Over 80% of the population in Latin America and the Caribbean (LAC) lives in urban areas which are increasingly threatened by climate risks that add pressure to increasing demand for basic services including water, sanitation, and housing. These challenging aspects also turn urban areas of the region into attractive zones for multi-functional solutions. Nature-Based Solutions (NBS) have been recognized by institutional actors as solutions that can help meet interconnected urban needs through cross-sectorial and multi-stakeholder strategies. The practice of NBS in the region builds on previews experiences with ecosystem-based approaches that include green/natural infrastructure, which have mostly focused on water management. Multi-scalar NBS projects have been focused on secure water supply, improve water quality, manage flood and landslide risks, as well as mitigate erosion. The Andean countries, especially Peru, Ecuador and Chile have identified how ancestral hybrid techniques and specific ecosystems located on the upper and middle fractions of the watershed have helped conserve water resources through approaches commonly known as “siembra y cosecha del agua” (SyCA; directly translated as sowing and harvesting water). The actions aim to supply water to nearby cities and rural communities. However, such approaches remain rare as NBS in LAC are more often implemented at isolated and/or small scales, with limited holistic approaches. Challenges to replicate multi-scalar NBS approaches persist. In the overall region, NBS are not often part of institutional urban planning initiatives and successful cases are poorly studied or undocumented. Our systematic review of the current literature on urban NBS in LAC helps identify patterns and recurrent barriers that impede the implementation of multi-scalar NBS. One of them shows how indigenous practices that play a key role in biodiversity preservation are not receiving the required support. This provides regional evidence that NBS will only be sustainable and equitable if such approaches are integrated into enabling governance structures.