Barriers to Cataract Surgery Uptake in Africa: A Systematic Review

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Methods We conducted a systematic review of multiple databases for studies published from January 2000 to March 2025. Searches combined controlled vocabulary and free text terms for cataract surgery, access or uptake, and African countries. Two reviewers independently screened titles, abstracts, and full texts with consensus resolution. Eligible studies enrolled African populations and explicitly reported barriers, facilitators, or determinants of uptake. Data were extracted into a piloted template and synthesised thematically without meta-analysis. Reporting followed the PRISMA 2020 guidelines; the study was prospectively registered (PROSPERO CRD420251145721). Results Following the screening of 737 records, a total of 108 studies were included, spanning Rapid Assessment of Avoidable Blindness surveys, cross-sectional, qualitative, and mixed-methods designs. Patient-level barriers most frequently reported were direct and indirect costs (surgery, travel, accommodation, income loss), limited awareness, fear of surgery or poor outcomes, gender inequities, and cultural beliefs. Community-level barriers included transportation constraints, weak referral pathways, and inconsistent outreach efforts. System-level barriers comprised workforce shortages, limited theatre capacity, equipment or consumable shortfalls, scheduling inefficiencies, and reliance on out-of-pocket financing with limited insurance or subsidies. Rural, urban, and regional disparities were consistent. Conclusion Barriers to cataract surgery uptake in Africa are multifactorial and interlinked. Evidence supports multi-component strategies, including patient education, targeted financial and transportation support, strengthened referral and outreach, service decentralisation, and health system investment, to improve equitable access and accelerate progress toward eye health targets. cataract surgery access to care health system barriers patient barriers Africa Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Cataract remains the leading cause of reversible blindness worldwide and a major contributor to visual impairment in Africa [ 1 ]. Modern cataract surgery is safe, effective, and highly cost-efficient, with advances in small-incision techniques, biometry, intraocular lenses, and peri-operative pathways further enhancing outcomes [ 1 , 2 ]. Globally, the proportion of people who have undergone cataract surgery continues to increase, yet it remains uneven across regions and income groups, indicating disparities in access and uptake [ 3 , 4 ]. Many countries still report cataract surgical rate (CSR) and cataract surgical coverage (CSC) below recommended thresholds, and CSR is strongly linked to socioeconomic development and health-system capacity [ 1 , 4 ]. These disparities persist despite policy momentum under VISION 2030: In Sight, For All, which prioritises equity and integrated, people-centred eye care [ 5 ]. This review examines barriers to cataract surgery uptake, particularly the gap between the need for surgery and its utilisation, drawing on evidence that combines patient, community, and health system factors in African settings [ 1 , 6 ]. Service organisation, financing, and workforce capacity are recurring system drivers of access and outcomes, shaping both CSR and CSC [ 4 , 7 ]. Ongoing inequalities based on sex further hinder uptake, with women less likely than men to undergo surgery despite having similar or greater need [ 6 – 8 ]. We place these issues within the broader context of universal eye health planning and implementation to inform practical, scalable solutions that align with global commitments [ 5 , 9 ]. We synthesised studies from 2000 to 2025 to: (1) identify and categorise barriers; (2) describe regional variation; and (3) highlight evidence gaps to guide implementation and research priorities. Methods Protocol Registration and Reporting This review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251145721) and conducted in accordance with PRISMA 2020. Literature Search and Study Selection We systematically searched PubMed/MEDLINE, Scopus, Web of Science, and Africa-Wide Information (EBSCO) from January 2000 to March 2025 (search executed September 2025). The PubMed strategy combined MeSH and free-text terms for cataract surgery, access/uptake, and African countries; equivalent strategies were adapted for other databases. Reference lists of included articles and relevant reviews were hand-searched. English-language studies were eligible. Two reviewers independently screened titles/abstracts and full texts in Rayyan; discrepancies were resolved by discussion. Inclusion: African populations; barriers, facilitators, or determinants of access/uptake; quantitative, qualitative, mixed-methods designs, and RAAB surveys. Exclusion: case reports; studies outside Africa; studies reporting only surgical outcomes without access/uptake data. A PRISMA flow diagram and checklist are provided as online supplements (Figure 1) Data Management, Extraction, and Synthesis Records were de-duplicated in EndNote and screened in Rayyan. Data were charted in a structured Excel form (year, country, design, sample size, barrier domains), and they were synthesised thematically with frequency counts to highlight dominant barriers; qualitative excerpts were extracted for context. Ethics approval was not required (review of published literature). Quality Appraisal Two reviewers independently assessed the methodological quality using suitable tools: the JBI Checklist for Studies Reporting Prevalence Data for RAAB and other prevalence surveys, the JBI Analytical Cross-Sectional Checklist for analytical observational studies, the CASP Qualitative Checklist for qualitative studies, and the Mixed Methods Appraisal Tool (MMAT, 2018) for mixed-methods designs. When applicable, non-randomised intervention evaluations were assessed using the ROBINS-I. Disagreements were resolved through discussion, with a third reviewer making the final decision on unresolved items. We tested the appraisal process on 10% of the included studies, aiming for Cohen’s κ ≥ 0.70 for item-level agreement. Agreement was then calculated across the entire set (κ with 95% CIs). Risk-of-bias assessments influenced the narrative synthesis by giving more weight to higher-quality evidence and were examined in sensitivity analyses, excluding studies with a high risk of bias. Additionally, we summarised study-level evidence quality using the Oxford Centre for Evidence-Based Medicine scheme for the evidence-rating table. Study selection The systematic search retrieved a total of 737 records across the selected databases. After the removal of 389 duplicates in EndNote, 348 unique articles remained. These records were screened by title and abstract using Rayyan, leading to the exclusion of 44 studies that were unrelated to cataract, were not conducted in Africa, or did not address issues of uptake or access. The full text of 304 articles was obtained and thoroughly assessed for eligibility. Of these, 196 were excluded: 72 were not cataract-related, 55 were conducted outside African populations, and 69 did not address barriers or access to surgery. Ultimately, 108 studies were included in the final systematic review. The study selection process is illustrated in the PRISMA 2020 flow diagrams. Figure 2 presents the simplified top-to-bottom version, while Figure 1 shows the formal four-column PRISMA 2020 layout, including detailed reasons for exclusion at the full-text stage. Study characteristics The included studies were published between 2000 and 2025, covering over two decades of research on cataract surgery access in Africa. The most common study designs were cross-sectional surveys, either hospital-based or population-based. A significant number of studies were population-based Rapid Assessment of Avoidable Blindness (RAAB) surveys, providing valuable epidemiological estimates of cataract prevalence and surgical coverage. Qualitative research, using interviews and focus groups, enriched the dataset by offering insights into the lived experiences and cultural factors that influence cataract surgery uptake. Mixed-methods designs have also emerged, especially in recent years, combining statistical analysis with qualitative perspectives to provide a more comprehensive understanding. Sample sizes varied considerably across the included studies. Small qualitative studies sometimes involved fewer than 50 participants, while large RAAB surveys included over 10,000 individuals. This variety enabled both a detailed and a broad understanding, though it also highlighted the differences in methodological approaches used across different study regions. Results Geographic distribution The geographic distribution of included studies demonstrated concentration in certain countries [6,7]. Nigeria, Ethiopia, Kenya, Ghana, and South Africa contributed the largest number of studies, reflecting both their population size and relatively strong research infrastructure [6,7]. Other countries represented included Malawi, Tanzania, Uganda, Rwanda, Cameroon, Senegal, and Egypt [6,7]. Several studies were multi-country in nature, particularly RAAB surveys coordinated by the World Health Organization or the International Agency for the Prevention of Blindness, which provided broader regional perspectives (Figure 3) [10,11]. Despite this diversity, significant gaps were identified [6]. Central Africa and francophone West Africa were underrepresented in the literature, with only a few studies originating from these regions [6,7]. Similarly, limited research was found from North Africa, aside from Egypt and a small number of studies from Tunisia and Morocco [6]. This suggests that, although considerable knowledge exists about barriers in certain parts of sub-Saharan Africa, other regions remain understudied and require further research (Figure 3) [6]. Barriers to cataract surgery uptake Patient-level barriers Patient-level barriers were the most frequently reported across the 108 included