Social enterprises and stakeholder’s views regarding collaboration with commercial enterprises in the provision of eye care services in Kenya

The global burden of uncorrected refractive error (URE) warrants a coordinated effort between sectors engaged in the delivery of refractive error (RE) services (Li et al., 2022; Marques et al., 2020; Yang et al., 2021). Given that commercial enterprises (CE) which are entities such as the private optical shops prioritizes profit generation and dominates the eye health ecosystem in low income countries such as Kenya, the majority of the underserved population cannot access nor afford the available RE services (Austin et al., 2012). As a result, social enterprises (SE) which are organizations participating in business ventures through a commercial approach to fulfil a social purpose in a society are desirable (Luke and Chu, 2013). However, given that approximately 90% of the underserved population in low income countries suffers from URE with only 10–20% being able to access and afford the available RE services (Cao et al., 2022) collaboration between sectors engaged in RE service delivery is ideal to supplement each other’s efforts. This is attributed to the variation in the mission of the enterprises and the target population destined to benefit from the services from each enterprise.

In Kenya, the prevalence of RE is estimated at 6.39% with approximately 822 eye care professionals destined to attend to 54 million Kenyans (Muma et al., 2023). However, approximately 560 meet the threshold of functional clinical refractionists who are individuals undertaking refraction 100% of their time while others engage in various roles such as screening for eye diseases, eye surgery, training and treatment (Kenya Ministry of Health, 2022). Given that majority of the public health sectors lack RE services in Kenya, almost three quarter of the eye care professionals works within the private sector with minimal information on existence of SE and the strength of the referral pathway (Morjaria et al., 2013). Notwithstanding, given that CE depend majorly on eye care professionals with conventional training which remains limited, SE should adopt innovative approaches inclined towards scaling and addressing human resources and RE concurrently. Therefore, this study intends to explore the impact of collaboration between SE and CE in scaling eye care services in Kenya.

In Kenya, the Eye Rafiki program which is a replica of the EyeMitra Optician Programme Model in India (Bagrodia and Maini, 2015) entails identification of a section of community members and training them on the basics of refraction to qualify as Eye Rafikis. The training is undertaken through a partnership between OneSIGHT EssilorLuxottica Foundation and a strategic partner which undertakes execution roles. The EyeMitra strategic partner reported challenges such as difficulty in mobilization of the candidates for training, ensuring high quality healthcare service delivery by the trained personnel and acceptance of the trained personnel by existing cadres in the eye health sector (Bagrodia and Maini, 2015). Even though the Eye Rafiki adopted the EyeMitra approach without paying attention to the challenges reported, the challenges experienced by the Eye Rafikis remain unknown. Although the eye care workforce in Kenya meets the World Health Organization (WHO) recommendation of 1:250,000 population, unequal distribution of vision centres offering comprehensive eye care services still pauses a challenge. Given that majority of the vision centres are located in urban areas, the 72% of Kenyans residing in rural cannot access the available eye care services (Kenya National Bureau of Statistics, 2019). This imbalance motivates SE such as the Eye Rafiki to establish vision centres within remote rural areas so as to address the aforementioned challenges and scale referral for eye conditions requiring further management by specialist (Muma et al., 2024a). However, the SE alone may not effectively scale the eye care services to remote areas in the absence of a strengthened collaboration with other stakeholders such as the CE. According to Hsu et al. (2009), partnership is crucial within the healthcare ecosystem and should be prioritized for effective and efficient healthcare delivery. Therefore, with the current situation in which collaboration exists only between a section of SE and CE in Kenya (Muma et al., 2024b), this study intends to explore the factors impacting a collaboration between CE and SE in synergizing effective RE coverage which is the measure of the met, unmet and the for under met needs for RE correction in Kenya (McCormick et al., 2020).

