• Users Online: 160
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2016  |  Volume : 3  |  Issue : 4  |  Page : 176-181

The eye health system and social influence on health decision making − An example from couching in Nasarawa State, Nigeria

1 Department of Ophthalmology, Federal Medical Centre, Keffi, Nasarawa State, Nigeria
2 Department of Ophthalmology, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria

Date of Web Publication11-Jul-2017

Correspondence Address:
Penzin Selben
Department of Ophthalmology, Federal Medical Centre, Keffi, Nasarawa State
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2384-5147.210202

Rights and Permissions

Introduction: The health systems assessment approach is applied to eye health to assess its readiness to meet the goals of the global action plan for eye care. The overall blindness prevalence in Nigeria is 0.78% (1.17 million people are blind of which 84% is avoidable). Cataract accounts for 43% of blindness. With a surgical rate of 300/million/year, couching is still being undertaken with 42.7% of eyes that had cataract treatment having been couched.
Aims: This study assesses the eye health system of Nasarawa State, Nigeria and to find out why couching is still being practiced.
Settings and Design: A mixed qualitative and quantitative method was used.
Subjects and Methods: Questionnaires and interview guidelines were adapted from the International Agency for Prevention of Blindness/Eye Health Systems Assessment manuals. Health systems building blocks of governance, finance, human resources and service delivery along with traditional system were assessed, and their strengths and weaknesses were identified.
Results: Eighteen interviews were conducted. There is no eye care coordinator to supervise eye care functions in the state. Eye care is not separately financed from the general healthcare. Seventy percent of healthcare expenditure is from out-of-pocket payments. There are enough but inequitably distributed eye care workers to meet the recommendations of vision 2020 for the population. The cataract surgical rate is less than 200/million/year and less than 100 surgeries/surgeon/year. Couching is encouraged through strong community influence despite the poor visual outcome.
Conclusion: The Nasarawa State eye health system has the resources to meet the eye care demands of the population; however, it lacks co-ordination, and ineffective service delivery makes the surgical output low, thereby encouraging couching.

Keywords: Blindness, cataract, couching, eye health systems, traditional eye medicine

How to cite this article:
Selben P, Mohammed A. The eye health system and social influence on health decision making − An example from couching in Nasarawa State, Nigeria. Sub-Saharan Afr J Med 2016;3:176-81

How to cite this URL:
Selben P, Mohammed A. The eye health system and social influence on health decision making − An example from couching in Nasarawa State, Nigeria. Sub-Saharan Afr J Med [serial online] 2016 [cited 2023 Mar 27];3:176-81. Available from: https://www.ssajm.org/text.asp?2016/3/4/176/210202

  Introduction Top

A functioning health system includes all health activities that have impact on health.[1] The Nigerian health system comprises tertiary healthcare delivered through teaching hospitals and federal medical centres, secondary health centres provided by the state governments and primary healthcare facilities by the local governments.[2]

An Eye Health Systems Assessment (EHSA) tool has been developed by the International Centre for Eye Health to determine how eye care fits into the broader health system.[3] Countries such as Ghana and Sierra Leone have conducted nation-wide EHSAs.[4],[5]

The Ghana report showed sustained support from international donors, health insurance that covers most eye diseases and reducing financial barriers to access. A low cataract surgical rate (CSR) of 900/million/year was recorded as well as inequitable distribution of eye care workers.[4] In Sierra Leone, eye care is integrated into government policies; faith-based organisations provide eye care where there are no government facilities. However, there is inadequate eye care budget and inequitable distribution of human resources.[5]

Globally, it is estimated that there are 39 million blind people. Over 80% of blindness is avoidable, with cataract accounting for 50% of blindness worldwide.[6] The Nigeria Blindness and Visual Impairment Survey revealed the prevalence of blindness is 0.78% for all ages with an estimated 1.17 million blind people of which 84% is avoidable. Cataract is the major cause of blindness (43%).[7]

CSR, a measure of the delivery of cataract surgical services as a ratio of operations per million population per year, was estimated in 2006 to be 300/million/year for Nigeria.[8] The low CSR has been thought to be as a result of barriers such as lack of awareness, cost and distance to eye care facilities or due to long waiting time because of inadequate or inefficient use of resources.[9]

