The study set out to compare the pandemic responses of two nations whose prior crisis experience could hardly have been more different. South Africa entered the pandemic carrying what public health experts describe as a quadruple burden of disease: a high prevalence of HIV, a substantial tuberculosis epidemic, rising rates of non-communicable diseases, and persistent violence and injury. Sierra Leone, by contrast, had recently emerged from the devastating 2014–2016 West African Ebola outbreak, an experience that had already forced its health authorities to confront an epidemic with limited infrastructure. The researchers wanted to know how these contrasting starting points shaped the leadership capacities each country could draw upon when SARS-CoV-2 arrived.

Methodologically, the study took the form of a qualitative comparative case study conducted during 2024 and 2025. The authors carried out semi-structured interviews with purposefully sampled senior decision-makers and policymakers in both countries — the people who had been in the room when critical pandemic choices were made. To give the analysis structure, they anchored it in two complementary frameworks: the World Health Organization’s COVID-19 Strategic Preparedness and Response Plan monitoring and evaluation framework, and a conceptual framework describing the dimensions of resilience management. Interview data were then analysed using a framework-based thematic approach, explicitly organised around three core capacities that resilience theorists distinguish: adaptive, absorptive and transformative capacity.

These three capacities form the technical backbone of the study. Absorptive capacity refers to a system’s ability to withstand a shock and continue functioning — to keep hospitals open, supply chains running and staff at their posts while the crisis rages. Adaptive capacity describes the ability to adjust strategies, policies and practices in response to changing conditions, pivoting when the original plan no longer fits reality. Transformative capacity, the most demanding of the three, involves changing the fundamental structures of the system so that it emerges from the crisis fundamentally stronger. The researchers used this triad as a diagnostic lens, asking which capacities each country’s leadership displayed, which were missing, and how the capacities interacted — or failed to interact.

The analysis generated nine themes in total, of which the authors report four as most significant: coordination and navigation of authority, mobilising health resources, communication during the crisis, and resource mobilisation through multisectoral partnerships. From these themes, two distinct strategic profiles emerged. Sierra Leone’s response drew heavily on adaptive and absorptive capacity, leveraging the institutional muscle memory built during the Ebola epidemic. South Africa’s response likewise showed strong adaptive capacity, visible in rapid policy pivots, but it ran into absorptive constraints — most notably difficulties with coordination and with public trust — that limited how much shock the system could actually absorb.

One of the sharpest comparative lessons concerns the decentralisation of decision-making. In South Africa, decentralised structures proved effective, allowing provinces and local authorities to tailor interventions to their own epidemiological situations. In Sierra Leone, the same principle appeared in a more fragmented form: authority was dispersed, but the connective tissue needed to coordinate dispersed actors was weaker, producing fragmentation rather than flexibility. The finding underscores a subtle but important point for preparedness planners — decentralisation is not inherently good or bad; its value depends on whether the surrounding coordination mechanisms are strong enough to hold the system together.

Trust emerged as the second major differentiator, and in an unexpected direction. Sierra Leone’s post-Ebola context had cultivated comparatively stronger trust in epidemic response institutions, a legacy of communities and health workers having lived through a previous outbreak together. South Africa, despite its far larger health budget and more elaborate institutional apparatus, faced coordination and trust issues that eroded the effectiveness of its response. The lesson is uncomfortable for wealthier nations: material resources cannot substitute for the social capital that allows public health directives to be believed, followed and sustained under pressure.

The third comparative lesson involved the continuity of essential services — the capacity to keep delivering HIV treatment, routine immunisation, maternal care and other non-COVID services while the pandemic consumed attention and resources. Here the study found that both countries fell short, but through different mechanisms. In each case, the pandemic disrupted the ordinary business of the health system, and in each case leadership struggled to protect routine services from the gravitational pull of the emergency. That shared weakness, the authors suggest, points to a structural blind spot in pandemic planning everywhere: plans focus on fighting the incoming threat while assuming the rest of the system can coast, an assumption that repeatedly proves false.

Taken together, the findings lead to the study’s central conclusion: resilience in a pandemic depends on the strategic integration of complementary capacities rather than on the isolated presence of any one of them, or on the volume of available resources. A system with superb adaptive capacity but weak absorptive foundations — South Africa’s profile in this comparison — can pivot brilliantly yet still crack under sustained load. A system with strong absorptive and adaptive reflexes but limited transformative reach — closer to Sierra Leone’s profile — can weather a storm without fundamentally upgrading itself for the next one. Leadership, in this framing, is the integrative function that binds the three capacities into a coherent whole, deciding when to absorb, when to adapt and when to transform.

The authors draw a pointed implication for future pandemic preparedness: context-specific factors should be prioritised over generic templates. The WHO strategic preparedness framework provided a useful scaffold for the analysis, but the study’s deepest insights came from the particular histories, institutions and social fabrics of the two countries — South Africa’s quadruple disease burden and federal-style decentralisation, Sierra Leone’s Ebola scar tissue and hard-won community trust. As governments and global agencies stockpile vaccines and draft the next generation of preparedness plans, this comparison from two very different African health systems offers a sobering reminder that the decisive variable in the next crisis may not be what is in the warehouse, but whether leaders can weave absorption, adaptation and transformation into a single, trusted strategy.

Subject of Research: Comparative health leadership and resilience during the COVID-19 pandemic in South Africa and Sierra Leone

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

Article References: Zembe, J., Senkubuge, F., Modisenyane, M., Wurie, H. R., Kanu, H. Y., & Barrie, A. (2026). Leading through the storm: a qualitative comparative case study of leadership during the COVID-19 pandemic in South Africa and Sierra Leone. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15712-7

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15712-7

Keywords: COVID-19, health leadership, health system resilience, South Africa, Sierra Leone, pandemic preparedness, adaptive capacity, absorptive capacity, transformative capacity, health policy, qualitative research, decentralisation