Frontline public health leadership during economic crisis: A qualitative study of challenges to sustaining universal health coverage in Sri Lanka

Frontline public health leadership during economic crisis: A qualitative study of challenges to sustaining universal health coverage in Sri Lanka | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Frontline public health leadership during economic crisis: A qualitative study of challenges to sustaining universal health coverage in Sri Lanka Mahendra Arnold, Dakshila Galappatti, Palitha Karunapema, Udayi Gunawardana, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9062276/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Economic crises threaten the sustainability of universal health coverage (UHC), particularly in low- and middle-income countries where preventive health systems operate with constrained resources. Sri Lanka’s 2022–2023 economic crisis created unprecedented disruptions to public health service delivery, yet limited empirical evidence exists on how frontline public health leaders experienced and managed these challenges. Methods A qualitative exploratory study was conducted among Medical Officers of Health (MOHs) and Additional Medical Officers of Health (AMOHs) who provide leadership in community level public health services and were serving in the Western Province of Sri Lanka during the economic crisis period. Twenty-four in-depth semi-structured interviews were completed following convenience sampling until thematic saturation was achieved. Interviews were audio-recorded, transcribed verbatim, and analyzed using inductive thematic analysis. Trustworthiness was ensured through triangulation, iterative coding, and independent review. Results Four major themes emerged: ( 1 ) work-related disruptions driven by resource shortages, workforce constraints, and declining morale; ( 2 ) barriers to achieving universal health coverage, including reduced service utilization, financial hardship among communities, and compromised preventive care; ( 3 ) adaptive strategies to mitigate deterioration of universal health coverage through prioritization of essential services, community engagement, and digital communication; and ( 4 ) anticipated long-term consequences, including widening health inequities and increased chronic disease burden. Despite severe systemic strain, participants demonstrated resilience and locally driven innovation to sustain core preventive services. Conclusions Frontline public health leadership played a critical buffering role in sustaining preventive health services during Sri Lanka’s economic crisis. Strengthening crisis-resilient health governance, workforce protection, decentralized resource management, and community-based service models is essential for safeguarding universal health coverage in future economic shocks, particularly in low-resource settings. Universal health coverage economic crisis health system resilience public health workforce Sri Lanka preventive health services low- and middle-income countries. INTRODUCTION Universal Health Coverage (UHC) represents a central global health priority, ensuring that all individuals receive promotive, preventive, curative, rehabilitative, and palliative health services without financial hardship ( 1 , 2 ). Although global service coverage has improved substantially over the past two decades, progress has slowed in recent years, and a large proportion of the world’s population continues to experience catastrophic health expenditures and impoverishment related to healthcare costs ( 2 , 3 ). These trends highlight the fragility of health-system gains and the persistent inequities in access to essential services, particularly within low- and middle-income countries (LMICs). Economic crises pose major structural threats to UHC by constraining fiscal space for health, disrupting supply chains, and weakening workforce stability ( 4 – 6 ). Evidence from previous global financial downturns demonstrates that austerity measures often lead to reduced public health expenditure, shortages of medicines and logistics, and deterioration of preventive and primary healthcare services, which are frequently deprioritized despite their long-term population health importance ( 5 , 7 ). Such disruptions can reverse health gains, widen inequities, and delay progress toward UHC targets. Beyond system-level financing shocks, economic downturns profoundly affect the health workforce. Reduced income security, increased workload, burnout, and migration pressures have been documented across diverse settings during periods of fiscal instability ( 8 – 10 ). Frontline public health leaders and managers play a critical buffering role in maintaining essential services, adapting delivery mechanisms, and sustaining community trust under constrained conditions ( 11 , 12 ). However, empirical qualitative evidence describing these leadership experiences in LMIC crisis contexts remains limited. Sri Lanka has historically achieved strong health indicators relative to national income through a publicly funded preventive health system anchored in the Medical Officer of Health (MOH) model ( 13 ). The severe national economic crisis that intensified in 2022–2023 generated widespread shortages of medicines, fuel, transportation, and essential supplies, alongside broader socioeconomic hardship ( 14 ). Preventive outreach services, clinics, and community programs were particularly vulnerable, while healthcare workers faced deteriorating working conditions and uncertainty regarding service sustainability ( 14 , 15 ). Despite emerging macro-level analyses of health-system disruption during the crisis, little empirical evidence exists on how frontline preventive health leaders experienced these challenges, adapted service delivery, and attempted to preserve UHC-oriented care. Understanding these lived experiences is essential for informing crisis-resilient governance, workforce protection, and service continuity strategies relevant to Sri Lanka and comparable LMIC contexts. This qualitative study explored the experiences of MOHs and Additional MOHs working in Sri Lanka’s Western Province during the 2022–2023 economic crisis, focusing on challenges to preventive health service delivery, implications for sustaining UHC, and adaptive strategies implemented at the frontline of the public health system. METHODS Study design and setting A qualitative exploratory study design was employed to investigate the challenges faced by MOHs and AMOHs in sustaining preventive health services during Sri Lanka’s economic crisis. The study was conducted in the Western Province, comprising the districts of Colombo, Gampaha, and Kalutara, which collectively represent diverse urban and semi-urban public health service environments. Participants and sampling Eligible participants were MOHs and AMOHs who had served in their respective administrative areas for at least six months during the period of economic hardship between 2022 and 2023. Postgraduate trainees on temporary placement and medical officers on prolonged leave were excluded to ensure consistency of experiential exposure to crisis conditions. Convenience sampling was used to recruit participants across the three districts, and recruitment continued until thematic saturation was achieved. A total of twenty-four in-depth interviews were completed. Data collection Data were collected using semi-structured, in-depth interviews