Visible expansion, fragile effective coverage: Using repeated eye health system assessments to interpret limited change in eye health outcomes in Sierra Leone, 2013-2025.

Purpose: To examine how reported changes in Sierra Leone's eye health system may help interpret limited change in avoidable blindness, cataract surgical coverage, and gender equity between repeated population eye health surveys. Methods: We reviewed four national reports: RAABs from 2010 and 2021 and EHSAs from 2013 and 2025. We extracted findings on governance, financing, workforce, service delivery, medical products, and information systems. We compared what changed and what persisted across the two EHSAs, assessed how comparable the reports were, and linked system themes to RAAB outcomes as plausible interpretations rather than direct causal effects. Results: Blindness among adults aged 50 years and older changed little, from about 4.9% in 2010 to 5.4% in 2021. Cataract surgical coverage rose from about 40.5% to 50.5%, but coverage fell slightly among women while rising among men. By 2025, eye health had stronger coordination, more district eye units, a larger workforce, wider equipment distribution, and eye indicators in DHIS2. These gains matched the modest rise in coverage. However, donor dependence, weak domestic financing, uneven workforce deployment, fragile procurement and maintenance, and weak routine data use remained. Conclusion: Repeated EHSAs can help explain why visible service expansion may not lead quickly to better population outcomes. In Sierra Leone, progress was real but too uneven and fragile to shift blindness more clearly or close the gender gap. Future gains will depend on stronger domestic financing, fairer workforce deployment, reliable supplies and maintenance, and routine equity monitoring.