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Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage
  1. Dan Schwarz1,2,
  2. Lisa R Hirschhorn1,3,
  3. June-Ho Kim1,4,
  4. Hannah L Ratcliffe1,
  5. Asaf Bitton1,4
  1. 1Primary Health Care, Ariadne Labs, Boston, Massachusetts, USA
  2. 2Division of Global Health Equity, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
  3. 3Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  4. 4Division of General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
  1. Correspondence to Dr Dan Schwarz; daschwarz{at}

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Summary box

  • Continuity is a critical but often neglected function of high-quality primary care and has three core domains: relational, informational and managerial continuity.

  • Improving continuity is feasible in low-income and middle-income country health systems by using comprehensive empanelment systems or community-based follow-up programmes to improve retention in care.

  • Continuity must receive more attention, measurement and improvement efforts, in order to achieve equitable, high-quality health for all.


Despite increasing attention to what the goals for universal health coverage are,1 the global health community still lacks clarity on how low-income and middle-income countries (LMICs) can strengthen health systems to reach these ambitious goals, while ensuring quality at the same time.2 In October 2018, the world commemorated the 40th anniversary of the Alma-Ata declaration and issued the Astana Declaration on Primary Health Care, clearly centralising the universal health coverage agenda within an overall framing of strong primary healthcare, and offering guidance for the way forward.3

To meet the Sustainable Development Goals4 and deliver quality universal health coverage, LMIC health systems will need more resources; they will need to be redesigned around the core elements of high-quality primary care. The Starfield ‘4C’ functions of effective primary care—first-contact access, continuity, care coordination and comprehensiveness—offer meaningful targets for policy and planning of primary care in LMICs.5 Unfortunately, health systems have not historically been designed or resourced to reliably provide these core functions of primary care.

While access, coordination and comprehensiveness have garnered some policy focus, continuity of care has received relatively little attention within LMICs. Continuity refers to coherent, linked care, between patients, families, communities and providers, across lifetimes. Continuity consists of understanding individuals’ contexts, with longitudinal clinical information, and using this knowledge to build trusting relationships over time.6 In higher-income settings, improved continuity has been associated with greater patient satisfaction, …

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