This qualitative study was a part of a bigger mixed-methods study aiming to assess the epidemic preparedness of health facilities and the impact of COVID-19 pandemic in Jodhpur district, Rajasthan. The study was undertaken in the primary and secondary level government health care facilities of Jodhpur district. Primary level health care facilities included Primary Health Centers (PHCs), while secondary level facilities include Community Health Centers (CHCs), Satellite Hospitals (SHs) and District Hospitals (DHs).

For the qualitative component of the study, data was collected through key informant interviews (KIIs) and in-depth-interviews (IDIs). Purposive sampling was used to select the participants for the interviews. This non-random sampling approach involves the identification and selection of individuals who are knowledgeable about and have direct experience with the phenomenon under investigation (9). Maximum variation strategy was used to capture a diverse perspective from different levels of healthcare facilities, healthcare workers, and vulnerable population groups (9).

One PHC, CHC, satellite hospital and district hospital were selected from the healthcare facilities in the district. Health facilities were selected to represent primary and secondary levels of care, as these facilities are central to the delivery of essential services for vulnerable populations and allowed exploration of service disruptions and adaptations across the referral continuum.

For the KIIs, Medical officer in charge of the selected healthcare facilities and one of the Accredited Social Health Activist (ASHAs) from each facility were interviewed. From patients attending these health care facilities, those belonging to vulnerable groups like pregnant women, elderly people (above the age of 60 years), malnourished people, mother of under-five children, and people who were immunocompromised were interviewed for the IDIs. Participants were purposively selected to include both service providers and service beneficiaries, enabling exploration of supply-side and demand-side perspectives on healthcare delivery.

Eight healthcare workers were interviewed, while patients interviews were conducted until data saturation was reached. Data saturation was considered when additional data collection did not yield any new themes, categories, or conceptual insights (10). In the present study, thematic repetition started after 14–15 interviews and saturation was considered complete after 20 patient interviews. So, a total of 28 interviews were conducted (eight KIIs with healthcare workers and 20 IDIs with patients).

Semi-structured interview guides were developed separately for healthcare providers and patients based on an extensive review of existing literature and detailed discussions among the authors. Semi-structured interview guides allow flexible collection of in-depth information while remaining aligned with the study objectives (11). A review of existing literature helped in developing a comprehensive understanding of the topic and identification of areas where additional empirical data were needed (12).

The healthcare providers were asked about the routine services provided before and during the pandemic, challenges faced in providing service during the pandemic, surveillance activities in the area, the status of services post lockdown and details regarding any catch-up programmes. While the patients were asked questions on the ground of the difficulties they faced in accessing the treatment during the pandemic, apart from the questions on the usual services they were getting from the health facility. Specific questions on COVID-19 vaccination were also incorporated to get an understanding of the real challenges faced in obtaining the vaccine.

The interview guides were internally tested through mock interviews conducted within the research team to assess the clarity, flow, and alignment of the contents with study objectives. It also helped to identify ambiguities, leading questions, and potential interviewer bias. Based on this process, the wording and sequencing of the questions were modified prior to data collection (11). All the authors underwent formal training in qualitative research through national level workshops ranging from three to five days duration.

Interviews were conducted between November 2021 and April 2022 (6 months). All interviews were conducted in the respective health facilities. They were conducted in a quiet and private space, with only the interviewer and participant present. This ensured privacy and confidentiality thereby encouraging participants to express their experiences openly and honestly. Informed signed consents were obtained prior to the interview. All the interviews were conducted in the local language- Hindi and voice recorded using a mobile phone.

An inductive thematic approach was used to analyze the data. It involves the development of themes directly from the data without applying any pre-existing codes or theories, thereby allowing the findings to be grounded in participants' experiences (13). This approach was appropriate for the study as it enabled an open and unbiased exploration of experiences related to healthcare delivery during the COVID-19 pandemic.

The audio recordings were transcribed into Hindi on the same day to avoid the loss of any vital information. This was done by the interviewer and another author proficient in Hindi. The transcript was then translated to English by a third author and then back-translated into Hindi by a fourth author. During translation, particular attention was paid to preserving meaning, tone, and culturally embedded expressions, prioritizing conceptual equivalence over literal translation. Any differences were resolved through discussion among the authors. This helped in ensuring linguistic accuracy and authenticity of the data collected.

The English transcript was used for data analysis. The analysis was done manually. The first step was familiarization with the transcripts through repeated reading. The transcripts were then subjected to line-by-line thematic analysis by two authors independently. This approach allowed close engagement with the data and is recommended for narrative qualitative studies with limited sample size (14). Verbatims were identified and initial coding was done to generate the detailed codes from the transcripts. The initial code lists generated by both authors were compared and discussed to reach to final agreement.

