sou · GTB3104d2 · 2006-01-01 00:00:00 — The main consequence of delayed efforts was the suffering which Swedish citizens were exposed to and which could have been avoided even with the extreme shortage in the afflicted region. Certain errors made could probably have been avoided if Swedish teams with qualifications in disaster medicine had reinforced the Thai institutions. These errors may lead to permanent injuries for those affected. In some cases there was an obvious risk of death which could only be avoided when the person concerned had the capability or contacts to ensure the necessary measures could be taken. It appears highly likely that many Thai citizens received poorer care as a result of the overtaxing of the services and the priorities made on the spot, and the possibility that Thai citizens died as a consequence of this cannot be ruled out. Consular management was adapted too slowly to the extreme situation that prevailed following the disaster. Personnel reinforcements were initially insufficient. A lack of empathy with the tourists who in many cases were badly hit is reported from many quarters. The routines for registering missing persons were undeveloped and in some cases led to serious mistakes in spite of a strong reinforcement of personnel and hard work on their part. Communication with the general public was inefficient. It is understandable that the resources were stretched in such an extreme situation but with better preparation the damage could have been limited. Public efforts in the logistics and transport area were insufficiently coordinated. As a result several people, both injured and uninjured, arrived home later than need have been the case. Cooperation with other countries – primarily bilateral cooperation – could have been further developed. Cooperation with NGO actors – volunteers, voluntary organisations, agencies and others concerned – would also have been more effective with better preparation. A further consequence of importance was that confidence in the Swedish government as the ultimate guarantor of security and safety was damaged. Everyone agrees that the level of ambition cannot be the same in distant countries as in the home country and that the strain on which had many nationals in the area was particularly great, however, it may still be established that asserted itself badly in essential respects in comparison with countries with more efficient crisis management. This impact on confidence is difficult to assess but – in broad outline – it extends much further than the group of Swedish citizens directly involved in the disaster, those immediately affected or their relatives. Causes of the deficiencies The Government Offices lacked an efficient crisis management organisation The basic deficiency in the organisation of the public administration was the lack of an efficient crisis management organisation. This explains several shortcomings in the Government Offices and its ministries, the and public authorities with regard to the late awareness of the nature and scale of the disaster, difficulties in assembling information, coordinating analyses and identifying relevant measures both within the Government Offices and in the interplay between ministries and authorities, as well as problems in executing measures effectively. In the initial phase, no decisions were taken by the Government in matters of importance for crisis management nor was the Government convened. Instead, it was believed that measures taken to manage the crisis within the normal procedures for the Government Offices and the Ministry for Foreign Affairs would suffice, supplemented by temporary groups of State Secretaries and Ministers. Leadership relations in dealings between the ministries during this crisis were unclear. The Ministry for Foreign Affairs undertook the role of leading ministry since the disaster had occurred abroad and the first information about it reached the Government Offices through the consular duty officer at the Ministry for Foreign Affairs. This did not, however, eliminate uncertainties regarding the division of authority between the ministries. The State Secretary Group considered itself responsible for coordination but cannot be seen as a group for actual crisis management. Decisions were not taken in the Group nor were any records kept of its meetings. This meant that many uncertainties about the division of responsibility remained. Problems in dealing with issues involving more than one ministry are illustrated inter alia by the protracted handling of the efforts of the in . With the loose procedure applied within the Government Offices and the Ministry for Foreign Affairs it was difficult to identify the point at which a consular regime for dealing with the situation should be replaced by more vigorous crisis management. When this took place, only informal signals were sent out in the organisation indicating that financing issues would not be a problem in the context. This matter should have been subject to a formal decision at a cabinet meeting at an early stage, marking the Governments responsibility and important role. A temporary organisation based on a vague principle concerning the leading ministry is totally inadequate for managing crises of major proportions. Experience from the has forcibly overthrown the idea that the task can be fulfilled without a formal organisation for crisis management under the Government. The Ministries after-hours services were inadequate Warning of the earthquake in the Indian reached the Ministry for Foreign Affairs through the consular officer on duty and very soon both press officers and the Duty Officer were involved in the matter. This first part of the 24-hour organisation worked well. The next step in the organisation was less efficient. The executives most closely involved at middle and senior levels – the Head of Group for consular assistance, the Head of the Consular Department and