studies [6,7]. The issue of cost and affordability consistently emerged as the leading obstacle [6,9]. Patients frequently cited the direct costs of surgery as prohibitive; however, indirect costs, such as transportation, accommodation near surgical centres, and loss of income during recovery, also played a major role [9]. In many rural contexts, these financial considerations effectively prevented patients from even presenting for assessment (Figure 4) [6,9]. Lack of awareness and knowledge regarding cataract as a treatable condition was another dominant theme [6,7]. In multiple RAAB surveys, large proportions of individuals with visually significant cataract reported that they did not know surgery could restore sight [10,11]. Cataract blindness was often seen as an inevitable consequence of ageing, particularly among elderly populations, which discouraged care-seeking behaviour [6]. Fear of surgery and poor outcomes represented another critical patient-level barrier [6]. Patients often reported fears of blindness or death during or after surgery, or anticipated poor recovery outcomes; such fears were reinforced by anecdotal reports of negative experiences within communities, which could discourage others from seeking surgery [6]. Gender inequities were also well documented. Women were consistently less likely than men to access cataract surgery, despite having equal or greater need [8]. Explanations included reduced decision-making autonomy, lower access to household financial resources, and cultural norms that prioritised men’s health needs over women’s [6,8]. Finally, acceptance and cultural beliefs were emphasised across different contexts [6]. Some individuals attributed cataract blindness to fate, divine punishment, or supernatural causes [6]. Others sought treatment through traditional healers, delaying or entirely avoiding surgery [6]. These beliefs not only delayed access but, in some cases, completely discouraged patients from seeking biomedical care [6]. Community-level barriers Barriers at the community level were also consistently reported across the included studies [6,7]. Transport and distance to surgical centres were among the most prominent challenges [6]. Patients in rural areas often had to travel long distances over poor infrastructure, which was further compounded by the limited availability of public transport [6,7]. The cost of travel, often requiring multiple companions, added to the already high economic burden (Figure 5) [12]. Weak referral systems between primary health care services and specialist eye hospitals also hindered access [7,13]. Many patients identified with cataract at community screening camps or during general medical visits were not successfully linked to surgical services [7,13]. Missed opportunities at the referral stage were reported frequently, reflecting fragmentation in the continuum of care [7]. Limited outreach and surgical camp activities were highlighted as additional obstacles [14,15]. Outreach programmes were highly effective in improving uptake where available, but their coverage was inconsistent [14]. Many rural and underserved areas remained unreached, while outreach programmes that did operate often faced sustainability challenges, leaving communities underserved once projects ended [14,15]. System-level barriers System-level barriers reflected broader health system challenges across the African continent [6,7,9]. Workforce and capacity constraints were identified in nearly every study (Figure 6) [6,7]. A shortage of ophthalmologists, coupled with insufficient numbers of trained nurses and allied eye health personnel, significantly limited the number of surgeries that could be performed [7,16]. Even where human resources were available, surgical throughput was often constrained by limited theatre time (Figure 6) [7,14,15]. Financing and insurance gaps were another recurrent theme [6,9]. In most settings, cataract surgery was financed primarily through out-of-pocket payments [12]. While a few countries had developed subsidy schemes or incorporated cataract surgery into insurance packages, these remained limited in scale and reach [9]. Voucher programmes and donor-funded initiatives were reported in some contexts, but were often temporary or geographically restricted [15]. The low cataract surgical rate (CSR) and cataract surgical coverage (CSC) highlighted the uneven distribution of services [4,7]. Urban populations were more likely to access surgery than rural populations [7], and in many countries, the overall CSR remained far below recommended targets [4]. Policy and infrastructure gaps were also widely reported [6,7,9]. Many facilities lacked basic equipment or suffered from frequent shortages of consumables such as intraocular lenses and sutures [6,7]. Long waiting lists and inefficient scheduling systems further delayed care [7,14,15]. These structural limitations reduced surgical volume and worsened inequities in access [7,9]. Regional variation Regional disparities were consistently reported [6,7]. Rural populations were found to experience disproportionately high barriers, including transport difficulties, limited outreach, and higher levels of poverty [7,12,14]. Gender disparities were striking, with women significantly less likely than men to undergo surgery [8]. Socioeconomic status was also a major determinant, as poorer households were more likely to delay or forgo surgery altogether due to financial and logistical constraints [4,7,12]. Differences between countries were also observed [6,7]. In relatively higher-income countries such as South Africa and Egypt, cataract services were better resourced and often subsidised, but inequities persisted among rural and marginalised groups [7,9]. In lower-income countries, systemic challenges such as workforce shortages and limited financial resources were the dominant barriers, with little evidence of comprehensive national strategies to address them [6,7,9,16]. Summary of findings Overall, the findings from this review demonstrate that barriers to cataract surgery uptake in Africa are multifactorial and interlinked, spanning patient, community, and system levels [6,7]. Patient-level barriers, such as cost, fear, and lack of awareness, were the most prominent; however, these were compounded by weak referral systems, transportation challenges, and systemic constraints in the workforce, infrastructure, and financing [6,7,9–14,16]. Importantly, most of these barriers are modifiable [9,15]. Evidence suggests that interventions such as patient education campaigns, transport vouchers, financial subsidies, decentralisation of services, and strengthened referral pathways have the potential to improve cataract surgical uptake across diverse African contexts substantially [12–16]. Discussion This review synthesised evidence from 108 studies (2000–2025), providing the most comprehensive overview to date of barriers to cataract surgery uptake in Africa. Across diverse settings, obstacles are complex and operate at multiple levels, including patient, community, and health-system levels [ 6 , 7 ]. Patient-level challenges included cost, lack of awareness, fear of surgery, gender inequalities, and cultural beliefs, which were the most frequently reported [ 6 ]. Community-level barriers encompassed transport difficulties, weak referral pathways, and limited or irregular outreach [ 6 , 7 ]. System-level constraints, notably workforce shortages (ophthalmologists and allied health personnel), inadequate theatre capacity and equipment, and financing gaps, further limited access [ 7 ]. Although contexts vary, the mechanisms are notably similar: individuals who would benefit most encounter the greatest frictions at each stage from diagnosis to operation, leading to persistently low cataract surgical coverage (CSC) and disparities based on sex, residence, and socioeconomic status [ 7 , 8 ]. These findings align with global evidence from other low- and middle-income countries, particularly in Asia and Latin America, where cost, fear, and limited awareness similarly prevail [ 9 – 11 ]. However, Africa faces distinct challenges. The number of ophthalmologists is among the lowest worldwide, and cataract surgical rates (CSR) and CSC often do not meet international standards [ 7 ]. Out-of-pocket (OOP) payments remain common, exacerbating inequalities and leaving the poorest and most marginalised without access [ 12 ]. Geographic disparities in the evidence base, particularly the under-representation of Central and francophone West Africa, highlight gaps in both service provision and scholarly reporting, underscoring the need for region-specific strategies and investments [ 6 ]. Patient-level barriers go beyond surgical fees. The indirect costs of transport, accommodation, and income loss often match or surpass the price of the operation [ 12 ]. Fear of surgery, often heightened by anecdotal reports of poor outcomes, discourages people from seeking care [ 6 ]. Gender inequalities are clear: women are less likely than men to undergo surgery despite having equal or greater need [ 8 ]. Cultural beliefs that cataract blindness is an unavoidable part of ageing or caused by fate or supernatural forces delay presentation and acceptance [ 6 ]. Tackling these barriers involves trusted counselling, clear communication of expected outcomes and risks, and targeted community engagement that respects local beliefs while addressing misinformation [ 13 ]. At the community level, weak links between primary care and specialist services hinder the transition from identification to surgery [ 7 , 13 ]. Many patients identified during screening camps or primary care visits are not successfully referred or do not complete the referral process [ 7 , 13 ]. Outreach programmes, which are effective when sustained, are often irregular and not synchronised with theatre lists, leaving large rural populations underserved [ 14 , 15 ]. Transport remains a recurring barrier, worsened by poor roads, long travel times, and the need for companions [ 12 ]. Practical solutions include providing guaranteed transport vouchers or buses, escorting policies