphasizing using the County Emergency Council (CEC) as a meeting arena for coordination at times of crisis management more generally and the challenges the CGs had to face in this respect. We ask (1) what kind of meeting arena is the CEC and (2) how does the CEC as a meeting arena facilitate coordination at this level of government? This study contributes to the literature on coordination as coordination is about meetings. Our theoretical approach draws on meeting science literature and organizational theory. Following the presentation of the county governor office and the CEC, we elaborate on the theoretical framework, research design and methods in further detail before we present the results. The article ends with a discussion and concluding remarks. 1.1. The County Governor Office and the County Emergency Council In all Scandinavian countries, the county governors are an historic, well-established part of the governance system with roots from the late Middle Ages as the King’s representatives in the regions (Flo 2014). As state representatives, they supervise municipalities with due respect to their autonomy. During the democratization of the governance system, and in particular the post-WW2 establishment of the modern welfare states in these countries, the county governor lost political support (Flo 2014). However, in 1982 the CGs obtained another, potentially central, role in the governance system: they were placed in charge of coordinating national policies at regional and local levels (Flo 2014). The delegated responsibility in emergency preparedness issues and crisis management has increasingly been directed at the coordination of regional resources. In Norway, as in other western countries (e.g., Brattberg 2012;Kettl 2003;Mascio et al. 2020;Petridou 2020), challenges in public safety and emergency preparedness have increased in recent years while national authorities only to a limited extent manage to coordinate across sectors and organizations, Adm. Sci. 2022,12, 154 3 of 15 given fragmented public administration and public services (Boin 2019;Christensen and Lægreid 2011). Following extensive mergers in local government in January 2019, there are now ten county governor offices with a total of about 2500 employees. There are large regional variations in size; the largest CG office covers about one-third of the population of Norway and fifty-two municipalities, while the smallest serve a few hundred thousand inhabitants and about forty municipalities. The regulations state that the aim of the CEC is to facilitate collaboration on emergency preparedness and crisis management in all regions. CGs manage and convene meetings in the CEC, and decide who will take part, which enables the composition of the CEC to be adjusted to a particular crisis or emergency situation. The work of the CEC is described in the instructions as follows: • To discuss relevant civil protection and contingency issues and provide general overviews and mutual orientation on these; • To provide a general description of risk and vulnerability and a common platform for planning civil protection and contingency in the county; •To be prepared to assist the county governor in coordinating crisis management. In practice, following the lockdown in Norway in March 2020, all CEC meetings were held online. 1.2. Theoretical Approaches In order to analyze the dynamics of CEC meetings, we will refer to two theoretical approaches, i.e., meetings science and coordination. 1.2.1. Meetings Freeman (2008) discusses meetings by asking what we learn from (attending) meetings. Drawing on learning and organization sociology, he approaches this apparently simple question from three perspectives: the “rational”, the “institutional” and “constructionist” understanding of meetings. Freeman (2008) focuses upon meetings as processes of introduction, presentation, recognition, confusion, socialization, communication and reporting. These micro-processes will enhance understanding of the dynamics of learning involved in attending meetings. Further, with reference to meetings in social movements and protest mobilization, Haug (2013) discusses how the complex configuration of meeting arenas constitutes an infrastructure that synchronizes the various activities of social movement actors in time and space. He maintains that this infrastructure is not an entirely emergent phenomenon but is also the result of conscious decisions by organizers. Drawing on Ahrne and Brunsson (2011), Haug (2013, p. 709) develops the concept of “meeting arena” as a hybrid of three principles of social order: organization, institution and network. By “organisation”, Haug (2013, pp. 714–15) refers to planned actions, formally organized for the purpose of instrumentality, in order to achieve a goal, generally through some kind of hierarchical structure with a formal leader. By “institution”, he refers to meetings as routine events. In this perspective, a meeting is an event where latent agreement is actualized and affirmed through rituals and routines. According to Haug (2013, p. 717), “Expressed disagreements are considered superficial and will eventually be resolved ’naturally’ as the participants develop a deeper sense of community”. Hence, formal structure and explicitly formulated goals are not key aspects of the dynamics of the meeting. Finally, “Network” implies that meetings are considered as hubs. From the network perspective, a meeting is an event where personal ties are created and fostered; it is a friendly setting, and sometimes a creative and transformative site of mutual learning. However, network meetings contain inherent limits, for instance the difficulty of acting collectively (Haug 2013, p. 719). For our purpose, these forms imply that meeting arenas are not understood in terms of hierarchical, vertical coordination and decisions, but rather that there are tensions between these forms, and that one should focus upon decisions rather than hierarchy when studying the organization of meetings. This seems relevant to the analysis of the CEC as a meeting Adm. Sci. 2022,12, 154 4 of 15 arena, as these meetings are organized as encounters without a clear-cut structure or a fixed group of participants. The exception to this is the mandatory participation by a number of regional leaders from public and private services, and the CG as the chair of the meetings. At the time of our study, these meetings were digital, implying a large number of participants with no predefined limits, as participants might invite colleagues to join meetings. Both Freeman (2008) and Haug (2013) focus on the dynamics of face-to-face meetings. When meetings are organized as digital encounters, opportunities for informal talk and “backstage” communication are usually prevented, which leads us to expect that the meetings will provide limited space for meso-level influence among the actors. However, the overall understanding of meeting spaces from three perspectives as organization, institution and network offers theoretical assumptions to aid our understanding of CEC meetings. 