Charges for cataract surgery.

Dear Editor: Studies such as that carried out by He et al 1 are important to anyone interested in developing financially sustainable eye care services in less developed countries. We have studied acceptance of cataract surgery and willingness to pay for it in Tanzania and found interesting similarities and some differences in our population. As in China, those with the lowest visual acuity (VA) are not necessarily the most likely to accept or to be willing to pay for cataract surgery. In a population-based cohort in Tanzania, we found that acceptance of surgery (priced at US $14) was more likely among younger people but not among those with the worst VA. 2 Interestingly, in another study in which cataract surgery was offered free to clinic patients who were recommended to have it but said they were too poor to pay, only 22% took advantage of the offer, and this was not related to VA. 3 A startling contrast to our findings in Tanzania was the amount people were willing to pay in China. Despite the fact that the average monthly household incomes are very low in both places (roughly $28 – 42 in China and $50 in Tanzania), the Chinese reported a willingness to pay $55 for cataract surgery (with IOL), compared with less than $3 in Tanzania. 4 Granted that purchasing power parity and lifestyle differ in the 2 countries, but another important difference that we think is critical is the people's expectation of the price of surgery—$500 to $600 in China, compared with $0 to $14 in studied regions of Tanzania. Even within Tanzania, the customary price was significantly associated with the amount patients were willing to pay. 4 We see several important implications from these studies: 1. Using VA cutoffs to refer patients for cataract surgery (e.g., referring only those blind or with severe visual impairment) will likely exclude those most willing to accept and pay for surgery. In this case, will lower-level health workers (primary eye care workers) be effective as gatekeepers or case finders for surgical services? 2. Because more people are demanding surgery well before they become blind, the quality of surgery must be high enough to ensure improved vision afterward. 3. Finally, although segments of the population are too poor to pay for surgery, we agree with He et al that offering free or very low cost surgery universally may undermine willingness to …