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Improvement in the effective cataract surgical coverage in Malaysia: evidence of impact from a mobile cataract outreach program

Abstract

Background

Effective Cataract Surgical Coverage (eCSC) is one of the Universal Health Coverage (UHC) indicators recommended by the World Health Organization (WHO). It is calculated from a population survey and measures access and quality of eye care services in the community. We conducted simultaneous population-based eye surveys in two regions in Malaysia in 2023 to estimate eCSC and compare the results with the survey in 2014 following the implementation of a mobile cataract program.

Methods

The surveys were simultaneously done in Eastern and Sarawak administrative regions using the Rapid Assessment of Avoidable Blindness (RAAB) technique. It involved a multistage cluster sampling method, each cluster comprising 50 residents aged 50 years and older. Presenting visual acuity (PVA) was checked, and subjects with cataracts were identified. The corrected VA (Pinhole) of those who had undergone cataract surgery was measured. eCSC was calculated at all levels of cataract surgical thresholds according to the protocol. The findings were compared with the previous survey.

Results

A total of 10,184 subjects were enumerated, with 9,709 examined and 475 non-respondents. Females had a significantly lower Cataract Surgical Coverage (CSC) than males for cataract surgical threshold of <鈥3/60 for both regions in National Eye Survey (NES) II in 2014, [Eastern female 82.0%, 95% Confidence Interval (CI) (72.5, 91.5) vs. male 97.8%, 95% CI (92.8, 100.0), Sarawak female 76.9%, 95% CI (66.4, 87.3) vs. male 96.4%, 95% CI (91.6, 100.0)]. However, there was no significant gender difference in eCSC. Comparing NES II (2014) and NES III (2023) at various levels of cataract surgical threshold, eCSC improved within the range of 13.8-19.2% and 18.6-23.8% for Eastern and Sarawak, respectively.

Conclusion

The improvement in eCSC could likely be attributed to both quality outcome enhancement and increased coverage, possibly due to the impact of the mobile cataract services in both regions. However, a coordinated approach is necessary to further strengthen and expand the coverage of the program to enable the country to achieve the 30% increase in eCSC as targeted by WHO.

Peer Review reports

Background

Malaysia is one of the 37 member states of the World Health Organisation (WHO) Western Pacific Region [1]. As part of the global and regional eye health agendas, Malaysia has been actively engaged with other countries within the Western Pacific Region in planning, implementing, and monitoring community programs related to the Prevention of Blindness and Low Vision (PBL) initiatives. The activities鈥 coverage expanded and strengthened after the country endorsed and signed the World Health Assembly (WHA) 66.4 resolution in May 2013 [2, 3]. By signing the resolution, Malaysia is committed to being part of the Global Action Plan, the core activity and aim of which is providing Universal Health Coverage (UHC) to the population [3].

Malaysia is divided into six regions for the PBL administrative purposes: Northern, Eastern, Central, Southern, Sabah, and Sarawak (Fig.听1). Simultaneous surveys were done in 2014 for each region as a baseline, and the results were published [4]. The main finding of the surveys was a low cataract surgical coverage (CSC) in the peripheral regions, namely Sabah, Sarawak, Northern, and Eastern Regions, discrepancy between the regions, and variation of CSC and effective Cataract Surgical Coverage (eCSC) across four cataract surgical thresholds based on level of visual acuity (<鈥6/12, <鈥6/18, <鈥6/60 and <鈥3/60) [4]. One of the national action plans planned and implemented was to introduce a mobile cataract outreach service, which could potentially reach the underserved population, especially in remote areas. Guided by the pre-existing basic community eye care services and the availability of eye-trained human resources, the Eastern Region and Sarawak were selected as the regions where this program would be piloted.

Fig. 1
figure 1

Survey administrative regions, total population, and percentage of individuals 50 years and older in Malaysia. (This study surveyed Eastern and Sarawak only)

eCSC indicator is the WHO鈥檚 preferred measure for countries to monitor progress towards universal health coverage. It captures data on the coverage of services in the population (a measure of access), as well as quality of care [5, 6]. eCSC and CSC are reported at four cataract surgical thresholds i.e. <6/12, <鈥6/18, <鈥6/60, and <鈥3/60. The gap between CSC and eCSC values can be considered a quality gap; the relative quality gap is calculated as (total CSC鈥搕otal eCSC)/ total CSC), with lower values reflecting better quality of cataract surgical services [7,8,9].

