In uncharted territory: managing the COVID-19 pandemic in Swedish regions and municipalities from a primary health care perspective

Abstract

Objective

To explore experiences and challenges faced by regional and municipal health care leaders during the COVID-19 pandemic, with a focus on primary health care and care of older adults.

Design

A longitudinal qualitative study based on two rounds of semi-structured interviews 2–3 months apart.

Setting and participants

Fifteen health care leaders strategically recruited from regions and municipalities across Sweden. The first interviews took place in November–December 2020, the second in January–March 2021.

Results

Four themes were identified. The first captured the challenge of navigating uncharted territory during an unprecedented crisis. The second addressed ethical dilemmas arising from public health priorities. The third highlighted the growing significance and evolving role of infection prevention and control. Finally, the fourth illustrated how initially productive and solution-oriented local collaboration and communication gradually gave way to tensions and conflicting responsibilities.

Conclusions

In the early phases of the pandemic, the Swedish Public Health Agency’s leadership and measures were generally appreciated, although the initial response was widely perceived as slow and insufficient. The high mortality among older adults was regarded as a major failure, raising ethical concerns and exposing tensions in collaboration between actors. Pandemic work was experienced as exhausting yet meaningful, and the field of infection prevention and control gained increased recognition and status. Some distinctive features of Sweden’s pandemic response – such as decentralised decision-making and an emphasis on individual responsibility – may have been shaped by the constitutional prohibition of ministerial rule and the substantial autonomy granted to regional and local authorities.

Introduction

The COVID-19 pandemic constituted a global crisis, prompting a wide range of national responses. Sweden’s pandemic strategy aimed to minimise mortality and morbidity while also mitigating other negative public health consequences. This approach, characterised by relatively few government-imposed restrictions in the initial phase, attracted both praise and criticism [1–5].

At the outset of the pandemic, Sweden recorded a higher incidence of COVID-19-related deaths across all age groups compared to its Nordic neighbours [6]. The limited restrictions during the early stages, combined with differences in how care and housing for older adults are organised, likely contributed to this outcome [7,8]. In contrast, Norway, Denmark, and Finland experienced a delayed rise in excess mortality during the pandemic [9].

However, the overall impact of the pandemic extends beyond reported COVID-19 deaths, due to limitations in death registration systems and difficulties in attributing deaths to COVID-19 with certainty [10]. This variation in national strategies and outcomes makes Sweden a particularly relevant case to explore how pandemic management was interpreted and enacted in practice. Especially, it is important to understand how health care leaders in primary health care and municipal services experienced and responded to a strategy that was both internationally debated and implemented under conditions of uncertainty.

Sweden’s healthcare system is decentralised, with 21 regions and 290 municipalities responsible for public services. These entities operate autonomously and cooperate horizontally rather than within a hierarchical structure. The regions are responsible for primary health care centres, including physicians providing medical services in nursing homes, as well as for hospital care. The municipalities provide home care and nursing home services, employing nurses and nursing assistants. All regions and municipalities are members of, and supported by, the Swedish Association of Local Authorities and Regions (SALAR, Sveriges Kommuner och Regioner) [11]. SALAR is an employers’ organization that exerts influence over health and social care operations, although it is not governed through general elections. The fact that those working on SALAR’s behalf are not elected in general elections may contribute to some uncertainty regarding roles, responsibilities, and coordination between actors in municipalities and regions, which is particularly relevant in the context of pandemic management.

As in other parts of the world, local adaptations of Swedish COVID-19 management involved rapid reporting of outcomes, including the identification of barriers and facilitators during the pandemic [12]. Primary health care, including the care of older adults, is influenced not only by political decisions as described above, but also by decisions and activities from several government authorities. These authorities shape everyday primary health care through guidance, governance, coordination, and information flow. Understanding how these influences are experienced and managed in practice is particularly important in the context of a pandemic. The National Board of Health and Welfare is a government agency with broad responsibilities in medical services, patient safety, and epidemiology, including maintaining national health data registers and producing official health statistics [13]. The Public Health Agency of Sweden has a national responsibility for public health, including protection against communicable diseases. This encompasses issuing preventive measures such as recommendations and guidance for health care professionals on basic hygiene routines, source control, testing, and contact tracing [14]. Multilevel governance in healthcare may present challenges due to tensions between the public health goals in communicable disease control and the health care system’s traditional focus on individual care [15].

