Framework Program in Global Health: Grant Recipients

Fang Ko
Willingness-to-Pay for Cataract Surgery
in Southern China
Spring 2006

JHU advisor: Nathan Congdon
Country: China
Program: School of Medicine, MD program

Project Abstract:
PURPOSE: We studied willingness to pay for cataract surgery with extra services in southern China, to determine whether it would be possible to generate revenue from the higher-income population, which could then be used to subsidize surgeries among the lower-income population.

DESIGN: Cross-sectional willingness-to-pay interview incorporating elements of the “bidding” format and payment cards.

PARTICIPANTS: 1000 persons and caretakers presenting for cataract screening, in the city of Yangjiang, the city of Yangchun, and rural areas surrounding Yangjiang. Interviews were conducted for those with presenting visual acuity of ≤ 6/60 in either eye due to cataract.

METHODS: Subjects underwent measurement of their visual acuity and a willingness-to-pay interview. Subjects were asked their willingness to pay for cataract surgery, as well as their willingness to pay for a variety of extra services, including transportation, senior surgeon, improved intraocular lens, and meals. Age, gender, literacy, education, employment status, and annual income were also recorded.

RESULTS: Among the 656 patients who completed the interview, 208 were willing to pay an additional fee for transportation (mean 29 +/- 49.88 RMB), 217 for a senior surgeon (mean 372 +/- 296.2 RMB), 254 for an improved intraocular lens (mean 272 +/- 419.9 RMB), 226 for food (mean 12 +/- 11.42 RMB). Among the 344 caregivers who completed the interview, 135 were willing to pay an additional fee for transportation (mean 52 +/- 54.91 RMB), 128 for a senior surgeon (mean 401 +/- 382.2 RMB), 155 for an improved intraocular lens (mean 385 +/- 596.4 RMB), 138 for food (mean 17 +/- 25.90 RMB). 88% of the patients surveyed and 80% of caregivers surveyed had a household income below 1000 RMB per month. (8 RMB = 1 US dollar)

CONCLUSIONS: Of the amenities offered, having the cataract operation performed by a senior surgeon has the greatest probability of generating revenue. The majority of patients surveyed are unwilling to pay for extra amenities. This makes sense, as the population interviewed was drawn from those presenting for free cataract screening at HKI-subsidized centers. One expects such patients to have limited resources, and hence be unwilling to pay for extra amenities. In order to create a sustainable program by generating revenue from extra amenities, HKI needs to attract patients with greater resources, who are willing and able to pay for extra amenities.

Personal Account:
As I sat in the van, staring out the window, flutters of excitement and nervousness alternated up and down my abdomen. It had been a week since my partner Jonathan and I arrived in China. Since then, we had met Dr. He Mingguang and his assistant Christine, as well as their staff of a dozen nurses and researchers at the Zhonghshan Ophthalmic Center in Guangzhou. Dr. He was the country director of Helen Keller International, as well as the brilliant mastermind behind the Zhongshan office. To prepare for the summer of work, Dr. He had described the landscape and population we were to expect. Their nurses had patiently spent hours editing and piloting the survey which Jonathan and I had laboriously translated from English to Chinese. We had also met the “other” Dr. He, the director of the Ophthalmic Hospital in Yiangjiang, bearing the same name as our mentor at Zhongshan. The “other” Dr. He allotted us three of his nursing staff, whom we trained to administer the survey. After the week’s worth of flurried activity and preparation, Jonathan and I could only sit quietly as the van drove us to our destination, Yiangchun Hospital, where HKI provided subsidized cataract surgeries.

As the van pulled up to the hospital, the driver gasped, “Look at all those people! You won’t be able to see all of them.” He was speaking to the surgeon Dr. Huang, and referring to the 60 patients and their caregivers milling around the hospital lobby. Jonathan and I looked at each other with trepidation. As soon as we stepped off the van, a frenzy of activity began. The patients were quickly shuttled through a vision screening, surgery prep, and cataract removal. Jonathan and I tried to catch the patients between their vision screening and surgery prep, at the same time overseeing the nurses administering surveys. The day was hot, and sweat dripped down our necks, to trickle down our backs. The patients were old and hard of hearing. (“Would you be willing to pay a little extra for transportation?” “Eh?” “WOULD YOU BE WILLING TO PAY…” “Eh?” “WOULD---YOU---BE---WILLING…”) By five-thirty in the evening, the surveys were completed.

Jonathan and I were invited to observe Dr. Huang as he completed the final surgeries of the day. We changed into scrubs and hospital slippers. In the O.R., a single air conditioning unit kept the room at a bearable temperature. Two tables were set side-by-side, and patients lay on each table under local anesthesia. Dr. Huang sat at the head of one table. He made a precise incision, removed the white opaque disc that had once been transparent, and expertly inserted a synthetic intraocular lens. The entire surgery took five minutes. Dr. Huang then shifted his chair to the next table, and began another incision. The nurses helped the patient off the first table, and brought another patient in to lie down. I was stunned. The efficiency and expertise was beyond what I thought possible. Indeed, by the end of the day, Dr. Huang was able to complete 60 surgeries.

The remainder of my summer would be filled with eye-opening surprises. I would see 80-year-old grandmothers ride on the back of a motorcycle, receive surgery, then get back on the motorcycle immediately after surgery. I would see a young man with trauma-induced cataract, needing surgery to resume work. I would also taste the exotic flavors of southern China, with such foods as pig’s tongue, wild hens, and frog soup. I would learn how hospitals are run in a population with different needs from those of America. Sitting on a van, one week after arriving in China, I knew I could expect eye-opening experiences; yet, I could not predict all that I would learn. The summer has affected me, both in my professional goals and my personal development.

Photos © Fang Ko

>> See all Spring 2006 Framework Award winners