Original Research

Assessing accessibility of eye health through human resources in South Africa

Lehulere Mophosho, Hlabje C. Masemola, Zamadonda N. Xulu-Kasaba

Received: 26 Feb. 2025; Accepted: 17 Oct. 2025; Published: 28 Nov. 2025

Copyright: © 2025. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Globally, equitable access to vision and eye health services has been a public health challenge for a few decades.

Aim: This study aimed to map human resources for eye health (HReH) availability and distribution, explore current practices and highlight factors that impact eye health service outcomes and coverage within the public sector of the Free State province of South Africa.

Setting: The study was conducted in the Free State province of South Africa in 2022.

Methods: Using an exploratory, descriptive qualitative design, data were gathered between May 2021 and May 2022 through in-depth individual interviews. Twenty-seven eye health workers were selected as participants using purposive sampling. Data were thematically analysed with NVivo version 12. Thematic analysis was centred on the capacity-building framework, namely, organisational development, workforce development, resource allocation, partnerships, leadership and building capacity dimensions.

Results: Twenty-seven of the 33 human resources for Eye Health participated in the study. Sub-themes extracted highlighted operational challenges and staff shortages that create high workloads and hinder workforce development. Limited equipment access, leadership problems and sustainability issues are those that inhibited capacity building within the Free State eye health system.

Conclusion: This study underscores the critical role of human resources in the accessibility of eye health services in the Free State province.

Contribution: The significance of this study lies in its contribution to the broader discussion on human resources for eye health (HReH) to achieve universal eye health through sustainable human resource strategies.

Keywords: accessibility; human resources; health services; equity in healthcare; Free State province; South Africa.

Introduction

Globally, equitable access to vision and eye health services has been a public health challenge for a few decades.¹ Despite concerted efforts to reduce the prevalence of blindness and visual impairment, the burden of eye diseases continues to escalate, more so in low- to middle-income countries (LMICs) and underserved populations.¹ VISION 2020: The Right to Sight suggested three development foci – human resources, infrastructure, disease control and prevention of visual impairment – to curb these challenges.² However, access to vision and eye health services remains an unmet need and a public health concern. When these goals remained unmet in the year 2020, the World Health Organization (WHO) further advocated for investment in human resources for eye health (HReH) development, with emphasis on adequate skills and numbers and fair distribution sufficient for population needs. Furthermore, it emphasised the integration of vision and eye health services into the broader health systems to increase access, strengthen health systems and improve health outcomes.¹ There is a paucity of information on HReH, infrastructure and development within South Africa (SA), particularly in the Free State province.

The capacity-building framework (CBF) is a sophisticated theoretical construct for systematic organisational development and transformation.³ This framework has emerged as a critical tool in addressing challenges faced by health systems globally and seeks to build on existing structures and capabilities to improve the sustainability of health systems.^4,5,6 The CBF is a framework that conceptualises capacity building as a dynamic, multilayered process across individual, organisational and systemic domains.⁷ Rooted in critical social science perspectives, this framework creates adaptive systems principles that draft the institution’s development approaches, ensuring guided methods to strengthen the institutions. The core premises of the CBF are centred around intentional, strategic interventions that are ideally designed to amplify organisational resilience, human resource potential and institutional sustainability.⁸ Through the integration of these domains, the CBF provides a robust and analytical outlook that ultimately guides the organisation on systematically developing and addressing increasingly complex societal and contextual challenges. In the context of eye health, the holistic approach of the CBF would address integrating the availability and competencies of HReH, eye clinic infrastructure and exploring eye health systems in their capacity to provide equitable services to all communities. This is the first qualitative study in the Free State province focused on HReH and among the few studies to apply CBF to the eye health context in SA.

Free State is the central province of SA by geographic location.⁹ It has an estimated population of 2.96 million and comprises four districts and one metropolitan municipality.⁹ Previous authors have highlighted the challenges experienced in providing vision and eye health services in the province.¹⁰ In addition, there has been a significant data deficit from this province on HReH availability, distribution, training, recruitment and retention to date. Regularly updating data on HReH is important as it helps with strategies and regular development in a health system.¹¹ This study aimed to map HReH availability and distribution, explore current practices within eye health services and highlight factors that influence eye health services within the public sector of the Free State province in SA. The emerging data were necessary, as they would fill the information void on HReH in the province and assist in guiding policymakers on staffing issues.