The Swedish Civil Contingencies Agency (MSB, Myndigheten för samhällsskydd och beredskap) is responsible for helping society prepare for major accidents, crises, and the consequences of war [16].

Guidelines, recommendations, and preventive measures related to COVID-19 required local adaptation by health care leaders such as county medical officers for communicable disease control, infection prevention and control physicians, chief medical officers, medically responsible nurses in municipalities, regional directors of health services, and heads of municipal administration. Transforming national-level guidance into context-specific, locally adapted actions was both demanding and complex, particularly in light of the global debate surrounding Sweden’s pandemic strategy.

This study explores the perspectives of health care leaders in primary health care, with the aim of uncovering their experiences and reflections on the management of COVID-19 in primary health care and in the care of older adults in Sweden during the pandemic.

Materials and methods

Study design

This was a longitudinal qualitative interview study using a semi-structured interview guide across two rounds [17]. The first round was conducted between November and December 2020, and the second from January to March 2021. The second round of interviews involved follow-up conversations with the same participants, conducted approximately two to three months after the initial interviews.

During the study period (late 2020 to early 2021), Sweden experienced successive waves of the pandemic, characterised by evolving national recommendations and locally adapted restrictions. Measures affecting primary health care and the care of older adults changed over time, including guidance on social contacts, infection control, and access to services. The introduction of vaccination and concerns about subsequent waves further contributed to a dynamic and uncertain context that may have influenced leaders’ experiences and priorities [18].

Research team

This study was part of the CovidNor project, which encompasses several studies exploring the management of the COVID-19 pandemic in Norway and Sweden [19,20]. The present study was a collaborative effort between Region Västra Götaland in Sweden and the Department of General Practice at the University of Oslo in Norway.

Setting, participants and recruitment

Fifteen individuals in leading roles in regional and municipal pandemic response efforts were interviewed twice during the first year of the COVID-19 pandemic by members of the Swedish research team (PDS and IMS). The rationale for conducting two rounds of interviews was to explore temporal changes in the participants’ reflections and experiences, particularly in relation to the development of preventive measures over time.

Participants were recruited during October and November 2020 via email and telephone, using the national professional networks of PDS and IMS. Individuals were strategically selected to ensure variation in managerial perspectives from primary health care across diverse Swedish regions and municipalities. Inclusion criteria were holding a strategic leadership position in a region or municipality with responsibility for COVID-19-related decision-making in primary health care or in the care of older adults. Consideration was given to urban and rural settings, gender, geography, and regional variation in COVID-19 incidence.

All but one of the invited individuals agreed to participate. Informed consent was obtained in writing from all participants. Although some participants were previously known to the interviewers through professional networks, there were no dependent or supervisory relationships. Reflexivity was considered throughout the study design and analysis.

Participants were purposively selected to reflect variation in geographical settings, organisational contexts, and professional roles within primary health care and the care of older adults. The participants held a variety of professional roles, including county medical officer responsible for communicable disease control, physician in infection prevention and control, regional director of health services, chief physician and manager of a large primary care area, head of a COVID-19 testing and vaccination centre, head of municipal administration, and medically responsible nurse within a municipality.

Of the 15 participants, nine were physicians, four were nurses and two had other professional backgrounds. Eight participants were aged 40–59 years, seven were aged 60–70 years, and ten participants were women. Gender and age diversity were considered important to capture a broad range of leadership perspectives.

Data collection and analysis

The interview guide was developed based on existing knowledge of the COVID-19 pandemic, the collective clinical experience of the research team, and the overall aim of the project. All interviews were conducted in Swedish via speakerphone (by PDS and IMS), digitally recorded (Olympus DM-720), and transcribed verbatim (by SS). The transcripts were subsequently proofread (by PDS, SS, and IMS). Interviews lasted approximately one hour in the first round and slightly less in the second. A written summary of each interview was shared within the research team. The second round followed the same core themes as the first but was tailored to each participant by following up on their previous responses.

Thematic reflexive analysis was conducted using Braun and Clarke’s framework [21], see Table 1. An inductive approach was applied, focusing on a semantic and realist reading of patterns, meanings, and implications across the dataset. Each participant’s two interviews were initially analysed as a linked case over time (within-participant comparison). Subsequently, patterns were explored across participants to identify shared and divergent experiences. Time was thus considered both as an analytic dimension and as part of the contextual understanding of participants’ experiences over time. Initial impressions were discussed in a research meeting. Coding was performed by PDS and IMS and discussed among all authors. Themes were developed through iterative grouping of codes into candidate themes, followed by review and refinement based on coherence, relevance to the research question, and consistency across the dataset. Themes and codes were repeatedly reviewed and revised within the Swedish research team, while transcripts were re-read by PDS and IMS to validate the thematic structure.

