The Beginnings of a Fuzzy Big Picture

From what I’ve heard and experienced today, here seems to be the current situation with cataract patients in rural China:

I had the wrong idea; cost still IS the most important determinant of surgery acceptance, hands down. With the slew of free surgery programs in the last few years—Million Cataract Program, the Jiangxi cataract and cleft lip program, and the variety of programs rolled out by NGOs such as ORBIS’ flying hospital, the surgery acceptance rate has shot up, to the point where outreach screening is often not needed to keep up a steady stream of patients, as long as the program is publicized well. Exact numbers, even a ZOC project manager doesn’t know off the top of his head, but he estimates around 70-80% acceptance for those diagnosed. Once the free surgeries run out, that proportion drops again.

Except something funny happens. It doesn’t always return to the level it was at before. It plummets even lower. Patients are no longer willing to pay what they had been willing to pay before, not for surgery, not even for eyeglasses. When they arrive at the clinic for a free surgery only to learn that transportation and food are not subsidized, they accuse you of “玩鬼” –of playing a trick.

It appears, perhaps, that the phenomenon of free has changed their expectations, to the point where they don’t see the reason in paying for surgery when they could (and think they will be able to) get it for free. They want the surgery, but they also want free surgery, free services, subsidies for all associated costs. The government didn’t help the situation by setting quotas that each county had to fulfill, placing an extraordinary burden on eye centers and hospitals who scrambled to train doctors and amass equipment, to meet a demand they had never been faced with. In turn, they resorted to…creative measures to recruit the necessary numbers of patients, calling home constantly, providing a shuttle service, and even offering up to 300 RMB paid directly to the patient to get surgery done. All the while, patients are wondering why in the world these hospitals want them so badly, thinking maybe they’re doing the hospitals a favor for getting surgery…and feeling like they’re in a position to demand more.

It’s true, I’ve only heard the medical side of the story, and surely the view is a biased one. I haven’t yet ascertained the exact out of pocket costs to the patient, and how that compares to their annual income—perhaps cost is still a legitimate limiting factor in their ability to accept surgery. But if it has really come down to a question of expectations, then it seems the best objective would be to change their expectations again, induce them to see past the cost debates and power plays and realize that treatment is ultimately a good thing for them in its own right, that the ability to see is worth paying for. Because only then can the treatment system be sustainable; the doctors I work with think the government will continue providing funds for free surgeries until the need runs out, but government funding can be a fickle thing, and waiting for the officials to cut off funding when they reach an “acceptable” level of cataract-induced blindness in the population leaves me with a bitter taste.

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