Patient level barriers include lower health literacy and self-efficacy to navigate the health care system, treatment burden, fragmentation and suboptimal coordination of care, limited social resources to support self-management (e.g. family support, employment and community support), environment (e.g. living in rural areas far from health services or in residing in unsafe areas that are a barrier to outdoor physical activity); or inadequacy of financial protection to meet healthcare or related costs.

System level barriers include availability, appropriateness and access to services.278,279 In most health systems, consultation times are limited and patients and providers can be frustrated that issues were not addressed adequately.233

Personal and health system barriers can combine, for example patients with multimorbidity often experience functional limitations, which restrict their mobility and ability to access treatment.

LMICs barriers are expected to be augmented and amplified in settings, characterized by weak, fragmented, and acute-oriented healthcare delivery systems.280–282 Such pressures affect families as well as the precarious and overloaded health system, and require household-level and creative community-level responses to decrease the load on health services. The reach of initiatives like care coordination222 often deployed in HICs, may be restricted in LMIC settings with fragmented health services or non-existent chronic care, but this can also be a challenge in HICs lacking universal access to healthcare free at point of delivery. In Peru, more than 90% of care for people with disabilities relies on household relatives, largely women.283

There are opportunities in LMICs to leverage innovative delivery channels, such as technology-enabled tools or mHealth for physical and mental chronic conditions223,285–287 and the utilization of non-healthcare delivery settings such as barbershops to manage risk factors like hypertension288 and places of religious worship and informal social networks to promote healthy lifestyles.289–291 These can be aided by co-production approaches, which are likely to yield interventions responsive to people’s preferences,292,293 and, therefore, enhance patient-centred approaches. Multilayered interventions in the field of dementia have shown promising results by improving patient-related and caregiver-related outcomes.224,284 As with other LMIC challenges, there are opportunities for ‘leap-frogging’, a concept describing an approach that bypasses arduous and expensive development phases and adopts proven technologies and systems as a way to build better health systems.294