the Director-General for Administrative Affairs – were on holiday and took between one and two plus days to arrive at the Ministry – an unacceptable delay. Both the Head of Group and the Head of Department began work on but by telephone from a distance. As a result, management of efforts at the Ministry was weak for more than a day. Not until the head of a department is physically present can any really effective build-up of activities – in terms of personnel and structure – be secured in the initial phase of a crisis such as this. Added to this, within the Ministry for Foreign Affairs there appears to have been uncertainty about who is the most senior executive with operative responsibility for crisis efforts of the kind that became necessary – the State Secretary for Foreign Affairs or the Director-General for Administrative Affairs. Most people seem to have considered the State Secretary should obviously have this role, but he had a different perception of his role. Many of the problems can be explained by the inadequate routines for communicating information in the Ministry. With improved routines for spread of information and analysis, the organisation would have started on its crisis management work more rapidly, even with the incomplete 24-hour service at middle management level. Among other things, contacts could have been made with other capital cities. The threshold for directly alerting higher levels of the hierarchy of officials must be low regarding information of an emergency nature. The system with what is called the Ministers Office established as a link between Minister and the State Secretary and between the Ministry management and Heads of Department contains problems. Instead, this office risks becoming a filter. At the , the alarm function worked thanks to initiatives by an individual officer. The routine of having an officer on duty at home after office hours had been withdrawn in the summer of 2004. There seems to have been no uncertainty as to who had the main operative responsibility in this Ministry. The national and health services were inadequately prepared for efforts abroad An early and strong Swedish effort was justified. The great strain on the Thai services lasted for many days and could have been alleviated by Swedish contributions. In this way the physical and mental suffering of both Swedish and Thai citizens could have been reduced. Moreover, earlier and more extensive efforts were needed in order to plan and effectively implement the evacuation of those injured. In the event of crises and disasters, it is the duty of to keep the Government informed of developments, the ongoing situation and anticipated further developments. If many Swedes can be expected to arrive home in need of qualified care, it may be said to lie within the framework of this duty to obtain information about the number of patients, the situation regarding injuries, etc. The appropriate way to do so is to send an assessment team to the disaster area. If this had been done, the team would probably have undertaken tasks there and, in addition, immediately requested reinforcements from home. The authority responsible at the national level, with its Department, reacted late and, furthermore, was understaffed during the first week after the disaster, despite the fact that personnel were available. The Department could also have been reinforced with experts in disaster medicine from one of the knowledge centres in this area which have been created with the Boards participation. There was no lack of personnel qualified in disaster medicine and many of those who had participated in such training were prepared to make a contribution in at short notice. There was even an arrangement for personal contracts for work abroad. When a crisis is handled by a ministry (in this case the Ministry for Foreign Affairs) which does not have its own experts, the mobilisation of resources is protracted. was responsible for coordination in this area but did not take that responsibility until , more than seventy-two hours after the disaster – an unacceptable delay in the prevailing situation. The consular system was inadequately prepared for major disasters The disaster in south-east was of an exceptional nature and to demand a plan adapted to such an extreme event would be unreasonable. At the same time, preparedness in the consular area did not live up to more modest demands either. The Ministry for Foreign Affairs may be said to have confirmed this assessment in that many changes have been announced and taken in the period following the . The hastily organised system for registering missing persons data contained far too many sources of error. The methods used meant there was a danger of serious mistakes, which were also made with grave consequences in some cases. Personnel for registration of personal data should have been mobilised more rapidly, above all at executive level. Personnel from the Consular Department were engaged in individual consular cases instead of leading the registration work which came partly to be performed by personnel with no experience of such tasks. It would have been more expedient to call in reinforcements of personnel from the , who have the relevant experience. The Ministry for Foreign Affairs did not make appropriate use of the expert support and assistance available at authorities such as the and the Swedish Tax Authority rapidly enough, partly due to deficiencies in communication between the Ministry and the . Planning for reinforcement of personnel in places hit by a crisis was also inadequate. Before the disaster, the Embassy in had taken preparatory measures for major accidents and in that respect was probably better equipped than many other embassies. Reinforcements from the Ministry for Foreign Affairs in and from other embassies came too slowly in the first week for it to be possible to gain control over the situation and this applies in both and . Ambassador took the first measures in accordance with the applicable rules and crisis plan. Whether his instructions were adequate for securing the management function at the embassy in his absence may be discussed. Management problems also arose in . Reports back to the Ministry were unsatisfactory. On the first night after his arrival in , Ambassador should not have been satisfied with following the ordinary routines but should have contacted the State Secretary or the Minister for Foreign Affairs directly to inform them of the gravity of the situation, the measures he planned to take and the acute need of personnel reinforcements. Many of those afflicted and their relatives have described to the Commission what they perceived as a lack of empathy on the part of the both in the region and back home in . Consular support in the region was characterised by strict adhesion to the consular framework of rules without regard for the extraordinary situation. In this context it should be mentioned that the new rather stringently formulated Financial Assistance to Swedish Citizens Abroad Act from 2003 was adopted by a unanimous Riksdag. In the Commissions view, it is clear that this Act came to mark the behaviour of many officials in the first period after the disaster. The Government Offices inadequate ability to manage crises The task of the Government Offices is to process government business and to generally assist the Government and cabinet ministers in their activities. The Prime Minister is head of both the Government Offices and the Prime Ministers Office. The responsibility for the organisation of the Government Offices, and hence for the existence or absence of a crisis management organisation as well as its structure, in reality rests with the Prime Minister. This responsibility cannot be delegated from the Prime Minister since by nature it embraces all ministries. In the Commissions view, there are no circumstances that could warrant any other assessment of where the responsibility lies. If one chooses to divide responsibility according to the principle of responsibility the result will be the same; he who has responsibility for an activity under normal conditions – in this case the Prime Minister –has responsibility during crises and disasters. When the occurred, the Prime Minister, , had been in office for over eight years. The crisis management question had been raised in different contexts, primarily in connection with the report of the Commission on Vulnerability and Security and the bills presented by the Government on the basis of this report. The fact that the Government Offices did not have a crisis management function was not because the matter had not been discussed but was rather a conscious standpoint. It must also be mentioned that the majority of the bodies to which the matter was referred for consideration were positive to the proposal for a national crisis management organisation. bill, the Government cited constitutional reasons against the proposal. These arguments were noteworthy as arguments against certain elements of the proposal but appear to the Commission to be weak as an impediment to the introduction of a crisis management function based with certain adjustments on the proposal. The Riksdag took a decision in accordance with the Governments proposal; matters concerning the organisation of the Government Offices are traditionally considered to be an internal matter for the Government, ultimately the Prime Minister. However, in this matter, the parliamentary had made certain statements in favour of the proposal from the Commission on Vulnerability and Security. In the Commissions view, it was the Prime Minister, , who was generally responsible for the shortcomings of the Government Offices in managing the consequences of the . The inadequate after-hours service Regarding the division of responsibility between the State Secretary for Foreign Affairs and the Director-General for Administrative Affairs mentioned, there is some guidance in the Government Offices rules and code of procedure for the Ministry for Foreign Affairs and . Under the Minister, work is coordinated by the State Secretary. The Director-General for Administrative Affairs is responsible under the State Secretary for management of the in administrative terms. Management of a major operation following a natural disaster is not in common parlance an administrative task. There is scope for any other assessment than that the State Secretary must be regarded as primarily responsible for operations in situations such as this. In the situation prevailing on and the time immediately thereafter, he cannot be said to have fulfilled the expectations accompanying such responsibility. The Director-General for Administrative Affairs is responsible for emergency planning in the . This responsibility includes on the one hand satisfactory replacement arrangements in the event of his own absence from work and the absence of subordinate executives and, on the other, instructions for duty officers and other subordinate personnel concerning what is to be observed in the case of occurrences of a serious nature. the Director-General cannot be considered to bear sole responsibility for the accessibility of other executives and other emergency functions. There is a management responsibility at a higher level also. The political leadership of the Ministry is responsible for ensuring the stability of the organisation and that its emergency capability is adequate. It should be added that each executive at the different levels of an organisation has a personal responsibility to be available at the workplace when the task and situation so demand. Heads of department lead and distribute work within their departments. They have a principles responsibility for their area of expertise and should – in accordance with the provisions that apply throughout the Government Offices – keep the Minister for Foreign