1.2.2. Coordination The basic strategy in dealing with national crises is various forms of coordination (Lango and Lægreid 2014). Coordination concerns the adaptation of actions and decisions among interdependent actors to achieve specific goals (Christensen et al. 2016), which involves both structures and processes (Axelsson and Axelsson 2014), and thus informal values and cultural norms (Egeberg 2012). Structure deals with how to organize information channels or how to organize arenas for coordination. Process is about how to arrive at a goal and how to coordinate an effort. These factors should be adapted to each other if effective coordination is to be achieved. Without suitable common arenas, it can be difficult to achieve a satisfactory coordination process. This is considered to be important even in crisis situations and underlines that formal and informal structures as well as procedures and processes are key elements in crisis management (Christensen et al. 2016). Coordination can be both vertical and horizontal (Peters 2018). Vertical coordination implies that the CG has a central role in coordinating the state and the municipalities. Horizontal coordination implies that the CG could facilitate coordination among different regional actors. Horizontal networks can provide solutions where hierarchical coordination does not capture challenges and potential solutions in a complex wicked problem (Head and Alford 2015). Such networks can draw on the fact that the participants have different information and competencies and can contribute different approaches to how the problem should be handled (Ferlie et al. 2011). The aim is to reach a common solution through discussion and joint analysis. This requires that the participants have a common understanding of the challenges they face, that they are able to agree on a common goal, and that they have mutual trust in each other. In order to realize this, actors need arenas where they can collaborate (Head and Alford 2015). 2. Materials and Methods The present study is based upon an exploratory research strategy to analyze how the CGs responded to the challenges when the COVID-19 pandemic hit Norway. The study focused on the generic role of the CGs as coordinators at local and regional levels of government and included experiences from dealing with coordination issues between regional actors at county and local government levels. Although the CGs had largely the same role and tasks in handling the pandemic, there were differences in how they solved the tasks and designed their role. Individual interviews were chosen to be able to capture such variations and each person’s reasons for choices and actions (Danermark et al. 2003). Sixty-four interviews with CGs and managers of the county offices (e.g., contingency office, medical office, and education office) were conducted during the spring and summer of 2020. Approximately half of the interviews were conducted by one or more representatives from the research team visiting the informant’s office and conducting face-to-face interviews, while the other half were conducted digitally via video calls. This mixture provided Adm. Sci. 2022,12, 154 5 of 15 flexibility for local matters to be elaborated or matters informants wanted to mention to be addressed. The interview guide was semi-structured and we asked questions about experiences from the first months of COVID-19: how prepared was the CG office for such a crisis, how fare did the regulations provide clear guidelines on division of labor and responsibilities, how did different professional departments cooperate and interact during crisis management and finally, how did the CG and the office cooperate and interact with national, regional, and local authorities, including what were the main challenges. This included themes such as experiences with the dimensions of the pandemic situation at the time, experiences of vertical coordination as the role between municipalities and national ministries, horizontal coordination within the CG offices and with the CEC and communication between the CG and its collaborative partners. In order to perform their role of generic coordinator of national policy at regional/local levels of government, the CGs firstly had to ensure that the coordinating organization itself (i.e., the CG agency) was internally coordinated to act in a consistent way, and secondly, to find a role as coordinator in relation to local and regional actors by communicating externally in accordance with national policies. One would expect the first point to be a prerequisite for the second one. Both of these represented challenges, especially because the CGs had recently been reorganized, primarily through mergers, starting on 1 January 2020. The CG’s coordination role embedded in the new institutionalized strengthening of its powers still was (and is) in the making, with formal guidelines being introduced in 2017. Documents were provided by interviewees as supplementary background information. In addition, three situation reports from each CG were analyzed. The situation reports summed up the local government’s reporting to national authorities, systematized by the CG office. It was not possible to collect data through observations of meetings and what took place in them. Due both to the COVID-19 situation and the fact that the study started after a number of CEC meetings had already been held, we were unable to participate in the meetings. However, we received multiple accounts of the meetings from different staff of the CG office. The interviews lasted between 40 min and two hours, and all those invited agreed to participate. The interviews dealt with the above-mentioned questions, but interviewees were eager to offer personal points of view to supplement the strict interview guide, including generic issues relating to the role of the CG in the governance system. All quotations are anonymized, and each interviewee has been given a random number from 1 to 64. Additionally, the first two randomly chosen numbers refer to the CG