for carers, and scheduled block lists that coordinate outreach with surgical capacity [ 13 , 14 ]. System-level barriers are the most structural. Workforce shortages restrict annual surgical volume, while limited theatre time, shortages of equipment and consumables, and supply-chain disruptions reduce productivity even when skilled personnel are available [ 7 , 16 ]. Financing remains a persistent gap, with cataract rarely covered comprehensively by insurance and services heavily dependent on donors or OOP payments [ 12 ]. This model restricts access and entrenches inequality [ 12 ]. Policy solutions include integrating cataract surgery into publicly financed benefit packages, ensuring timely provider reimbursements, and developing robust procurement and information systems to prevent stock-outs and support equitable planning [ 9 ]. Evidence supports the use of multi-component strategies tailored to individual barrier profiles [ 13 , 17 ]. On the demand side, counselling and education address fear and misconceptions; subsidies/insurance and transport vouchers reduce both direct and indirect costs [ 12 , 13 ]. On the supply side, integrating screening and referral into primary care, maintaining sustained outreach with guaranteed linkage to surgery, decentralising surgical capacity where feasible, and investing in workforce, theatre time, scheduling, and supply chains are essential [ 7 , 14 , 16 , 18 , 19 ]. Interventions carried out in isolation often produce short-term gains; coordinated packages are more likely to increase CSR and CSC at scale, aligning with national eye-health plans and equity objectives [ 9 , 13 ]. Women, rural residents, and poorer households face higher cumulative barriers. Programmes should incorporate gender-responsive strategies (such as flexible scheduling for carers, accompaniment, community champions, and engagement of household decision-makers) and pro-poor designs (including means-tested waivers, cash or transport stipends, and mobile payment options). Routine monitoring must disaggregate uptake, CSC, and waiting times by sex, residence, and socioeconomic status; where disparities persist, managers can adjust outreach locations, referral pathways, and subsidy levels [ 7 , 8 , 12 , 20 ]. Without this equity perspective, overall volumes may increase while the most disadvantaged remain excluded [ 9 ]. Outreach and surgical “camp” models can expand access quickly; however, linkage to surgery and post-operative follow-up are inconsistent [ 14 ]. A hybrid approach, combining periodic outreach for identification and counselling with guaranteed transport and scheduled operating lists at referral centres, tends to achieve more reliable conversion [ 13 , 14 ]. When caseloads permit, decentralised “satellite” lists in district theatres, with visiting surgeons or task-sharing, can reduce travel and waiting times. However, decentralisation requires attention to equipment maintenance, consumable supply, and supervision to maintain surgical quality and patient safety [ 16 , 21 ]. Direct fees are only part of the economic equation. Since indirect costs often outweigh direct expenses, successful schemes blend fee protection (waivers/insurance) with last-mile support (transport vouchers, organised buses, group lodging) [ 12 , 13 ]. Providers should ensure all costs are transparent during counselling, simplify pre-authorisation for subsidies, and reduce the number of visits required between diagnosis and surgery (e.g., one-stop biometry, pre-assessment, and booking) [ 13 ]. At a policy level, integrating cataract treatment into universal health coverage benefits and securing predictable funding are vital to maintaining progress and preventing informal payments [ 9 ]. Beyond training more ophthalmologists, teams can boost throughput through task-sharing (e.g., non-physician cataract surgeons; nurses/allied health personnel for biometry, counselling, and post-operative checks), standardising pre-operative protocols, and implementing block scheduling to reduce theatre downtime [ 16 ]. Mentorship, supportive supervision, and continuous quality improvement should accompany scale-up to maintain outcomes while increasing volume [ 16 ]. Low-cost digital tools, such as SMS reminders, simple electronic booking lists, and phone guidance for referrals, can reduce no-shows and streamline workflows when integrated into routine pathways [ 9 ]. Fear of “bad surgery” is a recurrent deterrent. Programmes must pair access interventions with visible quality assurance, including routine outcome audits, respectful communication, clear expectation-setting, and prompt management of complications [ 15 , 22 ]. Publishing local outcome dashboards, sharing patient testimonials, and enabling contact with previous beneficiaries can counter misinformation [ 15 ]. Throughput should not compromise pre-operative optimisation or post-operative follow-up; cutting corners risks new fear narratives that depress future uptake [ 6 , 15 ]. Heterogeneity in defining “uptake” complicates comparison. We recommend standardising uptake as the proportion of those assessed and deemed eligible who undergo surgery within a defined window (e.g., 3–12 months), reporting both the numerator and denominator, and clarifying whether the units are eye-versus person-level [ 7 ]. Reasons for non-uptake should be coded to a common patient, community, or system taxonomy, allowing for multiple selections. Time-to-surgery, referral-to-surgery conversion, and no-show rates are pragmatic, programme-relevant metrics that should be recorded and disaggregated by equity [ 7 , 21 , 23 , 27 ]. Consistent definitions will strengthen future evidence and enable benchmarking [ 7 ]. Despite extensive observational work, causal evidence on what reliably increases uptake remains limited. Priorities include pragmatic evaluations of transport/fee support, as well as counselling packages (e.g., cluster or stepped-wedge trials), interrupted time series analyses for policy changes (such as insurance coverage and fee waivers), and hybrid effectiveness-implementation studies that assess fidelity, cost, and scalability [ 13 , 24 – 26 , 28 – 32 ]. Mixed-methods approaches are vital; incorporating qualitative inquiry allows for a deeper understanding of acceptability, household decision-making processes, and unintended outcomes [ 13 ]. Under-represented regions, including Central and francophone West Africa, require targeted support [ 6 ]. Cost analysis should extend beyond surgical fees to encompass patient-incurred indirect costs and health-system expenses related to outreach and decentralisation, enabling value-for-money assessments [ 12 , 24 ]. Cataract services intersect with primary care and the management of chronic diseases. Coordination with diabetes and hypertension clinics can identify eligible patients, provide peri-operative optimisation, and bundle transport for multipurpose visits [ 9 , 19 ]. Partnerships with social protection programmes can channel means-tested subsidies efficiently [ 9 ]. In humanitarian or fragile settings, mobile theatres with robust referral and follow-up protocols may be suitable, with planned transition to sustainable fixed services [ 14 ]. Study designs varied and the risk of bias was diverse; Rapid Assessment of Avoidable Blindness (RAAB) surveys offered breadth, while qualitative studies provided contextual depth [ 6 , 11 ]. Geographic focus (Nigeria, Ethiopia, Kenya, Ghana, South Africa) and the restriction to English may bias the results; Central and Francophone West Africa remain understudied [ 6 ]. Few studies have measured the effects of interventions or assessed the sustainability of outreach or voucher schemes over time [ 13 , 14 , 26 ]. Varying definitions of uptake and inconsistent reporting of denominators hindered comparison and prevented meta-analysis [ 7 ]. Although higher-quality evidence was given more weight and sensitivity analyses were performed, residual confounding and publication bias cannot be ruled out [ 7 ]. Where national or international cataract guidelines exist, our synthesis supports recommendations for counselling, cost mitigation, outreach, and primary-care integration; availability and quality vary by country [ 9 , 30 ]. Programmes should align delivery models with current guidance and use routine data to iterate (equity-disaggregated uptake/CSC, no-show rates) [ 9 ]. When guidance is absent or outdated, the multi-component, equity-centred package outlined here provides a practical default that can be adapted to local barriers and capacity [ 13 ]. Improving cataract surgery uptake in Africa requires addressing interconnected barriers at the patient, community, and system levels. The most promising approach combines targeted financial and transport support, trusted counselling, strengthened referral and outreach, careful decentralisation with assured quality, and ongoing investments in workforce and theatre capacity [ 12 – 19 ]. Incorporating equity metrics, standardised definitions, and rigorous, yet practical evaluation into routine practice can turn incremental improvements into lasting gains in CSC and CSR, delivering high-value, sight-restoring care to those who need it most [ 9 , 13 ]. Conclusions Cataract surgery uptake in Africa is limited by modifiable barriers at the patient, community, and system levels. Coordinated, evidence-based strategies, such as education and counselling, financial and transportation support, enhanced referral and outreach, decentralised capacity, and system investments, can improve equitable access and accelerate progress towards reducing avoidable blindness. Declarations Author Contribution K.N. conceived the study, designed the search and protocol, led screening and data extraction, performed the analysis, and drafted the manuscript. W.H. refined the search strategy, verified screening and data extraction, prepared the tables and figures, and contributed to interpretation. W.H. and K.N. revised the manuscript for important intellectual content. All authors approved the final version. References World Health Organization (WHO) (2025) Blindness and vision impairment. WHO, Geneva. https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment. Accessed 14 Sep 2025 O’Brart DPS (2025) The future of cataract surgery. Eye (Lond) 39:1451–1456. https://doi.org/10.1038/s41433-025-03745-x Hashemi H, Fayaz F, Hashemi A, Khabazkhoob M (2025) Global prevalence of cataract surgery. 