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Ten pressure points in primary care during COVID-19: findings from an international narrative review

BMC Primary Care volume 26, Article number: 19 (2025) Cite this article

Abstract

Background

Strong primary care (PC) services are the foundation of high-performing health care systems and can support effective responses to public health emergencies. Primary care practitioners (PCPs) and PC services played crucial roles in supporting global health system responses to the COVID-19 pandemic. However, these contributions have come at a cost, impacting on PC services and affecting patient care. This secondary analysis of data from an integrative systematic review across international PC settings aimed to identify and describe burdens and challenges experienced by PCPs and PC services in the context of their contributions to COVID-19 pandemic responses.

Methods

We conducted an integrative systematic review and narrative analysis, searching PubMed/Medline, Scopus, Proquest Central and Cochrane Database of Systematic Reviews, plus reference lists of key publications. Included studies were published in peer-reviewed English or Chinese language journals, and described collective responses to COVID-19 undertaken in PC settings or by PCPs. Narrative data regarding impacts on PC services and challenges experienced by PCPs were extracted and analysed using inductive coding and thematic analysis.

Results

From 1745 screened papers 108, representing 90 countries, were included. Seventy-eight contained data on negative impacts, challenges or issues encountered in PC. Ten ‘pressure points’ affecting PC during COVID-19 were identified, clustered in four themes: demand to adopt new ways of working; pressure to respond to fluctuating community needs; strain on PC resources and systems; and ambiguity in interactions with the broader health and social care system.

Conclusions

PCPs and PC services made critical functional contributions to health system responsiveness during the COVID-19 pandemic. However, both practitioners and PC settings were individually and collectively impacted during this period as a result of changing demands in the PC environment and the operational burden of additional requirements imposed on the sector, offering lessons for future pandemics. This study articulates ten empirically derived ‘pressure points’ that provide an initial understanding of burdens and demands imposed on the international primary care sector during the COVID-19 pandemic. The impact of these contributions should inform future pandemic planning, guided by involvement of PCPs in public health preparedness and policy design.

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Background

Primary care (PC) services, including family practice, operated at the clinical frontline of the global COVID-19 pandemic by providing accessible first-contact care in the community. Responses to emerging healthcare needs were often reactive and emergent, including examples such as mobile outreach testing in residential aged care settings and schools, remote home monitoring of unwell patients, vaccine administration, and management of post-acute sequelae of COVID-19 (PASC) or Long COVID [1,2,3]. PC is an essential component of primary health care (PHC), along with multi-sectoral policy and action, engagement of empowered individuals and communities, and essential public functions [4], and a fundamental pillar of universal health coverage [5]. In this context, such PC activities were essential strategic functions that enabled rapid health sector adaptation and contributed to robust system-level responses to the evolving pandemic [6, 7].

Crucial PC responsibilities during COVID-19 included maintaining access to routine and essential health services, supporting COVID-19 surveillance and response, and promoting prevention and vaccination [8]. Internationally, a wide range of early studies described actual and potential roles for primary care practitioners (PCPs) in triage, assessment, treatment and ongoing monitoring of COVID-19 cases [1, 7, 9,10,11]. PCPs were also engaged in overcoming vaccine hesitancy, allocating essential resources and equipment, ensuring accessibility and affordability of care, undertaking planning and communication, transforming and adapting work processes and healthcare flows, responding to context-specific community needs, and supporting pandemic recovery [12,13,14,15,16,17,18]. These roles were undertaken while also responding to the dual challenge of providing continuing patient care under uncertain conditions, and ensuring staff and patient safety [18, 19]. They were also accompanied by mounting reports of service disruptions and delays in routine care, increased workload, reductions in income and economic sustainability, concerns about staff and patient safety [20], and limitations to communication, technology and governance structures [17].

Despite the importance of PC as the foundation of universal health care systems, and at the clinical frontline of the COVID-19 pandemic, there has been a relative mismatch between this “position on the ground” in supporting patients and public health (PH) responses to COVID-19, and research that synthesises collective accounts of the PC contribution [21].