Research methods and design

Study design

This study utilised an exploratory, descriptive and qualitative design. It was chosen to obtain a deeper understanding of the under-researched context of HReH in the Free State. This method made it possible to generate rich, in-depth descriptions of participants’ lived experiences as well as to explore difficult, context-specific problems. The research articulated in this article formed part of a larger study aimed at determining access to eye health through HReH in the Free State Department of Health (Free State DoH). Furthermore, thematic data analysis adapted the CBF for vision and eye health in public health.¹²

Study setting and context

This study was conducted in the Free State province of SA. The province has one large district called Mangaung and classified as a metro, and four district municipalities: Fezile Dabi, Lejweleputswa, Thabo Mofutsanyana and Xhariep. Geographically, the Free State expands over approximately 129 825 km².⁹ Within the Free State DoH, vision and eye health services are primarily provided in hospitals that have dedicated eye clinics; hence, these hospitals were selected for the study. A total of seven hospitals, categorised into two district, four regional and one tertiary eye care hospital, met the inclusion criteria and were included in the study.

Study population and sampling strategy

Purposive sampling was used to identify information-rich participants who were HReH in hospitals with eye clinics. The target population in this study were all HReH cadres (clinical and non-clinical) in selected hospitals. Initially, all the public hospitals in the province were approached to establish which ones had eye clinics. This confirmed eligible hospitals and allowed the primary investigator (PI) to start inviting participants at the correct hospitals from the five districts. A non-random purposive sampling strategy was employed in the study because of the projected small and specialised HReH population employed in Free State DoH and expected saturation confirmed by no new themes emerging after the 24th interview.

Data collection process

All HReH employed in the Free State DoH eye clinics were eligible for the study. Following ethical approval, all eligible eye clinics were telephonically contacted, informed of the study, and emailed details thereof. Interested participants were told of the PI’s visit to conduct the study and obtain contact information of those not present. Each willing participant was briefed on the aim and objectives of the study. Voluntary consent was emphasised to all enrolled willing participants. In addition, an information sheet with details of the research team and a consent form to peruse prior to commencement of in-person one-on-one interviews. Amicable interview dates and times were centred around the participants’ preferences and interviews commenced on submission of the signed consent forms.

Data were collected between May 2021 and May 2022 in a well-ventilated room that was outside the clinic to facilitate personal comfort and open and honest expression of the participants. Confidentiality and anonymity were assured through data coding, ensuring that responses could not be traced back to any individual. Data collection tools included a semi-structured interview guide and two digital recording devices. The interview guide was developed by integrating the key domains of the CBF and used to structure the flow of the interviews, systematically addressing all key thematic areas of the CBF. This ensured uniformity and consistency in the scope and focus of the data collected. Probing questions were used wherever needed to extract thick descriptions and detail. Albeit guided in English, other interviews were conducted in a mixture of Sesotho, the most widely spoken language in the province, and English. However, all depended on the language preferred by the participant. To minimise bias and reinforce consistency in the data collection process, the interviews were conducted by the same trained qualitative researcher who had no prior relationship with the participants. In addition, a neutral and non-leading language was used during the interviews to avoid influencing the participants’ responses.

All recorded interviews were transcribed verbatim and further translated into English by the interviewer, who is a native Sesotho speaker and fluent in English. This ensured that translations maintained both linguistic and contextual accuracy. To enhance the reliability of the translated data, a second bilingual translator independently reviewed a sample of the translated transcripts. Although back-translation was not applied to all transcripts because of resource limitations, discrepancies identified during the review process were discussed and resolved between the PI and the independent reviewer. This process helped ensure the trustworthiness and consistency of the translated qualitative data. The interviewer, trained as an optometrist with experience in both public and private eye care, acknowledged their professional background through reflexive journaling and engaged in regular peer debriefing with the research team to minimise bias and ensure balanced interpretation of participants’ narratives. Prior to data collection, the interviewer received training in qualitative research methods, including the use of semi-structured interview guides, probing techniques, and maintaining neutrality to avoid leading participants’ responses. This background provided a strong foundation for understanding the clinical and systemic challenges within the study setting.

