**Background:** India ranks among the top five countries globally for child deaths due to pneumonia, recording 127,000 deaths of children under 5 years in 2018. Uttar Pradesh (UP) and Madhya Pradesh (MP) have higher Infant Mortality Rates (40 and 50/1000 live births respectively) than the national average (32/1000). In 2015, more than half of children under 5 in these states had pneumonia (565 cases per 1000 children in UP; 563 per 1000 in MP). Despite national programs like the Integrated Management of Neonatal and Childhood Illnesses (IMNCI), delivery has been suboptimal. This qualitative study, guided by the Andersen-Newman health care utilization framework, explored health care provider (HCP) perceptions of challenges in delivering pneumonia care services in select districts of UP and MP.
**Methods:** The study was conducted in three districts of UP (Kanpurnagar, Faizabad, Shravasti) and three of MP (Bhopal, Satna, Panna), selected in consultation with government health representatives. Semi-structured interviews (SSIs) were conducted with 15 medical officers (MOs) — 7 in UP and 8 in MP, all male, aged 28–55 years. Eight focus group discussions (FGDs) were carried out with 82 community health workers (CHWs), including Auxiliary Nurse Midwives (ANMs) and Accredited Social Health Activists (ASHAs). In UP, 5 FGDs were conducted (3 with ASHAs, n=32; 2 with ANMs, n=14). In MP, 3 FGDs were conducted (mixed groups, n=36). SSIs and FGDs were audio-recorded with consent, transcribed verbatim, translated into English, and analyzed using NVivo software. A hybrid deductive-inductive thematic analysis approach was used, guided by the health systems and evaluated need components of the Andersen-Newman framework.
**Key Results:** Two main themes emerged: (1) Health systems barriers in delivery of care services, and (2) Evaluated need: perceptions on community awareness and practices. Under health systems, systemic barriers included shortages of drugs (antibiotics like amoxicillin, cotrimoxazole), inadequate oxygen cylinders, absence of separate pediatric wards, lack of 24-hour pathology and X-ray facilities, and insufficient human resources. In MP's Panna district, only 2 of 6 CHCs had X-ray facilities. MOs reported working at 40% of required manpower. CHWs reported not receiving medicines for 6 months, receiving only paracetamol, or getting medicines near expiry. Shortages of nurses compromised patient monitoring, with one MO stating they were "afraid of admitting patients" due to lack of monitoring staff. Most MOs reported no specific training on childhood illnesses including pneumonia for 5–7 years. CHWs also reported no training on pneumonia management, though some had training on diarrhea and breastfeeding. Under evaluated need, HCPs reported poor community awareness of pneumonia symptoms, reliance on home remedies (turmeric, garlic, brandy), dependence on unqualified care providers (UCPs), and non-adherence to prescribed treatment. Exclusive breastfeeding (EBF) rates were estimated at 15–20% by MOs in Kanpurnagar, with early introduction of top feeds from the 2nd or 3rd month. Cultural beliefs against colostrum were reported among tribal populations. Poor nutrition and hygiene were widespread, with one CMHO noting 50% of newborn mortality was due to sepsis. Indoor air pollution from coal cooking ("chula") was used by 50% of families in some areas.
**Clinical Implications:** The study identifies critical gaps in government health infrastructure, training, and community engagement that must be addressed to reduce childhood pneumonia mortality in high-burden Indian states. Strengthening public health facilities with adequate drugs, equipment, and trained personnel is essential. Regular training and supervision of CHWs in pneumonia identification and management, particularly through programs like IMNCI and ICCM, could improve early detection and appropriate referrals. Community-level interventions to improve EBF rates, nutrition, hygiene practices, and health literacy about pneumonia danger signs are needed. Building trust in government health services is critical to reduce dependence on unqualified providers. The authors note that Tamil Nadu, with better IMR (19/1000 live births), demonstrates that improved government health service utilization is achievable, suggesting lessons for UP and MP.