Methods

This study aimed to identify and describe the operational and organisational challenges experienced by PCPs and PC services in the context of their policy and program-level contributions to broader health system responses to the COVID-19 pandemic. It describes sub-analysis results from a systematic scoping review of PC contributions to national and sub-national responses to COVID-19 [22], and focuses on the impact of the pandemic as experienced in family practice and other PC settings.

Systematic searches of PubMed/Medline, Scopus, Proquest Central and the Cochrane Database of Systematic Reviews were conducted for the period December 2019 to May 2021, as well as hand searching reference lists of relevant studies. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed [23]. See Tables 1 and 2 for search terms and inclusion/exclusion criteria.

Table 1 Exemplar search string
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Table 2 Inclusion and exclusion criteria
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Data were extracted from included studies by one of three reviewers (SH, AP, WW) using a standardised template. Study characteristics and PC roles were recorded, as well as results and outcomes attributed to these roles, and the difficulties and challenges encountered, reflecting the impact of the pandemic on PC (See Supplementary data, Appendix 1). Only data relating to the final section of the extraction tool focused on PC impact and challenges are reported in this paper. Data on PC roles were analysed independently and will be reported separately [22]. Narrative data were coded sequentially by two investigators (AP, SH) using NVivo software (QSR International, version 12, released 2018), in an iterative process consistent with Braun and Clarke’s six-step approach to thematic analysis [24]. Data on impact were initially reviewed to re-familiarise analysts with the content and distinguish descriptions of issues, challenges and negative effects on primary care from claims about the results or outcomes of primary care roles. Challenges and issues encountered were then coded inductively using an open coding process to generate an extensive series of initial nodes encompassing the range of experiences described. Subsequently, using axial coding, these nodes were examined and reviewed to refine content and explore relationships between nodes. Nodes were then clustered and categorised to capture common elements and differentiate concepts, with classifications and emerging relationships reviewed and discussed by two reviewers. Categories were progressively reviewed using a best-fit approach to identify and refine emergent themes.

Data

All data relating to this analysis are presented within the manuscript or as supplementary files.

Results

Included in this analysis are 78 of 108 papers included in the broader review of PC roles which will be reported separately [22]. See Fig. 1 for the PRISMA flowchart.

Fig. 1
figure 1

PRISMA study selection diagram Adapted from Page et al. 2021 [25]

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These 78/108 (72.2%) papers yielded data regarding impacts, challenges or issues faced by PCPs and settings (see Table 3, Additional File). The remaining 30 papers did not report data describing these issues. We identified ten thematic ‘pressure points’ that encapsulate the challenges experienced by PCPs internationally during the first 18 months of the COVID-19 pandemic. Thematically, these clustered in four broad categories of impact (see Table 4).

Table 3 Summary of included studies, n = 78
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Table 4 Ten PC pressure points during COVID-19, arranged by theme
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Demand for new ways of working

Rapid adaptation in a high-pressure environment

A significant challenge for PCPs was the repeated, unrelenting pressure to adapt in real time to a fast-changing pandemic context. This was particularly evident in the immediate demand for rapid transition to virtual consultations in order to minimise COVID-19 transmission [11, 25, 28, 33, 44, 46, 51, 58, 59, 61, 66, 70, 71, 82, 84, 92, 100], while education and training in effective and efficient use of digital modalities remained an identified gap in many countries (see Table 5) [32, 33, 51, 58, 70, 82, 84, 100]. Balancing operational efficiency, PH directives, and staff safety was often difficult, requiring open and transparent communication between management and staff, and coordination of change management processes, simultaneously with accelerated implementation in Canada [32]. While new and innovative modes of care, such as electronic prescribing and medication delivery, were often established, they also required adaptation to new workflows for pharmacists, clinicians, and delivery drivers as well as coordination between pharmacies, primary care, postal and other community services (for example in Qatar and South Africa) [25, 38].