Social and CE face various challenges which potentially limits them from achieving their full potential when it comes to service delivery (Baporikar, 2017; Panum and Hansen, 2014). As a result, a strengthened collaboration between the two could potentially address the challenges faced by each individually. In the eye health ecosystem in Kenya, SE denote challenges such as policy regulation, financing solutions, lack of community awareness of SE and lack of support which in turn compromises their sustainability (Seda et al., 2020; Spear et al., 2009). The aforementioned challenges could impact negatively on the potential of SE in scaling effective RE coverage if not addressed. Notwithstanding, CE within the eye health ecosystem also denote challenges such as financial constraints limiting the efficiency of their operations and expansion to rural areas (Cicinelli et al., 2020). These challenges experienced by the enterprises could potentially arise due to the fact that most embrace the independent operation approach (Hushie, 2016; Khan et al., 2008; Rowe et al., 2020). As a result, exploring the need for a collaboration between SE and CE in synergizing effective RE coverage is desirable. However, considering that social entrepreneurship is an emerging concept within the eye health ecosystem in low income countries such as Kenya (Caló et al., 2019; Hunter, 2009), the views of stakeholders trained by SE such as the Eye Rafikis and the beneficiaries from their services on the need for collaboration with CE remains unknown in Kenya and yet may provide useful perspectives on the issue.

This was an exploratory case study conducted among the Eye Rafikis (n = 112) and beneficiaries (n = 674) of RE services from activities of the Eye Rafikis. The study design was adopted given that minimal information exists on SEs who are inclined towards scaling human resources in Kenya. Hence the design was suitable to provide finer details from the identified SE. Purposive and snowball sampling was used to identify the Eye Rafikis who operate refraction points within rural areas and the beneficiaries of their services (Essilor, 2018). The snowball sampling was adopted given that the beneficiaries of the Eye Rafikis was unknown hence the sampling approach allowed for referral and identification of additional beneficiaries to yield a quantifiable result. The Eye Rafikis only provided a section of the list of the beneficiaries and through the identified beneficiaries, referral was considered critical. The rationale for selecting the Eye Rafiki was based on the assumption that they are the first group of primary vision technicians in Kenya trained and supported by SE to establish refraction points in rural areas to scale the social entrepreneurship concept of fulfilling a social impact of providing cost effective services to the underserved population in remote areas. Notwithstanding, given that the Eye Rafiki is a programme undertaken by the OneSight EssilorLuxottica Foundation, including them was deemed relevant as the organization undertaking this programme is a strategic stakeholder to the Ministry of Health Kenya and it support aspects around scaling human resources and establishment of vision centres in Kenya. Furthermore, the preference for the Eye Rafikis was based on the assumption that their activities are more inclined towards social entrepreneurship hence they are well placed to provide informed perceptions on possible collaboration based on the challenges they may have experienced.

The SE representative engaged in the Eye Rafiki program was contacted with a request to provide the list of the Eye Rafikis with functional vision centres and active phone numbers. However, to ensure that the list of the Eye Rafikis provided response was not influenced by the representative from the OneSight EssilorLuxottica Foundation, the researchers informed the representative not to brief the Eye Rafikis about the study and to leave the whole process for the researchers. This was intended to ensure that the Eye Rafikis provide accurate information and highlight some challenges that they experience which was to help OneSight EssilorLuxottica Foundation in betterment of the programme. After the aforementioned list was obtained, the listed Eye Rafikis were contacted telephonically and details about the study were provided to them. Telephonic interviews were conducted given that most of the beneficiaries who had received RE services from the Eye Rafikis and were responding to the researchers invitation to participate in the study had moved to different urban areas. Again for the Eye Rafikis, the telephonic interviews were deemed suitable given that they are not stationed in one locality and they keep on moving from one locality to the other conducting vision screenings. Only Eye Rafikis with functional refraction points were included in this study with an assumption that they attend to community members in need of RE services and therefore would technically provide their view on the worth of collaboration. The Eye Rafikis who consented during the first telephonic call constituted the sample size (n = 112) out of a total of 128 Eye Rafikis on the list obtained. Semi-structured interviews were conducted telephonically with the consenting Eye Rafikis which lasted between 20 and 30 min with 10 interviews per day. The interview constituted questions around the reasons behind resorting to utilizing RE services from the social enterprise, the benefits accrued from the social enterprise, how the benefits accrued have impacted on their health, preference for a collaboration or SE operating as standalone and the justification for the preference on operation of enterprises by the Eye Rafikis and the beneficiaries. The authors did not use other forms of interviews given that the target population was not uniformly distributed in the same geographical location.