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McGuinness MB, Moo E, Varga B, Dodson S, Lansingh VC, Resnikoff S et al (2025) The Better Operative Outcomes Software Tool (BOOST) Prospective Study: improving the quality of cataract surgery outcomes in low-resource settings. Ophthalmic Epidemiol. Epub ahead of print. Patrick-Ferife G, Ashaye A et al (2006) Rapid assessment of cataract blindness among Ughelli Clan in an urban/rural district of Delta State, Nigeria. Ann Afr Med. Pagination unavailable. Lee CN, Ramke J, McCormick I, Zhang JH, Aghaji A, Mwangi N et al (2020) Are we advancing universal health coverage through cataract services? Protocol for a scoping review. BMJ Open 10:e039458. https://doi.org/10.1136/bmjopen-2020-039458 Berhane Y, Worku A, Bejiga A, Alemayehu W et al (2007) National survey on blindness, low vision and trachoma in Ethiopia: methods and study clusters profile. Ethiop J Health Dev 21(3):185–203. https://doi.org/10.4314/ejhd.v21i3.10049 Khoza LB, Nunu WN, Tshivhase SE, Murwira TS, Mambanga P, Ramakuela NJ et al (2020) Survey on prevalence of cataract in selected communities in Limpopo Province of South Africa. Scientific African 8:e00352. https://doi.org/10.1016/j.sciaf.2020.e00352 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Dec, 2025 Read the published version in International Ophthalmology → Version 1 posted Editorial decision: Revision requested 27 Oct, 2025 Reviews received at journal 26 Oct, 2025 Reviews received at journal 22 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers invited by journal 14 Oct, 2025 Editor assigned by journal 03 Oct, 2025 Submission checks completed at journal 03 Oct, 2025 First submitted to journal 01 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7759268","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":535872877,"identity":"34eaa959-a73f-479a-8120-f6e31c537e74","order_by":0,"name":"Wilhelm 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1","display":"","copyAsset":false,"role":"figure","size":227040,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Diagram\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7759268/v1/6f360cc4ae64d3b418c278f3.png"},{"id":94672253,"identity":"96dd875d-2cb7-452b-9f7b-dca54176563c","added_by":"auto","created_at":"2025-10-29 13:40:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":278059,"visible":true,"origin":"","legend":"\u003cp\u003eSimplified PRISMA Diagram\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7759268/v1/d55a361de6ef8f5d891e0a98.png"},{"id":94672289,"identity":"acd0cee0-7416-4f33-8eab-a712edd6721b","added_by":"auto","created_at":"2025-10-29 13:40:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":531073,"visible":true,"origin":"","legend":"\u003cp\u003eGeographic Distribution of Included Studies in Africa (2000–2025).\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7759268/v1/711fc02e6679286562f11abe.png"},{"id":94672555,"identity":"25984c4d-2865-4002-a4d8-d5dd8c70b891","added_by":"auto","created_at":"2025-10-29 13:40:42","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":231726,"visible":true,"origin":"","legend":"\u003cp\u003ePatient-Level Barriers to Cataract Surgery Uptake (proportion of studies reporting each barrier)\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7759268/v1/a7a2b6221c7063681750f833.png"},{"id":94672769,"identity":"5f2c002f-9462-4b98-80d2-79118a828fe5","added_by":"auto","created_at":"2025-10-29 13:40:57","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":386345,"visible":true,"origin":"","legend":"\u003cp\u003eCommunity-Level Barriers to Cataract Surgery Uptake (proportion of studies reporting each barrier)\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7759268/v1/1e749a15b6527a1f5f116f3c.png"},{"id":94672333,"identity":"5a709b29-4271-48e7-a514-ea7ca46559e3","added_by":"auto","created_at":"2025-10-29 13:40:18","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":218228,"visible":true,"origin":"","legend":"\u003cp\u003eSystem-Level Barriers to Cataract Surgery Uptake: Workforce, Financing, Cataract Surgical Rate (CSR), and Cataract Surgical Coverage (CSC)\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7759268/v1/c4f1a7dba59036b06aa4eb3b.png"},{"id":98244136,"identity":"54977133-8214-40a1-aa75-0e7aeeab4ae1","added_by":"auto","created_at":"2025-12-15 16:13:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2325873,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7759268/v1/2a033b8a-1056-4552-a221-a31f6c1c6d74.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers to Cataract Surgery Uptake in Africa: A Systematic Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCataract remains the leading cause of reversible blindness worldwide and a major contributor to visual impairment in Africa [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Modern cataract surgery is safe, effective, and highly cost-efficient, with advances in small-incision techniques, biometry, intraocular lenses, and peri-operative pathways further enhancing outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, the proportion of people who have undergone cataract surgery continues to increase, yet it remains uneven across regions and income groups, indicating disparities in access and uptake [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Many countries still report cataract surgical rate (CSR) and cataract surgical coverage (CSC) below recommended thresholds, and CSR is strongly linked to socioeconomic development and health-system capacity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These disparities persist despite policy momentum under VISION 2030: In Sight, For All, which prioritises equity and integrated, people-centred eye care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis review examines barriers to cataract surgery uptake, particularly the gap between the need for surgery and its utilisation, drawing on evidence that combines patient, community, and health system factors in African settings [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Service organisation, financing, and workforce capacity are recurring system drivers of access and outcomes, shaping both CSR and CSC [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Ongoing inequalities based on sex further hinder uptake, with women less likely than men to undergo surgery despite having similar or greater need [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe place these issues within the broader context of universal eye health planning and implementation to inform practical, scalable solutions that align with global commitments [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. We synthesised studies from 2000 to 2025 to: (1) identify and categorise barriers; (2) describe regional variation; and (3) highlight evidence gaps to guide implementation and research priorities.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003e\u003cstrong\u003eProtocol Registration and Reporting\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251145721) and conducted in accordance with PRISMA 2020.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eLiterature Search and Study Selection\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eWe systematically searched PubMed/MEDLINE, Scopus, Web of Science, and Africa-Wide Information (EBSCO) from January 2000 to March 2025 (search executed September 2025). The PubMed strategy combined MeSH and free-text terms for cataract surgery, access/uptake, and African countries; equivalent strategies were adapted for other databases. Reference lists of included articles and relevant reviews were hand-searched. English-language studies were eligible. Two reviewers independently screened titles/abstracts and full texts in Rayyan; discrepancies were resolved by discussion. Inclusion: African populations; barriers, facilitators, or determinants of access/uptake; quantitative, qualitative, mixed-methods designs, and RAAB surveys. Exclusion: case reports; studies outside Africa; studies reporting only surgical outcomes without access/uptake data. A PRISMA flow diagram and checklist are provided as online supplements (Figure 1)\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eData Management, Extraction, and Synthesis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eRecords were de-duplicated in EndNote and screened in Rayyan. Data were charted in a structured Excel form (year, country, design, sample size, barrier domains), and they were synthesised thematically with frequency counts to highlight dominant barriers; qualitative excerpts were extracted for context. Ethics approval was not required (review of published literature).\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eQuality Appraisal\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eTwo reviewers independently assessed the methodological quality using suitable tools: the JBI Checklist for Studies Reporting Prevalence Data for RAAB and other prevalence surveys, the JBI Analytical Cross-Sectional Checklist for analytical observational studies, the CASP Qualitative Checklist for qualitative studies, and the Mixed Methods Appraisal Tool (MMAT, 2018) for mixed-methods designs. When applicable, non-randomised intervention evaluations were assessed using the ROBINS-I. Disagreements were resolved through discussion, with a third reviewer making the final decision on unresolved items. We tested the appraisal process on 10% of the included studies, aiming for Cohen\u0026rsquo;s \u0026kappa; \u0026ge; 0.70 for item-level agreement. Agreement was then calculated across the entire set (\u0026kappa; with 95% CIs). Risk-of-bias assessments influenced the narrative synthesis by giving more weight to higher-quality evidence and were examined in sensitivity analyses, excluding studies with a high risk of bias. Additionally, we summarised study-level evidence quality using the Oxford Centre for Evidence-Based Medicine scheme for the evidence-rating table.