Barriers to cataract surgery in Africa: a systematic review

Methodological quality of the review:  Low confidence

Author: Aboobaker S.,Courtright P.

Region: Africa

Sector: Cataract

Sub-sector: Barriers to cataract surgery

Type of cataract: Age-related cataract

Equity focus: Gender differences

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable


Cataract remains the leading cause of blindness in Africa. According the World Health Organization, 39 million people worldwide are blind and cataract remains the leading cause of blindness in low- and middle-income countries. Subsequently, many surveys were conducted highlighting the magnitude of cataract elated vision loss in Africa. However, Africa remains the continent with the lowest cataract surgical rate (CSR), defined as the number of cataract surgeries done per million population per year. There has been a considerable research on the barriers to use of existing cataract surgical services in Africa.

Research objectives:

In this review, the authors aimed to evaluate the barriers to cataract surgery in Africa and to identify key themes.

Main findings:

In total, 86 articles were included in the review, of which 12 were Rapid Assessment of avoidable blindness (RAAB) studies, 10 were quantitative studies and five were qualitative studies of barriers to utilizing cataract surgical services. Among the 12 RAABs, only nine reported barriers to cataract surgery, where the outcomes varied considerably: awareness and access were more commonly reported than variables to acceptance.

In relation to non-RAAB surveys, not all were population-based surveys. Findings from these suggest that cost (both direct and indirect) was the most commonly reported barrier in six out of 10 studies.

Authors reported that the qualitative studies of barriers which were conducted in Tanzania and Kenya, suggested that complex emotional and social interventions exist within the family network which influence the mobilization of financial resources to use cataract surgery. Elderly patients place the financial needs of their children ahead of their own and do not wish to be considered a burden. In terms of gender differences, authors noted that males had higher perceived need than females who tended to suffer their disability in silence. Authors noted that these studies found that patients were willing to pay for cataract surgery. This willingness increased when knowledge of the actual cost of surgery and trust in that service improved. Reviewers stated that cost was found to be convenient explanation which is usually unchallenged by the health care workers when they are asked about reasons for not undergoing cataract surgery. Authors mentioned that in Kenya, patients with poorer visual acuity were only slightly more likely to accept surgery while lower quality of life scores were consistently associated with increase uptake of cataract surgery.

In relation to gender differences, reviewers noted a total of 17 surveys providing information on cataract surgical coverage (CSC) and findings for both males and females. Based on these, CSC among males was higher than in females; for all surveys the average difference between male CSC and female was 9.42%.

Authors note that quantitative studies may not be ideal to tackle questions around barriers to cataract surgery. To this end, authors state that qualitative work likely presents a better understanding of some of the complex social, family, financial, community and gender interactions. Therefore, authors recommend that further studies are required to understand the role of poor outcomes and uptake of cataract surgery and to understand how families make decisions regarding seeking care.


Authors conducted a search on PubMed and Google Scholar. Search terms included: “Barriers, cataract, Africa, cataract surgery, cataract surgical coverage (CSC), and Rapid Assessment of Avoidable Blindness (RAAB).” The search was limited to articles published between 1999 and April 2014. The references in the articles were also reviewed to identify other articles that may not have been identified by the search terms.

Authors noted that as female gender is a recognized risk factor for lower utilization of cataract surgical services, all quantitative surveys of CSC were reviewed for any gender differences.

Applicability/external validity:

Due to the sensitive nature of questioning people about reasons they have not undergone surgery, qualitative data collection is likely to be the most valuable approach. Current qualitative literature on the topic remains limited to a few settings. However, findings from these settings may not be applicable to other regions in Africa.

Geographic focus:

Authors focused in low- and middle-income countries, specifically in Africa. Therefore, findings may only be applicable to Africa only and not Asia. It should be noted however, as mentioned above, qualitative studies included in the review may not applicable to other regions in Africa.

Quality assessment:

This review was attributed low confidence in its conclusions as significant limitations were identified. The search of the literature was not comprehensive enough to avoid publication bias as authors only included published studies. It is also not clear if authors used were rigorous as they do not report the selection and data extraction process of included studies (potential selection/reporting bias) and did not report the quality or risk of bias of included studies. On the other hand, authors appropriately conducted a narrative synthesis of the findings by grouping the different type of studies into sub-groups and reported findings accordingly.

Publication Details

Aboobaker S, Courtright P “Barrier to cataract surgery in Africa: a systematic review” Middle East Afr J Ophthalmol. 2016 Jan-Mar;23(1):145-9.