guided by a pre-developed interview framework, drafted for this study based on the study objectives and refined through expert consultation in public health and qualitative research. Interview domains included resource constraints, effects on work performance, barriers to preventive service delivery, and coping or adaptive strategies implemented during the crisis. All interviews were conducted in English, audio-recorded with participant consent, and transcribed verbatim. Face and content validity of the interview guide were established through expert review. Ethical approval was obtained from the Ethical Review Committee of the National Institute of Health Sciences, Kalutara. Participation was voluntary, informed consent was obtained prior to interviews, and confidentiality of responses was maintained throughout the study. Data analysis An inductive thematic analysis approach was applied. Transcripts were reviewed iteratively to achieve familiarization, followed by manual coding, development of categories, and refinement into overarching themes. Analytical rigor was supported through triangulation across districts, independent review of coding, and consensus discussions to enhance credibility and dependability. As the study was purely qualitative, no statistical software or quantitative analytical procedures were used. RESULTS Participant characteristics Twenty-four in-depth interviews were conducted with MOHs and AMOHs across Colombo (n = 9; 37.5%), Gampaha (n = 8; 33.3%), and Kalutara (n = 7; 29.2%) districts. Participants had professional service experience ranging from two to twenty-eight years and included both male (54.2%) and female (45.8%) officers. Thematic analysis generated four overarching themes: Work-related disruptions during the economic crisis Challenges to achieving Universal Health Coverage Strategies to mitigate deterioration of UHC Anticipated long-term implications and system recovery needs Theme 1: Work-related disruptions during the economic crisis Resource shortages and operational constraints Participants consistently described substantial disruption to routine preventive health activities due to shortages of essential supplies, transportation limitations, staff deficits, and escalating workload. Routine vaccination programs, outreach field visits, and supervisory functions were frequently rescheduled or curtailed. Due to lack of resources rescheduling of vaccination programmes done and affected badly on daily work. Remarkable deviations were noted from advance programme. Workforce strain, morale decline, and migration pressures Emotional exhaustion, low morale, and workforce instability were widely reported. Participants emphasized that preventive health staff were disproportionately affected by increased workload combined with inadequate remuneration and limited institutional support. Concerns were also raised regarding declining public trust in preventive services. Overall, the preventive health staf are struggling. They are exhausted. Service provision is mainly affected due to shortage in resources. This distrust has led to clients avoiding our field staff and our services. Theme 2: Challenges to achieving Universal Health Coverage Reduced service utilization and financial hardship among communities Participants observed declining utilization of preventive health services as households prioritized basic survival needs amid rising living costs. Transportation expenses, income instability, and competing livelihood demands contributed to delayed care-seeking and reduced preventive engagement. People are understandably prioritizing basic survival over their health. Preventive care falls to the bottom of the list. Barriers to preventive service delivery Financial constraints, infrastructure limitations, workforce shortages, and reduced outreach capacity collectively hindered delivery of preventive services, particularly among vulnerable and underserved populations. Migration and displacement further disrupted continuity of care. Shift toward curative and emergency care Participants reported increasing reliance on emergency services while preventive care was deferred, posing significant risks to long-term population health and undermining UHC objectives. Theme 3: Strategies to mitigate deterioration of Universal Health Coverage Prioritization and adaptive service delivery Despite severe constraints, participants described pragmatic adaptations to sustain essential preventive services. These included prioritizing high-risk populations, optimizing limited resources, extending clinic accessibility, and leveraging community engagement mechanisms. Digital communication platforms, mobile outreach approaches, and collaboration with local organizations were used to maintain continuity of care. System-level coping strategies Participants highlighted broader mitigation approaches such as strengthening government financing, fostering public–private collaboration, extending service hours, and mobilizing retired personnel to address workforce shortages. Theme 4: Anticipated long-term implications and recovery needs Potential deterioration in population health outcomes Respondents expressed concern regarding future increases in non-communicable diseases, maternal and child health setbacks, widening inequities, and escalating healthcare costs if preventive services remain compromised. “The long-term implications are concerning. We may see a rise in preventable diseases and a decline in overall health outcomes.” Recommended system strengthening and resilience measures Participants emphasized the need for sustainable health financing, strengthened community health workforce capacity, improved logistics, stable supply chains, and expanded partnerships with non-governmental and community organizations. Public–private collaboration and community empowerment were viewed as critical to long-term UHC protection. We need a proper health financing mechanism… UHC should not be compromised at whatever cost. Community empowerment is more long-term and sustainable. DISCUSSION Principal findings This qualitative study provides in-depth insight into how frontline public health leaders navigated severe systemic disruption during Sri Lanka’s 2022–2023 economic crisis. Participants described profound resource shortages, workforce strain, declining service utilization, and threats to preventive health delivery, all of which collectively undermined progress toward UHC. Despite these challenges, locally driven adaptive strategies, such as prioritization of high-risk populations, digital communication, and community partnerships, enabled partial preservation of essential preventive services. These findings highlight the critical buffering role of frontline public health leadership in sustaining health-system functionality during economic shocks. Comparison with global evidence on economic crises and health systems The disruption of supplies, logistics, and preventive services observed in this study aligns with international evidence demonstrating that economic downturns frequently weaken primary healthcare delivery and public health infrastructure ( 5 , 7 , 16 ). Experiences from the 2008 global financial crisis and subsequent austerity periods in Europe showed reductions in service accessibility, deterioration of preventive programs, and widening health inequities ( 7 , 17 ). Similar patterns have been documented across LMICs, where constrained fiscal capacity