Table 1.

Braun and Clarke’s six stages of reflexive thematic analysis with examples from the present study.

Phase		Description of analysis step	Example of analysis
1	Familiarizing with the data.	Initial readings were conducted shortly after each interview, accompanied by note-taking. The transcripts were then read and re-read through thoroughly searching for meanings and patterns.	Initial reflections: The informants described a professional assignment they had never experienced before. The pandemic plans that were at hand could not be used as the events during the pandemic had not been envisaged in the planning. They experienced stress but also meaningfulness. Depending on where they worked, they had to create different and new courses of action. The ways of doing this depended on which organization they belonged to, but new ways of working were needed.
2	Generating initial codes.	Organizing the data into meaningful code groups. Codes were identified, read, re-read, and continuously discussed.	Preliminary code groups: New and unknown events. Long-term sustainability and being able to cope stress. Great meaning. Clear shortcomings in elderly care, including protective equipment. Balancing act in giving advice between life and death. The importance of infection prevention and control. The importance of teamwork. Difficulties in communication, especially between different organizational levels. Tension between different levels of decision-making.
3	Searching for themes.	Refocusing the analysis to the broader aspect of themes. Possible overarching themes were identified based on the codes, with ongoing reflection and iterative re-reading.	Themes: To navigate in new surroundings. Ethical dilemmas in relation to different parts of the population. Sadness over shortcomings in elderly care. A new role of infection prevention and control? Teamwork and good collaboration. Growing conflicts and tensions over time. Sub-themes: Care for the elderly. Difficulties in communication. Responsibility for initial decision-making.
4	Reviewing themes.	Continued review, reflection and discussion of identified potential themes, based on the codes, to assess coherence, relevance, and consistency in relation to the dataset. Re-reading as necessary.	Main theme: How the COVID-19 pandemic in uncharted territory was managed from a primary health care perspective. These themes were preliminary versions of the final themes presented in phase 5.
5	Defining and naming themes.	Themes were defined and named thorough iterative team discussions and writing. Re-reading was conducted when necessary.	The essence of the themes: Navigating uncharted territory without a map or compass. Demands to implement ethically complex public health priorities. Increasing focus on and impact of infection prevention and control. Fruitful communication and collaboration shifted to tensions over time.
6	Producing the report.	Final analysis and write-up of the report. The analytic narrative needs to go beyond the description of the data and make an argument in relation to the research question.

The research team was multidisciplinary and included general practitioners (IMS, PDS, JS, SRH), research nurses (SS, AMB), an ear, nose and throat specialist (GHF), and a medical anthropologist (MBR). Several members had direct clinical experience from primary care during the COVID-19 pandemic, while others contributed with research expertise and broader perspectives on health systems and organisation.

Reflexivity was actively considered throughout the study. The study was designed as a collaborative effort, drawing on the complementary expertise of the team. Interviews were conducted by researchers with clinical experience in Swedish primary care during the pandemic and were discussed within the Swedish team, supported by reflexive notes.

The analytic process was iterative and involved regular discussions within the Swedish research team and with collaborating Norwegian researchers. Differences in interpretation were actively explored and negotiated through team discussions, contributing to researcher triangulation and enhancing the credibility and interpretative rigour of the analysis.

The study was approved by the Swedish Ethical Review Authority (ref. 2020-04963).

Quotations from participants are marked with SE (Sweden), followed by the participant number (1–15) and interview round (1 or 2).

Results

We identified four main themes. The first describes the experience of navigating uncharted territory during an unprecedented crisis. The second highlights the ethically challenging nature of public health prioritisation. The third emphasises the growing importance and impact of infection prevention and control. Finally, the fourth theme illustrates how initially fruitful local collaboration, and communication gradually gave way to tensions and conflicting responsibilities over time.

Navigating uncharted territory without a map or compass

The shortcomings in national pandemic and crisis preparedness became evident when authorities were tasked with managing a novel virus with an unpredictable trajectory. While existing plans may have sufficed for events such as major traffic accidents or influenza outbreaks, they were ill-suited to a prolonged and evolving pandemic. Contingency stocks were insufficient, and access to testing equipment was limited.