Table 5 Risks and requirements in transitioning to digital modalities
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Radical adoption of infection prevention and control (IPC) measures

While the necessity to prioritise IPC was broadly recognised, greater knowledge about preventive measures and handling suspected cases of COVID-19 was needed [73, 76, 90, 93], especially the correct use of personal and protective equipment (PPE) [30, 92]. Instigating measures to isolate and segregate patients within clinical spaces proved challenging [78, 89], especially managing patients who did not complete required pre-screening activities, creating concerns about staff safety in Australia [20]. Asymptomatic and non-specific illness presentations made COVID-19 differentiation difficult [83, 91], while reliance on non-clinical telephone and online triage raised concerns about patient safety, correct diagnosis and recognition of disease severity and progression in the UK [52]. Lack of appropriate PPE was particularly challenging, especially early in the pandemic when regular supply chains were disrupted [20, 30, 32, 35, 39, 42, 44, 47, 48, 50, 54, 57, 67, 68, 73,74,75,76, 78, 82, 84, 86, 89, 92,93,94,95,96, 100]. Some PCPs sourced PPE at their own personal cost (Greece) [89], or made their own (China) [93].

Fluctuating community needs

Maintaining routine and preventive care

Access to routine non-COVID-19 related PHC services was radically curtailed due to the imposition of PH restrictions on movement and social activity [20, 29, 36, 41, 44, 54, 56, 63, 66, 68, 76, 80, 82, 83, 86,87,88,89, 97, 98]. Some patients delayed seeking care due to fear of infection [20, 54, 83], including for childhood immunisations (Qatar) [29], generating concern about increased population burden of non-COVID related illness in both the immediate and longer term. The repercussions of reductions in routine care included potentially delayed diagnoses [20, 36, 68], reduced continuity of care [86], lack of chronic disease management [54, 89, 97, 98], lack of preventive care and screening programs [29, 88], reduced access to child and maternal care [87], and neglect of conditions such as malaria and tuberculosis in some African countries [83, 87].

Exacerbation of social determinants of health

The pandemic severely exacerbated the effect of social determinants of health, compounding negative impacts for people of low socioeconomic status (SES) [26, 37, 42, 68, 77, 87], racial and ethnic minorities [27, 85], opioid drug users [40, 54], released offenders [81], and people living in rural areas [33, 69]. In some countries, the ability of people of low SES to access testing and care was severely restricted by out-of-pocket costs [26, 37, 42, 77, 87]. The synergistic effect of systematic inequalities and the pandemic, especially for those already subject to socioeconomic or clinical vulnerabilities, contributed to higher rates of clinical risk for COVID-19 and its sequelae (see Table 6) and ongoing pressure on PC services to respond to increased health needs.

Table 6 Social determinants and syndemic effects of COVID-19
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Mental health issues in patients and workforce

Many studies described increased and unmet demand for community mental health services for patients impacted by the pandemic [20, 28, 33, 44, 54, 58, 63, 66, 97, 98]. The personal impact on PCPs was also considerable, with many experiencing mental health issues [29, 33, 44, 45, 74], related to psychological stress [44, 74], exhaustion [29, 45], worry about infection [45, 74], increased workload [45, 74], anxiety and depression [33], and in some cases, feelings of isolation because of lack of contact with colleagues, and a sense of inadequate guidance from authorities [45].

Strain on PC resources and systems

Financial burden

Many PCPs reported significant financial impact during the pandemic due to reduced volumes of face-to-face consultations [34, 36, 48, 54, 58, 62, 65, 82, 89], increased administrative requirements [58], and the cost of transitioning to virtual consultations and upgrading technological capacity [82, 89, 92]. Rapid transition to virtual consultations exposed the need for updates to regulatory and security standards which were no longer fit for purpose, especially those related to financial remuneration, eligibility of providers, and reporting [32, 58, 65, 72, 79]. In some countries, for example the US and Canada, remuneration systems with billing codes tied to in-person consultation services saw self-employed PC practices became financially unviable [28, 54].

Workforce challenges

Staff shortages and depleted workforce sustainability were an operational and financial pressure point [28, 29, 43, 63, 66, 75, 84, 89]. These resulted from the need to quarantine or furlough unwell staff or those exposed to COVID-19 [29, 66], selective loss of at-risk staff who chose to resign or take leave [84], burnout [29], and reassignment of PCPs to Greek secondary care facilities [89]. Business continuity was affected by staff layoffs in practices that could not financially sustain pre-pandemic staffing numbers [54, 65], and the need to offer financial incentives to attract and maintain staff under substantial workforce duress in the US [28]. Compounding these stressors was an increase in pandemic related workload [48, 56, 70, 74, 82, 84].