The recommended feasible global target for effective coverage of cataract surgery, endorsed during the 74th WHA, is a 30% point increase in effective coverage of cataract surgery by 2030 [10]. This study aims to determine the difference or improvement in the eCSC between the two administrative regions by comparing the results to the previous survey.

Methods

A follow-up survey was required to compare the CSC and eCSC before and after implementing the mobile cataract outreach program. These cross-sectional, population-based surveys were conducted using the WHO-recommended Rapid Assessment of Avoidable Blindness (RAAB) protocol. The RAAB is a well-established method used in population-based eye health assessments. In addition to reporting priority eye care service indicators, it evaluates the prevalence and aetiology of blindness and vision impairment in adults aged 50 years and older. The follow-up survey utilised RAAB 7, the seventh generation of the RAAB, which was developed through a collaboration between the International Centre for Eye Health (ICEH) at the London School of Hygiene & Tropical Medicine and Peek Vision. RAAB 7 features comprehensive digitisation and employs web and mobile-based software. Through this software, data automatically synchronises with a virtual private cloud, allowing investigators to monitor data collection in real-time [11]. The follow-up survey was conducted in Sarawak and the Eastern region of Malaysia simultaneously from July to October 2023. The surveys also collected data on the prevalence of visual impairment and its causes, the prevalence of cataract, visual outcomes after cataract surgery, and effective Refractive Error Coverage (eREC), the results of which will be discussed in other manuscripts.

Each region had six data collector teams comprising three individuals; two resident doctors trained in Ophthalmology and one allied health personnel, which could be a nurse, medical assistant or optometrist. Each team was responsible for surveying 16鈥17 randomly selected clusters, examining 50 residents aged 50 years and older. Population sampling was per RAAB methodology, a widely used, WHO-recommended method for population-based surveys. The RAAB survey protocol and methodology have been described elsewhere [12].

Sampling frame and sample size calculation

Department of Statistics, Malaysia (DOSM) conducts nationwide data collection for the National Population and Housing Census once every ten years. An Enumeration Block (EB), the smallest population unit, with 80鈥120 living quarters each, is demarcated based on the latest findings and the population distribution, followed by the development of a corresponding geographical map, indicating the exact location and boundaries of each EB. The EBs are gazetted for field work operations, for example, Morbidity, Nutrition, Household Expenditure, and Labour Force Survey [13]. The latest population data was obtained from the Malaysian National Census 2020 [14, 15]. The complete list of all EBs from the 2020 national census was used to select clusters for the RAAB.

The sample size calculation depends on the total population aged 50 years and older, as well as the prevalence of blindness derived from prior surveys. A prevalence of blindness of 1.5% in Eastern and 1.6% in Sarawak among subjects aged 50 and older from NES II (2014) was used in the calculation using a 95% Confidence Interval (CI), precision of 30%, and estimated design effect (DEFF) of 1.5. It took into consideration the possibility of 20% non-response [4, 12]. The calculation resulted in a sample size of 105 clusters (5239 subjects aged 50 years and older) and 98 clusters (4900 subjects aged 50 years and older) for Eastern and Sarawak, respectively. All the EBs for both regions were randomly selected using the Probability Proportionate to Size (PPS) technique. The DOSM has classified the strata into ten distinct groups based on the population density per area and the travel time to the city centre. This study focuses specifically on areas with higher population densities and those that require less than one hour of travel to the city centre. Strata located in remote areas, which necessitate longer travel times or alternative modes of transportation such as helicopters or boats, have been excluded from this study due to safety concerns.

The higher number of EBs in the Eastern region corresponds to a larger population of individuals 50 years and above, as well as a lower previous prevalence of blindness compared to Sarawak. Individual EB codes and the corresponding maps were then used to identify the location of the EBs during fieldwork data collection.

Training

Training for survey teams was conducted separately in each region before the fieldwork by a certified Western Pacific RAAB trainer to ensure data quality and strict adherence to study protocol. Survey team members were required to attend four training days, including RAAB lectures, inter-observer variation (IOV) assessment, and an actual survey in one of the nearby EBs during fieldwork. Each region had one coordinator responsible for the smooth implementation and progress of the survey.