…It’s not like a bus accident where you have to manage the accident site and a large influx [of patients] for two or three days. It is completely different… (SE13_2).

The lack of preparedness necessitated rapid and strategic decisions. Knowledge about the virus was limited and constantly shifting, which required informants to adopt a pragmatic approach. There was no time for extensive investigation or impact assessments. Many expressed humility in their decision-making, acknowledging that no one had encountered this situation before. Alongside the ongoing rapid changes, constant reprioritisation of decisions, recommendations, and resource allocation was required. Informants, other health leaders, and the general population were described as constantly ‘on their toes’.

At the outset, participants had to rapidly process large volumes of new and evolving information. Over time, although the overall pace remained high, the cognitive load eased somewhat as the stream of entirely new knowledge began to slow.

The pandemic brought a sustained and intense workload. Uncertainty regarding how long the situation would last generated anxiety about long-term endurance, both for leaders and frontline staff. It was often about perseverance, as the following quote shows.

… it’s less a matter of adrenaline and more about… yes, just biting the bullet and carrying on. (SE09_2)

As routines became established and preparedness improved, such as access to protective equipment and testing materials, participants reported increased confidence. However, they also observed rising fatigue and exhaustion among staff and expressed growing concerns about workforce resilience. While many routine tasks were postponed initially, expectations to return to normal operations gradually re-emerged. Staff shortages during holiday periods posed challenges in the care of older adults. Contracted employees were not subject to the same obligations as permanent staff, which exacerbated pressure during critical periods.

[Silence…] …what is always a concern in older adults’ care is staff […] they don′t step forward in the summer […] nor on Christmas or New Year’s Eve […] the permanent employees can be ordered to work, but we can′t handle the hourly employees like that […] it seems unreasonable… (SE11_2)

Despite the strain, many participants described the pandemic response as one of the most meaningful experiences of their professional careers. Several emphasised the value of prior experience in emergency care, infectious diseases, research, private enterprise, or even personal hardship. With previous experience, it was often easier to come up with solutions for previously unknown situations.

How do we handle this situation? Well, we need to approach it this way, and then we act accordingly. There have been several occasions when you have had to change your plan […] there haven’t been any templates at all during the pandemic, there are no obvious solutions, you constantly must figure out ‘what do we do now?’ (SE12_1)

Demands to implement ethically complex public health priorities

Over time, protecting older adults, particularly those with cognitive impairment, became increasingly challenging. It was often impossible to help them understand why maintaining distance and wearing face masks were necessary. Several informants expressed that effective preventive measures were not implemented because municipal care and welfare services for older adults had been involved too late.

Instead, the initial focus was on intensive care units and hospital wards. The delayed involvement of municipal care, combined with an unfavourable distribution of resources, further hampered the municipalities’ ability to respond effectively. One informant described how staff in municipal care were sometimes forced to manufacture their own personal protective equipment due to supply shortages.

To reduce viral transmission among older adults in care, a long-term ban on visits from relatives was introduced during the first year of the pandemic. Informants responsible for these decisions expressed doubts about their effectiveness. As it became clear that the virus was mainly transmitted by staff, some feared that older adults had been prevented from seeing their families at the end of life due to a potentially ineffective policy. The sense of failure surrounding the protection of older adults was widespread.

I still don’t know if we did the right thing or not. In some instances, I think we did the right thing, in others not, but the greatest sadness is that we failed to prevent nursing homes from being affected so early [in the pandemic]. (SE02_1)

Nevertheless, informants felt they had done their very best under the circumstances, and that their work was often met with great understanding from next of kin. As a result, they did not share the critical conclusions about the care of older adults presented by the Health and Social Care Inspectorate at the time of the interviews.

And I think that even if we then had an increased spread of infection in healthcare, there are very few cases that we can deduce to not following restraining orders. (SE07_1)

Many informants found it ethically challenging, bordering on unethical, to justify restrictions on nursing home visits, cultural activities, church services, and sports, while large shopping centres remained open with significantly fewer restrictions. Although these measures were intended to protect at-risk groups, they were perceived to have negative effects not only on older adults but also on younger people, raising concerns about the long-term consequences.

Increasing focus on and impact of infection prevention and control

Many informants felt that infection prevention and control had been neglected prior to the pandemic. It was often regarded as a straightforward task, typically delegated to nursing staff. However, the pandemic revealed that it was far more complex in practice.

