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

objectiveTo 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.

designA longitudinal qualitative study based on two rounds of semi-structured interviews 2-3 months apart. SETTING AND

participantsFifteen 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.

resultsFour 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.

conclusionsIn 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.