Unmet resourcing & support needs

The move to virtual consulting exposed serious infrastructure and technology constraints including for equipment, internet connectivity and access, and technology literacy [28, 32, 33, 58, 94, 100]. Lack of physical infrastructure was problematic for practice restructuring that required environmental controls to manage provision of space for segregation and infection control [48, 49, 78, 95], including provision of water and appropriate sanitation in some African countries [78]. The need for pulse oximetry was problematic in some European PC services with few, if any, suitable devices [95]. Ongoing management of Long COVID which continues to increase in prevalence, and where PC is well placed to provide integrated community management [58, 97], will require dedicated planning and resources. Supply and logistics challenges impacted on delivery of multiple services (see Table 7).

Table 7 Services affected by supply disruptions
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Ambiguity in health system interactions

Uncertainty & inconsistency

Ongoing, often necessary, changes to PH decision making and changing epidemiological conditions created an environment of substantial uncertainty and instability. Inconsistent communication and inadequate guidance from central agencies were often reported, leaving PCPs with suboptimal clarity about the correct procedures and approaches to follow [45, 48, 54, 58, 64, 68, 73, 92,93,94]. Frequent modifications to advice [89], ambiguity about vaccination programs [55], and delayed implementation of quarantine policies [73], created confusion amid the need for constant review of emerging pandemic information [48]. Poor and confusing communication to the public about issues such as vaccination dosing in the UK were also noted [56], often obliging PCPs to translate and interpret critical information for patients.

Insufficient cross-system coordination

Fragmented leadership, unpredictable political responses, and lack of clear central guidance reportedly slowed pandemic responses [62, 68, 95], highlighting insufficient preparedness [46, 54, 101]. Limited attention to the role of PC in PH planning was noted in countries such as Canada [45], despite acknowledged need for comprehensive approaches that build cross-sectoral and public-private partnerships in others such as Oman [27]. PCPs reported ineffective communication and engagement with policy planners and a need for better integration and consideration of PC experience in future pandemic planning in Germany and Canada [48, 64]. However, PCPs’ own views did not always align, or concur with jurisdictional guidelines [64, 99]. Included papers across multiple countries found little policy focused on clear roles or support for PC [54, 62], nor how to sustain PC in a prolonged health emergency [54].

Discussion

This analysis identified ten pressure points impacting on PCPs and PC services as they contributed to international health system responses to the COVID-19 pandemic. These pressure points clustered in four themes: the first two reflecting challenges created by changing circumstances in the PC environment as a result of the pandemic; and the last two describing burdens imposed by the work required of PC services in response to the pandemic.

This review was among the first to synthesise multiple accounts to consider collective impact on PC systems as a result of the COVID-19 pandemic. A late 2020 scoping review of 32 studies from 18 countries identified reductions in capacity and quality of PC services, with effects on privacy, treatment relationships and delayed care; and deleterious effects of these disruptions on patient outcomes, especially for socially or economically vulnerable individuals, or those with existing comorbidities and mental health conditions [102]. Other early COVID-era studies identified implementation barriers for PC services including the impact of PH measures on PC functions, problems with multi-sectoral integration and governance, poorly managed risk communication, critical knowledge gaps, time and technology constraints, and limited recognition and support [4, 17]. Lessons from previous pandemics have been similar, highlighting the importance of clear, coordinated, reliable information, clearly delineating roles, improving cross-sectoral collaboration and protecting health workforce [103, 104].

Our findings are consistent with these accounts, while extending and building on them to accommodate evolving data and locate widely observed impacts on PC within a thematic framework of collective pressure points. This framework offers a structured approach for conceptualising the impact on PC during COVID-19 and informing future pandemic planning. While many of the challenges described in this study were not unique to PC, and were faced across health systems and throughout communities, these findings highlight the range of factors that should be addressed to acknowledge and facilitate the crucial contributions of PC to pandemic response. The ten pressure points outlined here provide a framework for conceptualising the ongoing impact of these COVID-19 contributions on PC services, and developing strategies to accommodate and mitigate these effects.