I have been involved so many times in infection prevention and control situations where you’ve had an outbreak in care units, and then you get it under control and everyone asks, ‘Can we go back to what we had?’and then you wonder ‘are they nuts or something?’ (SE14_1)

Before the pandemic, many informants perceived that the staff had limited knowledge about protective measures against various types of infections. Although visors were available, there was little understanding of how to use them or even where to find them. The upheaval caused by the pandemic brought infection control and hygiene practices to the forefront, not only for clinical personnel, but also for kitchen staff, taxi drivers, caretakers, transport workers, and even those responsible for handling the deceased. The number of people involved in infection prevention and control efforts increased rapidly.

Health care hygiene per se really came to the forefront, and it′s still very much there […] Our manager the other day said ‘Yes, there are so many questions about infection prevention and control […] it′s almost as if people have got used to this now – they know what protective equipment to wear. […] I just wish they could continue to take it seriously’. (SE14_2)

Although there was a longstanding tradition of implementing infection prevention and control measures in patient care, such practices had not previously been emphasised among staff themselves. For example, maintaining distance in staff break rooms or other confined spaces had been uncommon. Even though basic hygiene routines had long been in place, informants described how these practices gained renewed attention.

…it was, in a way, new to be working to protect the older adults from us, ha-ha [laughs]. In other cases, it’s the other way around – that we should protect our employees from the residents’ or patients’ possible infections, no matter what sort. (SE04_1)

Exposing care recipients to multiple staff members was increasingly viewed as a risk for infection spread. As a result, staff began working in more limited areas compared to pre-pandemic times.

Contact tracing within municipal care for older adults was described as one of the most complex tasks during the pandemic. Nevertheless, the responsibility for tracing was often assigned to primary healthcare centres, which lacked prior expertise in this area. Informants were critical of this management, stating that the required experience had not been in place.

Fruitful communication and collaboration shifted to tensions over time

Initially, the regional and municipal efforts were characterised by strong team spirit and solution-oriented collaboration, both within and across organisations. Professionals quickly assumed responsibility and acted as they deemed appropriate. However, tensions arose when regional managers made decisions without sufficiently accounting for local contexts.

Communication was reported as difficult at all organisational levels. At times, guidelines had to be read aloud among colleagues to facilitate clarity and prevent misinterpretations. Both written and verbal messages needed to be clear, practically applicable, and trustworthy – although the implementation of new measures often took time.

Staff and managers alike were stressed by the overwhelming volume of new knowledge and guidance. Distilling the essential information and presenting it in an accessible, searchable way at the regional and local levels was a demanding task. New guidance often raised immediate questions, which led to the decision to avoid publishing updates during weekends. These challenges are illustrated in the following quote:

If you are asked, as an employee [standing there with a sick patient], about ‘household contact’ […] while the official has written a document relating to the spread of infection […] the employee may have to search through 10 or 20 documents and may have 90 seconds to find it […] how do we provide information in a good way? (SE05_1)

Local media were initially seen as a valuable channel for information. However, over time, many informants grew frustrated with coverage by self-appointed experts who seemed more focused on assigning blame than on presenting reliable facts.

Sometimes it is perhaps more important to communicate that you don’t have an answer than not to communicate at all. It may be more important to say, ‘it is noted that this is not resolved, and we will resolve it’. (SE05_2)

As remote work became more common, communication shifted towards digital platforms. While this facilitated teleworking, it also made it harder to gauge how staff were coping without face-to-face meetings. Some found digital leadership uninspiring, with varying views on its overall effectiveness.

…It is not well looked upon to work at home, as if you are just having a good time […] but then you produce incredibly more at home than in the office, because there [in the office] considerable time goes to mingling, which, of course, also drives processes forward. It does. But whatever you can produce, you produce more at home. (SE11_2)

Informants generally viewed the Public Health Agency’s early actions as timely and effective in averting a worse outcome during the first wave. Due to the urgency of the situation, decision-making bypassed routine investigations, impact assessments, and consultations.

…I can’t help but thinking that there would have been a much more catastrophic outcome in the first wave if the Public Health Agency had failed to take the helm and do what was immediately necessary. (SE09_2)

While participants acknowledged that not all decisions could be correct from the outset, they sometimes found the authorities’ communication vague. The Public Health Agency was gently but clearly criticised for slow or flawed decisions, including the early discontinuation of contact tracing.

