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While the functional approach to increasing access to healthcare is to reduce its cost, it should not compromise the quality of healthcare (13). With regard to self-care, the financial demands it places on the patient affects the extent to which they can interact with self-care activities, irrespective of the patient's desire to embrace it (14).

Because of the nature of self-care interventions like self-monitoring, or self-screening, people expect such interventions to provide them with immediate or direct benefits (15). However, these benefits may not outweigh their costs, particularly if individuals are responsible for the costs themselves. Although self-care often means self-financed, ideally, interventions begun in health facilities and shifted to home settings should not garner additional costs to the patient nor require further subsidisation. There is a fair amount of evidence to suggest that self-care could reduce direct patient costs and the risk of financial hardships (16). The HIV Self-Testing in Africa (STAR) Phase 2 Evaluation Report shows how HIV self-testing (HIVST) cost will potentially decrease as newer products enter the market (17).

Furthermore, patients who opt for self-care, can often obviate their transport costs and needing to visit hospitals for HIV related care (18). This is crucial for patients in low income settings whose financial constraints are a barrier to seeking medical attention (19). Cost efficiency resulting from self-care can extend beyond the patient too. Increased numbers of patients who engage in self-care practices, means that healthcare facilities and healthcare workers will likely experience reduced and possibly manageably patient loads (20). Thus, health systems stand a greater chance of being more efficient and more targeted (16).

Various reports estimate large cost savings from self-care, however, whether all patients are able to care for themselves competently independently of a healthcare worker must be considered.

Self-care interventions play a pivotal role in the prevention, identification, management, treatment optimisation, and decreasing disease incidence (21). For self-care to be a viable option, patients need to demonstrate a level of self-efficacy, which can be defined as a person's belief in their own ability to organise their behaviour for the purpose of achieving the desired outcome (22). Within the healthcare context, this would mean patients being able to engage with instructions for use (IFU), instruments and equipment and availing alternate monitoring methods in an independent manner.

Independence hinges on the end user being able to comprehend instructions for the use of medication and instruments (23). In South Africa, over 4 million adults are illiterate (24, 25), so it is to be expected that for poorly literate patients, there will be limitations in their ability, particularly when it comes to comprehending written IFU, resulting in the correct engagement with various self-care activities being compromised. One common effect of poor comprehension of IFU is patients taking the incorrect dosage of medication (26, 27).

To combat the pre-requisite of being literate for a person to be able to adopt self-care, methods of information dissemination that go beyond the written word, such as videos, need to be employed (28, 29). Similar considerations need to be made with regards to the language used in IFU, given that SA has 11 official languages. Therefore, for successful use of self-monitoring devices, patient autonomy and its relationship to literacy and comprehension levels of end-users must be considered (30).

Compared to people without HIV, people living with HIV (PLHIV) find themselves twice as likely to be at risk for cardiovascular disease (CVD) and their mortality risk increases if the CVD risk is left unmitigated (31). Hypertension (HTN) is a recognised contributor to PLHIV developing CVD, yet its monitoring particularly in Sub Saharan Africa remains underwhelming. Among the many reasons for this, like stigmatisation and insufficient personnel, non-optimisation of blood pressure (BP) monitoring devices is one (32). Teshome DF et al. identify the lack of sufficient BP monitors and appropriately skilled health extension workers as being hindrances to home-based HTN screening in a rural Ethiopian region. They put forward that establishing systems that address the minimising of these obstacles would render home-based HTN monitoring to be a practicable option (33). Moreover, availing testing instruments and equipment, like blood pressure (BP) monitors and wearables to patients, which can be used in their homes, is a further means to promote independence. Such is the need that the WHO developed interventions for primary health care in low-resource settings, some of which include the self-monitoring of BP to manage hypertension for example, where access and cost are not hindering factors (14).

On a systemic level, digital health platforms provide further solutions to promote self-care, as these also have the advantage of allowing patients to monitor (34) their health without needing to visit healthcare facilities. South Africa has a significant rural population for whom accessing healthcare services is often problematic. Rural communities can benefit significantly from telehealth offerings that would otherwise be unavailable to them in person (35). This possibility becomes particularly important when information needs to be disseminated urgently, as we experienced during the Covid-19 pandemic. Research into the viability of HIV related health apps like iThemba (36) which facilitate the monitoring and medication of HIV patients, have already shown that they can be beneficial to patients who ordinarily would need to visit clinics at short intervals and pick up medications at centralised healthcare facilities.

Irrespective of how encouraging these interventions are, overcoming the current obstacles to its uptake needs more robust efforts to mitigate the costs and practicalities associated with establishing e-/ telehealth pathways (37, 38). A further complement to patients being able to monitor their own health, is the strengthening of individual and community engagement in the promotion of healthcare.