magnifies the health impact of macroeconomic instability ( 6 , 18 ). Importantly, preventive and community-based services appear disproportionately vulnerable during crises despite their cost-effectiveness and long-term population benefits ( 19 ). The decline in preventive engagement and shift toward emergency or curative care reported by participants mirrors global observations that delayed care-seeking and reduced service coverage contribute to worsening chronic disease burden and avoidable mortality following economic shocks ( 20 , 21 ). Health workforce resilience and leadership under crisis Workforce strain, burnout, and migration pressures described by participants are consistent with international literature linking economic instability to deteriorating mental health and occupational wellbeing among healthcare workers ( 8 , 9 , 22 ). Evidence indicates that workforce instability reduces productivity, increases absenteeism, and compromises quality of care, thereby threatening continuity of essential services ( 23 ). Frontline public health leaders occupy a uniquely critical position in crisis response. Studies across diverse settings demonstrate that adaptive leadership, task-shifting, community engagement, and decentralized decision-making enhance health-system resilience during emergencies ( 11 , 24 , 25 ). The locally driven coping strategies identified in this study, particularly service prioritization and digital communication, reflect similar resilience mechanisms documented in crisis-affected health systems globally ( 24 , 26 ). Governance, financing, and system resilience Participants’ concerns regarding delayed administrative responses, limited guidance, and centralized procurement constraints underscore the importance of governance structures in crisis resilience. Global evidence emphasizes that decentralized authority, flexible financing, and strengthened supply-chain governance are key determinants of health-system performance during shocks ( 12 , 27 ). Failure to address these structural factors risks prolonged service disruption and widening inequities. The strong emphasis placed by participants on sustainable financing, community empowerment, and public–private collaboration is also consistent with global UHC discourse, highlighting multisectoral governance and resilient primary healthcare as foundational to crisis preparedness ( 28 – 30 ). Implications for LMIC health systems and UHC protection This study contributes context-specific qualitative evidence from an LMIC experiencing acute economic collapse, a setting under-represented in global literature. Findings reinforce the need to embed crisis resilience within UHC strategies through: protection of preventive and primary healthcare financing safeguarding workforce wellbeing and retention strengthening decentralized governance and procurement investing in low-cost digital public health infrastructure deepening community partnerships for service continuity Such measures are increasingly recognized as essential for sustaining UHC progress amid growing global economic volatility and climate-related disruptions ( 29 , 30 ). Policy and practice implications • Protecting preventive and primary healthcare during economic shocks Preventive and community-based services were disproportionately affected during the crisis despite their foundational importance for long-term health outcomes. Policy frameworks should therefore ensure: ring-fenced financing for preventive and primary healthcare continuity of immunization, maternal-child health, and chronic disease prevention services crisis-responsive outreach delivery models Protecting these services is essential to prevent reversal of population health gains. • Strengthening health workforce resilience Workforce burnout, migration pressures, and declining morale emerged as central threats to service continuity. Sustainable UHC requires: financial protection and timely remuneration for public health staff structured mental-health and wellbeing support systems retention incentives and career-development pathways surge-capacity workforce planning for emergencies Investment in workforce resilience is fundamental to crisis preparedness. • Enhancing decentralized governance and flexible financing Participants emphasized delayed decision-making and procurement rigidity as major operational barriers. Strengthening crisis responsiveness will require: decentralized budgetary authority at district and MOH levels streamlined procurement and supply-chain mechanisms transparent accountability structures paired with local autonomy Decentralized governance is a key determinant of adaptive health-system performance during shocks. • Leveraging digital and community-based service delivery Low-cost digital communication and community partnerships played a vital role in sustaining services. Future resilience strategies should include: scalable digital public-health communication platforms remote supervision and training systems strengthened collaboration with community organizations and local authorities Such approaches offer cost-effective continuity mechanisms in resource-constrained crises. • Implications for LMICs and global UHC resilience Findings from Sri Lanka provide transferable lessons for other LMICs experiencing economic instability: crisis preparedness must be embedded within UHC strategies preventive systems require explicit protection during fiscal contraction frontline leadership capacity is central to maintaining service continuity multisectoral and community-engaged governance strengthens resilience These insights contribute qualitative evidence to the global discourse on safeguarding UHC in an era of increasing economic and environmental uncertainty. Strengths and limitations A key strength of this study is the use of in-depth qualitative inquiry capturing lived experiences of frontline public health leaders across multiple districts, enhancing contextual richness and transferability. Rigorous thematic analysis, triangulation, and consensus coding strengthened credibility and dependability of findings. However, some limitations should be considered. Convenience sampling may have introduced selection bias, although thematic saturation suggests comprehensive issue coverage. Restriction to the Western Province may limit generalizability to other regions with differing crisis severity. Additionally, qualitative design precludes causal inference or quantitative measurement of service disruption magnitude. Conclusions This qualitative study provides detailed insight into how frontline public health leadership functioned under conditions of acute national economic disruption in Sri Lanka. Medical Officers of Health and Additional Medical Officers of Health described profound operational constraints, including shortages of medicines, transportation, workforce capacity, and logistical support, that collectively threatened continuity of preventive health services and progress toward Universal Health Coverage. Despite these systemic pressures, participants demonstrated notable resilience through pragmatic local adaptation, prioritization of high-risk populations, strengthened community engagement, and the use of low-cost digital communication strategies. These responses highlight the critical buffering role played by decentralized public health leadership in sustaining essential service delivery during macroeconomic shocks. However, the persistence of workforce strain, declining preventive service utilization, governance constraints, and widening social inequities signals substantial risk to long-term population health outcomes if structural reforms are not implemented. Strengthening crisis-resilient health systems is therefore essential to safeguard UHC achievements in Sri Lanka and comparable low- and middle-income country settings experiencing economic instability. Abbreviations UHC Universal Health Coverage MOH Medical Officer of Health AMOH Additional Medical Officer of Health LMIC Lower–middle income country Declarations Ethics approval and consent to participate – Ethical approval for this study was obtained from the Ethics Review Committee of the National Institute of Health Sciences, Sri Lanka (Reference No: NIHS/ERC/23/49, dated 05 January 2024). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection. Consent for publication - Not applicable Funding – Self-funded Author Contribution MA developed the study, conducted the analysis, and drafted the manuscript as the principal author. DG contributed to the study design, supervised the work, and served as the corresponding author. PK, UG, BM, and AS contributed to the study development, data collection and development the manuscript. All authors reviewed and approved the final manuscript. Acknowledgement The authors thank all participants for their valuable contribution to this study. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request References Debie A, Nigusie A, Gedle D, Khatri RB, Assefa Y. Building a resilient health system for universal health coverage and health security: a systematic review. Glob Health Res Policy. 2024;9:2. Russo G, Vageesh BG, Baade PD. Universal health coverage, economic slowdown and health outcomes. BMJ Glob Health. 2017;2(3):e000400. Kieny MP, Bekedam H, Dovlo D, Fitzgerald J, Habicht J, Harrison G, et al. Strengthening health systems for universal health coverage and sustainable development. 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Supplementary Files Interviewframework.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 30 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor invited by journal 20 Mar, 2026 Editor assigned by journal 20 Mar, 2026 Submission checks completed at journal 20 Mar, 2026 First submitted to journal 20 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9062276","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":623934807,"identity":"b31a08cb-6c83-4a13-840c-f29c892e4f9f","order_by":0,"name":"Mahendra Arnold","email":"","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mahendra","middleName":"","lastName":"Arnold","suffix":""},{"id":623934809,"identity":"b2bc71e3-6467-4f15-b7a9-b63bb6dc0169","order_by":1,"name":"Dakshila Galappatti","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYDCCA2wMBxIYbOT42XvAfB4+IrWkGUv2nAFygFrYiNECBIcTN9zIAWthIKiF7/ixxAMPfgG13Hx78PHHHDsZNgbmh49u4NEieSbtwIHEvnTjmbfzkg0ObksGOozN2DgHjxaDA+kNBxJ7rGX7bueYSRzcxgzUwsMmjVfL+ecgLcyMDTfPgLTUE6HlBtBhCT+cFSfc4AFpOUxYi+SNZwkHEhtAgZxjbHB223EeNmYCfuE7n2b88ccfUFSeMXxQua3anp+9+eFjfFrAgLENmcdMSDkY/CFK1SgYBaNgFIxUAADa8FS7yhEJcAAAAABJRU5ErkJggg==","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":true,"prefix":"","firstName":"Dakshila","middleName":"","lastName":"Galappatti","suffix":""},{"id":623934810,"identity":"f365bc0f-bf5a-4249-8342-59a6452a8cc4","order_by":2,"name":"Palitha Karunapema","email":"","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":false,"prefix":"","firstName":"Palitha","middleName":"","lastName":"Karunapema","suffix":""},{"id":623934812,"identity":"80efadf1-42d9-45b3-901e-d145fb9431b1","order_by":3,"name":"Udayi Gunawardana","email":"","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":false,"prefix":"","firstName":"Udayi","middleName":"","lastName":"Gunawardana","suffix":""},{"id":623934815,"identity":"6e61dfe3-5146-4f99-b817-76b56a74f465","order_by":4,"name":"Buddhika Mahesh","email":"","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":false,"prefix":"","firstName":"Buddhika","middleName":"","lastName":"Mahesh","suffix":""},{"id":623934820,"identity":"5242a6e9-cc46-4f5d-9caf-f04ec79d9fe3","order_by":5,"name":"Aathirayan Sivanantharajah","email":"","orcid":"","institution":"Ministry of Health, Nutrition and Indigenous Medicine","correspondingAuthor":false,"prefix":"","firstName":"Aathirayan","middleName":"","lastName":"Sivanantharajah","suffix":""}],"badges":[],"createdAt":"2026-03-08 06:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9062276/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9062276/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107705885,"identity":"aa61ce52-6aab-41aa-a91f-3f906de06a65","added_by":"auto","created_at":"2026-04-24 09:15:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":212360,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9062276/v1/2a386257-296b-4bf8-a08e-08b49fceb1f7.pdf"},{"id":107541989,"identity":"6b4ca015-3b6a-4820-a8e7-685e2fbf6a67","added_by":"auto","created_at":"2026-04-22 12:28:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":392786,"visible":true,"origin":"","legend":"","description":"","filename":"Interviewframework.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9062276/v1/38709348bccaada394c793b7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Frontline public health leadership during economic crisis: A qualitative study of challenges to sustaining universal health coverage in Sri Lanka","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eUniversal Health Coverage (UHC) represents a central global health priority, ensuring that all individuals receive promotive, preventive, curative, rehabilitative, and palliative health services without financial hardship (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Although global service coverage has improved substantially over the past two decades, progress has slowed in recent years, and a large proportion of the world\u0026rsquo;s population continues to experience catastrophic health expenditures and impoverishment related to healthcare costs (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These trends highlight the fragility of health-system gains and the persistent inequities in access to essential services, particularly within low- and middle-income countries (LMICs).\u003c/p\u003e \u003cp\u003eEconomic crises pose major structural threats to UHC by constraining fiscal space for health, disrupting supply chains, and weakening workforce stability (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Evidence from previous global financial downturns demonstrates that austerity measures often lead to reduced public health expenditure, shortages of medicines and logistics, and deterioration of preventive and primary healthcare services, which are frequently deprioritized despite their long-term population health importance (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Such disruptions can reverse health gains, widen inequities, and delay progress toward UHC targets.\u003c/p\u003e \u003cp\u003eBeyond system-level financing shocks, economic downturns profoundly affect the health workforce. Reduced income security, increased workload, burnout, and migration pressures have been documented across diverse settings during periods of fiscal instability (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Frontline public health leaders and managers play a critical buffering role in maintaining essential services, adapting delivery mechanisms, and sustaining community trust under constrained conditions (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, empirical qualitative evidence describing these leadership experiences in LMIC crisis contexts remains limited.