Establishing consistent practices at the regional and local levels was complex, particularly when information about the latest decisions was lacking. Informants expressed a clear wish for timely insights into local conditions from their own and other organisations—such as sampling capacity and transport logistics—before national decisions were made. Between the two interview rounds, it became clear that much of the information had been obtained through media channels.

…for example, when it came to school closures or openings, the Minister of Education said at a press conference, ‘Talk to the county medical officer for communicable disease control, who can decide what you should do here’. Nobody had a clue; we were completely inundated with calls. It was complete chaos–almost to the point that all digital mailboxes and phones were blocked. (SE02_2)

Over time, informants perceived a return to conventional consensus-based decision-making, involving all 21 regions and 290 municipalities. The informants expressed that responsibility for overall decisions was unclear, which caused delays in acting.

In Sweden we are not used to someone else making decisions. We haven’t had a war [for 200 years] or anything like that. We are not used to someone just dictating terms; instead, we always negotiate, discuss, and then make recommendations. (SE14_2)

Decision-making increasingly came to be viewed as a power struggle between national and regional actors. The regions felt unfairly blamed when outcomes were poor. The National Board of Health and Welfare was initially regarded as insensitive and overly bureaucratic, though this view softened over time. The Swedish Civil Contingencies Agency was also criticised for lacking effectiveness, despite having received resources to prepare for the vaccine rollout. Delays in vaccinations and clashes between national and regional directives caused visible frustration.

Who, who will decide what to do next? There is a lack of an effective, coordinated, and rapid control in situations like this. (SE09_2)

National decision-making was often perceived as slow and poorly sequenced. Over time, the Public Health Agency’s scientific approach was criticised for being developed within a small, insular group of experts, with limited external input.

We usually gather expertise from different parts of the country and with slightly different skills. And that has been put out of action for some reason that is incomprehensible to me –probably because they thought we didn’t have time, I would think… I feel that we haven’t been able to simply participate and contribute what we can in an area where we can do a lot…. (SE08_1)

Discussion

Principal findings

During the first year of the COVID-19 pandemic, Swedish health care leaders in regional and municipal operations recognised a lack of strategies and resources suited to manage a prolonged and large-scale public health crisis. One central dilemma was that measures intended to protect older adults could have negative consequences for younger populations, and vice versa. As a result, prioritisation became increasingly complex and demanding over time, and the high mortality among older adults was widely perceived as a failure. Despite these challenges, the initial pandemic response was marked by collaboration, determination, a strong sense of purpose, and effective use of professional expertise. However, as the pandemic progressed, the expanding volume of information and the constantly evolving knowledge base became increasingly difficult to absorb and apply.

Many participants expressed that the Public Health Agency′s early leadership at the national level was necessary. At the same time, they expressed a need for national authorities to demonstrate a deeper understanding of local realities before making decisions, particularly over the longer term. The pandemic also prompted a renewed focus on infection prevention and control, likely driven by concerns about the unpredictable nature of viral spread. Finally, the division of responsibility between decision-making bodies was viewed as unclear. Over time this ambiguity contributed to friction and struggles over authority. These findings are largely in line with the conclusions drawn by the Swedish Corona Commission in 2022 [22].

Strengths and limitations

One of the strengths of this study is its longitudinal design, which enabled follow-up on the experiences and reflections of 15 informants in leadership roles within the Swedish pandemic response during the first year of the crisis. The semi-structured interview guide was developed in collaboration with Norwegian research colleagues and applied consistently across all interviews, ensuring a broad and consistent exploration of the topic.

Two of the Swedish authors are academic general practitioners with leadership experience at local, regional, and national levels, and the third is a research nurse with extensive field expertise. Although none of them held leadership roles in the COVID-19 response—thereby reducing the risk of role-related bias in data interpretation—their professional backgrounds may nonetheless have influenced their interpretation of the interview materials. At the same time, these experiences likely contributed to a nuanced appreciation of the informants’ working conditions. To address potential bias, the team engaged in regular reflexive discussions throughout the research process, acknowledging that prior experience cannot be entirely bracketed.

Throughout the analysis and writing process, the Swedish and Norwegian authors engaged in regular analytical discussions, providing external perspectives that strengthened the interpretation of findings.