All six survey team members underwent an IOV assessment, during which their level of agreement was evaluated. This process involved administering 15 questions to subjects comprising patients and staff from the Ophthalmology Clinic. There were 20 subjects with mixed normal and impaired vision, including cataracts, pseudophakia, or other eye diseases. The six survey teams examined the same 20 individuals during the assessment. The other teams鈥 findings were compared to those of the most senior or experienced team (as the gold standard).

For the IOV assessment, the kappa coefficient values were classified as poor (<鈥0.20), fair (0.21鈥0.40), moderate (0.41鈥0.60), good (0.61鈥0.80), and very good (0.81-1.00). RAAB methodology required agreement for each question to be >鈥0.60. The kappa results for the Sarawak team were 37.0% for kappa value鈥夆墹鈥0.60 (28 out of 75 questions) and 63.0% for kappa value鈥>鈥0.60 (47 out of 75 questions) compared with the 鈥済old standard鈥 survey team. The kappa results for the Eastern Region team were 18.7% for kappa value鈥夆墹鈥0.60 (14 out of 75 questions) and 81.3% for kappa value鈥>鈥0.60 (61 out of 75 questions) compared with the 鈥済old standard鈥 survey team. The questions and the corresponding team with a low kappa value鈥夆墹鈥0.60 were identified. Following the IOV exercise, post-mortem evaluations were conducted through interviews with all data collectors. Each question was thoroughly discussed to ensure a unified understanding among team members. Subsequently, all groups participated in retraining sessions that concentrated on areas of disagreement. Additionally, each team convened with their coordinator and trainer to reinforce their ability to conduct examinations and interviews in accordance with the RAAB protocol prior to the actual survey implementation.

On the field survey methods

Each team was assigned to survey 16鈥17 EBs. Subjects were selected from each block using the Compact Segment Sampling method. The population area was divided into segments of equal population size, enough to provide the required number of eligible people aged 50 years and older. The survey started in a randomly selected segment until 50 eligible people had been examined. If all houses in the segment had been visited and the number of subjects was insufficient, then a second random segment was picked for the survey team to continue until they recruited 50 subjects.

If the subject was unavailable at home, the contact number would be taken from the neighbours, and a revisit would be done before the team left the survey area. If the subject could not be examined after three revisits, this person would be recorded as `Not Available鈥, and the vision status reported by relatives or neighbours would be taken. Door-to-door interviews were conducted in each randomly selected EB. Subjects were recruited if they were 50 years and older, a Malaysian resident of at least six months, and gave informed consent. A total of 50 subjects were recruited in each EB. All recruited subjects had a brief interview, where demographic, medical, and ocular history data were taken. It was followed by visual acuity assessment at a distance of three meters using tablets installed with the RAAB 7 application with built-in quality control measures [11, 16]. An eye examination was performed by the doctors in the survey team using a hand-held ophthalmoscope. If the subjects had a visual impairment, the primary cause was identified, and the subjects were referred to the nearest ophthalmic care facility for further management. The doctor in the team will provide a comprehensive explanation of the subjects鈥 eye conditions, and a referral letter, including the date of the scheduled appointment at the designated ophthalmic facility, will be provided to the subjects.

Definition

National Eye Survey II (NES II) was conducted in 2014, and the survey under discussion, National Eye Survey III (NES III), was conducted in 2023. Although the later survey only involved two out of six regions, the national PBL committee agreed to maintain the 鈥淣ational/NES鈥 label for branding and advocacy purposes.

The cataract surgical thresholds were reported using Pinhole Visual Acuity (PinVA) in the better eye, measured with correction, if available. Visual Impairment (VI) categories were defined according to the Visual Acuity (VA) thresholds used in the WHO鈥檚 International Classification of Diseases (ICD-11) [17].

Blindness: VA less than 3/60 in the better eye.

Severe VI: VA less than 6/60 to 3/60 in the better eye.

Moderate VI: VA less than 6/18 to 6/60 in the better eye.

Mild VI: VA less than 6/12 to 6/18 in the better eye.

