Background: Strong primary health care (PHC) is the cornerstone for universal health coverage and a
country’s health emergency response. PHC includes public health and first- contact primary care (PC).
Internationally, the spread of COVID-19 and mortality rates vary widely. The authors hypothesised that
countries perceived to have strong PHC have lower COVID-19 mortality rates.
Aim: To compare perceptions of PC experts on PC system strength, pandemic preparedness, and
response with COVID-19 mortality rates in countries globally.
Design & setting: A convenience sample of international PHC experts (clinicians, researchers, and
policymakers) completed an online survey (in English or Spanish) on country- level PC attributes and
pandemic responses.

Method: Analyses of perceived PC strength, pandemic plan use, border controls, movement restriction,
and testing against COVID-19 mortality were undertaken for 38 countries with ≥5 responses.
Results: In total, 1035 responses were received from 111 countries, with 1 to 163 responders per
country. The 38 countries with ≥5 responses were included in the analyses. All world regions and
economic  tiers  were  represented.  No  correlation  was  found  between  PC  strength  and  mortality.
Country- level  mortality  negatively  correlated  with  perceived  stringent  border  control,  movement
restriction, and testing regimes.

Conclusion: Countries perceived by expert participants as having a prepared pandemic plan and a
strong PC system did not necessarily experience lower COVID-19 mortality rates. What appears to
make a difference to containment is if and when the plan is implemented, and how PHC is mobilised
to respond. Many factors contribute to spread and outcomes. Important responses are first to limit
COVID-19 entry across borders, then to mobilise PHC, integrating the public health and PC sectors
to  mitigate  spread  and  reduce  burden  on  hospitals  through  hygiene,  physical  distancing,  testing,
triaging, and contract- tracing measures.