office where the interviewee was employed (e.g., 0205: CG office No. 2, interviewee No. 5). All interviews were recorded and transcribed verbatim and a thematic analysis was performed (Braun and Clarke 2006). We first took an inductive approach, and the interviews were read, synthesized and analyzed by pairs of authors, before being discussed by the authors and the research team in several meetings. The purpose was to reduce the risk of misinterpretations of the data due to the researchers’ pre-understanding (Malterud 2001). We organized the codes into a data coding structure based on our experience of the research topic. In this sense, we anticipated certain core concepts or codes in the data set. In order to understand the particular characteristics of actors from different agencies, the interviews were also analyzed with the participant’s department in the CG organization in mind, considering potential specific sectoral challenges. Second, we took a more deductive approach (Braun and Clarke 2006). This implied taking the instructions for the CEC as our starting point and how the CGs have interpreted and adapted them, also drawing on theories of meeting science and coordination. The code structure was first tested on parts of the dataset, and then on the entire dataset. Finally, we refined and restructured the codes and code structure and developed main themes. A few examples are presented in Table 1 below. Adm. Sci. 2022,12, 154 6 of 15 Table 1. Examples of codes and main themes. Data Extract Codes Main Theme It is true to say that we have spent a lot of time cleaning up the flow of information and ensuring that correct and clear information is always sent out to each sector Cleaning up information Sharing information We get regular information from the government about any cases we need to deal with—including this one. We then automatically pass on the information to municipalities and CECs when it’s natural to do so, to make sure they also have the same information Passing on information We communicated everything we knew, often before things were completely ready. We said, “Now there’ll probably be some new stuff about this and that”. And then the municipalities could prepare for it Communicating We’re buried in an avalanche of communication—in both directions. A huge amount of data collected from national authorities, particularly in healthcare A large amount of information The county municipality was invited because it is in charge of upper secondary schools Meeting with representatives of sectoral interests Splitting the CEC meeting into smaller meetings I know that if two or three of us are in close contact, we deal with things much faster and more efficiently Few participants—quick decisions The pandemic is more of a civil protection challenge than an emergency rescue challenge, and there were therefore a wider range of actors involved in the incident management A range of relevant actors We used a more limited selection from the CEC in a number of meetings. So that meant healthcare, police, the home guard, civil defense—we had a more limited group that we worked more closely with than the big CEC Working closely with a smaller selection In the following, the results are presented according to the following four main themes: (1) taking different approaches to the CEC, (2) sharing information, (3) discussing challenges and coordination and (4) splitting the CEC meetings into smaller meetings. 3. Results At regional level, a large number of actors, both private and public, were invited to participate in the meetings. The formal structure of coordination took place in the online meetings chaired by the CG. Before the pandemic, the CEC met about two or three times a year. Participation in CEC meetings was relatively open; here, leaders from the municipalities, county municipality, health enterprises, welfare agencies, defense/civil defense, religious leaders, key actors from the transportation sector and large private businesses were represented. The municipalities were formally invited, but their participation was not mandatory. When the pandemic struck, some CGs continued to hold two to four meetings during the first six months, while others invited the CEC to hold virtual meetings once a week. The CGs had different opinions on the frequency of CEC meetings; particularly those agencies with the most participants thought it better to separate actors in different parts of the region to make the meetings more suitable for dialogue between the actors. The agenda of the CEC meetings mainly dealt with issues relating to regional problems when national policies were decided, how to understand the implications at regional level, and to identify specific issues that the CGs could communicate to national authorities. In addition to health issues and the consequences of the lockdown strategy, welfare concerns such as compensation to people laid off and other economic problems were mentioned as important to inform about at the meetings. 3.1. Taking Different Approaches to the CEC Our informants described considerable variation in how tasks were solved and emphasized. One reason may have been that the various CGs had very different attitudes and Adm. Sci. 2022,12, 154 7 of 15 approaches to the CECs. Some of them found that CEC meetings were too expensive in relation to their usefulness. One of them explained: What you’ll find when you interview people in the other counties is that they probably had CEC meetings more often than us. One of the differences you’ll find is that here we try to reduce the frequency of meetings in different areas. (1001) This statement suggests a desire to limit meetings. Others also tended towards this approach and several clearly stated that setting aside time for meetings could not be a priority when resources were to be used for ongoing crisis management. Such statements suggest not only concern about their own use of time, but also about the extent to which key actors such as municipalities could participate in meetings. Some of the CGs may have had a general negative attitude towards CECs, but there also seems to be a connection to the number of municipalities in the region. The largest regions were more critical of the CEC than the smaller regions. Nevertheless, several informants pointed out that COVID-19 meant that they had to hold online meetings and they came to realize the benefit of this because participants did not have to spend time travelling to the meetings. This was a great advantage since many of the participants could spend more than one