Cataracts remain the leading cause of blindness globally, accounting for about half of the world’s 43 million cases of blindness. Despite its straightforward and highly cost-effective treatment—a 20-minute surgery—millions still suffer from this preventable condition. In Rwanda, cataract surgery is primarily available in tertiary hospitals around Kigali, with regular surgical outreach programs extending services to rural areas. In 2015, the effective cataract surgical coverage rate was 54% on average at the national level, highlighting a critical access gap, particularly in rural areas.

In 2022, the Fred Hollows Foundation engaged a team of consultants from Eureka Idea Co. (EIC) to deliver a clear and up-to-date analysis of cataract surgery needs and gaps, assess in-country plans, and propose options for scaling up efforts to sustainably meet current and future demands.

EIC developed a comprehensive analytical framework to examine multiple dimensions of the issue, including human resources, health financing, quality of care, and availability of consumables and equipment. In partnership with the Ministry of Health, the team conducted primary data collection through a health facility assessment in nine hospitals and key informant interviews, complemented by a review of secondary data from HMIS and existing scientific and grey literature.

The Problem

Rwanda has made significant strides in expanding access to eye care, and cataract surgery in particular, largely through specialized eye units within two hospitals: Kabgayi Hospital and Rwanda Charity Eye Hospital, which together accounted for the bulk of cataract surgeries performed in Rwanda in 2022. These high-volume centers have demonstrated both efficiency and high standards of care. Nevertheless, the current system faces several barriers:

  1. Limited Geographic Access: Five of the seven hospitals offering cataract surgery on a continuous basis were in or near Kigali in 2022. There was a high unmet need for specialized eye care in the Western, Eastern, and Northern provinces.
  2. Human Resource Limitations: There has been a critical shortage of ophthalmologists, with only 1.7 ophthalmologists per million people in Rwanda, and most of them are based in Kigali.
  3. Referral Gaps: The number of identified cataracts was much higher than the number of surgeries performed, especially in provinces without permanent ophthalmologists, suggesting that many operable cataract patients face barriers. The study identified long waiting times between diagnosis and date of surgery (up to seven weeks) as one possible factor leading to drop-outs.
  4. Costly Outreach Programs: While surgical outreach programs have improved geographical access, they are difficult to scale due to higher operational costs and high patient drop-out rates.
  5. Health Financing: In Rwanda, most eye care procedures, including cataract surgeries, are reimbursed by the Community-Based Health Insurance (CBHI), covering 90% of the population. This means that the cost of surgery is not a major barrier for cataract patients. However, the reimbursement tariffs are lower than the actual costs of performing eye surgery, leading to a funding shortfall for hospitals.

Learning from Global Models

The EIC team assessed various models across the globe that have successfully expanded access to cataract surgery, notably:

  • India’s Aravind Eye Care System: The largest provider of ophthalmological services worldwide has managed to drastically reduce costs by achieving high patient volumes. Aravind’s innovative operating room layout and efficient use of staff have enabled them to perform 6–8 surgeries per hour, with costs as low as $50 per surgery.
  • Task-Shifting to Non-Physician Cataract Surgeons: Countries such as Kenya, Malawi, and The Gambia have showcased the effectiveness of task-shifting to non-physician cataract surgeons. Although task-shifting remains controversial as quality of care remains a concern, there is evidence of increased cataract surgery rates and better access in these regions where it has been deployed.

Strategic Models for Scaling Cataract Surgery in Rwanda

EIC assessed three models to scale up cataract surgeries in Rwanda:

  1. Optimizing Existing Outreach Programs: Increase outreach frequency and coverage by mobilizing all public-sector ophthalmologists to dedicate a significant portion of their time to rural surgical outreaches. Challenges include limited willingness/availability of ophthalmologists, high costs, lack of equipment, and bureaucratic obstacles.
  2. Establishing High-Volume Specialized Eye Units: Create eye units in provincial/referral hospitals, supported by better referral systems from primary care. This approach improves access in underserved regions, reduces surgery costs through economies of scale, and strengthens financial sustainability.
  3. Maximum Accessibility Model: Decentralize surgeries to all district hospitals, leveraging task-shifting to train less specialized workers. However, quality concerns and stakeholder resistance made this model unsuitable.

The Way Forward

Under the leadership of the Ministry of Health, the eye health technical working group convened in July 2023 to review the strategic options. The members recommended establishing new specialized eye units in strategically located hospitals to improve access and reduce geographic inequities. Four recently graduated ophthalmologists have since been deployed in public hospitals in the Western, Eastern, and Northern regions. Because establishing and consolidating these eye units takes time, it was also agreed to pursue cataract surgery outreaches in regions with still low access.

 

 

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