Among the variables which influence an individual's willingness to embrace self-management of their health, are the intersectionalities of culture, sex, gender, age and class (39, 40). To address particular needs of various sections of society, differentiation in health-management is a practical approach. Differentiated care support is not new in South Africa's healthcare system, and was envisioned as a client-centred approach that simplifies and adapts chronic services to manage HIV across the cascade of care, while decongesting burdened health facilities (41).

Differentiated care support needs to expand, to address the additional self-care activities required for effective self-management of chronic conditions. Some of these additional interventions include education and community engagement to promote behaviour and lifestyle modifications (42).

Health education is pivotal in promoting healthy life-styles, encouraging individuals to take accountability for their health (43). Perhaps to kickstart community-based initiatives, investing in national educational programmes that target youth might be a feasible approach. The Grassroots SS (44) of which SKILLZ Street (45) is an example of how health education can be included within youth empowerment projects. In this initiative, young girls learn about their sexual reproductive health and rights, and general life skills which are essential in steering their decision making in terms of sexual behaviour and reproductive health (44–46). While innovative educational strategies such as this are promising, such interventions need to be enhanced and sustained as innovative health education strategies have been shown to enjoy success when entrenched at a structural level (29, 47).

However, society does not only have to rely solely on directives from health authorities in how to manage their health. Malama K et al. (2022) explain that ensuring that communities have adequate education on HIV self-care practices as well how to avail such, can play a significant role in promoting HIV self-care (48). This is especially true for vulnerable populations like the elderly. A recent South African study revealed that healthcare for the aged particularly in low-resource communities is sorely lacking in patient-centredness, resulting in inadequate health care for this sector of the population (49). A means to overcoming this marginalisation of the elderly (43) is to provide them with the skills and opportunities that they require to adopt and maintain self-care whenever possible. Studies conducted on the viability of self-care among older persons following an acute illness admission show a decline in ones' s ability to perform activities of daily living such as bathing, eating, and walking (50, 51), therefore, one's ability to self-care post hospitalization necessitates binary support systems such as home based care (52).

Knight L, et al. (2018) suggest the formulation of Chronic Care Clubs in a community setting, which decentralise HIV treatment and monitoring for the elderly with co-morbidities, thereby providing them with a workable way to manage their conditions (53). Understanding these dynamics, and their implications can provide valuable insight to allow for the planning and execution of alternative healthcare interventions to cater particularly to people in low income and vulnerable communities (54), including women who require emergency maternal care (55).

On a more individualised level, differentiation can also take into consideration the cultural (40) values and attitudes that influence gender roles. In African and Asian societies, these values play a major role in health decisions: men are largely the sole decision makers in their families. However, studies show that in such circumstances, women are often eager to bypass the cultural expectations. For example, when offered self-care approaches to HIV testing, most women in rural SA opted for HIV self-testing because they felt more empowered, and independent (56).

Thus it is important to understand all enabling factors that help or disturb self-care behaviours and strategize ways in which to mitigate them. In doing so, deep-rooted behaviour and attitudes which are detrimental to health and self-care may be able to be changed.

Policy makers, implementers and governments should also consider fostering collective healthy living through community exercise sessions (42), to support self-care practice.

Linkage to care is a self-management intervention which offers strategies that promote active participation of individuals in their health, and ways to reach improved outcomes like increased access to testing (57). However, for self-care to be viable, patients must understand that synergies between self-care, and facility-based health provision are negotiated by the severity of a condition, the complexity of its care, and the expertise required to manage a patient's health (13). So, despite the promising future of self-care, it must be remembered that practising self-care activities is an accompaniment to, not an obliteration of the need to link to professional care.

The term “linkage to care” was first coined to define a patient's initial clinical visit, following an HIV positive, and most recently, reactive self-screening result. It is regarded as a crucial step in the management of HIV and viral suppression (58). In South Africa, while HIV self-screening can be attributed to an increase in access to HIV testing, it is also reported to have worsened the rate at which people link to care (59).

Evidence points to financial constraints and time needed to access health facilities, patient and provider relationships (60–62), as well as transport vulnerability (63, 55) as being key indicators to delayed care. Like in Kenya and Tanzania, decreased linkage and retention in care in SA can also be attributed to discrimination (64) and staff attitudes (65, 66).

While various initiatives such as mobile health clinics (67) for hard to reach communities, mobile health for pregnant mothers (68) and Pulmonary Tuberculosis patients (69),, self-triage apps for acute illnesses (70) and community tracking initiatives have been instrumental in addressing some of the gaps in linkage to care, a lot of work is required in addressing barriers to facility attendance, such as patient satisfaction and provider communication (71).

Limited access to the internet, language barrier and in some instances, infrastructural resources such as mobile health cars can pose limitations to these recommendations, particularly in poorer countries.