Health system barriers and pathways to strengthening early detection of pediatric type 1 diabetes in low- and middle-income countries: a systematic review

Abstract Background Type 1 diabetes mellitus (T1DM) affects approximately 1.2 million children and adolescents globally. Delayed diagnosis in low- and middle-income countries (LMICs) is a key factor for high morbidity and mortality. The available evidence suggests systemic barriers across the diagnostic pathway. This systematic review aims to synthesize evidence on facilitators and barriers to early detection of pediatric T1DM in LMICs. Methods We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Web of Science, Embase and Cochrane Library were searched in February and March 2026. Additional targeted grey literature searches of the World Health Organization IRIS repository, and the International Diabetes Federation website were conducted separately. Studies were eligible if they examined interventions, implementation strategies, or health system approaches to improve timely detection and diagnosis of pediatric T1DM in LMICs. Two reviewers independently screened studies in Covidence. Risk of bias was assessed, and findings were synthesized using descriptive and thematic analysis according to the WHO health system building blocks framework. Results Nine studies met the inclusion criteria. Barriers were most frequently identified in service delivery, the health workforce, and access to diagnostics. Early detection was largely passive and concentrated in higher-level facilities, with limited integration into primary care. Fragmented referral pathways, weak linkage to care, and gaps in provider knowledge contributed to delayed diagnosis. Several approaches, including integration with existing programs and community-based strategies, demonstrated promise; however, they were not implemented at scale and remained fragmented. Conclusion Early detection of pediatric T1DM in LMICs remains challenging and is primarily constrained by health system limitations rather than the absence of diagnostic tools. Evidence evaluating implemented strategies remains limited. Addressing these delays requires coordinated, system-level strategies that strengthen primary care capacity, expand access to basic blood glucose testing at first-contact points, and improve referral and follow-up across the care pathway. The limited number of studies evaluating implemented interventions highlights a critical need for research on scalable, integrated approaches in resource-constrained settings. Trial registration CRD420261330542 (March 03, 2026).