When data collection was concluded, the recordings were downloaded onto a folder on the research team’s cloud account and stored in a password-protected file. Data were transcribed verbatim, translated, and cleaned. Codes were allocated to each interview to ensure anonymity, and each file was stored in the cloud folder, together with the original recordings, prior to analysis.

Data analysis

A thematic analysis approach was employed, involving a systematic process of preparation, organisation and reporting of data.¹³ Using a deductive methodology informed by the CBF, the qualitative analysis method as outlined by Elo and Kyngäs was used to analyse the data.¹³ In the preparation phase, the transcripts were read repeatedly to ensure immersion in the data and to gain an overall understanding. Based on the CBF, a systematic categorisation matrix was developed during the organising phase. Following a line-by-line review, the data were categorised based on how well they fit into these predetermined categories. Within each primary category, subcategories were created inductively to capture subtle themes that emerged from participant responses. NVivo version 12 was used to support the coding and an independent coder assessed it to increase rigour.

To ensure credibility and trustworthiness, several criteria were employed. Prolonged engagement was maintained with participants during data collection, allowing the interviewer to build rapport, foster trust and obtain deeper insights into the participants’ experiences and perceptions. Thick description was used throughout the analysis to capture the complexity of the findings, with illustrative quotes included to provide rich context and meaning. Furthermore, member-checking was conducted with participants by sharing their transcripts for verification, and all participants who reviewed their transcripts confirmed the accuracy of the captured responses, and no changes were requested.

Themes and sub-themes, supported by direct excerpts, were established using the adapted CBF (Figure 1) as a guide. The research team further peer-reviewed and analysed the process and contents for reliability, validity and credibility, further ensured by the input from the independent coder. The New South Wales (NSW) Health CBF was designed to help health systems improve their ability to deliver better health outcomes and strengthen the foundations for effective service delivery. The framework recognises that capacity-building strategies need the right context and features, infrastructure, skills and relationships for an effective health system. The adapted framework focused on five key areas:

• Developing equipped eye clinics: In this version of organisational development, the operations, organisational culture and processes would ensure activities that improve eye health.
• Adequately skilled HReH: Ensuring adequately staffed clinics, the skillset, knowledge and capabilities of staffing would result in improved work in the eye clinics.
• Resource availability: Ensuring sufficient availability and distribution of equipment and other resources to support capacity-building efforts.
• Collaboration with other stakeholders: Working together with other health professionals to ensure collective expertise and input on patient cases.
• Leadership to direct eye health: Ensuring effective leadership that can drive and sustain improvements in ocular health outcomes.

FIGURE 1: Capacity-building framework adapted for human resources for eye health.

Ethical considerations

Ethical clearance to conduct this study was obtained from the University of KwaZulu-Natal (No. BREC/00000609/2019) and the Free State Department of Health. The Helsinki Declaration was followed in conducting the study, considering voluntary participation, confidentiality during data collection and reporting of findings.¹⁴ The head of Free State DoH granted permission to implement the study, and Chief Executive Officers (CEOs) and clinical managers of the respective health facilities were informed accordingly. Ethical clearance was obtained from the Biomedical Ethics Research Committee at the University of KwaZulu-Natal and the Free State Research and Ethics office. The authors informed all participants that participation was voluntary, unremunerated and could be withdrawn at any time. To confirm voluntary participation, each participant gave written consent prior to data collection. All data were de-identified and safely stored in password-protected digital files that were only accessible by the research team in order to maintain confidentiality and anonymity. In reporting and transcripts, participant codes were used in place of names. These procedures were put in place to respect ethical standards and protect research participants’ privacy.