Cataract surgery involves surgical removal of the lens nucleus and cortex; vision is restored after surgery by implanting an intra-ocular lens in the remaining posterior capsule with excellent safety and visual outcomes. The commonest form of cataract extraction in Nigeria is the extra-capsular cataract extraction (ECCE).[10]

Couching is a traditional method of cataract extraction where the lens is dislocated posteriorly into the vitreous.[11] The Nigeria blindness survey showed that couching is still being practiced with 42.7% of eyes with cataract being couched.[12] Couching is not a problem only in Nigeria. In Mali, a survey showed that couching (0.15%) was nearly twice as frequent as cataract surgery (0.09%).[13]

This study assesses the eye health system of Nasarawa State, Nigeria, to understand why couching still remains an alternative to formal cataract surgery.

  Subjects and Methods Top

This is a population-based mixed qualitative and quantitative study performed in Nasarawa State, Nigeria, with a population of approximately two million.[14]

Study tools

The eye health system was assessed using methods adapted from the EHSA[3] manual tailored towards the finance, service delivery, human resources for eye care and the governance modules. Added information on service delivery was obtained from the International Agency for Prevention of Blindness (IAPB)[15] essential equipment list for cataract services.

Study population

These were heads of ophthalmology departments, ministry of health (MOH) directors involved with clinical services, couched and pseudophakic patients and couchers [Table 1]. Respondents were selected purposively based on their perceived role in the study objectives.
Table 1: Demographic characteristics of respondents

Click here to view

Data collection

A review of published reports on health service delivery for Nasarawa State was conducted. Direct observation, using a checklist, was used to assess facilities for cataract services by the principal investigator. Semi-structured interviews were done with the selected respondents. Questions were based on guidelines adapted from the IAPB–EHSA manuals. The interviews were conducted by the investigator and a field assistant. Digital audio recorders were used to capture responses, and notes were taken by the investigator. Data were collected between June and July 2015.

Data analysis

Data were collected and analysed descriptively Microsoft Excel 2010 v.14 (Microsoft corporation, Redmond WA, USA); qualitative analysis was done by the investigator. Representative quotations were used to illustrate identified themes.

Ethical clearance

Ethical clearance was obtained from the London School of Hygiene and Tropical Medicine and the Nasarawa State MOH, and each participant gave consent for interview.

  Results Top

Eighteen interviews were conducted, and three cataract surgical centres were assessed. Three couchers and two couched patients, all male, were interviewed.


The state MOH makes policies and oversees the functions of all the health facilities in the state. Eye care functions are supervised by the director of clinical services, as there is no specific eye care coordinator.

Three hospitals provide eye care services but are supervised under different governance systems. The state government funds the Specialist Hospital in Lafia, while the Federal Medical Centre in Keffi is funded by the federal MOH. Both provide eye care at the tertiary level. A faith-based hospital in Aloshi funded by the Evangelical Reformed Church of Christ (ERCC) and supported by the Christoffel Blinden Mission (CBM) provides primary eye care and cataract surgical services.

There is no vision 2020 committee or a prevention of blindness committee in the state, even though it is recommended in the strategic plan for vision 2020 in Nigeria.[16] Activities of civil groups are not well coordinated. The state branch of the Nigeria Association for the Blind is excluded in planning, advocacy and world sight day activities. The Ophthalmological Society of Nigeria and the Nigeria Optometrists’ Association are not functional at the state level; only the Nigeria Ophthalmic Nurses Association is functional.

Data on healthcare are routinely reported to the MOH but are not aggregated into different sub-specialities; eye care data are not specifically reported. Each hospital keeps its data, making it available on request to the supervising authority. There is no routine monitoring of cataract surgical outcome.

‘We do not keep data in the ministry. Our data collection system is poor but we are trying to strengthen it now with a series of workshops we are conducting on data handling’. (MHD2).

‘We compute our numbers at the end of each month and send the report to the medical director’s office. We have never reported our data to the state MOH as a collective unit. But when required by the Federal MOH, we send the reports there’. (HoD2).

Eye health financing

Funding for healthcare comes from the federal government, disbursed through the different levels of government. Government funding covers salaries, equipment purchasing and overhead costs. There is no specific budget for eye care and all eye care services are included in the general health fund.

