Stigma and poverty block eye care for older Ugandans with disabilities

Eye care in Karamoja, one of Uganda’s poorest and most underdeveloped sub-regions, is failing older people with disabilities at nearly every step of the care pathway, according to a new qualitative study of health workers published in BMC Health Services Research. The research, led by Emma Jolley of Sightsavers together with colleagues from Moroto Regional Referral Hospital, the National Council for Persons with Disabilities and the London School of Hygiene and Tropical Medicine, interviewed 13 health workers involved in eye health services at national, regional, district and village levels. Their accounts, analysed through the supply-side dimensions of the Levesque conceptual framework of access to healthcare, reveal interlinked barriers across all five access domains, with age-related and disability-related stigma overlapping and reinforcing each other throughout.

The Levesque framework, widely used in health services research, breaks access into five supply-side dimensions: approachability, acceptability, availability and accommodation, affordability, and appropriateness. Applying this structure to the Ugandan eye care context allowed the researchers to map precisely where the system reaches out to older people with disabilities and where it falls short. Uganda, notably, already has a supportive disability-inclusive health policy framework on paper, which makes the gap between policy and practice in Karamoja all the more striking. The study complements an earlier companion paper that documented the experiences of older people with disabilities themselves; this new work turns to the providers, capturing the technical and structural constraints they face in delivering quality services.

Approachability, the first domain, concerns whether services are visible and inviting to the population they aim to reach. Health workers described limited and non-inclusive health messaging as a fundamental constraint. Outreach and information campaigns rarely accounted for the communication needs of older people with disabilities, meaning that those most likely to need eye care were often the least aware that services existed. In a sub-region where literacy levels are low and many older people live in remote villages, the absence of tailored messaging effectively screened out a large share of the target population before any clinical encounter could begin.

Acceptability, the second domain, was shaped by local understandings of ageing and by poverty. Health workers explained that vision impairment among older people is frequently regarded as an inevitable consequence of growing old rather than as a treatable condition, which suppresses demand for care. Household poverty then compounds this: families must decide how to allocate scarce resources, and an older person’s eye problem often loses out to more immediate needs. Where disability stigma is also present, older people with disabilities may be deprioritised within their own households, a dynamic that providers said directly undermines efforts to bring patients into the clinic.

Availability and accommodation, the third domain, emerged as perhaps the most physically concrete set of barriers. Health workers described long distances to facilities, poor transport infrastructure, inaccessible buildings, limited outreach services, and a shortage of assistive technology such as low-vision devices. Karamoja’s scattered settlements and rough roads mean that a journey to an eye clinic can consume an entire day, and facilities themselves often lack ramps, accessible entrances and adapted equipment. Outreach programmes, which could bring services closer to villages, are constrained by funding and logistics, and the limited availability of assistive technology means that even patients who reach a clinic may leave without devices that would restore functional independence.

Affordability, the fourth domain, centred not on the cost of treatment itself but on indirect expenses. Health workers emphasised that transport and food costs are the decisive financial barriers for older people and their families. Eye care services in Uganda are often subsidised or free at the point of delivery, yet a patient travelling from a remote village must pay for transport, and accompanying family members must be fed during what can be a multi-day trip. These indirect costs, invisible in most health financing analyses, effectively price out the poorest households and disproportionately affect older people with disabilities, who often require an escort and face higher transport expenses.

Appropriateness, the final domain, was compromised by insufficient staffing, equipment shortages, weak coordination with social support systems, and limited training on disability inclusion. Health workers described struggling to communicate with patients who have severe and complex impairments, lacking both the technical skills and the time to adapt consultations. Equipment shortages mean that even when staff are present, diagnostic and treatment capacity is constrained. Weak links between health services and social support systems mean that older people with disabilities who need assistance beyond clinical care, such as rehabilitation or social grants, often fall through the gaps between sectors.

Underlying all five domains, health workers identified three cross-cutting structural factors: age-related and disability-related stigma, dependence on implementing partners, and low levels of development in Karamoja. Stigma operates at every level, from household decisions to provider attitudes to the design of health messaging. Dependence on non-governmental implementing partners means that services can be fragile and discontinuous, vulnerable to funding cycles and project timelines rather than embedded in a sustainable public system. And Karamoja’s low development base, reflected in infrastructure, education and economic indicators, means that the sub-region starts from a fundamentally weaker position than other parts of Uganda.

The technical significance of this study lies in its systematic application of a validated access framework to a population that is usually invisible in health services research. Older people with disabilities in low- and middle-income countries face a double burden: they are older, and they are disabled, and each status independently reduces access to care. By interviewing providers rather than patients, the researchers captured the supply-side constraints that policy interventions must address if inclusive eye care is to become a reality. The findings suggest that responsive, integrated approaches, combining outreach, accessible infrastructure, assistive technology provision, disability-inclusive training and stronger coordination with social support systems, are needed simultaneously rather than piecemeal.

For a global health community grappling with rapidly accelerating population ageing, the Karamoja experience offers a sobering case study. As numbers of older people with vision impairment rise across sub-Saharan Africa, health systems must adapt not only their clinical capacity but their approachability, acceptability, accommodation, affordability and appropriateness. The health workers interviewed in this study, working in one of the most challenging environments in East Africa, have mapped the terrain with unusual clarity. Their testimony makes clear that delivering disability-inclusive eye care is not simply a matter of adding ramps to clinics or translating leaflets, but of redesigning the entire care pathway around the needs of a population that has been systematically overlooked.

Subject of Research: Delivering disability-inclusive eye care for older people in northern Uganda: a qualitative study of provider experiences using the Levesque framework

Article Title: Delivering disability-inclusive eye care for older people in northern Uganda: a qualitative study of provider experiences using the Levesque framework

Article References: Jolley, E., Bechange, S., Atto, G., Namukasa, L., Guzu, B., Flight, S., Sentongo, J., Kuper, H., & Wilbur, J. (2026). Delivering disability-inclusive eye care for older people in northern Uganda: a qualitative study of provider experiences using the Levesque framework. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15445-7

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15445-7

Keywords: Delivering, disability-inclusive, care, older, people, northern, Uganda, qualitative, provider, experiences, Levesque, framework