Cataract surgical coverage (CSC) and effective cataract surgical coverage (eCSC) [7]:

CSC is defined as (X鈥+鈥塝) / (X鈥+鈥塝鈥+鈥塟).

eCSC is defined as (A鈥+鈥塀) / (X鈥+鈥塝鈥+鈥塟).

where, (for example, at the <鈥6/12 cataract surgical threshold):

A鈥=鈥塱ndividuals with unilateral operated cataract attaining 6/12 or better post-operative presenting VA in the operated eye, who have best corrected visual acuity (BCVA)鈥<鈥6/12 in the other eye.

B鈥=鈥塱ndividuals with bilateral operated cataract attaining 6/12 or better post-operative presenting VA in at least one eye.

X鈥=鈥塱ndividuals with unilateral operated cataract (regardless of visual acuity in the operated eye) and best corrected visual acuity (BCVA)鈥<鈥6/12 in the other eye.

Y鈥=鈥塱ndividuals with bilateral operated cataract (regardless of visual acuity in the operated eyes).

Z鈥=鈥塱ndividuals with best corrected visual acuity (BCVA)鈥<鈥6/12 in both eyes with cataract as the main cause of vision impairment in one or both eyes.

Relative Quality Gap is the gap between CSC and eCSC and is calculated as (total CSC鈥搕otal eCSC)/ total CSC). Lower values reflect better quality of cataract surgical services.

Unmet need for cataract surgery is defined as the number of individuals who have cataracts and would benefit from cataract surgery but not receiving it. People with unmet need for cataract surgery may have cataract in one or both eyes, or cataract in one eye and a different cause of visual impairment in the other eye [18].

Statistical analysis

Data were entered into the cloud-based RAAB 7 software using tablets. The RAAB 7 software utilised R application in which automated analysis code is freely available at GitHub page [19]. The software had an in-built inconsistency check and validation for double data entry. It reported the CSC and eCSC in percentages and 95% CI values by adjusting for age and sex. Other categorical data were reported in frequency and percentage. Raw data and digital reports were generated automatically in real-time and accessible to authorised investigators through the web-based portal [20, 21].

Results

A total of 10,184 subjects 50 years old and older were enumerated (Eastern, n鈥=鈥5,250, Sarawak, n鈥=鈥4,934). A total of 9,709 were examined [Eastern, n鈥=鈥4,961 (94.5% response) and Sarawak, n鈥=鈥4,748 (96.2% response)]. These subjects represented 0.5% of all people aged 50 and older in both regions. More female subjects were examined, n鈥=鈥5,520 (56.8%) (Table听1).

Table 1 Examination status and age distribution in the sample, NES III (2023)

There was a total of 475 non-respondents. The subjects classified as non-respondents were neither interviewed nor examined. 73 of them (0.7%) refused to participate in the study, while 329 subjects (3.3%) were considered incapable of being examined due to communication problems such as deafness, dementia or psychiatric illnesses. Furthermore, 73 subjects (0.8%) were unavailable for the study. The response rates in both regions were within the range of 94.5鈥96.2%. Comprehensive details are provided in Table听1.

In NES II (2014), females had a significantly lower CSC than males for cataract surgical thresholds of <鈥3/60 in both regions. Otherwise, generally, the CSC for females at each cataract surgical threshold was lower than for males but the difference was insignificant. For eCSC, the females had higher percentages than males, but the difference was insignificant. (Table听2).

Table 2 Adjusted cataract surgical coverage and effective cataract surgical coverage at the person level - comparing NES II (2014) and NES III (2023)

In NES III (2023), both CSC and eCSC for females at each cataract surgical threshold were lower than males except for eCSC at the cataract surgical thresholds of 6鈥<鈥60 and <鈥3/60 in Eastern. However, the gender difference was insignificant (Table听2).

The significantly lower CSC among females at the cataract surgical threshold of <鈥3/60 in NES II (2014) for both regions was consistent with the significantly higher unmet need for cataract surgery among females at the cataract surgical threshold of <鈥3/60 during the same survey (Table听3).

Table 3 Prevalence of unmet need for cataract surgery at pinhole VA thresholds鈥<鈥3/60, <鈥6/60, <鈥6/18 and <鈥6/12 - comparing NES II (2014) and NES III (2023)

Comparing NES II (2014) and NES III (2023) across the various levels of cataract surgical thresholds, CSC improved in the range of 0.1-14.9% and 7.2-17.5% for Eastern and Sarawak, respectively. eCSC improved in the range of 13.8-19.2% and 18.6-23.8% for Eastern and Sarawak respectively. There has been a notable improvement in the relative quality gap across all visual acuity thresholds from 2014 to 2023. The relative quality gaps were reduced in the range of 18.0-20.0% and 17.9-19.4% for Eastern and Sarawak, respectively (Table听2).