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eStudy selection\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe systematic search retrieved a total of 737 records across the selected databases. After the removal of 389 duplicates in EndNote, 348 unique articles remained. These records were screened by title and abstract using Rayyan, leading to the exclusion of 44 studies that were unrelated to cataract, were not conducted in Africa, or did not address issues of uptake or access. The full text of 304 articles was obtained and thoroughly assessed for eligibility. Of these, 196 were excluded: 72 were not cataract-related, 55 were conducted outside African populations, and 69 did not address barriers or access to surgery. Ultimately, 108 studies were included in the final systematic review.\u003c/p\u003e\n\u003cp\u003eThe study selection process is illustrated in the PRISMA 2020 flow diagrams. Figure 2 presents the simplified top-to-bottom version, while Figure 1 shows the formal four-column PRISMA 2020 layout, including detailed reasons for exclusion at the full-text stage.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eStudy characteristics\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe included studies were published between 2000 and 2025, covering over two decades of research on cataract surgery access in Africa. The most common study designs were cross-sectional surveys, either hospital-based or population-based. A significant number of studies were population-based Rapid Assessment of Avoidable Blindness (RAAB) surveys, providing valuable epidemiological estimates of cataract prevalence and surgical coverage. Qualitative research, using interviews and focus groups, enriched the dataset by offering insights into the lived experiences and cultural factors that influence cataract surgery uptake. Mixed-methods designs have also emerged, especially in recent years, combining statistical analysis with qualitative perspectives to provide a more comprehensive understanding.\u003c/p\u003e\n\u003cp\u003eSample sizes varied considerably across the included studies. Small qualitative studies sometimes involved fewer than 50 participants, while large RAAB surveys included over 10,000 individuals. This variety enabled both a detailed and a broad understanding, though it also highlighted the differences in methodological approaches used across different study regions.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003e\u003cstrong\u003eGeographic distribution\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe geographic distribution of included studies demonstrated concentration in certain countries [6,7]. Nigeria, Ethiopia, Kenya, Ghana, and South Africa contributed the largest number of studies, reflecting both their population size and relatively strong research infrastructure [6,7]. Other countries represented included Malawi, Tanzania, Uganda, Rwanda, Cameroon, Senegal, and Egypt [6,7]. Several studies were multi-country in nature, particularly RAAB surveys coordinated by the World Health Organization or the International Agency for the Prevention of Blindness, which provided broader regional perspectives (Figure 3) [10,11].\u003c/p\u003e\n\u003cp\u003eDespite this diversity, significant gaps were identified [6]. Central Africa and francophone West Africa were underrepresented in the literature, with only a few studies originating from these regions [6,7]. Similarly, limited research was found from North Africa, aside from Egypt and a small number of studies from Tunisia and Morocco [6]. This suggests that, although considerable knowledge exists about barriers in certain parts of sub-Saharan Africa, other regions remain understudied and require further research (Figure 3) [6].\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eBarriers to cataract surgery uptake\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e\u003cstrong\u003ePatient-level barriers\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003ePatient-level barriers were the most frequently reported across the 108 included studies [6,7]. The issue of cost and affordability consistently emerged as the leading obstacle [6,9]. Patients frequently cited the direct costs of surgery as prohibitive; however, indirect costs, such as transportation, accommodation near surgical centres, and loss of income during recovery, also played a major role [9]. In many rural contexts, these financial considerations effectively prevented patients from even presenting for assessment (Figure 4) [6,9].\u003c/p\u003e\n\u003cp\u003eLack of awareness and knowledge regarding cataract as a treatable condition was another dominant theme [6,7]. In multiple RAAB surveys, large proportions of individuals with visually significant cataract reported that they did not know surgery could restore sight [10,11]. Cataract blindness was often seen as an inevitable consequence of ageing, particularly among elderly populations, which discouraged care-seeking behaviour [6].\u003c/p\u003e\n\u003cp\u003eFear of surgery and poor outcomes represented another critical patient-level barrier [6]. Patients often reported fears of blindness or death during or after surgery, or anticipated poor recovery outcomes; such fears were reinforced by anecdotal reports of negative experiences within communities, which could discourage others from seeking surgery [6].\u003c/p\u003e\n\u003cp\u003eGender inequities were also well documented. Women were consistently less likely than men to access cataract surgery, despite having equal or greater need [8]. Explanations included reduced decision-making autonomy, lower access to household financial resources, and cultural norms that prioritised men\u0026rsquo;s health needs over women\u0026rsquo;s [6,8].\u003c/p\u003e\n\u003cp\u003eFinally, acceptance and cultural beliefs were emphasised across different contexts [6]. Some individuals attributed cataract blindness to fate, divine punishment, or supernatural causes [6]. Others sought treatment through traditional healers, delaying or entirely avoiding surgery [6]. These beliefs not only delayed access but, in some cases, completely discouraged patients from seeking biomedical care [6].\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCommunity-level barriers\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eBarriers at the community level were also consistently reported across the included studies [6,7]. Transport and distance to surgical centres were among the most prominent challenges [6]. Patients in rural areas often had to travel long distances over poor infrastructure, which was further compounded by the limited availability of public transport [6,7]. The cost of travel, often requiring multiple companions, added to the already high economic burden (Figure 5) [12].\u003c/p\u003e\n\u003cp\u003eWeak referral systems between primary health care services and specialist eye hospitals also hindered access [7,13]. Many patients identified with cataract at community screening camps or during general medical visits were not successfully linked to surgical services [7,13]. Missed opportunities at the referral stage were reported frequently, reflecting fragmentation in the continuum of care [7].\u003c/p\u003e\n\u003cp\u003eLimited outreach and surgical camp activities were highlighted as additional obstacles [14,15]. Outreach programmes were highly effective in improving uptake where available, but their coverage was inconsistent [14]. Many rural and underserved areas remained unreached, while outreach programmes that did operate often faced sustainability challenges, leaving communities underserved once projects ended [14,15].\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eSystem-level barriers\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eSystem-level barriers reflected broader health system challenges across the African continent [6,7,9]. Workforce and capacity constraints were identified in nearly every study (Figure 6) [6,7]. A shortage of ophthalmologists, coupled with insufficient numbers of trained nurses and allied eye health personnel, significantly limited the number of surgeries that could be performed [7,16]. Even where human resources were available, surgical throughput was often constrained by limited theatre time (Figure 6) [7,14,15].\u003c/p\u003e\n\u003cp\u003eFinancing and insurance gaps were another recurrent theme [6,9]. In most settings, cataract surgery was financed primarily through out-of-pocket payments [12]. While a few countries had developed subsidy schemes or incorporated cataract surgery into insurance packages, these remained limited in scale and reach [9]. Voucher programmes and donor-funded initiatives were reported in some contexts, but were often temporary or geographically restricted [15].\u003c/p\u003e\n\u003cp\u003eThe low cataract surgical rate (CSR) and cataract surgical coverage (CSC) highlighted the uneven distribution of services [4,7]. Urban populations were more likely to access surgery than rural populations [7], and in many countries, the overall CSR remained far below recommended targets [4].\u003c/p\u003e\n\u003cp\u003ePolicy and infrastructure gaps were also widely reported [6,7,9]. Many facilities lacked basic equipment or suffered from frequent shortages of consumables such as intraocular lenses and sutures [6,7]. Long waiting lists and inefficient scheduling systems further delayed care [7,14,15]. These structural limitations reduced surgical volume and worsened inequities in access [7,9].\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eRegional variation\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eRegional disparities were consistently reported [6,7]. Rural populations were found to experience disproportionately high barriers, including transport difficulties, limited outreach, and higher levels of poverty [7,12,14]. Gender disparities were striking, with women significantly less likely than men to undergo surgery [8]. Socioeconomic status was also a major determinant, as poorer households were more likely to delay or forgo surgery altogether due to financial and logistical constraints [4,7,12].