The Missing Middle in Chronic Disease Care: Addressing Continuity Gaps in African Health Systems

Background: The burden of chronic diseases is increasing across Africa, while many health systems continue to face challenges in delivering sustained, long-term care. Although diagnosis and treatment remain essential, chronic disease management extends well beyond the clinical encounter and requires ongoing medication adherence, self-management, monitoring, dietary and lifestyle support, and timely follow-up. Problem: Chronic disease services in many low-resource settings remain organised around episodic clinical encounters, creating a gap between treatment received within health facilities and the day-to-day management required outside them. Patients spend much of their time managing their conditions at home and within their communities, where access to structured follow-up and support may be limited. Community pharmacies, family and social networks, and mobile communication increasingly help patients navigate this gap, but these mechanisms often operate without systematic integration into formal care. Argument: This paper conceptualises this space between clinical encounters as the “missing middle” in chronic disease care. We argue that improving long-term outcomes requires greater attention to the systems that connect clinical encounters with patients’ everyday experiences of managing chronic conditions. The paper proposes a community-integrated digital continuity framework that brings together community-based support, digital communication, patient education, monitoring, medication adherence support, and care coordination as complementary components of longitudinal chronic disease management. Implications: Addressing the missing middle requires health systems to move beyond a predominantly encounter-based approach toward models that provide structured support across the full course of chronic illness. Integrating community actors and accessible digital communication into routine care may offer a practical pathway for strengthening continuity, particularly in settings where health-system resources are constrained. The framework provides a basis for further implementation research and evaluation of community-integrated approaches to chronic disease continuity in African health systems.