The sample of the beneficiaries of RE services provided by Eye Rafikis was sought from the selected Eye Rafikis and through engagement with a representative from the organization who undertakes training of the Eye Rafikis. The Eye Rafikis were notified to inform the beneficiaries that the role of the study is for the betterment of the services they provide to them hence should participate to allow for identification of the challenges. Given that this study was only for academic purposes, the researcher’s interest was only to identify the contact details of the beneficiaries from a SE engaged in delivering RE services through establishment of vision centres in remote areas. Therefore, the Eye Rafiki being the only programme which undertakes the aforementioned activities, getting such information was considered relevant. Engagement with a representative from the training organization was to ensure that the Eye Rafikis provide a list of the beneficiaries of their services for the last six months voluntarily to act as a measure of the efforts they undertake to create an impact among the community members. The inclusion of this cohort of the sample was intended to identify a neutral group of individuals not engaged in any form of entrepreneurship.

After the list was accrued, the beneficiaries of the Eye Rafikis refraction points were contacted telephonically with an invitation to participate in the study after which informed consent was obtained either verbally or in writing from those who had active emails. This approach was intended to ensure that the Eye Rafikis do not influence the information that the beneficiaries would provide. Semi-structured interviews were conducted through telephonic calls with the beneficiaries entailing questions on the beneficiaries’ views on the preference for SE standalone or collaboration between CE and SE. The data collection instruments were piloted among the Eye Rafikis and beneficiaries. The reliability of the data collection instrument using the Cronbach’s alpha (0.82 and 0.87 for justification and preference questionnaire respectively) and validity using a Pearson correlation coefficient (0.000 < 0.05) was undertaken. The Eye Rafikis and the beneficiaries who participated in the pilot were not included in the final interview.

During the interviews with all the participants, the information was collected until data saturation was attained. Data saturation was considered attained when items were repeated in the responses from the interviewees with no new information forthcoming. Notwithstanding, all interviews were audio recorded using an electronic recording device, and the recording files were securely saved and de-identified, transcribed and coded.

The statistical data analysis for quantitative data was conducted in the Statistical Package for the Social Sciences (version 29). The descriptive statistics of the categorical variables were described as counts and percentage frequencies where tables were used to visually display the categorical variables. A Chi-Square Test was used to determine the association between categorical variables. For the qualitative data, thematic analysis was carried out by categorizing the codes into categories using NVivo Software (version 11) and themes based on the semantic meaning of the codes. It was an iterative process consisting of both deductive and inductive processes (Fereday and Muir-Cochrane, 2014). Initial codes and categories were generated from the interview guides (deductive process). New categories that consisted of similar codes were added as required to capture the participants’ comments in detail (inductive process). During this inductive process, the themes were identified by repetitions (the more the concept appears in the text, the more likely it is to be a theme), similarities and differences (Ryan and Bernard, 2003).

Table 1 details the demographics of the Eye Rafikis. Table 1 also details the demographics of the beneficiaries of RE services from the Eye Rafikis who from here onwards will simply be referred to as beneficiaries.

The majority (71.5%) of Eye Rafikis were between 25 and 35 years of age, while the majority of beneficiaries were 40 years and older. The majority (67.9%) of Eye Rafikis were female with secondary level of education, while the majority of the beneficiaries who were female had primary level of education.