\u003c/p\u003e \u003cp\u003eSri Lanka has historically achieved strong health indicators relative to national income through a publicly funded preventive health system anchored in the Medical Officer of Health (MOH) model (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The severe national economic crisis that intensified in 2022\u0026ndash;2023 generated widespread shortages of medicines, fuel, transportation, and essential supplies, alongside broader socioeconomic hardship (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Preventive outreach services, clinics, and community programs were particularly vulnerable, while healthcare workers faced deteriorating working conditions and uncertainty regarding service sustainability (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite emerging macro-level analyses of health-system disruption during the crisis, little empirical evidence exists on how frontline preventive health leaders experienced these challenges, adapted service delivery, and attempted to preserve UHC-oriented care. Understanding these lived experiences is essential for informing crisis-resilient governance, workforce protection, and service continuity strategies relevant to Sri Lanka and comparable LMIC contexts. This qualitative study explored the experiences of MOHs and Additional MOHs working in Sri Lanka\u0026rsquo;s Western Province during the 2022\u0026ndash;2023 economic crisis, focusing on challenges to preventive health service delivery, implications for sustaining UHC, and adaptive strategies implemented at the frontline of the public health system.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA qualitative exploratory study design was employed to investigate the challenges faced by MOHs and AMOHs in sustaining preventive health services during Sri Lanka\u0026rsquo;s economic crisis. The study was conducted in the Western Province, comprising the districts of Colombo, Gampaha, and Kalutara, which collectively represent diverse urban and semi-urban public health service environments.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and sampling\u003c/h3\u003e\n\u003cp\u003eEligible participants were MOHs and AMOHs who had served in their respective administrative areas for at least six months during the period of economic hardship between 2022 and 2023. Postgraduate trainees on temporary placement and medical officers on prolonged leave were excluded to ensure consistency of experiential exposure to crisis conditions. Convenience sampling was used to recruit participants across the three districts, and recruitment continued until thematic saturation was achieved. A total of twenty-four in-depth interviews were completed.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected using semi-structured, in-depth interviews guided by a pre-developed interview framework, drafted for this study based on the study objectives and refined through expert consultation in public health and qualitative research. Interview domains included resource constraints, effects on work performance, barriers to preventive service delivery, and coping or adaptive strategies implemented during the crisis.\u003c/p\u003e \u003cp\u003eAll interviews were conducted in English, audio-recorded with participant consent, and transcribed verbatim. Face and content validity of the interview guide were established through expert review. Ethical approval was obtained from the Ethical Review Committee of the National Institute of Health Sciences, Kalutara. Participation was voluntary, informed consent was obtained prior to interviews, and confidentiality of responses was maintained throughout the study.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAn inductive thematic analysis approach was applied. Transcripts were reviewed iteratively to achieve familiarization, followed by manual coding, development of categories, and refinement into overarching themes. Analytical rigor was supported through triangulation across districts, independent review of coding, and consensus discussions to enhance credibility and dependability. As the study was purely qualitative, no statistical software or quantitative analytical procedures were used.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eTwenty-four in-depth interviews were conducted with MOHs and AMOHs across Colombo (n\u0026thinsp;=\u0026thinsp;9; 37.5%), Gampaha (n\u0026thinsp;=\u0026thinsp;8; 33.3%), and Kalutara (n\u0026thinsp;=\u0026thinsp;7; 29.2%) districts. Participants had professional service experience ranging from two to twenty-eight years and included both male (54.2%) and female (45.8%) officers.\u003c/p\u003e \u003cp\u003eThematic analysis generated four overarching themes:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWork-related disruptions during the economic crisis\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eChallenges to achieving Universal Health Coverage\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStrategies to mitigate deterioration of UHC\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAnticipated long-term implications and system recovery needs\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTheme 1: Work-related disruptions during the economic crisis\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eResource shortages and operational constraints\u003c/h2\u003e \u003cp\u003eParticipants consistently described substantial disruption to routine preventive health activities due to shortages of essential supplies, transportation limitations, staff deficits, and escalating workload. Routine vaccination programs, outreach field visits, and supervisory functions were frequently rescheduled or curtailed.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eDue to lack of resources rescheduling of vaccination programmes done and affected badly on daily work. Remarkable deviations were noted from advance programme.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eWorkforce strain, morale decline, and migration pressures\u003c/h2\u003e \u003cp\u003eEmotional exhaustion, low morale, and workforce instability were widely reported. Participants emphasized that preventive health staff were disproportionately affected by increased workload combined with inadequate remuneration and limited institutional support. Concerns were also raised regarding declining public trust in preventive services.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOverall, the preventive health staf are struggling. They are exhausted. Service provision is mainly affected due to shortage in resources. This distrust has led to clients avoiding our field staff and our services.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Challenges to achieving Universal Health Coverage\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eReduced service utilization and financial hardship among communities\u003c/h2\u003e \u003cp\u003eParticipants observed declining utilization of preventive health services as households prioritized basic survival needs amid rising living costs. Transportation expenses, income instability, and competing livelihood demands contributed to delayed care-seeking and reduced preventive engagement.