Summary of findings
This is the first systematic review of primary qualitative studies to assess the experiences and perceptions of organisations and actors at multiple levels of health systems internationally in responding to COVID-19. Experiences of frontline healthcare workers internationally were the predominant perspective analysed in the articles included in this systematic review. Responses to COVID-19 have impacted on the healthcare workforce, including home care workers, through new or expanded roles, increased workload, concerns associated with contagion of COVID-19 (including availability and use of PPE), and consequent experiences of burnout and stress. Some studies reported use of self-care strategies among staff and organisational interventions to protect healthcare workers from burnout and foster their physical and mental health. Other organisational actions included a shift towards more ‘open’ leadership, improving workforce morale and trust, introducing service changes like telemedicine, and a focus on how COVID-19 related information is gathered and shared. Actions at the wider system level included training delivery, provision of resources and finance, review of healthcare workers’ conditions, and updating regulations associated with service changes and innovations. Concerns were expressed about the sustainability of changes introduced in a context of emergency, including funding, resourcing and regulation.
Additionally, this review suggests that the reporting of qualitative research could be more rigorous, especially giving more detailed explanations in the methods section. Our review excluded nine potentially relevant studies due to their being of lower methodological quality. Authors of qualitative research worldwide could benefit from following free accessible guidelines for reporting (e.g. EQUATOR Network SRQR [
55] and COREQ [
56] guidelines).
Contributions to existing research
The majority of qualitative research on COVID-19 has focussed on the professional level and documented the experiences of frontline healthcare workers; narratives of exhaustion due to heavy workload, physical and emotional distress, stigma and fear of contagion are predominant themes [
57]. Other systematic reviews have identified the burden on healthcare workers’ mental health from responding to pandemics and that evidence on intervention measures is limited [
58,
59]. Additionally, this review highlights workforce resilience and their role in implementing innovations in ways of working and service developments. However, health systems’ reliance on, and the sustainability of, such resilience can be questioned when set against the documented impacts on health care workers’ physical and mental health.
This study complements research at the professional level by synthesising evidence on responses to COVID-19 at the organisational and local health system levels. Another systematic review has advocated the continuity of care offered by a subset of services, telehealth, in times of COVID-19 [
60]. This review adds to such research on service change outcomes by characterising processes of service change in response to COVID-19 at the organisational and local system levels. Our reading of evidence from qualitative studies indicates a number of patterns of service change that appear to be particular to COVID-19. Firstly, processes led at the wider health system level, rather than at the level of individual organisations, have been key to making service adaptations in response to COVID-19. Local system level interventions include safeguarding working conditions [
33,
43], facilitating inter-organisational cooperation [
30] and coordinating the sharing of relevant information [
31,
47]. The use of professional networks, spanning different organisations, has also supported the sharing of learning among organisations [
4,
41]. Such evidence of collaboration is at odds with much of the literature on major system change, in which improvements are coordinated among multiple organisations across a population area, yet is theorised to encounter significant resistance due to the presence of multiple stakeholder interests, including recognition that structural incentives may encourage healthcare providers to prioritise their own patients’ interests over those of the wider population [
61,
62]. As described above, examples of system-wide approaches to service planning and delivery in response to COVID-19 have been relatively prominent, although further evidence is needed on how individual provider organisations have engaged in such processes.
Second, service innovations have been introduced at a pace not typically associated with the healthcare sector. The introduction of innovations has been underpinned by both ‘softer’ and ‘harder’ organisational mechanisms. An example of a soft mechanism was COVID-19 as a ‘catalyst’ [
49] or motivation to accelerate the introduction of service innovations (e.g. telemedicine) by overcoming barriers that typically impede change processes. Advocacy by professional associations also supported introduction of service innovation [
48]. Examples of harder mechanisms to support service adaptation in response to COVID-19 included temporary funding [
49], new clinical training programmes [
50], system-wide information sources [
31] and changes to staff contracts [
34]. There is a need for alignment of soft and hard mechanisms to support the introduction and sustainment of service innovations. For instance, one study highlighted that, despite receiving advocacy from professional associations, there were concerns among some doctors that regulation of telemedicine in new service areas lagged behind [
48].