Only a few Eye Rafikis (n = 4; 3.6%) had the preference for SE as standalone with the majority (n = 108; 96.4%) having the preference for a partnership between SE and CE. There was no statistically significant association between gender (p = 0.15), age (p = 0.056) and (p = 0.064) with preference on the operation of the enterprise. The results are shown in Table 2.

The majority of the Eye Rafikis (46.5%) who had the preference for collaboration between SE and CE were aged 25 and 29 years. Based on level of education, majority of the Eye Rafikis with secondary (85.7%) and tertiary (10.7%) expressed preference for collaboration.

The majority of the beneficiaries less than 50 years of age had the preference for SE as a standalone while those aged 50 years and above expressed a preference for collaboration between CE and SE. Table 3 details the beneficiaries’ preference on operation of enterprises stratified according to age, gender and level of education.

Majority of the beneficiaries (44.4%) of female gender had the preference for SE as standalone. Based on level of education, majority of the beneficiaries with primary (36.5%) and secondary level (23.3%) expressed the preference for SE as standalone, while majority of the beneficiaries with tertiary level had the preference for collaboration with CE.

The views expressed by those participants who preferred collaboration between social and commercial enterprises were categorized into five themes as shown in Table 4.

Most beneficiaries (n = 410; 60.8%) reported that if collaboration can be established then they can consistently receive RE services from all sectors delivering RE services in Kenya. The beneficiaries denoted that prioritizing collaboration between commercial and social enterprises has the potential to address challenges around sustainability of service provision hindering effective RE service delivery similar to that expressed by the trainees (quotes 1 to 2):

Most Eye Rafikis (n = 104; 92.9%) reported that strong collaboration will ensure that all sectors delivering RE services support each other. The Eye Rafikis further denoted that sustainability is a great challenge that is experienced daily and for effective RE service delivery to be achieved, sustainability must be prioritized (quote 3):

More than half of the beneficiaries (n = 419; 62.2%) reported that accessibility is a challenge when it comes to RE service delivery and as a result they advocated for a collaboration between social and commercial enterprises. Some beneficiaries (n = 234; 34.7%) raised the issue of infrastructure as a dire need for effective delivery of RE services (quote 4):

The majority of the Eye Rafikis (n = 97; 86.6%) reported that the cost required in paying for the business premises remains expensive hindering them from becoming successful (quote 5). As a result, the Eye Rafikis argued that advocacy towards integration of their activities into the public health sectors is desirable:

The majority of the Eye Rafikis (n = 93; 83%) reported that the independent operation approach has forced them to establish optical outlets in setups which are non-attractive and this impacts negatively on patients visit to their setups (quotes 6):

More than half of the beneficiaries (n = 408; 60.5%) reported that collaboration is ideal to address the conflict of interest existing among social and commercial enterprises. A section of the beneficiaries (n = 126; 18.7%) reported that a suitable environment where unhealthy competition does not exist may be enhanced through partnership (quote 7):

All the Eye Rafikis (n = 112; 100.0%) reported that conflict of interest is a major problem that they are facing. The Eye Rafikis denoted that RE will only be addressed if other sectors can recognize their potential and collaborate with them (quotes 8 to 9):

The views of those participants who preferred SE to operate as standalone were categorized into two themes as listed in Table 5.