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePeople are understandably prioritizing basic survival over their health. Preventive care falls to the bottom of the list.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to preventive service delivery\u003c/h2\u003e \u003cp\u003eFinancial constraints, infrastructure limitations, workforce shortages, and reduced outreach capacity collectively hindered delivery of preventive services, particularly among vulnerable and underserved populations. Migration and displacement further disrupted continuity of care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eShift toward curative and emergency care\u003c/h2\u003e \u003cp\u003eParticipants reported increasing reliance on emergency services while preventive care was deferred, posing significant risks to long-term population health and undermining UHC objectives.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Strategies to mitigate deterioration of Universal Health Coverage\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003ePrioritization and adaptive service delivery\u003c/h2\u003e \u003cp\u003eDespite severe constraints, participants described pragmatic adaptations to sustain essential preventive services. These included prioritizing high-risk populations, optimizing limited resources, extending clinic accessibility, and leveraging community engagement mechanisms.\u003c/p\u003e \u003cp\u003eDigital communication platforms, mobile outreach approaches, and collaboration with local organizations were used to maintain continuity of care.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSystem-level coping strategies\u003c/h2\u003e \u003cp\u003eParticipants highlighted broader mitigation approaches such as strengthening government financing, fostering public\u0026ndash;private collaboration, extending service hours, and mobilizing retired personnel to address workforce shortages.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Anticipated long-term implications and recovery needs\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003ePotential deterioration in population health outcomes\u003c/h2\u003e \u003cp\u003eRespondents expressed concern regarding future increases in non-communicable diseases, maternal and child health setbacks, widening inequities, and escalating healthcare costs if preventive services remain compromised.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The long-term implications are concerning. We may see a rise in preventable diseases and a decline in overall health outcomes.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eRecommended system strengthening and resilience measures\u003c/h2\u003e \u003cp\u003eParticipants emphasized the need for sustainable health financing, strengthened community health workforce capacity, improved logistics, stable supply chains, and expanded partnerships with non-governmental and community organizations. Public\u0026ndash;private collaboration and community empowerment were viewed as critical to long-term UHC protection.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe need a proper health financing mechanism\u0026hellip; UHC should not be compromised at whatever cost. Community empowerment is more long-term and sustainable.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003ePrincipal findings\u003c/h2\u003e \u003cp\u003eThis qualitative study provides in-depth insight into how frontline public health leaders navigated severe systemic disruption during Sri Lanka\u0026rsquo;s 2022\u0026ndash;2023 economic crisis. Participants described profound resource shortages, workforce strain, declining service utilization, and threats to preventive health delivery, all of which collectively undermined progress toward UHC. Despite these challenges, locally driven adaptive strategies, such as prioritization of high-risk populations, digital communication, and community partnerships, enabled partial preservation of essential preventive services. These findings highlight the critical buffering role of frontline public health leadership in sustaining health-system functionality during economic shocks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eComparison with global evidence on economic crises and health systems\u003c/h2\u003e \u003cp\u003eThe disruption of supplies, logistics, and preventive services observed in this study aligns with international evidence demonstrating that economic downturns frequently weaken primary healthcare delivery and public health infrastructure (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Experiences from the 2008 global financial crisis and subsequent austerity periods in Europe showed reductions in service accessibility, deterioration of preventive programs, and widening health inequities (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Similar patterns have been documented across LMICs, where constrained fiscal capacity magnifies the health impact of macroeconomic instability (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImportantly, preventive and community-based services appear disproportionately vulnerable during crises despite their cost-effectiveness and long-term population benefits (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The decline in preventive engagement and shift toward emergency or curative care reported by participants mirrors global observations that delayed care-seeking and reduced service coverage contribute to worsening chronic disease burden and avoidable mortality following economic shocks (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eHealth workforce resilience and leadership under crisis\u003c/h2\u003e \u003cp\u003eWorkforce strain, burnout, and migration pressures described by participants are consistent with international literature linking economic instability to deteriorating mental health and occupational wellbeing among healthcare workers (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Evidence indicates that workforce instability reduces productivity, increases absenteeism, and compromises quality of care, thereby threatening continuity of essential services (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrontline public health leaders occupy a uniquely critical position in crisis response. Studies across diverse settings demonstrate that adaptive leadership, task-shifting, community engagement, and decentralized decision-making enhance health-system resilience during emergencies (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The locally driven coping strategies identified in this study, particularly service prioritization and digital communication, reflect similar resilience mechanisms documented in crisis-affected health systems globally (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eGovernance, financing, and system resilience\u003c/h2\u003e \u003cp\u003eParticipants\u0026rsquo; concerns regarding delayed administrative responses, limited guidance, and centralized procurement constraints underscore the importance of governance structures in crisis resilience. Global evidence emphasizes that decentralized authority, flexible financing, and strengthened supply-chain governance are key determinants of health-system performance during shocks (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Failure to address these structural factors risks prolonged service disruption and widening inequities.