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.