Out-of-pocket expenditure (consumers paying providers directly) accounts for 70% of the expenditure on healthcare.[2] In the ERCC hospital, there is a separate budget for eye care, of which about 60% is provided by the CBM and is directly managed by the hospital. In government hospitals, user fees generated from eye care are paid into a central hospital account, made available for purchase of consumables through the hospital requisition system. Nasarawa State government employees are not yet enrolled into the National Health Insurance Scheme (NHIS).

Cataract surgery costs N20,000–N30,000 naira ($70–100). There is no standard pricing for cataract surgery. Pricing is determined by location. For instance, in the federal medical centre Keffi (FMCK), pricing is done by a committee based on recommendations from the department and on the average income. Surgeries are sometimes subsidised at the specialist hospital.

Eye health service delivery

There are 909 healthcare centres in the state,[17] with 25 (3%) providing eye care [Table 2].
Table 2: Summary of health centres in Nasarawa state.

Click here to view

Eye surgical services are provided in three local government areas spread in the three senatorial districts (Lafia, Keffi and Akwanga), equipped with basic functional equipment for cataract [Figure 1].
Figure 1: Map showing location of eye care services

Click here to view

The number of surgeons over a period of 5 years and the surgical output for each year is presented in [Table 3]. Each surgeon performs less than 100 surgeries per year, and they all do a combination of ECCE and small incision cataract extraction. There are no routine community eye outreach activities.
Table 3: Surgical output and number of surgeons

Click here to view

There is a 3–4 weeks waiting time for cataract surgery, attributed to the cost of surgery, as many of the patients had to pay for their surgery as a one-off payment.

Human resources for eye care

There are an adequate number of eye care workers for vision 2020 criteria for the two million population [Table 4]. The number of ophthalmologists in the state fulfils the requirements of vision 2020 of 4/million; however, there is mal-distribution with 5 (63%) in one urban location.
Table 4: Ratio of eye care workers by cadre to population in the state

Click here to view

The traditional eye care system

The couchers located were all in Lafia local government area (LGA), the state capital (population 330,712).[14] There are five resident couchers with many more itinerants. They were identified through a register available at the pharmaceutical directorate of the MOH. Information on couchers in other locations was not available. All couchers work alone with no network of case-finders and acquire their skills through their parents. They treat a wide range of disorders, presumably glaucoma, trachoma and itching disorders. Surgical procedures are reserved for cataract only.

It was not possible to determine the surgical output for couching, but they estimated 10–20 procedures in 1 week. They were confident in the outcome of their procedure, though one patient tested had a best corrected visual acuity of 1/60, meaning that even with glasses this patient cannot read the largest symbol on the visual acuity chart. Couchers work independently and create demand by a network of beneficiaries who market their services. Respondents attributed the high output by couchers to lack of awareness of the availability of hospital treatment. The cost of couching was N2,000–N40,000 ($7–130), depending on the income of each client. The couchers said they accept cash payment only and recruit their clients by the convenience of home treatment and the flexible payment method. The couched patients had their procedures done the first day they consulted the couchers, which shows there is no waiting time for couching, as against the 4-week waiting time for cataract surgery.

The community influence on health decision making

The couched patients interviewed felt that their communities were more aware of the option of couching than hospital care. They admitted that even though they had gone to the hospital and were scheduled for surgery, their choice of couching was influenced by the opinions of their neighbours.

‘My neighbours convinced me that hospital operation will affect the next eye. They said that local treatment was better and the man would come to the house to do it for me which was really convenient. So many learned people came to me and asked me not to go to the hospital for surgery. You see when many reputable people tell you something, you will listen to them, otherwise when something goes wrong they will always remind you and say, “We told you so”’. (CP1).

The pseudophakic patients were aware of the traditional system, but chose hospital treatment because of the information they received from their neighbours.

‘A traditional eye healer came to advertise his work at my office, he talked about curing cataract. My colleagues were not convinced and they condemned his services so they discouraged me’. (PsP3).

The patients felt the major problem of hospital treatment is the high cost and the time it takes to see a doctor and schedule a surgery.

‘It cost my son a lot of money for the surgery. I am also not happy with the long waiting time in the hospital to see a doctor’. (PsP1).

The couched patients had their procedures done on the same day of meeting the couchers. The couchers are easily accessible to their clients and they adjust the price of their service to suit each client.