Results

Description of the participants

The sample comprised 27 participants, with 70.4% (n = 19) females and 29.6% (n = 8) males (Table 1). The age range was from 25 to 61 years, with the mean age being 44.5 years (standard deviation [s.d.] = 11.3). The most common qualification among participants was a B. Optometry (10 participants), with additional qualifications such as Matric (2), MBChB (2) and various specialised diplomas and degrees (e.g. Postgraduate Diploma in Ophthalmology, BSc Honours in Nursing Science), highlighting a skilled and well-rounded workforce. Experience in public sector roles varied significantly between 12.5 and 29 years (s.d. = 8.2).

Data are presented under the six themes centralised within the CBF (NSW Health Department 2001) for building capacity to improve health: organisational development, workforce development, resource allocation, partnerships, leadership and building capacity (Table 2).

Theme 1: Organisational development

A major theme among participants was associated with organisational development is halted by inefficiencies such as unclear referral protocols and inadequate policies, disrupting workflow and patient care, evidenced by the following excerpts: ‘There is no specific protocol for eyecare’ (P17, F, 37) and ‘I don’t know if there is any policy, but for our internal referrals we got the referral forms’ (P18, F, 37). Further expressed was the need for clearer communication channels as well as standard protocols to enhance eye clinic operations and efficiency. Others emphasised the need for policies and better-defined roles within the clinic to improve both staff experience and patient outcomes: ‘The last time eyecare policy was updated was many years ago’ (P10, F, 44).

Theme 2: Workforce development

Extracted from responses to the last three questions of the interview guide, staffing issues emerged as a crucial matter in the province’s eye clinics. Some participants reported that staff shortages are a primary concern in eye centres. In addition, others lamented overburdened staff that struggle to meet patients’ needs, thus impacting negatively on the quality of patient care and student training as an extended role. Henceforth, staff multitasking and stretching of resources are performed:

‘We are very short-staffed to the point that you have to improvise to cover many areas.’ (P8, F, 33)

‘When you don’t have enough staff, you find yourself multitasking and doing many things that go beyond your job description and find yourself being overloaded.’ (P15, M, 45)

‘The staff is not enough and, as a primary eye care provider, a lot of patients come to the clinic and for the number of staff that are there, it’s not really enough.’ (P3, F, 38)

Theme 3: Resource allocation

Sub-theme 3.1: Limited access to essential equipment and supplies

Several participants found limited access to equipment as a challenge for rendering services. Many clinics face significant resource constraints, including outdated or insufficient equipment, which limits their skills to deliver comprehensive eye care. Prioritising resource allocation and ensuring clinics are well equipped are considered to improve service delivery and patient outcomes. Furthermore, the non-service and maintenance of available equipment also deserve attention:

‘It’s not just about putting an optometrist in a hospital; you need to equip the room with necessary equipment and machinery to facilitate the service delivery.’ (P15, M, 42)

‘There is a lack of skills there because there’s shortage of equipment.’ (P4, F, 61)

‘The biggest hurdle in the public sector is the frustration of not having lenses and not being able to do work because some of the equipment is not working.’ (P12, F, 29)

Sub-theme 3.2: Funding constraints and budget limitations

Another major theme among participants related to funding constraints and limitations is budget allocation. Several participants found a lack of funding for HReH services, where other services and conditions take higher priority as compared to eye care needs:

‘Also, you need funding for that, and you need funding for the optometrist post.’ (P10, F, 33)

‘One of the challenging things might be the financial issues.’ (P3, F, 38)

Theme 4: Partnerships

Sub-theme 4.1: Inter-professional collaboration

There is limited collaboration between optometry and other healthcare disciplines, such as occupational therapy and psychology, which hinders holistic patient care. Strengthening partnerships with allied health services would improve patient outcomes by addressing comprehensive needs:

‘We don’t really get a lot of referrals from psychologists into our speciality clinic, and we also don’t do a lot of referrals to occupational therapists and the other professions.’ (P4, F, 61)

Despite expected collaborative patient care in an eye centre where optometry and ophthalmology coexist under the same building, this is not the case. A participant working in one of the eye centres reported poor integration of eye health disciplines:

‘We are largely working as silos, even though on paper we are regarded as an eye centre.’ (P16, M, 58)

