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Access, equity and service delivery

TL;DR — The 74th World Health Assembly set a global target of a 30-percentage-point increase in effective cataract surgical coverage (eCSC) by 2030 (Keel 2021, PMID 34237266). The world is not on track. Modelled from 233 population-based survey datasets across 68 countries, global eCSC (6/18 threshold) was 48.2% (39.7–57.2) in 2025 and is predicted to rise only 8.4 percentage points (8.1–8.6) between 2020 and 2030 — from 43.9% to 52.3% — against a target of 30 points (McCormick 2026, PMID 41687671). Country estimates ranged from 2.1% (Burundi 2024) to 77.7% (Qatar 2023). The gap is as much quality as access: uncorrected refractive error accounted for a median 26.4% of non-good outcomes, and correcting it alone could yield a median 3.7-percentage-point gain in eCSC at the 6/12 threshold (PMID 41687671). Coverage is systematically unequal — pooled across 148 earlier surveys, eCSC was higher in men (risk difference 3.2%, 95% CI 2.3–4.1; risk ratio 1.20, 1.15–1.25) (McCormick 2022, PMID 36240806) — and in India rose from 31.0% in illiterate participants to 59.7% in those educated to class 10 (Gupta 2024, PMID 38622863). Meanwhile cataract surgery remains one of the most cost-effective operations in medicine, at $9–$1,600/QALY in developing countries (Lansingh 2007, PMID 17383730).

Three different metrics, three different questions

Metric Question it answers Blind spot
Cataract surgical rate (CSR): operations per million population per year How much surgery is being done? Says nothing about need or outcome
Cataract surgical coverage (CSC): proportion of those needing surgery who have had it How much of the need is met? Counts a bad outcome as covered
Effective CSC (eCSC): CSC restricted to good visual outcomes How much need is met well? Threshold-dependent (6/12 vs 6/18)

Only eCSC contains outcome information, which is why it and effective refractive error coverage were chosen as the indicators for tracking universal health coverage progress in eye care (PMID 34237266). The relative quality gap — the percentage difference between CSC and eCSC — ranged from 10.8% in Argentina (CSC 65.7%, eCSC 58.6%) to 73.4% in Guinea-Bissau (CSC 14.3%, eCSC 3.8%) (PMID 36240806). In India, national eCSC was 36.7% (95% CI 33.6–39.9) against CSC of 57.3% (53.3–61.2), a relative quality gap of 36.0% (PMID 38622863).

Where coverage stands

Estimate Value Basis Source
Global eCSC (6/18), 2025 48.2% (39.7–57.2) 233 survey datasets, 68 countries, 2003–24; mixed-effects model McCormick 2026, PMID 41687671
Predicted change 2020→2030 +8.4 percentage points (8.1–8.6): 43.9% → 52.3% same PMID 41687671
Country range 2.1% (0.9–3.4) Burundi 2024 to 77.7% (72.9–82.5) Qatar 2023 same PMID 41687671
Uncorrected refractive error share of non-good outcomes Median 26.4% per survey; correcting it could raise eCSC(6/12) by a median 3.7 points same PMID 41687671
Earlier country range 3.8% (2.1–5.5) Guinea-Bissau 2010 to 70.3% (65.8–74.9) Hungary 2015 148 RAAB surveys, 55 countries McCormick 2022, PMID 36240806
Median eCSC by income High income 60.5% (IQR 55.6–65.4, n = 2 surveys); low income 14.8% (IQR 8.3–20.7, n = 14 surveys) same PMID 36240806
Sex difference in eCSC Risk difference 3.2% (2.3–4.1); risk ratio 1.20 (1.15–1.25) favouring men same PMID 36240806
CSR range 36 to 12,800 per million population; average CSC around 50% or lower in most countries Review Hashemi 2025, PMID 39638415
India eCSC 36.7% (33.6–39.9); males 38.0% vs females 35.6%; illiterate 31.0% → class 10 educated 59.7% 31 districts, RAAB pooled 2015–19 Gupta 2024, PMID 38622863
Hungary CSC (VA<3/60) 90.0%; good visual outcome in only 79.5%; ocular comorbidity caused 78.1% of poor outcomes National RAAB, 3,523 examined Sándor 2020, PMID 32309181
Palestine CSR 2,117 per million (2015); phaco 73.4% overall but 67% of government-centre operations were ECCE Cross-sectional survey of 22 centres Maswadi 2022, PMID 34121602

The commentary literature has begun to say plainly that the field is falling short of the 2030 target (Wiedemann 2026, PMID 42382972).