  Discussion Top

This study revealed the lack of coordination needed in eye care. It also showed under-utilisation of existing services. Lack of specific policies regarding eye care, supervision and the non-inclusiveness of eye care stakeholders like the Nigerian Association for the Blind in policy formulation reveals a gap in governance and leadership in the eye health system. Other civil groups who should lead advocacy for improved eye health system are not included.

Financing eye care is not separate from the general healthcare. Funds necessary for purchase and maintenance of equipment are not readily available, or because of poor management of healthcare revolving funds. This may be because of other life-threatening competing health needs such as malaria and human immunodeficiency virus/acquired immune deficiency syndrome.

The CSR in Nasarawa, based on a population of two million,[14] was consistently below the national CSR of 300/million/year.[8] This may be because of the high cost of cataract surgery to uninsured patients, as 60% of Nigerians live below $1 a day.[18] Cost and lack of awareness of where to get treatment were factors responsible for poor patronage of surgical services in northern Nigeria.[19] Although the cost of cataract surgery in this study is similar to couching, the long-term cost of couching is higher, especially when there are complications, and also with the added unquantifiable cost of the loss of an eye to a person.

Demand for eye care services is not created by the eye care workers, as there is no marketing effort or publicity except on the annual world sight day. This is indicated by the low surgical output per surgeon and the waiting time for consultation and surgery. This shows a low demand for and under-utilisation of services as suggested by Signes-Soler et al.[20] The absence of routine eye camps contributes to the low CSR, but the good geographical spread of existing surgical services should make access easy. The non-reporting of surgical output and outcome may also be a factor, as the poor cataract surgical outcome may be a deterrent for patients seeking eye care.

The National Association of Nigerian Traditional Medicine Practitioners[21] is a registered association under the pharmaceutical research department of the MOH. Although the association is structured with a chairman and a secretary, the practitioners do not work together as a unit and only know about each other by reputation. Ascertaining the exact number and distribution of couchers was therefore difficult.

Some complications of couching include poor visual outcome, corneal opacity, retinal detachments and optic atrophy.[22] Although the couched patients felt they would not recommend couching to anyone, people are still seeking couching. It shows that there is more acceptance of couching in the communities. This shows a failure of the eye care system to provide proper eye health education and outreach to the communities on the potential hazards of couching.

The social influence on health decision making is one strength of the traditional system where the opinion of the community is significant in decision making for patients. This could be attributed to a strong sense of community belonging which makes it possible for people to suggest treatment options for patients. This system relies on the beliefs of how patients are expected to make choices by their communities, whether or not it conflicts with their own reasoning. The couched patients admitted to having knowledge of hospital treatment but relied on the suggestions of the community to make their decision. This agrees with a study in Mali which showed that 60% of the couched patients were influenced by the opinion of their friends.[13] The couched patients did not attribute their decision to a failure in the eye health system, but chose couching because of peer influence, cost not being a major factor. The people still hold on to traditional beliefs in the techniques of the couchers because of the cultural acceptance as suggested by Goyal.[23]The strong community influence on eye health decision making can be used positively to influence eye health by training members of the communities on eye health education and the dangers of couching and incorporating community members in basic eye health provision like the lady health workers in Pakistan.[24] Engaging the couchers in primary eye care can also be done.

Being largely a qualitative study, the results may not be generalised, as the responses are subjective; however, data triangulation helped to reduce bias. A major limitation in terms of the traditional system would be the low coverage from few participants in each category interviewed.

  Conclusion Top

The eye health system of Nasarawa State has the potential to meet the cataract demands of the population but poor co-ordination and ineffective service delivery produce low surgical output. There is a need to coordinate eye care services in the state through public awareness campaigns on the availability of hospital treatment and the risks of traditional eye treatment.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

