Decision-Making in Public Health Crises: A Qualitative Systematic Review and Meta-Ethnography.

Introduction: Decision-making (DM) during public health crises occurs under uncertainty, time pressure and resource constraints. Although numerous studies examine leadership and governance during crises, evidence remains fragmented and has not been systematically synthesised to integrate the DM models used in practice with the factors that shape those decisions. This qualitative systematic review addresses this gap by examining how health system leaders make decisions during public health crises. Methods: A qualitative systematic review using a meta-ethnographic approach was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The protocol was registered in PROSPERO (CRD42023475382). PubMed, Medline, Embase, Scopus, Business Source, CINAHL and ProQuest were searched for English-language qualitative studies published since 1962. Results: Twenty-one studies were included with seven DM models and eight prioritised decision factors identified. Adaptive and evidence-based models predominated, reflecting the need to act under conditions of urgency while continuously incorporating emerging information. Knowledge and urgency emerged as key, interdependent drivers shaping model selection, highlighting that effective crisis DM depends not only on the choice of model but also on how the tension between rapid action and informed judgement is managed. Limitations: Non-English literature was excluded, and the evidence base was dominated by COVID-19 studies and developed-country settings, which may limit transferability to lower resource contexts. Conclusion: This review provides an integrated synthesis of DM models and prioritised decision factors during public health crises. The findings underscore the importance of strengthening real-time evidence systems and adaptive decision capacity to support timely, accountable and context-sensitive crisis decisions.