Service users’ perspectives on primary eye care services following performance-based financing in Rwanda: an exploratory qualitative study

Abstract

BACKGROUND: Visual impairment is a major global public health concern, disproportionately affecting populations in low- and middle-income countries (LMICs), where access to eye care services remains limited. In 2019, the Rwandan Ministry of Health integrated eye care services into the Performance-Based Financing (PBF) framework to improve accessibility, service quality, and utilization. However, service users' perspectives on this initiative remain underexplored. This study aimed to examine service users' perceptions of accessibility, quality, affordability, satisfaction, and challenges in accessing eye care services at primary healthcare facilities. METHODS: An exploratory qualitative study was conducted in six purposively selected health centers in Rwanda. A total of 72 participants were recruited using maximum variation sampling, including older adults, individuals with disabilities, and participants from different socioeconomic backgrounds. Data were collected through six focus group discussions (FGDs), each comprising 8-12 participants. Discussions explored perceptions of accessibility, quality, affordability, satisfaction, and recommendations for improvement. Audio recordings were transcribed, translated into English, and analyzed inductively using Dedoose software. Trustworthiness was ensured through prolonged engagement, member checking, peer debriefing, and triangulation. RESULTS: Participants reported that the decentralization of eye care services to health centers improved geographical access and reduced travel time. However, financial barriers remained a major constraint, particularly due to the cost of eyeglasses and certain medications not fully covered by Community-Based Health Insurance (CBHI). Users also described inconsistencies in service quality, including frequent stock-outs of essential supplies, limited equipment, and variability in the availability of eye care personnel. Despite these challenges, many participants expressed satisfaction with provider attitudes and interpersonal care, highlighting respectful and supportive interactions with health workers. At the same time, dissatisfaction was reported due to systemic inefficiencies such as limited service days, understaffing, long waiting times, and referral-related burdens. CONCLUSIONS: Findings indicate that decentralization may have contributed to improved geographic accessibility and perceived service responsiveness; however, these improvements are uneven and remain constrained by financial and system-level barriers. Addressing these barriers through expanded service packages, reliable supply chains, human resource strengthening, CBHI coverage, and community education is critical to optimize equitable eye-care delivery.