What determines the surgical rate

Cataract surgical rate tracks national wealth, not national need. CSR correlated with the Human Development Index (R² = 49.2%, β = 5.01, P < 0.001) and GDP per capita (R² = 38.9%, β = 0.56, P < 0.001), and longitudinal modelling found strong associations with HDI, GDP and the proportion of the population aged ≥50 (P = 0.001), with overall global CSR inequality remaining relatively stable across the study period (Yan 2019, PMID 30362287). The COVID-19 pandemic depressed rates in many countries (PMID 39638415). Socioeconomic status and access to services are the primary determinants of who is operated, with surgery more prevalent among older people, among men, and among those with private insurance (PMID 39638415).

Affordability and cost-effectiveness

Cataract surgery's cost-effectiveness is not in doubt: cost-utility ranged $245–$22,000/QALY in Western countries and $9–$1,600/QALY in developing countries, comparable to hip arthroplasty and generally better than knee arthroplasty or defibrillator implantation; in international dollars per DALY averted, I$730–I$2,400 in developed and I$90–I$370 in developing countries (PMID 17383730). Affordability relative to income is the binding constraint: the Cataract Surgery Affordability Index — the cost of surgery divided by gross national income per capita — varied 17–189% in developed and 29–133% in developing countries relative to the United States (PMID 17383730).

The economic evidence base is skewed toward the places with least unmet need: of 155 regional cost estimates in a systematic review of the economics of vision impairment, 103 (66%) came from high-income countries, and average cataract surgery cost per patient ranged $54–$3,654 PPP, with variation driven substantially by costing method (Marques 2022, PMID 35340626). For IOL choice specifically, 14 economic evaluations across 12 countries reported lifetime societal costs for multifocal IOLs of $5,780.79–$15,944.76 with QALY gains of 0.16–0.71 (Wu 2025, PMID 40838946); economic-evaluation methodology in cataract surgery is reviewed in (Ginel 2024, PMID 38347178).

Workforce, technique and throughput

Technique choice is a delivery decision. Phacoemulsification cost more than four times MSICS in the one randomised trial reporting cost, while producing equivalent best-corrected acuity (pooled RR 0.99, 95% CI 0.98–1.01) (Riaz 2013, PMID 24114262). MSICS is therefore the scalable technique for low- and middle-income countries: simulator-based training and new instruments improve early trainee proficiency, complication rates and patient-reported satisfaction are comparable to phacoemulsification given surgeon proficiency, and the named research gaps are skill transferability, long-term outcomes and sex disparities in access (Winterton 2026, PMID 41175388; Bernhisel 2020, PMID 31770166). Phacoemulsification provides the best visual outcomes but will only be accessible in poorer countries if machine and foldable-IOL costs fall (Riaz 2006, PMID 17054134). The persistent global constraint remains the backlog: training additional cataract surgeons does not keep pace with demand generated by population ageing (Lam 2015, PMID 27188414).

Efficiency levers with evidence:

  • Immediate sequential bilateral surgery. Non-inferior refractive outcome (97% vs 98% of second eyes within ±1.0 D; difference −1%, 90% CI −3 to 1), no endophthalmitis in 865 randomised patients, €403 lower societal cost per participant and 100% cost-effectiveness probability across the willingness-to-pay range (Spekreijse 2023, PMID 37201546); up to 50% lower CO₂ footprint per patient in registry-based synthesis (Staktopoulou 2026, PMID 41959995); cost savings to payers, patients and society (Nowrouzi 2024, PMID 38390776; Singh 2017, PMID 27684294). The equity and carbon arguments have been debated in correspondence (Ting 2024, PMID 38280774; Lin 2024, PMID 38280775; Spekreijse 2024, PMID 38280777).
  • Dropping unnecessary preoperative testing. No safety benefit and 2.55× higher cost (Keay 2019, PMID 30616299); ophthalmologist-led pathways without dedicated anaesthesia support were safe in a large observational cohort (Koolwijk 2015, PMID 25444350).
  • Artificial intelligence for detection and triage. Promising early performance but limited by non-diverse training data and absent external validation (Goh 2020, PMID 32349116); the same limitation applies to AI decision support for complex cases (Su 2025, PMID 40977894).

