BACKGROUND: This case study was conducted at Amana Regional Referral Hospital, a referral hospital of Ilala District in Dar es Salaam Region, Tanzania. The aim is to assess the adherence of healthcare providers to guidelines when providing health services to neonates with respiratory distress and how supportive the health system is in limited resource settings. METHODS: This is a case study that used a qualitative approach to data collection and analysis. A total of 16 participants participated in this study, of which the sample size was reached by the principle of information saturation in the field. The study population was healthcare providers (pediatricians, general medical doctors, and nurses) working in the neonatal ward who were selected purposively depending on their experience in the neonatal ward. In-depth interviews (IDI) and an observation checklist were used for data collection from key informants, and content analysis was used to analyze the data. RESULTS: The findings revealed that healthcare providers had partially adhered to guidelines in managing neonates with respiratory distress. The Silverman-Anderson Severity (SAS) score tool is recommended for decision-making in prioritizing neonates with respiratory distress to Continuous Positive Airway Pressure (CPAP) treatment in limited-resource health settings with low laboratory technology. Healthcare providers know the importance of using the SAS score tool, but this study shows partial adherence to the use of it. Understaffing, inadequate training, heavy workloads, and lack of motivation emerged as significant deterrents to adherence which are within the health system, and they negatively impact healthcare provider's adherence. These challenges hindered proper monitoring, documentation, and decision-making processes for CPAP initiation and monitoring. CONCLUSION: Partial adherence to guidelines for managing neonates with respiratory distress in the context of consistent use of the SAS score tool by healthcare providers was impacted by challenges like understaffing, heavy workloads, and low motivation. Improving staffing, providing comprehensive training, and ensuring adequate equipment are recommended to enhance guideline adherence and improve neonatal care in resource-limited settings.