The variation of eCSC across the level of cataract surgical threshold appeared to be improved (Fig.听2).

Fig. 2
figure 2

eCSC at various levels of cataract surgical threshold during NES II (2014) and NES III (2023), comparing all regions in Malaysia

eCSC鈥=鈥塭ffective Cataract Surgical Coverage

Discussion

The availability of RAAB 7 software during NES III significantly enhances data accuracy and contributes to the overall quality of the study. This software incorporates a fully automated system for data entry, data cleaning, analysis and reporting. The web platform offers live visibility of survey data, facilitating real-time monitoring for quality assurance throughout the survey process. The trainers and investigators were able to identify and address any issues or inquiries from data collectors on the ground instantaneously. This modernised framework not only enables real-time monitoring by investigators but also implements centralised data management practices. These advancements ensure improved data accuracy, and the quality of the study compared to NES II in 2014, which utilised the RAAB 6 software, characterised by manual data entry with a higher potential for errors. The use of RAAB 7 software also saved time and, hence, costs needed to support the survey teams on the ground as the duration of data collection was shortened.

In NES II (2014), females had a significantly lower CSC than males for cataract surgical thresholds of <鈥3/60 in both regions. This was consistent with the higher cataract unmet needs at that level of threshold in 2014. The gender difference was found to be insignificant during NES III (2023), which indicates that efforts to address gender disparities in cataract surgical services across both regions may have taken effect. This improvement suggests better delivery of eye care and increased utilization of cataract services among females. However, it鈥檚 important to note that this does not necessarily mean that complete equity has been achieved. Improved CSC might also indicate that within nine years, other than improved access to services, more individuals with cataracts, especially females, could have better awareness about eye health to come forward and seek treatment.

In both Sarawak and the Eastern region, cultural norms have traditionally placed an expectation on women to stay at home and prioritize the needs of men. These societal perceptions have made many women hesitant to travel long distances to seek treatment for eye-related issues. To address this barrier, outreach activities have been included in the national eye care agenda, with one of the main objectives being to encourage women to pursue treatment for cataracts.

Unpublished service data indicate a generally higher proportion of women presenting for cataract surgery at outreach program locations over the years, with the exception of the COVID-19 pandemic period, during which there was a noted decline in participation. This decline may be attributed to the observed trend of prioritising men in treatment-seeking behaviours during the pandemic. Further research is required to comprehensively understand the underlying factors influencing these patterns, which is beyond the scope of this manuscript.

Improved eCSC and a corresponding reduction in the relative quality gap represented the improvement in the quality of cataract surgery done throughout the years of service, not only in the outreach but also in the hospital setting. Sarawak demonstrates a more favourable baseline rate and a greater eCSC increase than the Eastern region. This disparity can be primarily attributed to a dedicated mobile unit operating solely within the Sarawak region. In contrast, the Eastern region comprises three administrative states; Kelantan, Terengganu, and Pahang. This region operates with one shared unit, resulting in a limited capacity for outreach activities and training initiatives. Consequently, this may account for the observed discrepancies between the two regions.

The comparison for all six WHO regions was done by McCormick et al. in 2022, comparing

148 RAAB surveys which were conducted in 55 countries (from 2003 to 2021). The analysis included results of the NES II (2014) [7]. In general, the CSC and eCSC measured in the country are comparable or higher [7, 22, 23]. Acknowledging the country鈥檚 achievement in cataract surgical coverage, compared to the countries within the same WHO region or the neighbouring countries is essential. However, achieving a reduction or improvement following an intervention is more important or meaningful.

Some surveys quoted females as having lower CSC or eCSC due to the lower uptake of services compared to males [24,25,26]. But both NES II (2014) and NES III (2023) did not reveal any specific trend. However, we would plan for a further study in the future to identify the trend and to further investigate factors that may influence the utilisation of services among genders.

