Low- and middle-income countries (LMICs) will see the largest increase in diabetes over the coming years. Health systems in LMICs are currently not prepared for the management of diabetes and other comorbidities. LMICs and their health systems need to address the increasing burden of non-communicable diseases (NCDs) in parallel to managing the existing populations with diabetes. LMICs and their health systems need to address the increasing burden of NCDs in parallel to managing the existing populations with diabetes. Global health policies and funding need to include the prevention and control of NCDs, including diabetes. In developing global and national health system and community responses, there is a need to understand the current situation with regard to the health system and its capacity to deliver diabetes care. For the reality of diabetes to fundamentally change in LMICs, health systems need to be at the centre of the response.