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Background: Rapidly growing coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to the health system in Nepal. The main objective of this study was to explore the characteristics and drivers of the health system preparedness towards COVID-19 and its impacts on frontline health care workers (HCWs) in Nepal. Methods: Semi-structured interviews (SSIs) were conducted among 32 HCWs who were involved in clinical care of COVID-19 patients and four policymakers who were responsible for COVID-19 control and management at central and provincial level. Participants were included from all seven provinces of Nepal. All SSIs were conducted through telephone or internet based tools such as Zoom and Skype. All interviews were audio-recorded, transcribed into English, and coded using inductive and deductive approaches. Results: Both HCWs and policymakers reported failure to initiate pre-emptive control measures at the early stages of the outbreak as the pivot in pandemic control. Although several measures were rolled out when cases started to appear, the overall health system preparedness was low. Specifically, there was inadequate personal protective equipment for HCWs, insufficient isolation beds for patients, poor coordination between the three tiers of governance, and poor engagement of the private sector. Additionally, HCWs experienced various degrees of stigma because of their profession and yet were able to maintain their motivation to continue working in the forefront. Conclusion: This study identified poor preparedness of the health system in the course of Nepal's COVID-19 response embedded in the governance. Specifically, the lack of human resources, inadequate logistic chain management and laboratory facilities for testing COVID-19 appeared to have jeopardized the health system preparedness and escalated the pandemic in Nepal. Despite the poor preparedness, and health and safety concerns, HCWs maintained their motivation. Urgent efforts are required to reform the governance and coordination mechanism in addition to incentivizing the HCWs for the current and future pandemics.

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