Theme 5: Leadership

Sub-theme 5.1: Supportive and transparent leadership

Another important area for improvement was leadership that encourages transparency and recognises staff participation. It was found that supportive leadership would boost morale and promote employee retention. Furthermore, it emphasised the necessity for transparent and approachable leadership. Employee satisfaction would increase if employees were given clear communication about departmental goals and participated in decision-making processes:

‘Leadership must be open to the staff and should be approachable. This way the staff members can be able to tell their grievances or whatever that might cause discontentment.’ (P24, M, 47)

‘Transparency is one main thing that people are feeling things are not as transparent as they should be in terms of contracts, hours, and payments.’ (P5, F, 58)

‘Leadership t need to fast track the issue of the provincial policy as it is very key.’ (P11, F, 52)

Sub-theme 5.2: Advocacy and recognition for eye health

Many participants believed that the healthcare system does not give optometry the credit it merits. Leadership advocacy would promote better funding and resources for the profession and increase its visibility. Increasing awareness of optometry and obtaining the necessary funds and resources would show support for the field and generally boost employee retention and morale:

‘there’s been a lot of investment in terms of eyecare in different provinces, and we know that isn’t a priority here in this province.’ (P15, M, 42)

‘there’s a need to recognise optometry to be more important; it feels like it has been neglected as compared to the other professions.’ (P8, F, 33)

‘Eye health is a very small department and gets to be marginalized quite easily.’ (P12, M, 29)

Theme 6: Building capacity

Sub-theme 6.1: Programme sustainability

Further highlighted were the challenges of sustaining eye care programmes, particularly with limited resources and outdated equipment. It was mentioned to often work with existing supplies, as new resources were rarely provided. To address these limitations, there was an establishment of non-profit organisations to help raise funds, intended to alleviate issues with consumable shortages. This initiative is seen as a critical step towards enhancing service continuity, enabling an increased number of people to be assisted effectively:

‘You must manage with what is available. You don’t get new stuff.’ (P7, M, 47)

‘We’ve started the non-profit organisation to fundraise and mitigate shortage of consumable to help expand service provision.’ (P12, F, 29)

Sub-theme 6.2: Problem-solving culture

Also highlighted were challenges and possible improvements in the delivery of eye care services, particularly in rural and semi-rural areas. There was an expressed need for more optometrists in underserved regions to reduce the burden on patients who must travel long distances for care. Additionally noted is that a challenging work environment can impact staff retention and emphasise the importance of appreciation and recognition to keep professionals motivated. Lastly, participants view their work as a form of community service, benefiting patients who may not otherwise access those services and resources:

‘More optometrists employed in rural and semi-rural areas; patients don’t need to travel here.’ (P11, F, 52)

‘it’s always a challenging environment and people always stay if they feel appreciated.’ (P6, F, 58)

‘If there were for the sake of the patients, then is the charity that we are also offering.’ (P15, M, 42)

Discussion

The study highlights systemic gaps in the accessibility of eye health services in the Free State province, SA. The findings reveal challenges such as unclear referral protocols, ill-defined policies, limited funding, outdated and unserviced equipment and a lack of recognition for eye health within the healthcare system. Also, it reveals the inadequate numbers of HReH and their unequitable distribution, leading to increased workloads and consequent staff burnouts that strain service provision. Strengthening leadership transparency, advocating for optometry, improving interdisciplinary partnerships and securing sustainable funding and resources were identified as crucial steps to enhance eye care services and address workforce challenges effectively.

The findings of this study illuminate critical operational and workforce challenges, which compromise the efficiency and quality of eye care services. Organisational inefficiencies, such as outdated or absent referral protocols and unclear policies, hinder workflow and effective patient management, emphasising the need to improve internal communication for optimal service provision. These findings are consistent with studies confirming that many eye care services lacking standardised referral protocols lead to delays in treatment and miscommunication.^15,16,17 Furthermore, work development is retarded by severe staff shortages and subsequent excessive workloads. This further exacerbates prevailing challenges, leading to multitasking and overextension of responsibilities beyond job descriptions and resulting in eventual burnout.¹⁸ The identified challenges resonate with findings from the IAPB Africa Human Resources for Eye Health Strategic Plan (2014–2023), which underscores staff shortages and uneven distribution as major barriers to achieving universal eye health.¹⁹ Similarly, research conducted in sub-Saharan Africa, specifically South Africa and Mozambique, revealed that urban areas often receive a disproportionately larger share of resources, leaving rural populations underserved.^20,21,22,23

