Cataract surgery is a highly cost-effective public health initiative, addressing the main cause of avoidable blindness. Nepal has a comparatively high rate of sight loss globally, with 6.7m people experiencing some form of sight loss, and 65% of this due to cataract.

A recent Rapid Assessment of Blindness Survey aimed to discover the magnitude and causes of sight loss in Nepal in those 50+. The participants were also given a questionnaire on the barriers to them receiving care for cataract, as part of a study including researchers from the International Centre for Eye Health.

In the study, 718 people confirmed to be blind (<6/60) were interviewed, 62.3% of whom were women. Of the responses:

• 33% did not feel the need to undergo surgery
• 30% mentioned cost as a barrier
• 13% were unable to access treatment
• 12% did not want to seek treatment due to fear

The overrepresentation of women included in the study was due to an overrepresentation in those confirmed blind in the original survey, suggesting that female gender itself is a big barrier. However, the researchers did not find a difference in barriers to care in the responses of women compared to men.

The authors also found there was large variation between provinces included in the study, for instance 49.7% of people in Madhesh responding they felt no need for surgery, compared to only 6.3% in Karnali. Meanwhile 51.8% of respondents in Western Province listed cost as a prohibitive reason, compared to 14.5% of those in Gandaki. These findings could help to inform provincial variations on national policies.

Recent work into the provision of eye care services in Nepal has found that NGOs and the private sector are responsible for most cataract surgeries, which are costly for those with vision impairment. Insurance-based provision is also failing due to dropouts of premium payments.

The lack of need reported requires further follow-up to understand exactly why this is occurring.

In order to address the problems discovered in the study, the authors have several recommendations:

• Health literacy campaigns can address the lack of awareness and fear of surgery, using successfully operated cases as champions to address lack of need felt
• Reducing direct and indirect costs for cataract surgery, for instance by developing screening camps in rural areas, transporting people to surgery, providing gender-specific services
• Costs can also be reduced through insurance, government subsidies, and incentives to ophthalmologists in the private sector. Subsidising out of pocket expenses for those needing surgery has also previously been shown to increase uptake

Universal efforts to address avoidable blindness will make inroads only if those suffering from cataracts and visual impairment are correctly understood. The barriers found in studies that review the perceived obstacles of those reaching and not reaching hospitals provide good insight to assist health planners and service providers.

Publication

Shah R, Mishra SK, Khandekar R … et al. Barriers to cataract surgeries as perceived by visually impaired 50 years and older cataract blind participants of Nepal survey for rapid assessment of avoidable blindness. PLOS One. June 2025. https://doi.org/10.1371/journal.pone.0312648