\u003c/p\u003e \u003cp\u003eThe strong emphasis placed by participants on sustainable financing, community empowerment, and public\u0026ndash;private collaboration is also consistent with global UHC discourse, highlighting multisectoral governance and resilient primary healthcare as foundational to crisis preparedness (\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eImplications for LMIC health systems and UHC protection\u003c/h2\u003e \u003cp\u003eThis study contributes context-specific qualitative evidence from an LMIC experiencing acute economic collapse, a setting under-represented in global literature. Findings reinforce the need to embed crisis resilience within UHC strategies through:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eprotection of preventive and primary healthcare financing\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003esafeguarding workforce wellbeing and retention\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003estrengthening decentralized governance and procurement\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003einvesting in low-cost digital public health infrastructure\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003edeepening community partnerships for service continuity\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eSuch measures are increasingly recognized as essential for sustaining UHC progress amid growing global economic volatility and climate-related disruptions (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003ePolicy and practice implications\u003c/h2\u003e \u003cdiv id=\"Sec29\" class=\"Section3\"\u003e \u003ch2\u003e\u0026bull; Protecting preventive and primary healthcare during economic shocks\u003c/h2\u003e \u003cp\u003ePreventive and community-based services were disproportionately affected during the crisis despite their foundational importance for long-term health outcomes. Policy frameworks should therefore ensure:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ering-fenced financing for preventive and primary healthcare\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003econtinuity of immunization, maternal-child health, and chronic disease prevention services\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ecrisis-responsive outreach delivery models\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eProtecting these services is essential to prevent reversal of population health gains.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003e• Strengthening health workforce resilience\u003c/h3\u003e\n\u003cp\u003eWorkforce burnout, migration pressures, and declining morale emerged as central threats to service continuity. Sustainable UHC requires:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003efinancial protection and timely remuneration for public health staff\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003estructured mental-health and wellbeing support systems\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eretention incentives and career-development pathways\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003esurge-capacity workforce planning for emergencies\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eInvestment in workforce resilience is fundamental to crisis preparedness.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Enhancing decentralized governance and flexible financing\u003c/h2\u003e \u003cp\u003eParticipants emphasized delayed decision-making and procurement rigidity as major operational barriers. Strengthening crisis responsiveness will require:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003edecentralized budgetary authority at district and MOH levels\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003estreamlined procurement and supply-chain mechanisms\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003etransparent accountability structures paired with local autonomy\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eDecentralized governance is a key determinant of adaptive health-system performance during shocks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Leveraging digital and community-based service delivery\u003c/h2\u003e \u003cp\u003eLow-cost digital communication and community partnerships played a vital role in sustaining services. Future resilience strategies should include:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003escalable digital public-health communication platforms\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eremote supervision and training systems\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003estrengthened collaboration with community organizations and local authorities\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eSuch approaches offer cost-effective continuity mechanisms in resource-constrained crises.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003e\u0026bull; Implications for LMICs and global UHC resilience\u003c/h2\u003e \u003cp\u003eFindings from Sri Lanka provide transferable lessons for other LMICs experiencing economic instability:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ecrisis preparedness must be embedded within UHC strategies\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003epreventive systems require explicit protection during fiscal contraction\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003efrontline leadership capacity is central to maintaining service continuity\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003emultisectoral and community-engaged governance strengthens resilience\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese insights contribute qualitative evidence to the global discourse on safeguarding UHC in an era of increasing economic and environmental uncertainty.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eA key strength of this study is the use of in-depth qualitative inquiry capturing lived experiences of frontline public health leaders across multiple districts, enhancing contextual richness and transferability. Rigorous thematic analysis, triangulation, and consensus coding strengthened credibility and dependability of findings.\u003c/p\u003e \u003cp\u003eHowever, some limitations should be considered. Convenience sampling may have introduced selection bias, although thematic saturation suggests comprehensive issue coverage. Restriction to the Western Province may limit generalizability to other regions with differing crisis severity. Additionally, qualitative design precludes causal inference or quantitative measurement of service disruption magnitude.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis qualitative study provides detailed insight into how frontline public health leadership functioned under conditions of acute national economic disruption in Sri Lanka. Medical Officers of Health and Additional Medical Officers of Health described profound operational constraints, including shortages of medicines, transportation, workforce capacity, and logistical support, that collectively threatened continuity of preventive health services and progress toward Universal Health Coverage.\u003c/p\u003e \u003cp\u003eDespite these systemic pressures, participants demonstrated notable resilience through pragmatic local adaptation, prioritization of high-risk populations, strengthened community engagement, and the use of low-cost digital communication strategies. These responses highlight the critical buffering role played by decentralized public health leadership in sustaining essential service delivery during macroeconomic shocks.