\u003c/p\u003e\n\u003cp\u003eDifferences between countries were also observed [6,7]. In relatively higher-income countries such as South Africa and Egypt, cataract services were better resourced and often subsidised, but inequities persisted among rural and marginalised groups [7,9]. In lower-income countries, systemic challenges such as workforce shortages and limited financial resources were the dominant barriers, with little evidence of comprehensive national strategies to address them [6,7,9,16].\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eSummary of findings\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eOverall, the findings from this review demonstrate that barriers to cataract surgery uptake in Africa are multifactorial and interlinked, spanning patient, community, and system levels [6,7]. Patient-level barriers, such as cost, fear, and lack of awareness, were the most prominent; however, these were compounded by weak referral systems, transportation challenges, and systemic constraints in the workforce, infrastructure, and financing [6,7,9\u0026ndash;14,16]. Importantly, most of these barriers are modifiable [9,15]. Evidence suggests that interventions such as patient education campaigns, transport vouchers, financial subsidies, decentralisation of services, and strengthened referral pathways have the potential to improve cataract surgical uptake across diverse African contexts substantially [12\u0026ndash;16].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis review synthesised evidence from 108 studies (2000\u0026ndash;2025), providing the most comprehensive overview to date of barriers to cataract surgery uptake in Africa. Across diverse settings, obstacles are complex and operate at multiple levels, including patient, community, and health-system levels [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Patient-level challenges included cost, lack of awareness, fear of surgery, gender inequalities, and cultural beliefs, which were the most frequently reported [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Community-level barriers encompassed transport difficulties, weak referral pathways, and limited or irregular outreach [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. System-level constraints, notably workforce shortages (ophthalmologists and allied health personnel), inadequate theatre capacity and equipment, and financing gaps, further limited access [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although contexts vary, the mechanisms are notably similar: individuals who would benefit most encounter the greatest frictions at each stage from diagnosis to operation, leading to persistently low cataract surgical coverage (CSC) and disparities based on sex, residence, and socioeconomic status [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese findings align with global evidence from other low- and middle-income countries, particularly in Asia and Latin America, where cost, fear, and limited awareness similarly prevail [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, Africa faces distinct challenges. The number of ophthalmologists is among the lowest worldwide, and cataract surgical rates (CSR) and CSC often do not meet international standards [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Out-of-pocket (OOP) payments remain common, exacerbating inequalities and leaving the poorest and most marginalised without access [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Geographic disparities in the evidence base, particularly the under-representation of Central and francophone West Africa, highlight gaps in both service provision and scholarly reporting, underscoring the need for region-specific strategies and investments [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePatient-level barriers go beyond surgical fees. The indirect costs of transport, accommodation, and income loss often match or surpass the price of the operation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Fear of surgery, often heightened by anecdotal reports of poor outcomes, discourages people from seeking care [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Gender inequalities are clear: women are less likely than men to undergo surgery despite having equal or greater need [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Cultural beliefs that cataract blindness is an unavoidable part of ageing or caused by fate or supernatural forces delay presentation and acceptance [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Tackling these barriers involves trusted counselling, clear communication of expected outcomes and risks, and targeted community engagement that respects local beliefs while addressing misinformation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAt the community level, weak links between primary care and specialist services hinder the transition from identification to surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Many patients identified during screening camps or primary care visits are not successfully referred or do not complete the referral process [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Outreach programmes, which are effective when sustained, are often irregular and not synchronised with theatre lists, leaving large rural populations underserved [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Transport remains a recurring barrier, worsened by poor roads, long travel times, and the need for companions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Practical solutions include providing guaranteed transport vouchers or buses, escorting policies for carers, and scheduled block lists that coordinate outreach with surgical capacity [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSystem-level barriers are the most structural. Workforce shortages restrict annual surgical volume, while limited theatre time, shortages of equipment and consumables, and supply-chain disruptions reduce productivity even when skilled personnel are available [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Financing remains a persistent gap, with cataract rarely covered comprehensively by insurance and services heavily dependent on donors or OOP payments [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This model restricts access and entrenches inequality [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Policy solutions include integrating cataract surgery into publicly financed benefit packages, ensuring timely provider reimbursements, and developing robust procurement and information systems to prevent stock-outs and support equitable planning [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEvidence supports the use of multi-component strategies tailored to individual barrier profiles [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. On the demand side, counselling and education address fear and misconceptions; subsidies/insurance and transport vouchers reduce both direct and indirect costs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. On the supply side, integrating screening and referral into primary care, maintaining sustained outreach with guaranteed linkage to surgery, decentralising surgical capacity where feasible, and investing in workforce, theatre time, scheduling, and supply chains are essential [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Interventions carried out in isolation often produce short-term gains; coordinated packages are more likely to increase CSR and CSC at scale, aligning with national eye-health plans and equity objectives [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWomen, rural residents, and poorer households face higher cumulative barriers. Programmes should incorporate gender-responsive strategies (such as flexible scheduling for carers, accompaniment, community champions, and engagement of household decision-makers) and pro-poor designs (including means-tested waivers, cash or transport stipends, and mobile payment options). Routine monitoring must disaggregate uptake, CSC, and waiting times by sex, residence, and socioeconomic status; where disparities persist, managers can adjust outreach locations, referral pathways, and subsidy levels [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Without this equity perspective, overall volumes may increase while the most disadvantaged remain excluded [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOutreach and surgical \u0026ldquo;camp\u0026rdquo; models can expand access quickly; however, linkage to surgery and post-operative follow-up are inconsistent [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A hybrid approach, combining periodic outreach for identification and counselling with guaranteed transport and scheduled operating lists at referral centres, tends to achieve more reliable conversion [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. When caseloads permit, decentralised \u0026ldquo;satellite\u0026rdquo; lists in district theatres, with visiting surgeons or task-sharing, can reduce travel and waiting times. However, decentralisation requires attention to equipment maintenance, consumable supply, and supervision to maintain surgical quality and patient safety [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDirect fees are only part of the economic equation. Since indirect costs often outweigh direct expenses, successful schemes blend fee protection (waivers/insurance) with last-mile support (transport vouchers, organised buses, group lodging) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Providers should ensure all costs are transparent during counselling, simplify pre-authorisation for subsidies, and reduce the number of visits required between diagnosis and surgery (e.g., one-stop biometry, pre-assessment, and booking) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. At a policy level, integrating cataract treatment into universal health coverage benefits and securing