This was followed by an intermediate coding process in which conceptually similar codes were brought together and used for the development of sub-themes and more abstract categories. These categories were further examined and refined through advanced coding, wherein relationships between categories were explored and integrated to identify overarching themes. This structured, sequential process enhances the rigor and trustworthiness of the themes developed from the collected qualitative data (13, 15).

Data collection and analysis proceeded concurrently. Any discrepancies in coding or interpretation were resolved through dialogue and consensus among the researchers to enhance inter coder reliability (16). The final findings were summarized using tables and figures.

The patient-related challenges included difficulty in transportation, financial issues, anxiety, and attitude. A qualitative study conducted in Eastern India also found that financial issues and fear of COVID-19 infection were the major challenges faced by people with chronic morbidities (19). Similarly, a study done in six countries from Asia and Africa also identified changes in availability of services due to systems restructuring, difficulty affording care due to the economic impacts of the pandemic, and fear of contracting COVID-19 as the main barriers in accessing care during the pandemic (20). These identical findings from various studies across the low-middle-income countries shows the common nature of challenges faced in all similar settings.

Healthcare provider related challenges included inadequate protective measures, insufficient training, the diversion of resources to COVID-specific care, limitations on conducting physical examinations, and suspension of general OPD services. A mixed-methods study among 120 healthcare workers in India also found that healthcare facilities were affected and surgeries were postponed, particularly during the initial phase of COVID-19 (21). A rapid review identified that multiple factors, including fear of contracting the disease, lack of personal protective equipment, long working hours, quarantines, knowledge gaps, financial losses, staff shortages, and widespread community stigmatization, resulted in high levels of stress among healthcare workers (22). In a qualitative study conducted in Bangladesh, 15 in-depth interviews of healthcare workers revealed higher workload, psychological distress, shortage of quality personal protective equipment (PPE), social exclusion/stigmatization, lack of incentives, absence of coordination, and inadequate management during their service (23).

This evidence across settings consistently shows that the lack of preparedness and non-availability of personal protective equipment have significantly affected healthcare delivery during the pandemic. It underscores the need for integrating workforce protection, psychosocial support, and role clarity in to the epidemic preparedness plans. Unlike many previous narratives that highlight health workers as victims of pandemic-related stress, this study reflects on how they adopted protective behaviors and provided services without fear or stigma.

Health system-related challenges included staff shortages, lab closures, restricted hospital admissions, disruptions to immunization and other routine services, and delays in follow-up for chronic conditions. A cross-sectional study across six states in India yielded comparable findings. Lack of infrastructural preparedness during outbreaks, shortage of human resources, difficulty in outreach services and irregular supply of supplementary nutrition by Anganwadi workers were the main supply-side challenges identified (24). In a telephonic survey conducted among healthcare workers from 21 states in India, challenges were more evident in ensuring the availability of routine services and continuity of medications for non-communicable diseases (25). These observations indicate that the health system constraints identified in this study are in line with the national evidence, underscoring the consistent pattern of service disruptions across the country.

While similar service disruptions were reported in different settings, this study demonstrates how they were experienced simultaneously at the provider, health system, and beneficiary levels, resulting in a compounding effect across the continuum of care.

Mitigation strategies for addressing these challenges included adherence to COVID appropriate behavior in hospital premises, utilization of telemedicine, and home delivery of medicines for NCDs. A cross-sectional study from South India has also shown an increased adoption rate of telemedicine during the pandemic with 38.63% participants already using it (26). Similarly, a study from Thailand had identified telemedicine, community delivery of medicines, and decentralized care as innovations to sustain NCD services in the context of COVID-19 (27). These mitigation strategies played a crucial role in ensuring services during COVID-19 and highlight the need to incorporate them into preparedness frameworks for future public health emergencies.

The challenges related to vaccination include complacency, confidence, and convenience (3 C's model); however, COVID vaccination represented a different scenario due to rapid research, accelerated vaccine development, and large-scale rollout (28). Apart from the usual 3 Cs, multiple additional challenges like hesitancy, availability, and registration issues were observed during the COVID-19 vaccination process.

Findings from the present study align closely with the existing literature, particularly regarding registration-related barriers. Online registration was one of the major challenges, especially in rural settings. Limited digital literacy, lack of identity cards, and a limited number of slots made it difficult to register for the vaccination. Similar issues were observed in qualitative studies done in India and Bangladesh. Community behavior, technical barriers, and dependence on digital platforms were found to limit vaccination uptake (29, 30). The reliance on E-mitra agents for registration emerged as a context-specific i.ssue in this study. The charges they collected imposed a financial burden on the community, creating a socioeconomic dimension to the “convenience” barrier described in existing literature.