Third, there has been recognition of the critical role of a variety of front-line workers that is often overlooked in change processes. In diffusion of innovations, the workforce can be regarded as a necessary obstacle to the implementation of change, with recommendations for achieving change tending to reflect rather than challenge existing power structures (e.g. prioritising engagement of powerful physicians over other types of stakeholder [
62]). The qualitative studies reviewed indicate instead the burden of impact on, and significant augmentation of the roles and workload of front-line staff, including the often-invisible role of home care workers [
41] and other less-recognised categories of healthcare staff [
46]. Some studies highlight the consequent need for managerial interventions [
30] and training [
50] that supports the workforce, including mitigation of impacts on their physical and mental health [
29,
32,
33,
35‐
37,
42‐
44], and improving staff morale and belonging [
42,
46,
52]. Decision-making on organisational change should reflect the perspectives of those upon whom the burden of changes fall, rather than be limited to the usual stakeholders with the positional power to block or stymie change.
Implications for policy and practice
The primary qualitative studies herein analysed suggest that emphasis should be placed on system-wide approaches to service planning and delivery. In responding to COVID-19, provider organisations in diverse settings have faced common challenges that include supporting the important role of community workers in primary care, clarifying the division of roles between community and primary care practitioners and support their coordination [
30]; the development of new technology, directing financial investment and developing the capacity of the health care workforce [
30]; and securing access to PPE and other COVID-related medical equipment [
33]. It would be logical to address these and related challenges through a system-wide approach; public health authorities therefore need to focus on the underpinning organisational arrangements that will support horizontal and vertical coordination where this can help to address common challenges. System-wide decision-making concerning service planning and delivery should involve strong representation from the front-line workforce who have carried the heavy burden of responding to COVID-19. The implementation of rapid service innovations catalysed by COVID-19 [
2], including telemedicine, will need to be reevaluated as to whether such changes in care planning, financing and delivery can or should be sustained beyond the ‘emergency’ phase.
Review limitations
The information retrieved covered primary studies published in the period from October 2019 to October 2020 and therefore summarises qualitative evidence on early responses to the pandemic published within a year of its onset. Considering that other qualitative studies on early responses to the pandemic could take more time to write-up and be published, potentially insightful data published after October 21, 2020, are not part of the sample. Moreover, early experiences and responses to the pandemic reported in this review are likely to have evolved with time and may be captured in more recent qualitative studies. To our knowledge, this review represents the first qualitative synthesis of multi-level responses to the pandemic internationally which can help to direct ongoing qualitative research on, and policy responses to, the pandemic.
Inclusion of ‘preprint’ articles would have captured more studies undertaken within the year of COVID-19 breaking; however, due to our aim of developing insights for informing policy and practice, we excluded studies that had not already navigated peer review. There is a need to establish guidance on the use of preprint articles in systematic reviews to improve the timeliness of review findings by clarifying how judgements concerning trade-offs between the timeliness and robustness of evidence presented in such reviews are made. Primary qualitative studies were retrieved and selected from multiple countries; however, this systematic review did not identify studies reporting the experiences of actors responding to COVID-19 in two continents, Africa and Oceania.
There was a lack of research informed by organisation theory in the studies reviewed. The widespread lack of use of extant theory or frameworks makes it difficult to evaluate, at this time, the relevance of previous conceptual work on key organisational themes to the navigation of responses to COVID-19 at different levels of health systems. Relevant theoretical frameworks include theories of coordinated change, e.g. major system change [
62]; how norms and values are influenced by environment “shock”, e.g. institutional change [
63]; and health system resilience as professions and organisations seek to adapt to the pandemic [
64]. Future qualitative studies should draw more explicitly on established theoretical frameworks that can be applied critically to the particular context of COVID-19, and then further developed in response to the empirical evidence identified, in order to better understand how health system responses to COVID-19 should be guided.