\u003c/p\u003e \u003cp\u003eHowever, the persistence of workforce strain, declining preventive service utilization, governance constraints, and widening social inequities signals substantial risk to long-term population health outcomes if structural reforms are not implemented. Strengthening crisis-resilient health systems is therefore essential to safeguard UHC achievements in Sri Lanka and comparable low- and middle-income country settings experiencing economic instability.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversal Health Coverage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Officer of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAMOH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdditional Medical Officer of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLower\u0026ndash;middle income country\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate \u0026ndash;\u003c/strong\u003e \u003cp\u003e Ethical approval for this study was obtained from the Ethics Review Committee of the National Institute of Health Sciences, Sri Lanka (Reference No: NIHS/ERC/23/49, dated 05 January 2024). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication -\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding \u0026ndash;\u003c/h2\u003e \u003cp\u003eSelf-funded\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMA developed the study, conducted the analysis, and drafted the manuscript as the principal author. DG contributed to the study design, supervised the work, and served as the corresponding author. PK, UG, BM, and AS contributed to the study development, data collection and development the manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank all participants for their valuable contribution to this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDebie A, Nigusie A, Gedle D, Khatri RB, Assefa Y. Building a resilient health system for universal health coverage and health security: a systematic review. Glob Health Res Policy. 2024;9:2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRusso G, Vageesh BG, Baade PD. Universal health coverage, economic slowdown and health outcomes. BMJ Glob Health. 2017;2(3):e000400.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKieny MP, Bekedam H, Dovlo D, Fitzgerald J, Habicht J, Harrison G, et al. Strengthening health systems for universal health coverage and sustainable development. Bull World Health Organ. 2017;95(7):537\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForoughi Z, Saeidnia F, Beheshti A, Ghiasvand H, Aryankhesal A. Analysis for health system resilience against the economic crisis: an adapted resilience assessment and monitoring framework. Health Res Policy Syst. 2025;23:33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFigueroa CA, Harrison R, Chauhan A, Meyer L. Priorities and challenges for health leadership and workforce management globally: a rapid review. BMC Health Serv Res. 2019;19:424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJesus TS, Bacigalupe G, Alarc\u0026oacute;n M, et al. 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Geneva: WHO; 2020.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Universal health coverage, economic crisis, health system resilience, public health workforce, Sri Lanka, preventive health services, low- and middle-income countries.","lastPublishedDoi":"10.21203/rs.3.rs-9062276/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9062276/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEconomic crises threaten the sustainability of universal health coverage (UHC), particularly in low- and middle-income countries where preventive health systems operate with constrained resources. Sri Lanka\u0026rsquo;s 2022\u0026ndash;2023 economic crisis created unprecedented disruptions to public health service delivery, yet limited empirical evidence exists on how frontline public health leaders experienced and managed these challenges.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative exploratory study was conducted among Medical Officers of Health (MOHs) and Additional Medical Officers of Health (AMOHs) who provide leadership in community level public health services and were serving in the Western Province of Sri Lanka during the economic crisis period. Twenty-four in-depth semi-structured interviews were completed following convenience sampling until thematic saturation was achieved. Interviews were audio-recorded, transcribed verbatim, and analyzed using inductive thematic analysis. Trustworthiness was ensured through triangulation, iterative coding, and independent review.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFour major themes emerged: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) work-related disruptions driven by resource shortages, workforce constraints, and declining morale; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) barriers to achieving universal health coverage, including reduced service utilization, financial hardship among communities, and compromised preventive care; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) adaptive strategies to mitigate deterioration of universal health coverage through prioritization of essential services, community engagement, and digital communication; and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) anticipated long-term consequences, including widening health inequities and increased chronic disease burden. Despite severe systemic strain, participants demonstrated resilience and locally driven innovation to sustain core preventive services.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eFrontline public health leadership played a critical buffering role in sustaining preventive health services during Sri Lanka\u0026rsquo;s economic crisis. Strengthening crisis-resilient health governance, workforce protection, decentralized resource management, and community-based service models is essential for safeguarding universal health coverage in future economic shocks, particularly in low-resource settings.\u003c/p\u003e","manuscriptTitle":"Frontline public health leadership during economic crisis: A qualitative study of challenges to sustaining universal health coverage in Sri Lanka","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 12:28:50","doi":"10.21203/rs.3.rs-9062276/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-01T01:18:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115719984255839516249165645800579231825","date":"2026-04-22T10:12:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T06:35:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-20T17:27:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-20T17:23:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-20T05:38:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-20T05:33:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c4f16a33-e163-4860-a230-35fc21097ea2","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-01T01:18:57+00:00","index":71,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T12:28:50+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 12:28:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9062276","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9062276","identity":"rs-9062276","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}