Table 2. Themes and illustrative quotations.

Themes and subthemes	Descriptions	Illustrative quotations
Rising demand and impact on GP services
Policy-driven growth in demand	The implementation of national health policies promoting primary care has significantly increased the demand for GP services.	With the rollout of numerous hierarchical medical care policies, more patients have been encouraged to seek care at the community level, substantially increasing GPs’ outpatient workload. (GP-08)
Rising demand for geriatric and chronic care	Population ageing and the rising prevalence of chronic diseases have increased demand for geriatric and chronic care services in primary care.	The demand for GPs among community residents has been increasing due to population ageing and the growing prevalence of chronic diseases. (GP-07)
Increasing workload among GPs	Increasing service demands and expanding scope of work have increased the workload of GPs.	Our workload is already full, and this year chronic obstructive pulmonary disease (COPD) was added to the basic public health service. If we are to properly manage these patients, it will mean an even greater workload. (GP-04)
Inadequate service quality and efficiency	Current workforce capacity and system support are insufficient to ensure high-quality and efficient GP services.	At present, meeting the demand for basic medical services often requires extending clinic hours, while public health work is largely reduced to meeting quantitative targets, with little assurance of quality. (D-08)
Supply challenges in the GPWF
Insufficient GPWF supply	The supply of the GPWF is insufficient to meet the growing demand for primary care services.	Because there are not enough GPs with Bianzhi, we can only hire contract-based GPs when the budget allows. To keep services running, GPs have to rotate across different institutions through flexible scheduling. (D-10)
Low attractiveness of GP careers	Social prejudice, role ambiguity and low income were identified as factors reducing the attractiveness of GP careers.	Many residents, and even doctors from other specialties, tend to see GPs as less authoritative than specialists. These views may influence medical students’ career choices. (D-08)
Misalignment between postgraduate training and practice needs	The limited effectiveness of postgraduate GP training was attributed to a mismatch between the design and content of training programmes and the actual needs of primary care practice.	GPs who complete standardised residency training are usually well-trained, but many still struggle when they enter a CHC. Although they have strong medical knowledge and clinical skills, they often lack training in competencies specific to primary care practice. (GP-06)
Limited supply of CSP GPs	The supply of CSP GPs remained limited due to multiple factors, including insufficient training quotas and attrition after the compulsory service period.	Our institution has to wait several years to receive even one CSP GP. Many of them leave once their service commitment ends, leaving us with a persistent shortage of GPs. (D-10)
Barriers to GP recruitment and retention	Recruitment and retention challenges made it difficult for CHCs to maintain a stable workforce.	Overall, Bianzhi positions often receive few eligible applicants, while contract-based GPs are difficult to retain. When a GP leaves, substantial work must be handed over, and frequent staff turnover also disrupts the routine functioning of CHCs. (D-04)
Challenges to GPs’ professional sustainability
Vulnerability to burnout	GPs are highly vulnerable to burnout due to heavy workloads, administrative burdens and limited professional autonomy.	There’s just too much to do. When you try your best to handle everything at once but still can’t manage it all, you begin to doubt your competence as a GP and often feel quite helpless. (GP-08)
Barriers to CPD	GPs face difficulties in participating effectively in CPD programmes and achieving professional development.	There are plenty of training opportunities, but most are task-driven. Some trainings are really useful, but since we rarely see the relevant cases in primary care, those skills gradually fade over time. (GP-02)
Distrust and professional jeopardy	GPs face distrust from patients and are exposed to complaints and potential conflicts that threaten their professional safety.	Some residents don’t trust your abilities and tend to question your judgment. Complaints are quite common, so I’m constantly on edge, worrying that one wrong word might cause trouble. (GP-07)

Bianzhi, government-funded positions with full benefits; CHC, community health centre; CPD, continuing professional development; CSP, compulsory service programme; D, director; GP, general practitioner; GPWF, general practitioner workforce.