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Implementing effective cataract surgical coverage: a comparative qualitative study in Kenya and Nepal.
Mattan Arazi1,2,3, Lila Puri4,5, Maureen Kiaraho4,6
1International Centre for Eye Health (ICEH), London School of Hygiene and Tropical Medicine, London, UK mattanarazi.md@gmail.com.
BMJ Global Health
|February 24, 2026
Summary
Achieving the World Health Organization's effective cataract surgical coverage (eCSC) target requires understanding how health systems implement changes. This study reveals that system structures, not just directives, drive progress in cataract care, highlighting the need for better monitoring and financing.
Area of Science:
- Global health policy
- Ophthalmology implementation science
- Health systems research
Background:
- The World Health Organization (WHO) aims to increase effective cataract surgical coverage (eCSC) by 30 percentage points globally by 2030.
- Low- and middle-income countries face challenges in implementing eCSC due to limited evidence on health system strategies.
- Effective cataract surgery is crucial for restoring sight and improving quality of life.
Purpose of the Study:
- To explore how low- and middle-income health systems are implementing effective cataract surgical coverage (eCSC) strategies.
- To identify factors enabling or constraining the implementation of cataract surgery programs in diverse health systems.
- To inform future strategies for achieving global targets in cataract blindness prevention.
Main Methods:
- A qualitative comparative case study design was employed in Kenya and Nepal.
- Twenty in-depth interviews were conducted with senior stakeholders across government, NGOs, academia, and clinical networks.
- Thematic analysis using the consolidated framework for implementation research, adapted into a growing systems framework, was utilized.
Main Results:
- Cataract service implementation is shaped by existing system structures (e.g., devolved government in Kenya, NGO networks in Nepal) rather than top-down mandates.
- Public-private partnerships enhance service reach but are hindered by fragmented financing and high out-of-pocket costs.
- Sporadic outcome monitoring limits learning and planning, impacting system-wide improvements in cataract care.
Conclusions:
- The WHO's eCSC target acts as a catalyst, highlighting implementation enablers and constraints.
- Sustained progress necessitates integrating outcome monitoring into routine information systems.
- Strengthening public stewardship, domestic financing, and context-specific service design are vital for improving cataract surgical coverage.