Emerging descriptive and experiential evidence resonates with these findings, highlighting additional PC workload [105], task changes [1], reductions in revenue and workforce availability [106], and shortages of resources such as medicines and PPE [107, 108]. Increases in COVID-19 related workload have been linked to heightened emotional states and reports of stress, frustration and mental overload [105, 109]; with PCPs describing personal psychological distress and reduced wellbeing, as well as concerns for their families [110, 111]. Some reported feeling overlooked, with inadequate recognition and remuneration [112], and frustrated by their inability to respond to non-pandemic health concerns [107], as fixed resources necessitated trade-offs in response to changing demands [2]. Perceptions of suitable government support and recognition were important protective factors in the face of such distress [113], and will form important components of planning for PC responsiveness in future pandemic scenarios. A 2021 rapid review of virtual PC in high income countries identified the need for ongoing work to address shortcomings exposed by COVID-19 and support sustainability, despite existing policy supports [72]. Consensus principles for pandemic recovery [114] underline the importance of acknowledging contributions and supporting wellbeing as a prelude to integrated planning based on communication and trust [114].

Widespread transformation in PC, while generating work and necessitating adjustment, also brought the advent of new tools and innovative solutions [102, 115]. PC contributions became increasingly acknowledged and integrated as the pandemic evolved [22, 116], with many promising practices and creative solutions emerging, both from the PC sector and from policymakers [6]. Mitigation strategies included examples of PC creativity, resilience and resourcefulness [117], and support from external policy, financial and regulatory measures [6, 102]. Responses encompassed rearrangement of tasks between PC professionals; leveraging of digital tools and systems by new legislation, new telemedicine services, or new guidelines and regulations; patient education initiatives; and rapid introduction of add-on payments for PCPs facing both increased workload and risks, including for teleconsultation services and home visits or for hygiene and safety measures [6, 102].

Strengths and limitations

Strengths of this study are the systematic methods, the international orientation and illustrative synthesis, supported by a robust international team of experienced PC investigators able to interpret and validate findings. The study is limited by the exclusion of grey literature which may provide more expansive description of impacts on PC settings. It also reflects a period in time (January 2020-May 2021) during the initial phase of the pandemic and is neither an exhaustive nor ongoing account. This period of significant disruption placed PCPs under intense pressure that varied across time and place. These variations were unable to be comprehensively examined in this indicative, narrative analysis.

Conclusions

The pivotal role played by PC in short- and long-term responses to PH emergencies has been established previously [118, 119], and now clearly demonstrated during the COVID-19 pandemic. Notwithstanding the strengths and contributions of PC, this paper focuses on challenges in order to identify key issues that require attention as part of health system strengthening and future pandemic planning. The potential roles of PC in the pandemic context should be acknowledged, resourced and planned for in consultation with the PC sector, and the pressure points for PCPs and PC services should be clearly understood in order to minimise unnecessary burden and optimise health system responses.

Principal lessons for policy makers, planners, and public health professionals include the importance of: support and resourcing to facilitate physical and operational adaptation and role evolution, including policy support to ensure and maintain supply chains for critical supplies; conscious recognition of PC roles in enabling comprehensive community responsiveness, and identifying and responding to emerging health needs; appreciation of business and operational strain imposed by changes in health service delivery models; and providing consistent, clear public health guidance and information that acknowledges and incorporates PC with active and ongoing inclusion in planning and preparation. Given the identified impact of the pandemic on exacerbating the effects of social determinants of health and driving differential and inequitable effects for some population groups, both policy and clinical strategies to address these issues in future events will be essential. Use of panel registries that identify at risk groups will facilitate the mobilisation of resources to identify needs, mitigate risks and support timely access to prevention and care.

There are also lessons for PCPs and PC services. Much of the hard work to innovate and establish new processes and systems of care, for example electronic prescribing, has been done. Maintaining and documenting these will ensure PCPs and PC services are in good stead when future pandemics or crises occur, as will sustaining investment in the effort expended to upskill the PC workforce for new ways of working, particularly the use of virtual and remote consulting modalities. Further implementation research into the delivery of care in this way at scale, and impacts on quality and safety is needed, as is the integration of knowledge gained from the pandemic into current and future training pathways. For example, experiences with addressing challenges related to IPC measures, and managing risks associated with increased reliance on non-clinical virtual triage offer a rich resource for developing clinical protocols and tools, as well as educational modules that can be deployed in future events or used in ongoing quality improvement and professional development activities, to maintain workforce readiness.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files], or available from authors on reasonable request.

