Barriers to Healthcare Access for Children With Congenital Heart Disease in Low- and Middle-Income Countries: A Systematic Review Using the SHEL Framework

Background: Access to timely and appropriate care for children with congenital heart disease (CHD) remains highly inequitable in low- and middle-income countries (LMICs).Objectives: This systematic review synthesizes recent evidence on barriers to healthcare access for pediatric CHD and applies the SHEL human factors framework to analyze system-level determinants.Design: This updated systematic review extends a prior analysis, applying PRISMA guidelines. Search was conducted in PubMed/MEDLINE, Scopus, and Web of Science. Regional trends were mapped via WHO classifications.Results: Most studies reported barriers related to environmental factors, followed by workforce limitations, infrastructure constraints, and policy or organizational deficiencies. Many obstacles originated at the primary care level, contributing to delayed diagnosis and referral. Although all regions exhibited barriers across SHEL domains, their relative distribution varied by region.Conclusion: These findings highlight that improving CHD outcomes in LMICs requires integrated health system strengthening across levels of care.