Participants were strategically selected from Sweden’s 21 regions and 290 municipalities. Although the sample size may be viewed as a limitation by some readers, the aim of the study was not to examine geographical variation quantitatively but to capture a broad spectrum of leadership experiences during the pandemic. The heterogeneity of the participants reflects the organisational complexity of primary health care, which spans multiple levels across regions and municipalities and is delivered in diverse settings. While this may limit applicability, it also provides a pragmatic illustration of how primary health care may function during a pandemic. The sample size was considered adequate for the study aim, providing sufficient depth and richness of the data to support well-developed themes.

Findings in relation to previous studies and policy literature

Sweden’s pandemic response attracted considerable international attention due to its distinctive strategy, which emphasised individual responsibility and avoided implementing nationwide lockdowns. In this section, we relate our findings to previous research and policy reports, including the final report of the Swedish Corona Commission (SCC) [22]. The Commission’s report, published on 25 February 2022, largely overlaps with the time covered in our study. While the Commission expressed support for the decision to refrain from lockdowns, it also highlighted significant shortcomings in the pandemic management, particularly with regard to high rates of illness and mortality among older adults [22]. Early in the pandemic, shortcomings in preparedness were highlighted by Swedish managers of home care providers for older adults, including limited stocks of personal protective equipment, a need for updated guidelines, and additional training on how to reduce the spread of infection [23].

At the outset of the pandemic, Swedish researchers described the national strategy as evidence-based, developed in close partnership with the government and society, and rooted in trust, emphasising voluntary individual responsibility [4]. The World Health Organization also noted the Swedish approach as a potential future working model [4].

Despite prior planning for pandemics and societal crises, the informants in our study reported being unprepared for the scope and duration of the COVID-19 crisis. This experience was shared across many countries, as the novel virus developed into a severe and prolonged public health emergency [24]. Several participants described shortages of testing materials and protective equipment, challenges also reported in several other European settings [25,26]. Many also felt that hospitals were prioritised, while primary and municipal care had to wait for resources, consistent with findings from a systematic review across multiple countries [27]. However, according to a report from the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), little knowledge has been gained from pandemic experiences of non-medical measures [28].

Informants were tasked with implementing unfamiliar and complex measures, such as contact tracing in nursing homes, a challenge echoed in other European contexts [25,29]. The SCC likewise emphasised the need to strengthen infection prevention and control [22]. Although Sweden initiated contact tracing early in the pandemic, the efforts were not sustained to the same extent as in other countries such as Denmark. According to the Commission’s findings, as well as participant accounts in our study, there was concern about this discontinuation, and case data suggest that Sweden had more undetected cases than Denmark [30].

Some aspects of Sweden’s national pandemic response may also be understood considering the country’s constitutional framework from 1974, which prohibits ministerial rule, emphasises individual rights and freedoms, and grants substantial autonomy to regions and municipalities. The Swedish Public Health Agency operated within this governance structure, and the informants’ experiences of delayed decision-making and complex coordination may reflect these systemic conditions [31].

Despite the high demands, many informants described their pandemic work as both stressful and deeply meaningful, perhaps the most significant challenge of their professional careers. Collegial support and a shared sense of purpose were keys to navigating difficult ethical dilemmas, both in leading and in implementing decisions. Similar reflections have been reported in studies of disaster healthcare [32]. Norwegian experiences also underscore the value of collaboration and teamwork in crisis response [20].

The high initial mortality among older adults was widely viewed by informants as a failure. Many believed that it was not possible to safeguard overall public health within the constraints of the existing COVID-19 regulations. These restrictions limited mobility and social interactions for both older and younger populations. While schools remained open for in-person teaching during the early phase of the pandemic, young people were frequently barred from participating in sports and cultural activities. The SCC report criticised the government for not enacting legislation early enough to enable broader and mandatory infection control measures to reduce community spread. It also noted that the precautionary principle had not been applied [22]. The state epidemiologist also characterised the situation regarding older adults as a failure during the pandemic, partly due to the decentralised responsibility of regions and municipalities, and partly because the Public Health Agency had limited insight into the organisation of older adults’ care [33]. He suggested that obtaining a comprehensive overview may have taken too long, thereby delaying better decision-making in the spring of 2020 [33]. He also traced structural challenges in the care of older adults back to 1992, when responsibility shifted from regional to municipal authorities [33]. These factors, combined with widespread community transmission, shortages of protective equipment, and limited testing capacity, contributed to a difficult situation [34]. Similar challenges in the care of older adults were also observed in countries such as the United States, Canada, and Spain [34].