Moreover, there were challenges in the allocation of resources, for example, funding and infrastructure, hindering the delivery of comprehensive eye care services. Many clinics struggle with outdated or insufficient equipment, preventing HReH from optimally utilising their skills and providing quality care. Similar findings were reported in the evaluation of eye health service delivery in South Africa, where inadequate resources lead to delays in service outcomes, such as cataract surgeries, contributing to avoidable blindness.²⁴ Facilities are ill-equipped and have been associated with long waiting times of up to 18 months for patients in need of cataract surgeries.^25,26 This imbalance contributes to inequitable access to care, a challenge highlighted in the Global Action Plan 2014–2019.²⁷

The inability to resource clinics to improve service delivery and patient outcomes has been reported in the study, which can be associated with a lack of financial models and support for eye healthcare services.²⁸ Concurrently, budgetary limitations further exacerbate these issues, with funding redirected to other health services. Investment in training and retaining HReH is crucial, considering that the global optometrist-to-population ratio is inadequate, particularly in LMICs.^29,30,31 These challenges will thus need strategic financial planning, advocacy for equitable distribution of resources and prioritisation within health budgets for eye care services. This study contributes to existing knowledge as it highlights the resource deficiencies in the Free State province, owing to poor funding. In addition, it amplifies systemic issues where some clinics have staffing, yet lack functional equipment and other consumables, thus hampering their ability to care for patients.

Inter-professional collaborative practice (IPCP) involves multiple health workers from diverse backgrounds working together to provide comprehensive care and these have been identified as a limitation which is essential for effective healthcare delivery.²⁵ In countries such as Rwanda and Cameroon, the absence of coordinated eye care systems and institutional support limits collaboration among professionals.^32,33 The lack of integration of optometry and ophthalmology is not unique to Free State, as studies show recent efforts have aimed to foster collaborations, particularly in Canada, where optometrists are increasingly involved in primary eye care.³⁴ Furthermore, successful initiatives in various regions have proven that improved communication and trust between ophthalmologists and optometrists lead to better patient outcomes and treatment.³⁴

In terms of leadership, there was emphasis on the need for supportive, transparent and approachable leadership to foster morale, address staff grievances and involve employees in decision-making processes. These results highlighted a call for transformational leadership, which has been shown to significantly enhance job satisfaction and productivity among healthcare workers.³⁵ In addition, transformational leadership has the potential to advocate for eye health, with participants calling for increased recognition of HReH within the healthcare system to secure better funding, resources and visibility. Improving teamwork, emphasising open leadership and promoting eye health as a crucial component of healthcare could raise the discipline profile, improve service delivery and increase employee morale.

The challenges and strategies related to building capacity and ensuring sustainability in eye care services are multifaceted, particularly in underserved areas. Participants emphasised the difficulties of sustaining programmes with limited resources and outdated equipment, often relying on existing supplies and creative solutions, like establishing non-profit organisations, to address consumable shortages. Such collaborative initiatives are critical for sustenance of service delivery and reaching underserved populations effectively.²⁴ In addition, an inclusive problem-solving culture is vital for improving service provision, particularly in rural and semi-rural areas, where the scarcity of HReH forces patients to travel long distances in seeking services. Participants stressed the importance of employing more optometrists, which is consistent with Liu et al.³⁶, where an emphasis on the need to increase community awareness of eye health by investing in human resources is championed.³⁷ Furthermore, commitment to community service among the participants reflects the sector’s dedication to providing care to patients who might otherwise lack access, underscoring the need for strategic investments to build capacity and sustain these programmes, which can be enhanced by job satisfaction and retention, particularly in rural settings.³⁸

