Cataracts are one of the most prevalent diseases of the lens, affecting the transparency and are the major cause of reversible blindness in South Africa and globally [1-4]. Visual impairment and blindness are major health challenges in the rural and remote communities in developing countries  . Several authors have long observed that visual impairment and age-related eye diseases are increasing due to aging populations, increasing life expectancy and impact of risk factors such as smoking, diabetes and hypertension [3, 6]. The World Health Organization (WHO) estimates that 314 million people have visual impairment globally . Of these, 269 million have low vision and 45 million are blind . According to recent estimates, un-operated cataracts account for 35% of cases of blindness and 25% of cases of moderate to severe vision impairment world-wide .
In the United Kingdom, visual impairment affects about 10% of the population aged 65-75 years and 20% of those aged 75 years and older with approximately 3 million surgeries performed annually and numbers continuing to grow  and 0.57 million people suffer from visual impairment in Pakistan alone  whereas, the highest prevalence of blindness is in Africa . As far back as 2002, WHO estimated that the unclassified prevalence of blindness in Sub-Saharan Africa is between 1% and 9% among the age group 50 years and above [7, 11]. In South Africa, there are about 330,000 blind people and of these, 80% live in rural areas .
The issue about scarcity of eye services in rural areas is not peculiar to South Africa. In their paper on the utilisation of public eye services by the rural community residents of the Capricorn district, Ntsoane et al (2012) reviewed several papers on this issue covering different parts of developing countries which showed that developing countries are also affected [5, 12-15]. Apart from scarcity or non-availability, access to available eye services, including cataract surgery might be due to affordability and non-acceptability. For example, in South Africa, several factors, such as non-availability, poor knowledge of available services, cultural barriers may prevent people from using eye services . Other reported barriers to increasing cataract surgery rates include inadequate commitment by hospitals or provincial managers to increase surgery numbers; insufficient access to theatre; erratic supply of surgery consumables; shortage of ophthalmic nurses; shortage of surgeons; inappropriate use of surgeons times; and theatre staff not familiar with high-volume cataract surgery [5, 11, 16].
Reference to Sweden, Smirthwaitte et al (2016) posited that although the Swedish Health and Medical Services act states that good care should be given to the entire population on equal terms, however, access to care in Sweden differs, for example due to gender and socio-economic variables . The availability of highly developed surgery occurs in industrial countries while such services are lacking in developing countries including South Africa [3, 18, 19].
Cataract is a major cause of blindness in South Africa in general and Limpopo province in particular. A study carried out in Cape Town , which is an urban city, showed that cataract was the second leading cause of blindness ( 27%) and the leading single cause of severe visual impairment (37%) . In another study conducted on the causes of visual impairment among eye clinic patients in a rural-based hospital in Mopani district, apart from uncorrected refractive errors, cataract was responsible for about 21% of the causes of significant visual impairment among the participants . According to Maake (2015), after optical corrections among the participants, the main cause of visual impairment was cataract (39.5%) . Although cataract is treatable by simple, inexpensive surgery, it is responsible for 66 % of all cases of blindness in South Africa.
Cataract removal is the most common and successful ophthalmic surgery, however, cataract surgery poses a major economic burden and in developing countries, such as South Africa, cataract surgery either is unaffordable or inaccessible or even unacceptable [20, 21]. Limpopo province features prominently in South Africa’s poverty ranking as being one of the least developed of the provinces in the country. Poverty and blindness or loss of vision are cyclically linked, with poverty increasing the risk of becoming blind and blindness exacerbating poverty through limiting opportunities to engage in income generating activities [22, 23].
Based on need, to meet the WHO’s vision 2020 programme objective of making cataract surgery accessible at a rate of 2000 to 3000 operations per million people per year, the Eastern Cape province requires 17500 cataract surgeries annually [7, 11]. As at 2011, government institutions conduct maximum of 3,000 operations annually, leaving an estimated shortfall of 14500 cataract operations per year. This annual shortfall does not address the backlog of over 35,000 cataract blind people .
Vision loss and utilisation of cataract surgery have important demographic and socio-economic determinants. In other words, poverty, for example, and availability, accessibility and utilization of cataract surgery services are cyclically linked, with poverty increasing the risk of inaccessibility to or non-affordability of cataract surgery and therefore increasing the possibility of becoming blind. Blindness, on the other hand, exacerbates poverty through limiting opportunities to engage in income generating activities [11, 18, 19, 24]. To date, there is no study that has explored the nature of this association among cataract patients in Limpopo province. Proper planning for Vision 2020 blindness prevention programmes in South Africa will only be possible if research evidence on the nature and extent of the problem of the major causes of visual impairment in both the rural and urban areas is known, hence the need for this type of study.
1.2 Aim of the study
The goal of the current study was to increase a better understanding of eye health inequalities in Limpopo province with specific reference to cataract surgery and care. The study sought to answer a central question “What are the barriers related to the low uptake of cataract surgery and care in Limpopo?”