A qualitative investigation into the barriers to the provision of free cataract surgical services: An ophthalmic service provider

INTRODUCTION

The World Health Organization – 2019 report on vision predicted a substantial increase in the number of people with eye conditions and vision impairment in the coming decades.^[1] The recent National Blindness and Visual Impairment Survey of India (2015–2019) indicated that cataract is the leading cause of blindness in people over 50 years old, and yet, the cataract surgical coverage rate has been sporadic and is below par at 70% in India.^[2-5] Despite the sustained efforts of providing free-of-cost cataract surgical services (CSS), success in reaching cataract-blind people has been limited, specifically in the northeast regions of India.^[6] Over the past few decades, numerous studies from India have shed light on the various determinants of cataract surgical treatments, predominantly focusing on the barriers from the patient’s perspective or the demand side of the healthcare access equation.^[6-15] Nevertheless, scientific investigation into barriers from an ophthalmic service providers (OSPs) perspective or supply-side determinants of eye healthcare provision has been negligible. Provider-specific determinants of health, such as policy-making, institutional, and community factors, as well as health services, have received very little attention.^[16] To achieve health equity for all and to narrow down the healthcare inequality gap as incorporated in the Alma-Ata Declaration of 1978^[17] and reiterated in the most recent Astana Declaration on Primary Health Care – 2018,^[18] it is vital to understand and address the determinants from the OSP perspective – the supply side of the healthcare spectrum.

In order for the existing healthcare system to reciprocate to the eye care needs of the population in the region, it is vital to understand the bottlenecks faced by OSP in the provision of comprehensive eye care services. Keeping this in mind, this study aimed to identify and report the perceived barriers to the provision of CSS in the northeastern Indian region – a region lacking significant eye health research. This study fills this knowledge gap.

MATERIALS AND METHODS

A cross-sectional, qualitative investigation was conducted to understand the provider-specific barriers to the provision of comprehensive CSS. The institutional review board of the partnering hospitals has approved this study.

Sampling and strategy

Regular community eye screening camps (CESCs) and screenings done at vision centers (VCs) are the standard practice for cataract screening in the four partnering base partner hospitals (BPHs). Figure 1 illustrates the locations of the four BPHs and their primary care VC and CESC sites. To understand provider-specific bottlenecks to CSS, qualitative semi-structured interviews (SSIs) were conducted with senior officials and functionaries from BPHs, which included medical and clinical services, administrative operations and finance, human resources, and community outreach departments. A non-probabilistic purposive sampling technique was adopted to recruit a variety of OSPs from across the spectrum. To be considered eligible and included in the sample, an OSP must have been employed with the treating BPH for at least five consecutive years. Our qualitative study required OSPs to have five years of experience to gain in-depth insights into complex, longstanding barriers. This ensured seasoned professionals could provide satisfactory and robust perspectives on the challenges. While prioritizing established bottlenecks, we acknowledge that this criterion may not reflect the initial experiences of newer staff. A total of 10 OSPs participated in the study. This number was determined not only by the staff strength at these specific tertiary, not-for-profit eye hospitals but also with consideration for achieving thematic saturation in qualitative research. Indeed, our thematic analysis yielded significantly rich data, whereby no additional themes seemed to emerge, suggesting sufficient data to develop themes. While this criterion prioritizes the robust perspectives of experienced individuals, we acknowledge that it inherently focuses on established, systemic bottlenecks and may not reflect the initial experiences of newer staff members. However, for the primary objective of this study – to deeply investigate entrenched barriers from the perspective of those with extensive hands-on experience – their insights were considered crucial. Once identified, detailed face-to-face in-depth interviews were conducted using SSI schedules.

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Figure 1:

Illustration of operational zones of partnering eye hospitals.

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Conceptual framework and measures

We adopted a two-pronged approach, based on our previous experience investigating the subject in the same region.^[6]

This approach involved investigating OSP-specific barriers that are (i) endogenous, or barriers that are within the purview of local OSP to remedy, and (ii) exogenous, those that are beyond the control of OSP to remedy [Figure 2]. To investigate the endogenous determinants, we adapted and used the standard “economic factors of production” (FoP) framework to understand bottlenecks faced from an OSP perspective [Figure 3].^[19-21] The production process involves utilizing a given mix of inputs to produce a unit of output.^[19] An “input” or “factor of production” is any good or service used to produce “output.”^[19-21] The four standard FoPs are land, labor, capital, and enterprise.^[19-21] We have applied this economic principle of the production process, wherein the treating BPH utilizes these four FoPs to produce comprehensive CSS as output, and in doing so, we attempted to document the various barriers faced by the OSPs in this region. We have considered the “building infrastructure” as synonymous with and in lieu of the first FoP “land.” Output was defined as the provision of comprehensive CSS that included screening, identification, referral, treatment, and follow-up rehabilitative services. To investigate the exogenous determinants, we adopted a standard analytical framework, wherein barriers that are beyond the scope of OSP, such as (i) structural, (ii) community-level, and (iii) sociocultural barriers were assessed.^[22-24] Consequently, comprehensive open-ended SSI schedules were designed in the English language and pre-tested to understand the context and to assess the acceptability and understanding of the stakeholder group. OSP who participated in the pre-pilot exercises were excluded from the main study.

