BACKGROUND:
Multimorbidity presents significant challenges for health systems, particularly in primary healthcare (PHC) settings that are often organised around single diseases rather than the complex needs of people living with multiple long-term conditions. Effective multimorbidity care requires person-centred services, continuity of care, and healthcare workers with strong communication, teamwork, and leadership skills. In South Africa, as in many low- and middle-income countries, health system responses to multimorbidity, especially at PHC level, remain under-described and under-evaluated. Understanding how PHC systems are structured and experienced by providers and service users is essential for strengthening integrated care.

METHODS:
This study examined barriers and facilitators in delivery of multimorbidity care within the uMgungundlovu District, KwaZulu-Natal, South Africa. Drawing on formative work from the ENHANCE study (2022–2023), a multimethod cross-case comparison was conducted across five PHC facilities. Within each facility, three multimorbidity care cases were examined, incorporating facility profiles, patient pathway process maps, clinical observations at facilities and during home-based outreach, and interviews with nurses, community health workers, and service users. Interviews and focus group discussions were conducted with policymakers. Data were analysed using inductive thematic analysis.

RESULTS:
Key barriers included the high treatment burden experienced by patients, challenges related to polypharmacy and food insecurity, difficulties managing specific multimorbid dyads (notably hypertension and diabetes, and HIV and tuberculosis), and gendered patterns affecting adherence, particularly among men. Outreach teams faced long travel distances, limited equipment, resource constraints, medication stock-outs and infrastructure limitations within facilities. Facilitators of care included person-centred consultations, strong nurse–patient relationships, community-based resources such as medication pick-up points and vegetable gardens, the central role of community health workers, and support for service integration through the Ideal Clinic system.

CONCLUSIONS:
Findings highlight the need to strengthen access, promote person-centred and integrated care, and leverage existing system strengths to improve multimorbidity management in similar PHC contexts.