Implementing effective cataract surgical coverage: a comparative qualitative study in Kenya and Nepal

The WHO has set a 2030 target to raise effective cataract surgical coverage (eCSC) by 30 percentage points in every country, requiring gains in surgical access and quality. Despite this mandate, evidence on how low- and middle-income health systems are implementing eCSC remains limited.

We conducted a qualitative comparative case study in Kenya and Nepal. 20 interviews were held with senior stakeholders from government, non-governmental organisations, academic institutions and clinical networks. Transcripts were thematically analysed using the consolidated framework for implementation research, adapted into a growing systems framework to capture national-level dynamics.

Implementation unfolds within the inherent structures of each cataract system rather than through centrally imposed directives. In Kenya, cataract services operate within devolved county structures supported by non-governmental organization (NGO) partnerships and national technical coordination. In Nepal, vertically organised NGO networks deliver care through a hub-and-spoke outreach model with limited government oversight. Both systems incorporate context-specific adaptations to overcome barriers in access and postoperative quality. Public-private partnerships expand reach but are weakened by fragmented financing, reliance on donors and high out-of-pocket costs. Outcome monitoring is sporadic and seldom informs planning, limiting system-wide learning.

The eCSC target prompts change less by prescribing reform than by revealing the features that enable or constrain implementation. Sustained progress will require embedding outcome monitoring within routine information systems, strengthening public stewardship of mixed provider networks, mobilising domestic financing and designing services attuned to geographic and sociocultural realities.