The relative quality gap serves as an indicator for assessing the quality of cataract surgical services. A reduction in this gap over a nine-year period signifies an enhancement in the services provided for cataract surgery. This improvement suggests advancements in numerous areas, including surgical techniques, training, access to care, and post-operative management. Across all cataract surgical thresholds, the relative quality gap decreased by 17.9鈥20.0% in both regions, highlighting significant progress in narrowing the disparities in cataract surgery outcomes.

Between 2014 and 2023, significant improvements have been observed in health systems in the country. These developments included enhanced training programs for cataract surgery, increased competency among surgeons, and strengthened advocacy efforts.

The leading national initiative that could have contributed to the improvement of eCSC and reduction in the relative quality gap in both regions is the Klinik Katarak-Kementerian Kesihatan Malaysia (Cataract Clinic Ministry of Health Malaysia, KK-KKM), an outreach arm of the ministry to reach the population (Fig.听3). It was launched in 2014 in Sarawak and the Eastern Region of Malaysia as part of the country鈥檚 progress commitments with the World Health Assembly (WHA) 66.4 resolution and as one of the national action plans following the findings of the NES II (2014). The modified buses transport surgical and medical equipment along the selected service routes according to the location of Provincial Hospitals (which are used as the primary service sites). Once arrived at the site, the equipment is offloaded and used in the clinic (for screening) or operating room (for cataract surgery). The service concept is based on operating near patients鈥 homes. But unlike other cataract mobile units in other countries, surgery is not done on the bus [27]. Instead, surgeries are done in sterile operating theatre facilities available at the Provincial Hospitals, hence minimising risks of infection. More than 90% of surgeries use the phacoemulsification technique (by portable phacoemulsification machine), and qualified optometrists do all biometry measurements for the intraocular lens [28, 29]. The surgeries are monitored by quality indicators such as the incidence of posterior capsular rupture, poor visual outcomes, and endophthalmitis [30, 31].

Fig. 3
figure 3

The mobile unit arrived at one of the locations in Sarawak

The KK-KKM project in both regions emphasises scheduled trips for screening, surgery and revisiting after one month by optometrists to assess patients鈥 visual outcomes. The timetable for the mobile unit is distributed to all the Provincial Hospitals at the beginning of each calendar year. The fixed schedule allows people in remote areas to plan their finances and trips to come forward and seek eye treatment. Operating in proper operating rooms using standard cataract extraction techniques, quality measurement of biometry, and fixing the timetable for the service maximize access and ensure quality surgery for the people.

We postulated that the implementation of the KK-KKM service had significantly enhance community advocacy for eye care. This initiative is designed to raise awareness of the eye care services provided by the Ministry of Health, with a particular focus on individuals residing in rural areas. We anticipate that this increased awareness will motivate more individuals to seek eye screenings and treatments, ultimately leading to an improvement in cataract surgical coverage.

Like in all other hospital facilities in the Malaysian Ministry of Health, data from cataract surgeries performed at the KK-KKM locations are entered into the National Eye Database, a web-based password-protected surveillance system collecting data on eye diseases and the clinical performance of the ophthalmology program in Malaysia. It consists of online systematic data entry according to predefined sets of preoperative, operative, and outcome forms. Details on the Malaysian Cataract Surgery Registry and Cumulative Summation (CUSUM) Techniques in cataract surgical performance monitoring have been published elsewhere [32, 33].

The concept of 鈥淏ringing High Impact Quality Eyecare closer to Home鈥, community engagement/advocacy, quality surgery, and performance monitoring in outreach cataract surgery could have explained the improvement in the eCSC and the reduction of the relative quality gap within both regions after nine years of service. The objective, concept, and work process of KK-KKM were endorsed by WHO when it was selected as a Case Study for the Western Pacific WHO Innovation Challenge in 2021/2022 [34].

The implementation of mobile cataract services has proven to be highly effective in improving access to eye care, particularly for communities in rural areas. By providing eye care services closer to home, this initiative not only facilitates treatment but also encourages more individuals to seek help for their eye conditions. Expanding this service will further reduce the prevalence of blindness, enhance the detection of cataracts, and ultimately improve cataract surgical coverage.

The KK-KKM initiative has been in continuous operation for ten years in Sarawak and the Eastern region. Efforts are currently underway to extend the service to other states in Malaysia. Initiatives are being pursued to secure financial support from the government, along with opportunities for public-private partnerships.

