Barriers to Cataract Surgery Uptake in Africa: A Systematic Review

Purpose To synthesise evidence on barriers to cataract surgery uptake in Africa across patient, community, and health system levels, describe regional variation, and identify evidence gaps. Methods We conducted a systematic review of multiple databases for studies published from January 2000 to March 2025. Searches combined controlled vocabulary and free text terms for cataract surgery, access or uptake, and African countries. Two reviewers independently screened titles, abstracts, and full texts with consensus resolution. Eligible studies enrolled African populations and explicitly reported barriers, facilitators, or determinants of uptake. Data were extracted into a piloted template and synthesised thematically without meta-analysis. Reporting followed the PRISMA 2020 guidelines; the study was prospectively registered (PROSPERO CRD420251145721). Results Following the screening of 737 records, a total of 108 studies were included, spanning Rapid Assessment of Avoidable Blindness surveys, cross-sectional, qualitative, and mixed-methods designs. Patient-level barriers most frequently reported were direct and indirect costs (surgery, travel, accommodation, income loss), limited awareness, fear of surgery or poor outcomes, gender inequities, and cultural beliefs. Community-level barriers included transportation constraints, weak referral pathways, and inconsistent outreach efforts. System-level barriers comprised workforce shortages, limited theatre capacity, equipment or consumable shortfalls, scheduling inefficiencies, and reliance on out-of-pocket financing with limited insurance or subsidies. Rural, urban, and regional disparities were consistent. Conclusion Barriers to cataract surgery uptake in Africa are multifactorial and interlinked. Evidence supports multi-component strategies, including patient education, targeted financial and transportation support, strengthened referral and outreach, service decentralisation, and health system investment, to improve equitable access and accelerate progress toward eye health targets.