Open Access Highly Accessed Research article

The breadth of primary care: a systematic literature review of its core dimensions

Dionne S Kringos1*, Wienke GW Boerma1, Allen Hutchinson2, Jouke van der Zee14 and Peter P Groenewegen13

Author Affiliations

1 NIVEL-Netherlands Institute for Health Services Research, Otterstraat 114-118, 3500 BN Utrecht, the Netherlands

2 ScHARR-School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK

3 Department of Human Geography, Department of Sociology, University of Utrecht, PO Box 80140, 3508 TC Utrecht, The Netherlands

4 Faculty of Health Sciences, Department of International Public Health, University of Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands

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BMC Health Services Research 2010, 10:65  doi:10.1186/1472-6963-10-65

Published: 13 March 2010



Even though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level.


A systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, King's Fund Database, IDEAS Database, and EconLit.


Eighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health.


A primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health.