Equity within and between countries

Coverage inequality is patterned, not random.

  • Sex. Global eCSC favours men (RR 1.20) (PMID 36240806), women bear 60% of cataract blindness and 59% of cataract MSVI (Vision Loss Expert Group 2024, PMID 38461217), and among children with bilateral non-traumatic cataract in low-income countries the proportion of operated children who were girls fell below the gender-neutral reference (Gilbert 2016, PMID 26992842).
  • Education and residence. eCSC in India rose from 31.0% to 59.7% across the education gradient, with rural residence, increasing age and eastern/north-eastern residence independently associated with worse eCSC (PMID 38622863).
  • Region. Cataract's share of blindness exceeds the global figure only in South Asia (62.9%) and Southeast Asia and Oceania (47.9%) (PMID 38461217); in East Asia cataract plus uncorrected refractive error account for ~57% of blindness (Cheng 2020, PMID 31462416); pooled severe visual impairment in Arab countries was 4.0% (95% CI 2.49–5.51) and blindness 4.65% (3.26–6.04) (Alsolami 2025, PMID 40633432).
  • Indigenous populations. Systematically higher visual-loss burden than non-indigenous comparators worldwide (Foreman 2018, PMID 29596691).

How eCSC is actually implemented

A comparative qualitative study of 20 senior stakeholders in Kenya and Nepal found that implementation follows the inherent structure of each cataract system rather than central directives: Kenya delivers through devolved county structures with NGO partnerships and national technical coordination, Nepal through vertically organised NGO networks using a hub-and-spoke outreach model with limited government oversight. Public–private partnerships expanded reach but were weakened by fragmented financing, donor dependence and high out-of-pocket costs, and outcome monitoring was sporadic and seldom informed planning — limiting system-wide learning (Arazi 2026, PMID 41735007). This is the operational counterpart to the modelling finding: an indicator that requires outcome data cannot drive improvement in systems that do not routinely collect it.

Quality and capacity are explicitly linked in the service-design literature: expanding throughput without measuring refractive, visual, complication and patient-reported outcomes does not produce effective coverage (Campbell 2019, PMID 31244461; Yorston 2022, PMID 36704526; Sommer 2011, PMID 21616210). Waiting-list management is part of the same problem — on a rationed New Zealand list, mean wait was 18.2 ± 11.6 months, only 49% were eventually operated in the public sector, 12% had died and acuity had deteriorated by 0.05 logMAR (Riley 2001, PMID 11778807). Future-of-service reviews name access, sustainability, new technology and AI as the four pressures shaping the next decades (O'Brart 2025, PMID 40082703).

Open questions

  • What would actually deliver a 30-point eCSC rise? The modelled trajectory is +8.4 points against a 30-point target (PMID 41687671), and the implementation study shows outcome monitoring is sporadic and rarely feeds planning (PMID 41735007) — no country-level intervention study demonstrating an eCSC gain of the required magnitude was identified in the searches behind this page.
  • Can spectacle provision be the cheapest eCSC lever? Uncorrected refractive error explains a median 26.4% of non-good outcomes and correcting it could give a median 3.7-point eCSC(6/12) gain (PMID 41687671); no trial of routine postoperative refraction-and-spectacle provision measuring eCSC has been reported here.
  • Does scaling volume degrade quality? The theoretical trade-off is stated repeatedly (PMID 31244461; PMID 36704526) and the quality gap is measured (PMID 36240806), yet no prospective evaluation of a national scale-up with risk-adjusted PCR, endophthalmitis and PROM endpoints exists in this evidence set.
  • Why is eCSC lower in women? The disparity is quantified globally (RR 1.20) and in childhood surgery (PMID 36240806; PMID 26992842) but not decomposed into referral, uptake, affordability, accompaniment and outcome components in any study cited here.
  • What quality indicators should be collected? The 2026 modelling paper explicitly calls for a suite of cataract surgery quality indicators to inform providers (PMID 41687671); no agreed international indicator set was identified in this session's searches, although EUREQUO-derived benchmarks exist for Europe (Lundström 2012, PMID 22541829).

References

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