The role of the district medical officer has been strengthened through increased relational collaboration and recognition, but this is not clearly rooted in the organisational structure. So is this an actual strengthening?
During the pandemic, most district medical officers played a key role in municipal infection control work, they were seated at the decision-making table and had the media spotlight on them (1). This contrasted sharply with the way in which many of them had perceived their role prior to the pandemic, as rather invisible in the organisation, with little access to decision-making arenas and a poorly defined role (2). After the pandemic, the authorities have pointed out the importance of strengthening and clarifying the district medical officers' role (3, 4). However, we have little knowledge of whether such strengthening has in fact taken place. A study from 2023 suggested that many district medical officers felt their role had reverted to the invisible and poorly defined position that it had occupied prior to the pandemic (5). The study by Vik et al., which is now published in the Journal of the Norwegian Medical Association, adds some nuances to this picture and provides more knowledge about the district medical officer's role post-pandemic (6).
Vik et al. have followed up a sample of district medical officers and municipal leaders whom they also interviewed during the pandemic (1, 6). This provides an enhanced description of how the role may have changed over this period. A further strength of this study is that it captures perspectives from the administrative and political leadership as well as from the district medical officers. This reveals both agreement and discrepancies between the groups.
One of the study's main findings was that the relational collaboration between the district medical officers and the municipal leadership was strengthened (6). Both parties reported that their collaboration had become easier with deeper involvement. This is in line with the recommendations from the authorities (3, 4). All district medical officers now had a higher FTE percentage, which also implies a strengthening of their role. FTE percentage is especially important for the exercise of this role in small and medium-sized municipalities, such as those in which this study was undertaken (2, 6).
Despite the increased recognition and FTE percentage, none of the district medical officers had had their organisational placement changed. Few of them had access to decision-making arenas, and only one was placed at a senior level. The district medical officers saw this as a problem, but the municipal leadership did not envisage any need to entrench the collaboration or the increased recognition in the organisation. The grounds given for this were 'short distances' and 'good relationships' (6).
There is a need for expertise in community health in the municipal leadership, and a stronger resource must be formalised in the organisational structure
Increased relational collaboration is positive for the district medical officer's role, but you do not need a master's degree in management to understand that basing a role on relational collaboration is not sustainable in the long term. In small and medium-sized municipalities, such relational collaboration can work, but only for as long as the relationships remain intact. In large municipalities this will be even more challenging, because of the greater organisational distances involved. Previous reports have pointed out the need for enhanced health management in the municipalities (7, 8). All municipalities go through regular shifts of political power, and they are facing major challenges that will require changes to be made. In such a landscape, two facts are clear: there is a need for more expertise in community health in the municipal leadership, and a stronger resource must be formalised in the organisational structure.
Why does the municipal leadership see no need to formalise this?
Municipal self-government is a democratic asset, but has also led to very variable prioritisation of the district medical officer's role (8). Strengthening the community health resource in the municipality will require the municipal leadership to rethink their own organisation. Prioritising or recognising something is rarely difficult when it requires no organisational changes; it is all talk and no action. Increased relational collaboration might strengthen the role of the district medical officer, but is vulnerable to changing relationships. So why does the municipal leadership see no need to formalise this?
As a community health specialist I have learned that prioritising something always means that less priority is given to something else. The number of seats around the chief administrative officer's table is not unlimited. Increasing the influence of the district medical officer will necessarily mean that others will have less influence. Is this alternative cost deemed to be too high? It would be interesting to see further research into the role of the district medical officer post-pandemic to elucidate this question.
We who were in our teens in the early nineties remember the rock band Extreme and its hit single 'More than words'. In soft, lilting voices accompanied by acoustic guitars they call for action – not just words and promises. Having read the article by Vik et al., this is the song I feel like playing to municipal leaderships around the country. If we are to succeed in reinforcing the district medical officer's role as recommended by national authorities, we need more than just recognition and relational collaboration. The role needs to be formally entrenched through organisational action.