Just over half of the beneficiaries (n = 385; 57.1%) reported that SE are linked to more benefits such as free and subsidized spectacles which other sectors are not offering. The beneficiaries reported that SE provides services which are cheaper when compared to commercial enterprises and this had impacted positively on their lives (quote 10):

A few Eye Rafikis (n = 48 42.9%) reported that the autonomy offered by SE as standalone is significant as they are thus able to provide services that are affordable, as well as empower community members to earn a livelihood (quote 11):

Just over half of the beneficiaries (n = 382; 56.7%) reported that SE target the base of pyramid population contrary to CE who target the population who can afford. Furthermore, they argued that SE as standalone is ideal as it bridges the gap of accessibility, availability and affordability of RE services to the base of pyramid population (quotes 12 to 13):

The majority of the Eye Rafikis (n = 109; 97.3%) reported that SE always adhere to their mission in achieving their goals (quote 14):

In low income countries, the private sectors tend to concentrate on economic sustainability with minimal focus on the human, social and environmental sustainability. This impact negatively among the underserved population who are unable to access and afford the available eye care services from the private sectors. However, given that millions of the underserved population in low income countries suffer from URE (Keel et al., 2020), SE are trying to bridge this gap by working towards fulfilling a social mission. With the current situation in which sectors engaged in RE service delivery undertake independent delivery of RE services, sustainability continues to pose a major challenge. In tangent with this, the current study findings have suggested that beneficiaries of RE services from SE and the Eye Rafikis prefer collaboration between social and commercial enterprises with an aim of addressing the economic sustainability challenge. This warrants the need for advocacy towards collaboration across all sectors engaged in RE service delivery. While economic sustainability has been an ever present problem with SE, prioritizing collaboration between CE and SE would potentially address this challenge (Caló et al., 2019; Hunter, 2009; Popoviciu and Popoviciu, 2011). Hence, for the Eye Rafikis, there are possibilities that they are experiencing challenges around economic sustainability for their rural independent refraction points approach. As a result, collaboration with CE may synergize the SE by referring to them patients who cannot afford the CE rates while scaling awareness on the existence of SE. However, to ensure this is effectively enhanced in the eye health ecosystem, all enterprises must adhere to their mission so as to supplement the gaps amongst themselves. Therefore, a strengthened advocacy on the need for collaboration between commercial and social enterprises should be undertaken to ensure sustainable and effective RE service delivery.

The eye health ecosystem in Kenya is marred with challenges around human resources to attend to the growing population (Palmer et al., 2014). However, scaling human resources in the eye health ecosystem remains expensive and time consuming (Chankova et al., 2009; Courtright et al., 2016) warranting the need for adoption of cost effective technological approaches such as telemedicine which is the provision of health care remotely via information and communications technology (Sood et al., 2007). Given that SE are fairly defined and are always motivated to embraces various innovative approaches such as telemedicine to scale eye care services to remote areas, prioritizing collaboration with CE would potentially motivate the CE to embrace such concepts to cost effectively scale the human resources to deliver eye care services across the economic pyramid. The findings of the current study have shown that beneficiaries and Eye Rafikis have the preference for collaboration between CE and SE so as to scale human resource in the eye health ecosystem in Kenya. With the engagement of SE in activities such as skills development with an aim of scaling human resource, the individuals who undertake such skills development find it hard to operate due to political issues and poor relationships with existing eye care professionals (Essilor, 2019; Khanna et al., 2019). As a result, collaboration between CE and SE would provide an enabling environment for the individuals with skills development such as the Eye Rafikis to work smoothly with the existing eye care professionals under supervision using telemedicine. Moreover, through a strong collaboration, individuals with skills development would potentially be integrated into the public sector so as to scale effective RE coverage under supervision of an optometrist through telemedicine. According to Du Toit et al., (Du Toit et al., 2013), the contributor to access gap where only 10% have access to RE services is as a result of the limited human resource due to a more facility based delivery approach. While in Kenya, the weak and under-resourced state provision of public services such as RE has been compromised by corruption and inadequate human resources (Palmer et al., 2014), prioritizing collaboration would potentially scale eye care personnel and a strengthened team approach. Therefore, through collaboration and team approach, effective RE would potentially be scaled in Kenya.

