Background Youth-friendly sexual and reproductive health (YFSRH) services are central to improving youth health outcomes. Despite national standards in Ethiopia, implementation challenges persist. Healthcare workers (HCWs) are key actors in promoting and delivering YFSRH services. This study explored HCWs’ perceptions regarding the promotion of YFSRH services in Gurage Zone, Southern Ethiopia.Methods An exploratory qualitative design was employed. In-depth semi-structured interviews were conducted with purposively selected HCWs. Data were audio-recorded, transcribed verbatim, and analyzed using Braun and Clarke’s thematic analysis framework. Trustworthiness was ensured through peer debriefing, audit trail documentation, and reflexive journaling. Reporting followed COREQ guidelines.Results Four themes emerged: structural constraints, socio-cultural resistance, provider attitudes, and system-level implementation gaps. HCWs perceived that although YFSRH services are formally available, promotion is hindered by infrastructure limitations, stigma, inconsistent training, and weak monitoring mechanisms. Confidentiality concerns and moral judgment were identified as critical factors influencing youth trust and service uptake.Conclusions HCWs recognize the importance of promoting YFSRH services but operate within structural, socio-cultural, and systemic constraints that limit effective implementation. Strengthening infrastructure, enhancing provider capacity, institutionalizing youth participation, and improving accountability mechanisms are essential to bridge the gap between policy and practice.