day on the return trip due to the long distances in many of the regions. Those CGs who had a positive attitude to the CEC placed great emphasis on the fact that it could make decisions on actions that concerned the entire region. It also seems that positive attitudes corresponded with previous positive experiences. Clearly, many of the CG offices have extensive experience of using the CEC in connection with various local and regional crises throughout the year related to severe weather and natural events. Here, the use of the CEC had almost become routine as seen in the following quote: . . . we hold meetings in our County Emergency Council much more often during incidents, which makes it not really a formal body, but only a body that meets when things happen and we solve things together. (0503) This experience made them see the need to hold CEC meetings as soon as COVID-19 threatened the country. In several regions, the CEC held meetings as early as January. In addition, several regions had regular weekly meetings of the CEC, at least in the period from the lockdown until the summer vacation of 2020. This indicates that the CEC is primarily perceived as a meeting arena where problems can be solved. 3.2. Sharing Information The extent to which the CEC could be used as an information channel was naturally affected by the frequency of meetings. At the same time, it is important to emphasize that there were also alternative information channels, including online tools, directly to various actors. It is thus clear that those who emphasized limiting the number of meetings had other satisfactory ways of accessing information. From the very beginning, a written information channel was established where the central government via the CGs requested status reports from municipalities. Both the questions from the government and the reports from the municipalities were to some extent processed by the CGs before being sent on. In addition, several CGs established their own systems where their staff answered questions from the municipalities via e-mail and telephone. However, many of them found this inadequate and during the first period of the lockdown several municipalities complained that they were better informed through online newspapers than through formal communication channels. Those who chose to use the CEC actively nevertheless emphasized their positive experiences. There is a difference between formal written information on decisions taken and informal information about what is being discussed. One of the informants elaborated on this: We get regular information from the government about any cases we need to deal with—including this one. We then automatically pass on the information Adm. Sci. 2022,12, 154 8 of 15 to municipalities and the CEC when it’s natural to do so, to make sure they also have the same information. (0103) Since January 2020, county medical officers had been in close contact with the government, but many of the issues and discussions did not end in formal decisions or recommendations. It was therefore important for the municipalities to know about the parts of these discussions that were not confidential and to be able to adapt to any measures they expected to be introduced. The following statement illustrates how some CG offices emphasized the communication of this information: We communicated everything we knew, often before things were completely ready. We said, “Now there’ll probably be some new stuff about this and that”. And then the municipalities could prepare for it. (0201) It is also interesting to hear descriptions of the practicalities of conducting meetings with over a hundred participants without major problems. Admittedly, it was difficult to involve a large number of people in a discussion, but several informants pointed out that they solved this by allowing those involved to submit written questions before and during the meeting. These questions were then answered by the county governors and in some cases also by other regional actors that participated in the meeting. 3.3. Discussing Challenges and Coordination Some of those with a positive view of the CEC emphasized that it could be a strategic forum where participants could discuss challenges and different solutions. Some of the CGs made it clear that they had already used the CEC early on in the process, as described in the following quote: So, we started the work quite early on. We had a meeting with the CEC in February, so I’d say that we were quite quick to start to create a common understanding of the situation in our office. What it would mean for us. (0206) In February, there was great uncertainty about what the pandemic would mean for society. A meeting of the CEC was seen as highly beneficial to clarify current knowledge and what could and should be done to prepare for COVID-19. There were clearly difficulties in running a meeting with so many participants, but generally the meetings were organized in such a way that all participants who wished to speak could do so. One of the CGs tried to arrange a round table meeting where everyone would provide information in turn. This later turned out to be difficult, but with meetings at least once a week, it did not take long before everyone was able to provide input. Allowing everyone to speak provided a good general idea of the situation in the various municipalities and the services in general. A further advantage was that frequent meetings and active participation by everyone present meant that the participants got to know each other. The following statement illustrates this: We really get to know each other. Everyone shares some of their experiences, and especially their challenges. I think it has worked very well. I think they say that too. (0402) This approach enabled discussions of problems and solutions involving a variety of perspectives. One of the informants therefore concluded that the participants in the CEC meetings had been good discussion partners. This suggests that the discussions provided new perspectives on how situations should be handled. At the same time, the input received by the CGs demonstrated a clear need to coordinate activities, for example in the municipalities. The CGs had different approaches to how to achieve coordination. The simplest way for a CG to achieve this was strong encouragement. One example was the work of the chief municipal medical officer. Small municipalities had only part-time medical officers, many of whom were young and new to the position. 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