predictable funding are vital to maintaining progress and preventing informal payments [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBeyond training more ophthalmologists, teams can boost throughput through task-sharing (e.g., non-physician cataract surgeons; nurses/allied health personnel for biometry, counselling, and post-operative checks), standardising pre-operative protocols, and implementing block scheduling to reduce theatre downtime [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Mentorship, supportive supervision, and continuous quality improvement should accompany scale-up to maintain outcomes while increasing volume [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Low-cost digital tools, such as SMS reminders, simple electronic booking lists, and phone guidance for referrals, can reduce no-shows and streamline workflows when integrated into routine pathways [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFear of \u0026ldquo;bad surgery\u0026rdquo; is a recurrent deterrent. Programmes must pair access interventions with visible quality assurance, including routine outcome audits, respectful communication, clear expectation-setting, and prompt management of complications [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Publishing local outcome dashboards, sharing patient testimonials, and enabling contact with previous beneficiaries can counter misinformation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Throughput should not compromise pre-operative optimisation or post-operative follow-up; cutting corners risks new fear narratives that depress future uptake [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHeterogeneity in defining \u0026ldquo;uptake\u0026rdquo; complicates comparison. We recommend standardising uptake as the proportion of those assessed and deemed eligible who undergo surgery within a defined window (e.g., 3\u0026ndash;12 months), reporting both the numerator and denominator, and clarifying whether the units are eye-versus person-level [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Reasons for non-uptake should be coded to a common patient, community, or system taxonomy, allowing for multiple selections. Time-to-surgery, referral-to-surgery conversion, and no-show rates are pragmatic, programme-relevant metrics that should be recorded and disaggregated by equity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Consistent definitions will strengthen future evidence and enable benchmarking [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite extensive observational work, causal evidence on what reliably increases uptake remains limited. Priorities include pragmatic evaluations of transport/fee support, as well as counselling packages (e.g., cluster or stepped-wedge trials), interrupted time series analyses for policy changes (such as insurance coverage and fee waivers), and hybrid effectiveness-implementation studies that assess fidelity, cost, and scalability [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29 CR30 CR31\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Mixed-methods approaches are vital; incorporating qualitative inquiry allows for a deeper understanding of acceptability, household decision-making processes, and unintended outcomes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Under-represented regions, including Central and francophone West Africa, require targeted support [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Cost analysis should extend beyond surgical fees to encompass patient-incurred indirect costs and health-system expenses related to outreach and decentralisation, enabling value-for-money assessments [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCataract services intersect with primary care and the management of chronic diseases. Coordination with diabetes and hypertension clinics can identify eligible patients, provide peri-operative optimisation, and bundle transport for multipurpose visits [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Partnerships with social protection programmes can channel means-tested subsidies efficiently [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In humanitarian or fragile settings, mobile theatres with robust referral and follow-up protocols may be suitable, with planned transition to sustainable fixed services [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudy designs varied and the risk of bias was diverse; Rapid Assessment of Avoidable Blindness (RAAB) surveys offered breadth, while qualitative studies provided contextual depth [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Geographic focus (Nigeria, Ethiopia, Kenya, Ghana, South Africa) and the restriction to English may bias the results; Central and Francophone West Africa remain understudied [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Few studies have measured the effects of interventions or assessed the sustainability of outreach or voucher schemes over time [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Varying definitions of uptake and inconsistent reporting of denominators hindered comparison and prevented meta-analysis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although higher-quality evidence was given more weight and sensitivity analyses were performed, residual confounding and publication bias cannot be ruled out [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhere national or international cataract guidelines exist, our synthesis supports recommendations for counselling, cost mitigation, outreach, and primary-care integration; availability and quality vary by country [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Programmes should align delivery models with current guidance and use routine data to iterate (equity-disaggregated uptake/CSC, no-show rates) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. When guidance is absent or outdated, the multi-component, equity-centred package outlined here provides a practical default that can be adapted to local barriers and capacity [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eImproving cataract surgery uptake in Africa requires addressing interconnected barriers at the patient, community, and system levels. The most promising approach combines targeted financial and transport support, trusted counselling, strengthened referral and outreach, careful decentralisation with assured quality, and ongoing investments in workforce and theatre capacity [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Incorporating equity metrics, standardised definitions, and rigorous, yet practical evaluation into routine practice can turn incremental improvements into lasting gains in CSC and CSR, delivering high-value, sight-restoring care to those who need it most [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eCataract surgery uptake in Africa is limited by modifiable barriers at the patient, community, and system levels. Coordinated, evidence-based strategies, such as education and counselling, financial and transportation support, enhanced referral and outreach, decentralised capacity, and system investments, can improve equitable access and accelerate progress towards reducing avoidable blindness.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eK.N. conceived the study, designed the search and protocol, led screening and data extraction, performed the analysis, and drafted the manuscript. W.H. refined the search strategy, verified screening and data extraction, prepared the tables and figures, and contributed to interpretation. W.H. and K.N. revised the manuscript for important intellectual content. All authors approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organization (WHO) (2025) Blindness and vision impairment. WHO, Geneva. https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment. Accessed 14 Sep 2025\u003c/li\u003e\n \u003cli\u003eO\u0026rsquo;Brart DPS (2025) The future of cataract surgery. Eye (Lond) 39:1451\u0026ndash;1456. https://doi.org/10.1038/s41433-025-03745-x\u003c/li\u003e\n \u003cli\u003eHashemi H, Fayaz F, Hashemi A, Khabazkhoob M (2025) Global prevalence of cataract surgery. Curr Opin Ophthalmol 36(1):10\u0026ndash;17. https://doi.org/10.1097/ICU.0000000000001092\u003c/li\u003e\n \u003cli\u003eWang W, Yan W, Fotis K et al (2016) Cataract surgical rate and socioeconomics: a global study. Invest Ophthalmol Vis Sci 57(14):5872\u0026ndash;5881. https://doi.org/10.1167/iovs.16-19894\u003c/li\u003e\n \u003cli\u003eStern J, Yasmin S, Qureshi MB et al (2024) 2030 In Sight: the future of global eye health. Eye (Lond) 38:1979\u0026ndash;1980. https://doi.org/10.1038/s41433-023-02815-2\u003c/li\u003e\n \u003cli\u003eAboobaker S, Courtright P (2016) Barriers to cataract surgery in Africa: a systematic review. Middle East Afr J Ophthalmol 23(1):145\u0026ndash;149. https://doi.org/10.4103/0974-9233.164615\u003c/li\u003e\n \u003cli\u003eLewallen S, Schmidt E, Jolley E et al (2015) Factors affecting cataract surgical coverage and outcomes in sub-Saharan Africa: a retrospective cross-sectional study. BMC Ophthalmol 15:67. https://doi.org/10.1186/s12886-015-0063-6\u003c/li\u003e\n \u003cli\u003eLewallen S, Mousa A, Bassett K, Courtright P (2009) Cataract surgical coverage remains lower in women. Br J Ophthalmol 93(3):295\u0026ndash;298. https://doi.org/10.1136/bjo.2008.140301\u003c/li\u003e\n \u003cli\u003eRamke J, Zwi AB, Silva JC et al (2018) Evidence for national universal eye health plans. Bull World Health Organ 96:695\u0026ndash;704. https://doi.org/10.2471/BLT.18.213686\u003c/li\u003e\n \u003cli\u003eLee CM, Afshari NA (2017) The global state of cataract blindness. Curr Opin Ophthalmol 28:98\u0026ndash;103. https://doi.org/10.1097/ICU.0000000000000340\u003c/li\u003e\n \u003cli\u003eSapkota YD, Pradhan S et al (2017) Prevalence of blindness and cataract surgical coverage in Narayani Zone, Nepal: a Rapid Assessment of Avoidable Blindness (RAAB) study. Br J Ophthalmol. https://doi.org/10.1136/bjophthalmol-2017-310716\u003c/li\u003e\n \u003cli\u003eIbrahim N, Pozo-Martin F, Gilbert C (2015) Direct non-medical costs double the total direct costs to patients undergoing cataract surgery in Zamfara State, Northern Nigeria: a case series. BMC Health Serv Res 15:163. https://doi.org/10.1186/s12913-015-0831-2\u003c/li\u003e\n \u003cli\u003eRazafinimpanana N, Nkumbe H, Courtright P, Lewallen S (2012) Uptake of cataract surgery in Sava Region, Madagascar: role of cataract case finders in acceptance of cataract surgery. Int Ophthalmol 32(2):107\u0026ndash;111. https://doi.org/10.1007/s10792-012-9523-7\u003c/li\u003e\n \u003cli\u003eUhumwangho OM, Olowolaiyemo MU, Osaguona VB, Osahon AI (2017) Cataract surgical outreach in a tertiary hospital in Nigeria\u0026mdash;an appraisal. Ann Med Health Sci Res 7:111\u0026ndash;114.