In 1999, the WHO and the International Association for Prevention of Blindness (IAPB) launched “Vision 2020: The Right to Sight” to eliminate avoidable blindness by the year 2020, which was actively supported by the Chinese government. Now, 12 years later, cataracts are still the leading cause of blindness in China. The CSR throughout China was only 670 in 2006, and 800 in 2008 . Shanghai, as an economically and culturally developed city in China, has made some progress in blindness prevention in recent years. However, its CSR was only 2210 by the year 2009, which lags behind the level of 3000, the minimum necessary to achieve the WHO goals of “Vision 2020” . A low number of cataract surgeries in suburban areas is the key factor that has significantly reduced the total CSR in Shanghai. Therefore, raising the CSR in suburban areas of Shanghai is crucial to increasing the total CSR in Shanghai.
According to literature reports, important barriers to cataract surgery in developing countries include the cost of surgery and IOL, lack of awareness, poor service, and long distances from surgical centers .
By 2009, the per capita disposable incomes of urban and rural residents in Shanghai were about US$4530 and US$1950 respectively. The cost of phacoemulsification with IOL implantation in Shanghai is about US$900, of which about US$600 is paid from Medicare. If the patient received a second eye cataract surgery, about US$800 was paid from Medicare. Therefore, suburban residents in Shanghai were able to afford the cost of cataract surgery.
One obvious indicator of poor quality of service is poor postoperative vision . The data in our study showed no differences in outcome between the two areas. Thus, cost and poor quality service may not be the main reasons for a low CSR in suburban areas.
The current situation discloses an improper distribution of cataract surgery resources in Shanghai, assigning much fewer resources to suburban areas. To balance this improper distribution, the “5 + 3 + 1” project was initiated by the government in 2009 . During the next few years, five tertiary hospitals will be established in Pudong, Minhang, Baoshan, Jiading, and Nanhui; three secondary level hospitals will be upgraded to tertiary B level hospitals in Chongming, Nanhui, and Qingpu; and one tertiary hospital will be relocated in Jinshan. According to the proposed schedule, it will require only 1 h for residents living in the suburbs to reach medical centers . However, we are doubtful whether this project alone can raise the CSR in suburban Shanghai.
Although many more people live in the suburbs, the actual number of cataract surgeries per surgeon there was only 90, less than the average of 136 in the city proper by 2009. These data may indicate that many patients in suburban areas of Shanghai were not willing to have cataract surgery, so the surgical workload of surgeons there remained unsaturated. Due to culture restraints and inaccessibility to current information, we suspect that lack of awareness might be one of the most important barriers to cataract surgery in suburban areas of Shanghai. Some reports describing barriers to cataract surgery in suburban China substantiate this viewpoint [10–13]. Therefore, we propose that it should be a priority to raise awareness in the suburban population to better understand and be more willing to accept cataract surgery at the present time. Without this prerequisite, despite construction of more surgery units in the suburbs to reduce travel distances to surgical centers, a significant increase in the CSR may not be likely.
Last but not the least, the considerable growing rate of cataract surgeries in private hospitals in recent years should not be overlooked. Under similar conditions of outcome and cost, why more cataract patients prefer to have surgery performed in private cataract surgery units is an important question, and problem, that eye doctors in public hospitals should ponder.
Limitations are unavoidable in this study. Because collecting all long-term follow-up data for cataract surgery patients in Shanghai is impossible, the outcome of cataract surgery was only measured by the 1st–3rd postoperative day corrected VA, which may not provide insight into the long-term effects of cataract surgery in Shanghai. In addition, more detailed data regarding surgical complications should be collected in future studies. Another limitation is that the age distribution pattern in the population was not considered in this analysis because only the data of the registered population who is over 60 years old could be found in the Shanghai Statistical Yearbook.