The SCC emphasised that scientific assessments during the pandemic in Sweden were conducted within a limited group of experts, in contrast to broader consultative approaches adopted in countries such as Denmark and Norway [22]. According to the Commission, this was partly a consequence of the 2014 reorganisation of the Public Health Agency, which had centralised many decision-making processes under the Director General. Similar criticism of Sweden’s scientific advisory structure during the pandemic was also raised by informants in this study and has been highlighted from a political science perspective [35].

Participants described several communication challenges during the pandemic. Guidelines to be implemented at regional and municipal levels were sometimes revised multiple times per day, creating confusion and uncertainty. Information on COVID-19 was perceived as inconsistent, uncoordinated, and inadequately targeted by medically responsible nurses and managers in Swedish care homes for older adults [36]. Prior to the pandemic, the international scientific community had emphasised that guidelines should be grounded in rigorously evaluated evidence. However, this approach was questioned for being too slow [37,38]. Alternative perspectives emerged, highlighting the need to integrate ethical considerations into evidence-based decision-making [39]. This concern was echoed by informants and aligns with the SCC’s critique of Sweden’s failure to apply the ‘precautionary principle’ as a guiding framework. In situations marked by high uncertainty and limited information, the principle advocates for early action rather than waiting for stronger data [22]. A similar hesitation was observed in Norway, where the Norwegian Institute of Public Health initially refrained from recommending face masks due to insufficient evidence [40].

The Public Health Agency and its leadership were generally supported by the informants in their handling of the pandemic, though some criticism was also expressed. The concept of ‘public health patriotism’ has been proposed to explain the widespread support for the state epidemiologist during this period [35]. In addition, findings from the World Value Survey, which highlight differences in societal values between Sweden and other Northern European countries, have been cited by political scientists as a possible explanation for Sweden’s distinctive approach to pandemic management [41]. Similar observations were noted by participants in this study. Survey data reported from the Society, Opinion and Media (SOM) Institute at the University of Gothenborg indicated that public trust in the Swedish strategy declined over time, but in opposite directions: some wanted stricter measures, while others preferred fewer [42].

In scientific literature, the concept of ‘patriotism’, as opposed to ‘trust’ and ‘freedom’, has been suggested as a factor underpinning the strong support for the Sweden’s pandemic management. The Swedish social scientist Gina Gustavsson expanded the notion of ‘public health patriotism in Sweden’ [35], suggesting that while Sweden is often seen as a modern society, a latent form of patriotism emerged in the public’s support for the Public Health Agency’s strategies. This might also have influenced the informants.

While much of the early pandemic response in Sweden was met with criticism, particularly in relation to older adults’ care, longer-term outcomes appear more favourable. A recent comparative analysis of 31 European countries found that Sweden had both the lowest estimated relative excess deaths and the lowest age-standardised excess death rate during the period 2020–2023 [43]. This suggests that, despite initial shortcomings, Sweden’s overall pandemic management may have been more effective than many contemporaneous assessments implied. Over time, Sweden’s strategy proved sustainable and effective, which has been recognized internationally. The comparatively open Swedish strategy appears to have caused milder medical consequences than the lockdown policy used in most countries [44].

Conclusions

In the early stages of the pandemic, the leadership of the Swedish Public Health Agency was generally appreciated. However, informants also criticised the initial response as too slow and insufficient. The high mortality among older adults, particularly at the beginning of the pandemic, was widely regarded as a failure and raised significant ethical concerns. Pandemic response efforts were described as both exhausting and meaningful. Tensions in cooperation between various actors contributed to the strain on those involved, yet the experience also reinforced the importance of infection prevention and control, increasing its perceived status. These findings underscore the complex role of health care leaders in navigating strategic decisions under conditions of uncertainty and organisational fragmentation.

Funding Statement

The Swedish authors received no specific funding for this study. Their contribution was conducted as part of their salaried research time within their employment. The Norwegian authors received funding from the Norwegian Research Council (grant number 312717).

Declaration of AI use

No generative AI tools were used in the development of the scientific content or analysis of this manuscript. However, OpenAI’s ChatGPT (version 4, enterprise setting) was used solely to support language editing and proofreading. This version does not retain user data or use it for model training. All AI suggestions were critically assessed by the authors and only edits that preserved the intended meaning and scientific accuracy were incorporated. The final manuscript reflects the authors’ own work and conclusions.

Disclosure statement

The authors report there are no competing interests to declare.