The unexpected finding was that HReH reported marginalisation from within the healthcare system. While HReH were valued and played a critical role in primary eye care, in the larger situation, participants perceived their profession as demeaned and ill-supported by regulators and directorate, as they were limited on resources and misdirected on policy and recognition. This is exceptionally concerning given the increasing burden of eye health issues such as diabetic retinopathy and myopia.³⁹ This finding is in line with international concerns raised by HReH in the Global Action Plan 2014–2019, which mentions the need for equitable recognition of all health professions to attain universal health coverage.²⁷ Furthermore, the novelty of problem-solving strategies adopted by the participants, such as establishing non-profit organisations to offset resource deficiencies, demonstrates resiliency and adaptability not commonly documented in health systems research.

Strengths and limitations

This is the first study in Free State province to explore and map HReH, and its use of the CBF to organise and interpret findings is a notable strength. It provides a comprehensive lens through which to examine challenges in organisational development, resource allocation and workforce development. Moreover, the qualitative approach provided rich and significant insights into the lived experiences of HReH, enabling a grounded understanding of systemic inefficiencies. The qualitative data have strong trustworthiness measures where member-checking and independent coding were used. However, its focus on a single province may limit the broader generalisations of findings to other regions in South Africa or sub-Saharan Africa with different demographic and resource profiles. In addition, the reliance on participant self-reporting could introduce bias, potentially over-representing negative aspects of the health system. The bilingual interviews enriched data, but translation may have affected nuance, which was mitigated by a bilingual reviewer cross-check. Despite these limitations, the findings provide valuable insights that contribute to the evidence base for policy and workforce development.

Recommendations

Systemic improvements within the eye health service are recommended through clear communication, updated policies and adequate staffing to help reduce burnout and enhance service delivery. It is important to invest in essential equipment and consider equitable distribution of resources to develop efficiency. Moreover, the call for a stronger multidisciplinary approach or collaborations would ensure comprehensive care for the patients. Advocacy for HReH, transparent leadership and staff participation in decision-making can enhance morale and retention, particularly in underserved areas. Resource gaps can be overcome through public–private partnership initiatives and by placement of more optometrists in rural areas to improve access to care. Longitudinal studies might also yield rich insights into the impact of targeted interventions to advocate for developing eye health systems that are equitable and sustainable.

Conclusion

This study underscores the critical role of human resources in the accessibility of eye health services in the Free State province. Its significance lies in the contribution to the broader discussion on HReH to achieve universal eye health through sustainable human resource strategies. The study highlights critical barriers to accessing eye health services in the Free State province, emphasising the need for strategic workforce planning, resource mobilisation and distribution and improved inter-professional collaboration to align with global frameworks such as the WHO Workforce 2030, which provides valuable guidance for addressing systemic challenges in eye health. Furthermore, the study contributes to the broader discourse on HReH by providing actionable insights for national policymakers and stakeholders to consider in planning eye health programmes, capacitation and their sustenance.

Acknowledgements

The authors greatly appreciate the Free State Department of Health and respective hospitals and all participants in accepting participation in this study.

The article is partially based on Lehulere Mophosho’s thesis entitled ‘Assessing accessibility of eye health through human resource in the Free State province, South Africa’ towards the degree of Master of Optometry in the Department of Optometry, University of KwaZulu-Natal, South Africa, on 14 May 2025, with supervisor Dr Zamadonda N. Xulu-Kasaba.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Lehulere Mophosho: Conceptualisation, Methodology, Formal Analysis, Investigation, Writing – original draft, Visualisation, Project Administration, Validation, Data curation, Resources, Writing – review & editing. Hlabje C. Masemola: Methodology, Formal Analysis, Writing – original draft, Visualisation, Software, Validation, Resources, Writing – review & editing. Zamadonda N. Xulu-Kasaba: Conceptualisation, Methodology, Writing – original draft, Visualisation, Project administration, Validation, Data Curation, Resources, Writing – review & editing, Supervision. All authors have read and agreed to the published version of the manuscript.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

The data supporting the conclusions of this study are available from the corresponding author, Lehulere Mophosho, upon reasonable request.

The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

References