\u003c/li\u003e\n \u003cli\u003eCongdon N, Thomas R (2014) How can we solve the problem of low uptake of cataract surgery? Ophthalmic Epidemiol 21(3):135\u0026ndash;137. https://doi.org/10.3109/09286586.2014.912333\u003c/li\u003e\n \u003cli\u003eLewallen S, Etya\u0026rsquo;ale D, Kello AB, Courtright P (2012) Non-physician cataract surgeons in sub-Saharan Africa: situation analysis. Trop Med Int Health 17(11):1405\u0026ndash;1408. https://doi.org/10.1111/j.1365-3156.2012.03084.x\u003c/li\u003e\n \u003cli\u003eCourtright P, Metcalfe N, Hoechsmann A, Chirambo M, Lewallen S, Barrows J et al (2004) Cataract surgical coverage and outcome of cataract surgery in a rural district in Malawi. Can J Ophthalmol 39:25\u0026ndash;30.\u003c/li\u003e\n \u003cli\u003eHabtamu E, Eshete Z, Burton MJ (2013) Cataract surgery in Southern Ethiopia: distribution, rates and determinants of service provision. BMC Health Serv Res 13:480. https://doi.org/10.1186/1472-6963-13-480\u003c/li\u003e\n \u003cli\u003eRono HK, Macleod D, Bastawrous A, Wanjala E, Gichangi M, Burton MJ (2019) Utilization of secondary eye care services in Western Kenya. Int J Environ Res Public Health 16:3371. https://doi.org/10.3390/ijerph16183371\u003c/li\u003e\n \u003cli\u003eMbeboh SN, Christie SA, Carvalho M, Dickson D, Nana T, Embolo F et al (2020) Prevalence, care-seeking practices and impact of self-reported vision impairment in Southwest Cameroon: a community-based study. BMJ Open 10:e041367. https://doi.org/10.1136/bmjopen-2020-041367\u003c/li\u003e\n \u003cli\u003eMathenge WC, Hillgrove T, Gisagara E, Kimenyi F, Kasiime J, Gishoma C et al (2021) The Rwanda National Blindness Survey: trends and use of the evidence to change practice and policy. Afr Vision Eye Health 80(1):a576. https://doi.org/10.4102/aveh.v80i1.576\u003c/li\u003e\n \u003cli\u003eRotchford AP, Rotchford KM, Mthethwa LP, Johnson GJ (2002) Reasons for poor cataract surgery uptake\u0026mdash;a qualitative study in rural South Africa. Trop Med Int Health 7(3):288\u0026ndash;292. https://doi.org/10.1046/j.1365-3156.2002.00850.x\u003c/li\u003e\n \u003cli\u003eMcCormick I, Nesemann JM, Zhao J, Mdala S, Kitema GF, Mwangi N et al (2023) Travel time to cataract surgical services in Kenya, Malawi and Rwanda: demonstrating a standardised indicator of physical access to cataract surgery. Eye (Lond). Epub ahead of print. https://doi.org/10.1038/s41433-023-02790-8\u003c/li\u003e\n \u003cli\u003eDean WH, Sherwin JC, Kumwenda S, Angeletti M, Wiehler U (2012) Willingness to pay for cataract surgery in post-operative cataract patients in rural Malawi. Ophthalmic Epidemiol 19(5):265\u0026ndash;271. https://doi.org/10.3109/09286586.2012.708085\u003c/li\u003e\n \u003cli\u003eMehari ZA (2013) Barriers to cataract surgical uptake in Central Ethiopia. Middle East Afr J Ophthalmol 20(3):229\u0026ndash;233. https://doi.org/10.4103/0974-9233.114798\u003c/li\u003e\n \u003cli\u003eRabiu MM, Ozemela CP et al (2007) Gathering baseline data for a rural cataract surgical outreach service in Igabi District, Nigeria. Niger J Ophthalmol 15(2):64\u0026ndash;68. https://doi.org/10.4314/njo.v15i2.12009\u003c/li\u003e\n \u003cli\u003eOlokoba L, Mahmoud O, Adepoju F, Olokoba A, Durowade K (2016) Evaluation of the community cataract surgical services of a university teaching hospital using cataract surgical coverage in Nigeria. Ethiop J Health Sci 26(2):109\u0026ndash;116.\u003c/li\u003e\n \u003cli\u003eMcGuinness MB, Moo E, Varga B, Dodson S, Lansingh VC, Resnikoff S et al (2025) The Better Operative Outcomes Software Tool (BOOST) Prospective Study: improving the quality of cataract surgery outcomes in low-resource settings. Ophthalmic Epidemiol. Epub ahead of print.\u003c/li\u003e\n \u003cli\u003ePatrick-Ferife G, Ashaye A et al (2006) Rapid assessment of cataract blindness among Ughelli Clan in an urban/rural district of Delta State, Nigeria. Ann Afr Med. Pagination unavailable.\u003c/li\u003e\n \u003cli\u003eLee CN, Ramke J, McCormick I, Zhang JH, Aghaji A, Mwangi N et al (2020) Are we advancing universal health coverage through cataract services? Protocol for a scoping review. BMJ Open 10:e039458. https://doi.org/10.1136/bmjopen-2020-039458\u003c/li\u003e\n \u003cli\u003eBerhane Y, Worku A, Bejiga A, Alemayehu W et al (2007) National survey on blindness, low vision and trachoma in Ethiopia: methods and study clusters profile. Ethiop J Health Dev 21(3):185\u0026ndash;203. https://doi.org/10.4314/ejhd.v21i3.10049\u003c/li\u003e\n \u003cli\u003eKhoza LB, Nunu WN, Tshivhase SE, Murwira TS, Mambanga P, Ramakuela NJ et al (2020) Survey on prevalence of cataract in selected communities in Limpopo Province of South Africa. Scientific African 8:e00352. https://doi.org/10.1016/j.sciaf.2020.e00352\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inte","sideBox":"Learn more about [International Ophthalmology](https://www.springer.com/journal/10792)","snPcode":"10792","submissionUrl":"https://submission.nature.com/new-submission/10792/3","title":"International Ophthalmology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"cataract surgery, access to care, health system barriers, patient barriers, Africa","lastPublishedDoi":"10.21203/rs.3.rs-7759268/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7759268/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTo synthesise evidence on barriers to cataract surgery uptake in Africa across patient, community, and health system levels, describe regional variation, and identify evidence gaps.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a systematic review of multiple databases for studies published from January 2000 to March 2025. Searches combined controlled vocabulary and free text terms for cataract surgery, access or uptake, and African countries. Two reviewers independently screened titles, abstracts, and full texts with consensus resolution. Eligible studies enrolled African populations and explicitly reported barriers, facilitators, or determinants of uptake. Data were extracted into a piloted template and synthesised thematically without meta-analysis. Reporting followed the PRISMA 2020 guidelines; the study was prospectively registered (PROSPERO CRD420251145721).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFollowing the screening of 737 records, a total of 108 studies were included, spanning Rapid Assessment of Avoidable Blindness surveys, cross-sectional, qualitative, and mixed-methods designs. Patient-level barriers most frequently reported were direct and indirect costs (surgery, travel, accommodation, income loss), limited awareness, fear of surgery or poor outcomes, gender inequities, and cultural beliefs. Community-level barriers included transportation constraints, weak referral pathways, and inconsistent outreach efforts. System-level barriers comprised workforce shortages, limited theatre capacity, equipment or consumable shortfalls, scheduling inefficiencies, and reliance on out-of-pocket financing with limited insurance or subsidies. Rural, urban, and regional disparities were consistent.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eBarriers to cataract surgery uptake in Africa are multifactorial and interlinked. Evidence supports multi-component strategies, including patient education, targeted financial and transportation support, strengthened referral and outreach, service decentralisation, and health system investment, to improve equitable access and accelerate progress toward eye health targets.\u003c/p\u003e","manuscriptTitle":"Barriers to Cataract Surgery Uptake in Africa: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 12:11:44","doi":"10.21203/rs.3.rs-7759268/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-27T18:14:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-26T23:11:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-22T19:31:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300426055067143279115055244201206811272","date":"2025-10-16T10:35:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"257983375332341597154416071412783865785","date":"2025-10-15T18:02:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-14T20:48:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-03T14:35:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-03T14:33:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Ophthalmology","date":"2025-10-01T11:44:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inte","sideBox":"Learn more about [International Ophthalmology](https://www.springer.com/journal/10792)","snPcode":"10792","submissionUrl":"https://submission.nature.com/new-submission/10792/3","title":"International Ophthalmology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d531ee34-9486-4805-8bd5-0f755304b677","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:06:02+00:00","versionOfRecord":{"articleIdentity":"rs-7759268","link":"https://doi.org/10.1007/s10792-025-03890-y","journal":{"identity":"international-ophthalmology","isVorOnly":false,"title":"International Ophthalmology"},"publishedOn":"2025-12-12 15:57:43","publishedOnDateReadable":"December 12th, 2025"},"versionCreatedAt":"2025-10-29 12:11:44","video":"","vorDoi":"10.1007/s10792-025-03890-y","vorDoiUrl":"https://doi.org/10.1007/s10792-025-03890-y","workflowStages":[]},"version":"v1","identity":"rs-7759268","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7759268","identity":"rs-7759268","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}