Affairs, other Ministers in the Ministry and executive officers informed of issues of major importance. Furthermore, the code of procedure for the Ministry for Foreign Affairs contains a rule on communication of information. detailed routines for this are not documented as far as the Commission is aware; they appear to be based on practice. In the Commissions view, the division of responsibility for the inadequate response in the Ministry for Foreign Affairs in the first few days after the crisis is as follows: –The State Secretary for Foreign Affairs, , was responsible for leading the Ministry for Foreign Affairs and thereby the Government Offices management of the disaster effort, and hence bears a major share of responsibility for the late response, inter alia by not having with his organisation actively sought information about the disaster and established contacts with other capitals at an early stage. first efforts could have been both speedier and more purposeful. He should furthermore have sought explanations as to why so many rang the Ministry and enquired about what they had to say. In that this did not take place, those responsible were not aware of the serious situation at an early stage. –The Minister for Foreign Affairs, , is responsible for the fact that the applicable rules concerning the emergency planning organisation and executives tasks in this context were inadequate for ensuring good emergency preparedness in the Ministry. Regarding the deficiencies in emergency planning, the Director-General for Administrative Affairs, Per Thöresson, also bears a considerable share of the responsibility. –The Head of Ministry is responsible for the inefficient internal communication routines that were in fact applied. She has to ensure the capability of her Ministers Office since this office is her link to the . The State Secretary for Foreign Affairs, , should be criticised for not informing the Minister for Foreign Affairs during the first 24 hours. The Head of the Consular Department, , as principle should be criticised for not directly or indirectly having ensured that the basic information available about the serious situation was communicated to the State Secretary and the Minister. –Per Thöresson, and , Head of Group, should be criticised for having stayed at their too long. At least one of them should have immediately interrupted their holiday and gone to the Ministry to lead activities from there. should have acted to ensure this. –The Commission finds it remarkable that the management of the had withdrawn the 24-hour service and hence at the time of the relied on other communication routines or voluntary efforts by officers after office hours. From a civil perspective, demands for a strong and clear contribution are justified. It is possible that had a clear regulation of national responsibility for emergencies been in place, possibly supplemented by agreements between the Government and the , this would have facilitated such a effort. However, it must be born in mind that the situation faced could have been the aim of such regulation. The perspective of legislation on emergency situations was national in the first instance. If, on the other hand, a central crisis management body with a cohesive overview had been established, the need for action in the area would probably have been identified earlier notwithstanding the absence of applicable legislation in the area. Even without such legislation and concerted crisis management, there was scope for a much more approach on the part of the Affairs. The State Secretary, , and Minister for Health, , must be considered responsible for this passivity. Responsibility for the delayed and initially underdimensioned effort rests with and its Unit of Crisis Preparednes. As mentioned above, the Director-General for Administrative Affairs is responsible for emergency planning at the Ministry for Foreign Affairs. However, comprehensive issues concerning the dimensioning of consular activities are of a political nature and hence lie within the remit of the State Secretary and Minister for Foreign Affairs. The Commission has the impression from interviews that for a long time consular issues have been given low priority in Ministry for Foreign Affairs operations. Furthermore, in connection with recruitment and training, the Ministry management is responsible for clarifying that the tasks include providing support and sympathy. The Commissions remit includes pointing to the need for changes in organisation, routines for interaction, governance, information matters and other routines for crisis management. The purpose of this part of the assignment is to strengthen preparedness and societys ability to deal with events that affect a large number of Swedes outside this country also. The Commission has chosen to focus in this context on the countrys central crisis management capability. in a global context The formulation in the Instrument of Government stating that the personal, economic and cultural welfare of the individual shall be the fundamental aims of public activity is the starting-point for a discussion of what may be reasonably expected of the public administration in a crisis situation. However, this needs to be concretised. The conclusions of the Commission imply mainly clarifications, and no significant changes to the basic division of responsibility between the individual citizen, private agents and the state. Even if the responsibility of the private agents and that of the state remain unchanged, the Commission considers that the state, on the basis of citizens´expectations, has a responsibility as the ultimate guarantor of the security and safety of its citizens. The first reasonable expectation applies to the physical demarcation of the administrations assignment. The public undertaking in respect of Swedes abroad in the Commissions view must be given a partly new content as a result of internationalisation.