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Figure 2:

The framework to assess barriers faced by eye care service providers.

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Figure 3:

The factors of production in healthcare service provision framework.

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RESULTS

DISCUSSION

Predominant barriers afflicting the OSP appear to be two-pronged – those that are within the purview of the OSP to remedy and those that are beyond their control. Such endogenous and exogenous determinants greatly hamper the provision of CSS in this region. Endogenous barriers, specifically issues related to human resource management, such as the lack of skilled staff or frequent staff attrition, are a cause of concern. Attracting and retaining sufficient healthcare staff to provide adequate services for residents of rural and remote areas is a global problem.^[26] It is estimated that there are about 14,000 ophthalmologists, 9,000 optometrists, and 3,000 ophthalmic assistants in the country.^[27] Although the estimated global ophthalmologist workforce appears to be growing, the appropriate distribution of the eye care workforce seems to be unfavorable, with rural and remote regions having a negligible density of OSP. A recent initiative to train young people from disadvantaged backgrounds in India, as part of AOP, is a welcome step in bridging this gap.^[28] Staff retention was also reported as a significant barrier to the provision of CSS in this region . Frequent attrition of trained ophthalmic staff due to higher studies, better career prospects in urban cities, and other personal reasons, such as marriage, is a concern. To maintain and retain a qualified workforce in the long term, it is recommended that organizations invest in and focus on effective communication, offer competitive compensation and benefits, and provide opportunities for career development. Investing in human resources to enable better service provision is crucial and is recommended as a model for the provision of primary eye care services.^[29]

The predominant exogenous barriers reported were associated with community and sociocultural aspects, including beliefs, myths, and misconceptions, as well as social isolation within communities. Although treating BPH organizes regular awareness activities in the operational geographic zones, such activities are often limited to certain fixed locations. Apart from routine publicity events, OSP should also focus on observing special ophthalmic and eye-related events like World Sight Day, specifically in rural and interior areas. In addition, intensive and targeted awareness and information, education, and communication strategies in the region could help generate demand for CSS. Furthermore, recruiting and training existing community health workers (CHWs) and utilizing their services to promote awareness in rural, remote communities is a practical option available.^[30] Active and sustained involvement of local CHWs would not only improve case detection but also help generate awareness in the communities, thereby increasing demand for CSS in the region.

Yet another exogenous barrier reported, which is beyond the control of OSP, is related to structural issues such as difficult terrain and uneven distribution of road and railway infrastructure in the region. OSP from all four BPHs reported this barrier. Inadequate road networks and difficult terrain hinder the provision of eye care services in northeast India. Inadequate road network and difficult terrain were previously reported as significant patient-specific barriers in a study from the same region.^[6] Accelerating the construction of road and rail networks in this region can improve access to cataract services by providing better transportation options for medical equipment and personnel, making it easier to deliver essential eye care services in remote and underserved areas. The recent progress made in rural road-building activity as part of the Pradhan Mantri Gram Sadak Yojana, a publicly funded national rural road construction program across India, is a welcome step in that direction.^[31,32] Other structural barriers unique to this region include poor internet network and telecom connectivity, and social isolation of populations. Investing in strategies that utilize trained CHWs and forging partnerships with local organizations and governments can be practical approaches for providing CSS in rural and remote areas in northeast India where telecom and internet services are unavailable. These strategies can help overcome the lack of infrastructure and technology by leveraging local resources to deliver effective eye care services.

The limitations of this study are recognized. A mixed-methods study, i.e., one that combines qualitative and quantitative approaches, could have provided a better insight into the perspectives of the service providers. This study reflects the perspective of a small number of selected OSPs. The selection method may have introduced a sampling bias, as healthcare providers were chosen based on their expertise and the researchers’ professional network. Furthermore, by only including OSPs from private, not-for-profit eye hospitals, the study may not accurately reflect the experiences and perspectives of all healthcare providers in the region, such as those at the public-funded government health facilities. Government eye health facilities may face a distinct set of challenges in delivering eye care services compared to not-for-profit organizations, which may not be fully captured and are beyond the scope of this current study. This limits the ability to generalize the findings. Therefore, results should be interpreted in this context and with caution. Despite these limitations, our study offers robust insights and generates local data on the supply-side determinants for the provision of CSS in the northeast Indian region.

CONCLUSION

The northeast Indian region is unique and is unlike the rest of India. The provider-specific barriers reported greatly hamper the provision of CSS in this region. Investing in human resource capacities and intensifying awareness generation activities would negate most of the barriers reported. Sustained engagement of isolated and rural communities through active local involvement of CHWs would generate demand for CSS.