The challenges in terms of availability, such as a lack of doses in rural areas, long waiting time, crowding at immunization centers, and the need to call the police to control crowd behavior, reported in this study, were similar to those identified in previous research conducted in other regions of India (31, 32). This study provides qualitative insights into how these availability constraints translated into operational challenges at the ground level.

Hesitancy emerged as a prominent challenge in this study. It was a result of fear of side effects, misinformation, concerns about vaccine safety, and misconceptions about COVID transmission among vaccinated individuals. These findings were consistent with earlier qualitative studies that identified fear, misbelief, and the influence of negative information as key drivers of vaccine hesitancy (29, 31). Elements of complacency were also evident, particularly among villagers who perceived low risk due to restricted mobility and absence of cases in their locality.

The present study also highlights the enabling factors that facilitated vaccination uptake. Doctor-led counseling, involvement of local leaders, community outreach, spot registration, deployment of dedicated staff, and home-based vaccination for bedridden individuals played a critical role in addressing hesitancy and access barriers. Similar findings were observed in a qualitative study done in Maharashtra, India, underscoring the importance of community-centered and health system driven approaches for achieving improved vaccination coverage (31).

The consistency of findings across different studies and settings suggests that the challenges encountered during COVID-19 vaccination were systemic rather than isolated. Lessons learned from the COVID-19 vaccination experience should be used as a reference for future outbreaks requiring rapid vaccine development or mass roll out. The findings from this study emphasize the importance of moving beyond the traditional 3 Cs model to ensure the success of vaccination campaigns.

The present study has considered March-August 2020 as the first wave and March-August 2021 as the second wave of COVID-19. Healthcare service delivery across the two waves was dependent on multiple factors, including disease severity, system readiness, and community attitudes. During the first wave, fear had led to compliance with preventive measures but health services were significantly disrupted. While in the more severe second wave, reduced fear resulted in non-compliance to preventive measures but there was marked improvement in the service continuity.

Consistent with findings from multiple hospital-based studies across India and other countries, the second wave emerged as the most severe phase of the pandemic. Studies from different settings in India- Rajasthan, Maharashtra, Delhi, and Rishikesh have uniformly reported higher hospitalization rates, greater need for oxygen and ventilatory support, increased ICU admissions, and significantly higher mortality during the second wave compared to the first (33–37). Similar findings were also observed in a study done in Brazil, which documented increased invasive respiratory support and more severe clinical manifestations during the second wave (38).

The findings from the present study complement and help explain the patterns observed in other studies which were largely quantitative studies. By considering the interplay of disease severity, health system preparedness, and community attitudes, it provides deeper insight into why the differences manifested from both health system and community perspectives. This helps in understanding how differences between waves translate into variations in healthcare service delivery, particularly for vulnerable populations.

The findings from this study underscore the need for catch-up programs to restore healthcare services post-disruption. In Jodhpur, strategies such as home-based service delivery, list-based cross-verifications, immunization catch-up sessions, and tracing back tuberculosis patients were used after the pandemic. Studies examining the catch-up strategies used in post-disruption contexts remain limited, underscoring the significance of these qualitative insights for uncovering service restoration beyond emergency response.

Comparable findings have been reported in few other studies. A study done in Rajasthan pointed out that the state had resumed immunization services quickly through outreach activities but did not fully cover for the doses missed during lockdown, particularly among underserved groups (39). A qualitative study from Madhya Pradesh, India, also documented complete disruption of immunization during the pandemic. Catch-up strategy planned in two phases, emphasizing on awareness campaigns including door-to-door health education, expanded immunization days to reduce crowding, and strengthened infection-prevention measures, resulted in successful coverage of most left-out children (40). Similarly, a study done in Kerala, India, reported the use of a targeted approach to maintain the continuity of TB-related health care services (41). Collectively, these findings reinforce the need for catch-up programs to ensure the equitable recovery of health care services post-disruptions, particularly among vulnerable groups. Recovery should be considered as an active phase in the emergency cycle, requiring as much planning and resourcing as the response phase itself. Successful recovery will depend on the effective coordination, community engagement, and frontline worker initiatives.

By bringing together these four interconnected dimensions, this study underscores the need for a preparedness framework inclusive of vulnerable groups. This framework must ensure the continuity of essential services, protect the healthcare workforce, incorporate structured recovery planning, and facilitate strong coordination across health and allied sectors during future outbreaks.