The world health report 2000: Health systems: Improving performance. Public Health Rep 2001; 116: 268–9.  Back to cited text no. 1
Federal Ministry of Health Nigeria. National Strategic Health Development Plan (NSHDP) 2010-2015; 2010.  Back to cited text no. 2
Blanchet K, Gilbert C, Lindfield R. Eye Health Systems Assessment (EHSA): How to Connect Eye Care with the General Health System; 2010.  Back to cited text no. 3
Potter A, Debrah O, Ashun J, Blanchet KL. Eye Health Systems Assessment (EHSA): Ghana Country Report. Ghana Health Service, International Centre for Eye Health, Sightsavers; 2013. p. 1–92.  Back to cited text no. 4
Potter AL, Vandy M, Smart N, Blanchet KL. Eye Health Systems Assessment (EHSA): Sierra Leone Country Report. Ministry of Health and Sanitation, International Centre for Eye Health, Sightsavers; 2013. p. 1–109.  Back to cited text no. 5
Taylor K. The Global Burden of Disease (GBD) 2010 Study; 2012. p. 1-5.  Back to cited text no. 6
Kyari F, Gudlavalleti MV, Sivsubramaniam S, Gilbert CE, Abdull MM, Entekume G et al. Prevalence of blindness and visual impairment in Nigeria: The National Blindness and Visual Impairment Study. Invest Ophthalmol Vis Sci 2009;50:2033-9.  Back to cited text no. 7
World Health Organisation. Global Initiative for the Elimination of Avoidable Blindness Action Plan 2006-2011; 2007.  Back to cited text no. 8
Yorston D. High-volume surgery in developing countries. Eye (Lond) 2005;19:1083-9.  Back to cited text no. 9
Nwosu SN. Survey of cataract surgical techniques in Nigeria. Niger J Ophthalmol 2011;19:9-11.  Back to cited text no. 10
Isawumi MA, Kolawole OU, Hassan MB. Couching techniques for cataract treatment in Osogbo, South west Nigeria. Ghana Med J 2013;47:64-9.  Back to cited text no. 11
Gilbert CE, Murthy GV, Sivasubramaniam S, Kyari F, Imam A, Rabiu MM et al. Couching in Nigeria: Prevalence, risk factors and visual acuity outcomes. Ophthalmic Epidemiol 2010;17:269-75.  Back to cited text no. 12
Schémann JF, Bakayoko S, Coulibaly S. Traditional couching is not an effective alternative procedure for cataract surgery in Mali. Ophthalmic Epidemiol 2000;7:271-84.  Back to cited text no. 13
Nigerian National Population Commission. Federal Republic of Nigeria 2006 Population and housing census. Population Distribution by Age and Sex, Abuja, Nigeria, 2010.  Back to cited text no. 14
International Agency for the Prevention of Blindness. Essential Equipment List for Cataract Surgery; 2015.  Back to cited text no. 15
Federal Ministry of Health. Federal Government of Nigeria. Strategic Plan Vision 2020: The Right to Sight for Nigeria 2007-2011; 2006.  Back to cited text no. 16
Federal Ministry of Health. A Directory of Health Facilities in Nigeria 2011; 2011.  Back to cited text no. 17
Trading Economics. Poverty Headcount Ratio at National Poverty Line (% of Population) in Nigeria. Available from: http://www.tradingeconomics.com/nigeria/poverty-headcount-ratio-at-national-poverty-line-percent-of-population-wb-data.html. [Last accessed on 2015 Jun 12].  Back to cited text no. 18
Rabiu MM. Cataract blindness and barriers to uptake of cataract surgery in a rural community of northern Nigeria. Br J Ophthalmol 2001;85:776-80.  Back to cited text no. 19
Signes-Soler I, Javaloy J, Montes-Mico R, Muñoz G. Cataract surgery in West Africa: Is couching still a choice? Acta Ophthalmol 2012;90:488-9.  Back to cited text no. 20
Adefolaju T. Traditional and orthodox medical systems in Nigeria: The imperative of a synthesis. Am J Health Res 2014;2:118-24.  Back to cited text no. 21
Asuquo IM, Busuyi HM, Umar KO. The dangers of couching in Southwest Nigeria. Malays J Med Sci 2014;21:60-5.  Back to cited text no. 22
Goyal M, Hogeweg M. Couching and cataract extraction: A clinic-based study in northern Nigeria. Community Eye Health 1997;10:6-7.  Back to cited text no. 23
Khan NZ, Khan AA, Awan HR. Women health workers: Improving eye care in Pakistan. Community Eye Health 2009;22:26.  Back to cited text no. 24


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
  Subjects and Methods
   Article Figures
   Article Tables

 Article Access Statistics
    PDF Downloaded1476    
    Comments [Add]    

Recommend this journal