Leading through the storm: a qualitative comparative case study of leadership during the COVID-19 pandemic in South Africa and Sierra Leone

The COVID-19 pandemic exposed systemic vulnerabilities within many health systems globally, illustrating the critical role of strategic leadership in managing and navigating unprecedented crises. This study investigated and compared the COVID-19 pandemic response in South Africa and Sierra Leone, two countries with different prior crisis experiences (a quadruple burden of disease in South Africa and Ebola in Sierra Leone). The comparison was on the leadership capacities required for effective pandemic preparedness and response. A qualitative comparative case study was conducted guided by the WHO COVID-19 strategic preparedness and response plan: Monitoring and evaluation framework, in conjunction with a resilience framework (a conceptual framework-The dimensions of resilience management) through 2024–2025, we conducted semi-structured interviews with purposefully sampled senior decision-makers and policymakers in both countries. The data were analysed using a framework-based thematic approach, explicitly structured around the three core capacities adaptive, absorptive and transformative capacities required to identify strategic insights for future pandemic preparedness and response. Different strategic profiles were identified through analysis of interpretive themes from interviews. Sierra Leone’s response drew on adaptive and absorptive capacity. South Africa’s response showed strong adaptive capacity through policy pivots, but faced absorptive constraints, including coordination and trust issues. Nine themes emerged; however, we reported on the four main themes: coordination and navigation of authority, mobilising health resources, communication during the crisis, resource mobilisation and multisectoral partnerships, suggesting that effective pandemic leadership requires strategic integration of all three complementary capacities rather than just their isolated presence. Comparing leadership responses in South Africa and Sierra Leone suggests that in a pandemic, resilience depends on the strategic integration of complementary capacities rather than just available resources. The most important comparative lessons learnt between the two countries were decentralisation of decision-making (effective in South Africa but fragmented in Sierra Leone), the role of trust (stronger in Sierra Leone’s post-Ebola context), and continuity of essential services (compromised in both countries but through different mechanisms). Future preparedness should prioritise context-specific factors over generic templates.