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Acknowledgements

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Funding

This research received no external funding and was funded in-kind by employing institutions of the investigators.

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Authors and Affiliations

  1. School of Medicine & Psychology, College of Health & Medicine, Australian National University, Canberra, Australia

    Sally Hall Dykgraaf, Katelyn Barnes & Kirsty Douglas

  2. National Centre for Epidemiology & Population Health, College of Health & Medicine, Australian National University, Canberra, Australia

    Anne Parkinson, Jane Desborough, Danielle Butler & Steph Davis

  3. Centre for Health Economics Research and Evaluation, University of Technology, Ultimo, Australia

    Michael Wright

  4. Faculty of Medicine and Health, University of Sydney, Sydney, Australia

    Michael Wright

  5. Department of Family Medicine and Primary Care Ap Lei Chau Clinic, University of Hong Kong, Hong Kong, China

    William C. W. Wong

  6. Centre for Community Health and Wellbeing, The University of Queensland, Brisbane, Australia

    Lauren Ball

  7. School of Primary and Allied Health Care, Monash University (Peninsula Campus), Frankston, Australia

    Elizabeth Sturgiss

  8. College of Health & Medicine, Australian National University, Canberra, Australia

    Garang M. Dut & Michael Kidd

  9. Adjunct Lecturer, University of New South Wales, Sydney, Australia

    Garang M. Dut

  10. Academic Unit of General Practice, ACT Health Directorate, Canberra, Australia

    Katelyn Barnes & Kirsty Douglas

  11. Institute for Urban Indigenous Health, Brisbane, Australia

    Danielle Butler

  12. Australian Government Department of Health and Aged Care, Canberra, Australia

    Steph Davis & Lucas de Toca

  13. Organisation for Economic Co-operation and Development, Paris, France

    Candan Kendir

  14. Department of Family and Community Medicine, University of Toronto, Toronto, Canada

    Danielle Martin, Katherine Rouleau & Michael Kidd

  15. Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland

    Robert Marten

  16. Special Programme on Primary Health Care, World Health Organization, Geneva, Switzerland

    Shannon Barkley

  17. Centre for Future Health Systems, University of New South Wales, Sydney, Australia

    Michael Kidd

  18. Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England

    Michael Kidd

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  1. Sally Hall Dykgraaf
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Contributions

SHD, JD, MK, DB & SD conceived the study questions and formulated the study design and methodology. All authors reviewed and approved the study protocol. SHD, AP, LB, LS, GMD, MW, JD, DB & WW screened studies and extracted data. SHD & AP managed and analysed data with input from JD & WW. SHD and AP drafted the main manuscript and prepared figures and tables. All authors reviewed analytical outputs and considered and contributed to the final manuscript.

Corresponding author

Correspondence to Sally Hall Dykgraaf.

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Competing interests

All authors have completed the ICMJE Disclosure of Interests Form (available on request from the corresponding author) and declare the following support and financial relationships: SHD, JD, AP, GD and KB are or were employed by the Australian National University during the study period, and seconded to the Australian Government Department of Health and Ageing undertaking action research in relation to COVID-19 and primary care. MK, SD, GMD and LdT were salaried officers of the Australian Government Department of Health and Aged Care at the time the research was conducted; MK also held an academic appointment with the Australian National University through which he received funding for post-doctoral positions, and is a Director of Therapeutic Guidelines Ltd. MW is the Chief Medical Officer of Avant Mutual, Australia. LB, KB, KD, ES are or have been executive committee members of the Australasian Association for Academic Primary Care. SB is a recipient of grants from the Bill and Melinda Gates Foundation, UHC Partnership and Susan Thompson Buffet Foundation for primary health care related research. All other authors (ES, KD, ES, CK, DM, RM, KR, SB) have no conflicts to declare.

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Dykgraaf, S.H., Parkinson, A., Wright, M. et al. Ten pressure points in primary care during COVID-19: findings from an international narrative review. BMC Prim. Care 26, 19 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12875-024-02640-w

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