While the SE model has been encouraged as a viable approach in serving the base of pyramid (Koitamet and Ndemo, 2017), encouraging a collaborative effort with the CE would potentially address URE in a resource constrained country such as Kenya. The findings of this study also indicate that beneficiaries and Eye Rafikis believe that collaboration between SE and CE may also address issues around conflict of interest among enterprises. Conflict of interest would potentially exist among enterprises due to a variation on their missions. Hence strengthening collaboration is desirable to address conflict of interest while directing efforts towards effective RE coverage. Furthermore, the other possible area of professional conflict of interest could arise due to variation in the scope of training for the human resource from the SE with skills development and eye care professionals from CE with conventional training. The global burden of URE however, warrants all sectors to direct their efforts collectively towards ensuring accessibility, availability and affordability of RE services across the economic pyramid. Therefore, to achieve the 2030 IN SIGHT which is the WHO initiative in collaboration with other stakeholders in eye health intended to end avoidable sight loss (International Agency for Prevention and Blindness, 2021), collaboration between SE and CE should be strengthened and activities resulting in unhealthy competition and conflict of interest should be eradicated. While the initiative focuses on self-caring for vision and achieving full potential through accessing and affording the available eye care services, the CE may find it hard to implement given their interest on profit generation warranting collaboration (S. Muma et al., 2024a). Therefore, the nature of this collaboration should be clearly defined by joint engagement of the stakeholders.

The key critical outcome of a SE is to create and sustain social benefits across the economic pyramid (Andrew and Kelley, 2016). This justifies that social entrepreneurs have to identify the challenges attributed to addressing URE and work towards enhancing equity when it comes to accessibility, availability and affordability of RE services. The current study finding showed that most beneficiaries and a few Eye Rafikis had the preference for a SE standalone due to the benefits attributed to SE. For the beneficiaries who majorly constituted the base of pyramid, the possible reason for their preference for SE as standalone is because SE majorly targets them due to inaccessibility and unaffordability of the RE services offered by CE. As SE uses various mechanisms such as subsidization and establishment of refraction points within rural areas they are able to address affordability and accessibility challenges, respectively. For the Eye Rafikis, their preference for SE as standalone was attributed to the fact that they have undergone skills development which gives them an opportunity to earn a livelihood. Hence, with approximately 72% of Kenyans living at the base of economic pyramid (World Bank, 2023), SE are ideal to address this challenge.

Social enterprises are majorly businesses intended to generate values that benefit the population at the base of economic pyramid with an aim of enhancing affordability and accessibility of RE services (Pangriya, 2019). Hence any enterprise which keeps focus on its goal and mission is well placed to fulfil them. From the current study it was noted that the majority of beneficiaries and some Eye Rafiki trainees preferred SE as standalone for the reason that their goals and interest are more inclined towards addressing the base of pyramid needs, while that of the dominant CE are more towards profit generation making their services unaffordable. Therefore, all enterprises should be flexible in accomplishing their goals and interest while directing more efforts towards scaling effective RE.

Getting the views of only the beneficiaries and the Eye Rafikis from SE without also exploring the views of CE was a limitation for this study. More studies should be conducted to seek the views of CE on the need for collaboration in addressing URE and to test the empirical potential of collaboration between SE and CE in scaling eye care services in low income countries such as Kenya. In conclusion, the potential of any enterprise engaged in RE service delivery would potentially be sustainable and cost effective if collaboration is strengthened as shown in this study. The study highlight that collaboration has the potential to strengthen a team approach among eye care professionals from CE and primary vision technicians from SE which may in turn scale effective RE coverage in low income countries such as Kenya. Notwithstanding, this study has also shown that most beneficiaries of eye care services from SE prefers SE as standalone contrary to individuals like the Eye Rafikis who prefers collaboration. Therefore, to scale effective RE coverage and other eye care services in low income countries such as Kenya, CE and SE should collaborate to enable the population across the economic pyramid to access and afford the available RE services across CE and SE without necessarily having to depend on services from standalone SE.

To all the participants who provided responses during the study period.