Purpose: The provision of accessible eye care services can help reduce the prevalence of avoidable blindness within a population by providing timely high-quality interventions to those in need. Our aim was to identify and quantify barriers to accessing eye care for the elderly population in Pakistan, which prevent effective eye care delivery to this group. Patients’ experiences with the Sehat Sahulat (health insurance) programme (SSP) in relation to eye care were also explored. Methods: Using an exploratory sequential mixed methods design, an initial qualitative phase explored participant experiences and identified specific barriers. The qualitative study provided the basis for the development of a customised survey tool. The survey tool was used in a second phase to obtain quantitative data of barriers and costs associated with accessing eye care. Results: Numerous considerable barriers were identified, including illiteracy, long travel times, female gender, old age, mobility issues, and costs, all of which limited access to eye care in Pakistan. Awareness surrounding the use of the SSP was poor, with the programme seldom used for eye care costs. Conclusions: This study provides valuable evidence on patient experience with eye care services in urban and rural areas of Pakistan, including expenditure, patient priorities, and enablers and barriers to accessing eye care. Areas for improvement should focus on educating the public on eye health, increasing the availability of secondary eye care services in rural areas, improving accessibility within eye care facilities, addressing gender disparities, and reducing costs associated with eye care treatments, potentially through advancement of the SSP.

Introduction The global burden of blindness is unequally distributed and affects rural areas to a greater extent. The World Health Organisation has specified task-shifting and increasing human resources for eye health as two strategies to improve access to eye care in under-served areas. It is unknown whether factors contributing to the successful task-shifting of mid-level eye care providers, and factors that lead to their successful recruitment and/or retention in under-served areas are similar or complementary. Methods A literature review was undertaken focussing on Ghana and Scotland: two countries that have implemented task-shifting in eye care. Results Four main areas were highlighted that must be addressed for task-shifting and recruitment/retention of eye care workers to be successful: training, incentivising to work in the right areas, motivation to stay, and the means of productivity. Discussion Incentives are effective in both task-shifting and recruitment/retention but both financial and non-financial incentives should be carefully considered, including at the student stage. Incentives should be given for trainers as well as trainees. Task-shifted clinicians are motivated to remain through clear career progression, learning opportunities, good relationships with colleagues and management, and suitable remuneration for the increased responsibility. The ability to meet the actual need of the population is important and requires the legal ability to prescribe medication. Adequate resources like equipment and consumables are required to maintain motivation. Conclusion Factors leading to successful task-shifting and recruitment/retention of eye care workers in under-served areas are similar. Designing strategies to improve these should evaluate context-specific motivational factors.