The China Study
Accessibility and affordability of cataract surgery has improved in China – but there is still more to achieve
Access to healthcare has improved dramatically in China over the last two decades. Before 2009, there were only three basic medical insurance systems. But thanks to persistent efforts from the government – and significant financial support – 95 percent of Chinese people are now covered by medical insurance. At present, this insurance covers between 70 and 80 percent of cataract surgical expenses. Not only that, the government initiated the “One Million Cataract Blindness Project” in 2009 to provide free cataract surgeries for poorer patients, with additional financial and medical support from NGOs. To speak from the perspective of ophthalmic resources in China, the number of ophthalmologists reached 37,000 in 2018 – 1.5 ophthalmologists per 50,000 people. 36 percent can perform cataract surgery independently, and of those, 34 percent can perform phacoemulsification. Currently, over 85 percent of hospitals have established ophthalmology departments, with 88 percent providing cataract surgery independently. These developments have all greatly increased access to affordable cataract surgery in China.
After the medical reform in 1998, an increased cataract surgical rate (CSR) saw the number of cataract operations performed per million population rise from 370 in 2000 to 2,205 in 2017. However, the CSR differs greatly in regions, being highest in Shanghai (4,251) and lowest in Hubei (763). Interestingly, in Shanghai, private hospitals completed more cataract surgeries than public hospitals, indicating that private hospitals are becoming an important force in preventing and treating cataract blindness. Furthermore, the cataract surgical coverage (CSC) in China among patients with severe cataract-related visual impairment and blindness has increased from 36 percent in 2006 to 63 percent in 2014, while good visual outcomes have increased from 47 percent to 62 percent in cataract-operated eyes.
But change is not happening as fast as some would like. Despite significant improvement, CSR in China it is still low compared with countries like the US (11,000) and India (6,000). Around 7.58 million patients with cataract-related visual impairment or blindness still await surgery in China. If we want to achieve a CSC of 95 percent, our CSR needs to reach 8,000. Not only that, even though the number of ophthalmologists has exceeded the standard defined by WHO in the “Vision 2020” initiative, most are in economically developed urban areas, with few working in rural zones, where the CSR and CSC are low. Of the 75 percent of county hospitals that can perform cataract surgery, most have only one or two cataract surgeons. Given the lack of experienced surgeons and qualified surgical treatment in county hospitals, some rural patients have to travel a long distance to seek surgical treatment in large cities – which can pose a problem; elderly patients who have difficulty traveling my not receive proper treatment. Though experienced ophthalmologists from provincial or municipal hospitals could come to county hospitals to operate on local patients, it would not substantially improve the surgical ability of local ophthalmologists or the eye care service the hospital provides.
A national training program called “Standardized Training to Elevate Eyecare in Rural China (China STEER)” has been established to improve the capability of county level hospitals to deliver high-quality eye care, including high-quality cataract surgery. Started in 2016, the strategy is set to redress existing CSR disparities between urban and rural areas. Given the expected rise in CSR – paired with a rapidly aging population – the financial burden of medical insurance system is expected to grow as well. Therefore, a multipronged strategy with new fundraising channels is needed to ensure patients receive the highest quality cataract care.