The improvements in CSC and eCSC could be attributed to the mobile cataract service. Bringing eye care closer to home is a key part of our branding strategy for outreach services, highlighting our commitment to accessibility and community health. Furthermore, this initiative has been expanded to include various outreach models, such as static, cluster, and satellite eye care services. We believe that these policy enhancements, guided by our data, have the potential to significantly improve cataract surgical coverage in Malaysia and help achieve global eye health objectives.

Strengths and limitations

Since its introduction in 2014, the mobile cataract service in Sarawak and the Eastern region has played a vital role in the provision of eye care across the country. Our focus on these regions has enabled us to comprehensively evaluate our eye care services and assess the specific benefits and effectiveness of the mobile cataract service in relation to surgical outcomes. This manuscript aims to demonstrate how the mobile cataract service has influenced eye care in the country, particularly in improving cataract surgical coverage. It is essential to clarify that this study does not intend to represent the entire Malaysian population.

The data collection conducted in the field coincided with the pre-election period for state legislative assemblies. Despite obtaining the highest level of permission from local authorities to visit residences, examine subjects, and conduct interviews, there was resistance from some subjects. This resistance was primarily attributed to concerns that the study may have had political intentions.

The other limitation of this study is the inability to analyse trends based on multiple time points due to various constraints. We are unable to conduct population surveys on an annual basis, primarily due to budget limitations and restricted human resources. However, we believe that conducting these surveys every 8 to 10 years is more beneficial. This time frame allows for a meaningful assessment of changes over time and facilitates the evaluation of the effectiveness of any interventions implemented between survey periods.

Conclusion

The improvement in eCSC and the reduction of the relative quality gap could likely be attributed to both quality outcome enhancement and increased coverage, possibly due to the impact of the mobile cataract services in both regions. However, a coordinated approach is necessary to further strengthen and expand the coverage of the program to enable the country to achieve the 30% increase in eCSC as targeted by WHO.

Data availability

All survey data are available at URL .

Abbreviations

BCVA:

Best Corrected Visual Acuity

CI:

Confidence Interval

CSC:

Cataract Surgical Coverage

CUSUM:

Cataract Surgery Registry and Cumulative Summation

DEEF:

Design Effect

DOSM:

Department of Statistics Malaysia

EB:

Enumeration Block

eCSC:

Effective Cataract Surgical Coverage

eREC:

Effective Refractive Error Coverage

ICD:

International Classification of Diseases

ICEH:

International Centre for Eye Health

IOV:

Inter-observer Variation

KK-KKM :

Klinik Katarak-Kementerian Kesihatan Malaysia (Cataract Clinic Ministry of Health Malaysia)

NES:

National Eye Survey

PVA:

Presenting Visual Acuity

PBL:

Prevention of Blindness and Low Vision

PPS:

Probability Proportionate to Size

RAAB:

Rapid Assessment of Avoidable Blindness

UHC:

Universal Health Coverage

VA:

Visual Acuity

VI:

Visual Impairment

WHA:

World Health Assembly

WHO:

World Health Organization

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Acknowledgements

The authors would like to thank the Director General of the Ministry of Health Malaysia for his permission to publish this article. The authors would also like to acknowledge the contribution of data entry by the data collectors during both NES II and NES III.

Funding

This study received financial support from the National Institute of Health (NIH), Ministry of Health (MOH) Malaysia (grant number 91000984).

Author information

Authors and Affiliations

Authors

Contributions

MAS and NNN conceived the idea for the study. MAS designed the study with input from all other authors. NM, WRWN, and SNS coordinated the data management. All authors interpreted the data and critically reviewed the manuscript. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication. MAS, NNN, and MAH accessed and verified the data.

Corresponding author

Correspondence to Nyi Nyi Naing.

Ethics declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Medical Research and Ethics Committee (MREC) of the Ministry of Health (MOH) Malaysia (Research ID NMRR-19-197-46172). The study was conducted in accordance with the tenets of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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Salowi, M.A., Naing, N.N., Mustafa, N. et al. Improvement in the effective cataract surgical coverage in Malaysia: evidence of impact from a mobile cataract outreach program. 樱花视频 25, 435 (2025). https://doi.org/10.1186/s12889-025-21602-0

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  • DOI: https://doi.org/10.1186/s12889-025-21602-0

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