Shortage of ophthalmologists and health care resources tests system’s strength

In a nation of 1.2 billion, there are only 22,000 eye care providers. Five to 6 million people are waiting for cataract surgery.

China’s eye care has improved significantly in recent years because of the nation’s rapid economic growth and a move by the government in 1987 to integrate eye care into the primary health schemes of urban workers. A survey of 1.5 million people conducted that year by the World Health Organization found that about 9 million people are blind and that 4 million cases of blindness are due to cataract. Ophthalmologists interviewed for this article say that today as many as 6 million people are blind due to cataract.

Compared with other medical fields, ophthalmology is more dependent on specialized equipment and training, and a lack of both has created a tremendous unmet need for eye care services in the nation of 1.2 billion people. The government has devised plans to improve eye health, but poor distribution of eye care resources and limited budgets have hindered plans.

Shortage of ophthalmologists

China’s biggest ocular health problem is its profound lack of ophthalmologists. Typically, one eye physician needs to care for over 60,000 people. Poor distribution of eye care providers compounds the problem. Craig F. Beyer, DO, president of Mednet International, an ophthalmic practice management company with operations in China, notes that more than 90% of the 22,000 eye physicians in the nation are in large- or average-sized cities, while only 3,000 eye physicians are in China’s 1,237 rural counties, or about one to two physicians per county.

“Bureaucracy is another problem,” he said. “Medical and financial decisions are centralized within the state-owned hospitals. Under this current socialized medical system, there is a lack of incentive for individual surgeons to increase surgical skill and competence.”

As an unfortunate consequence of old Communist ideology, there remains a significant amount of pressure forcing eye surgeons to conform to a common standards practice, Dr. Beyer said. Some standards may be lower than what is considered ideal by non-Chinese standards. Frequently, if a young surgeon demonstrates exceptional skill and innovation, he or she risks overshadowing his or her superiors and, as a consequence, may lose his or her employment with the state-owned hospital as well as his or her home and retirement pension.

No outlet

“Exceptionally talented surgeons who grow frustrated with conformity within the state-owned hospitals cannot leave for private practice, since they are not licensed to bill state-owned enterprises for medical fee reimbursement,” Dr. Beyer said. Rarely do physicians have the financial resources to acquire the necessary equipment to start their own practices because import duties into China are high. Sources note that duties typically range between 30% to 40% of equipment sales prices.

Despite these problems, and the shortage of eye care professionals, more than 90% of China’s ophthalmologists choose to sub-specialize, according to Prof. Hong Rong Zhao, MD, director of the Xiamen Eye Center in Fujian. “A high degree of sub-specialization allows new techniques and ideas to be integrated into clinical practice more quickly, but there is still a serious shortage of general ophthalmologists.”

Of the 22,000 eye care providers who call themselves ophthalmologists, there is some question as to the exact number who could be considered ophthalmologists by western standards. Yan-Nian Hui, MD, of the Department of Ophthalmology at the 4th Military Medical University in Xian, suggests that about only 40% of the 22,000 have training equivalent to western medical school.

Quality varies

Almost all eye care in China is provided by clinics and hospitals supervised by the government or the military. The quality of Chinese eye care varies considerably from region to region, with a marked difference between services in rural and urban areas. Small clinics, which numbered 51,535 in 1997, according to the Chinese Health Ministry, can only offer primary and curative care. These so-called “county level” hospitals provide about 75% of the health and eye care in China.

Hospitals at or above the county level include teaching and clinical training facilities that provide advanced care to patients. These facilities are usually centrally located within a province and are designed to meet the diverse needs of a large region. It was estimated in 1997 that there were 16,376 hospitals of this type in China, providing 22% of the total health care in China. Additionally, it was estimated in 1997 that there were about 300 military hospitals in China that offered services to the armed forces and to select high-ranking government and Party officials. Most of them established ophthalmology services to serve the neighboring civilian population, as well.

To solve problems related to poor distribution of ophthalmic services, a government program — the name of which translates roughly to “Action China, First Sight” — will relocate urban ophthalmologists to high-need rural areas.

Hong Kong is the only region that seems to be advancing in terms of hospital management and eye care administration. Reports on the strength of the relationship between ophthalmologists in Hong Kong and those on the mainland vary, depending on who you ask. When Ocular Surgery News first reported on China 2 years ago, all mainland ophthalmologists interviewed said they had little if any contact with their colleagues in Hong Kong. Since the transfer of Hong Kong back to China in 1997, the political atmosphere has changed. Some physicians now say relations are better, while report that there is still little contact. Staff members at the International Tianjin Intraocular Implant Training Center, however, are confident that in the future cooperation between mainland and Hong Kong ophthalmologists will improve. Fledgling academic exchanges and surgical skill seminars have been fairly successful, they report.

The Chinese Medical Ophthalmological Society plays a large role in the development of eye care in China. Presently, there are 16 ophthalmology magazines in China, covering 11 subspecialties.

Demand for services

Procedures such as cataract surgery, which are readily available in the rest of the world, are uncommon in the vast interior of China due to equipment and personnel shortages. An aging population is making the problem worse.

In 1997, 9.56%, or 114 million, of China’s population were above 60 years old, compared with only 6.08% of the population in 1964. The growing senior population has put a heavy burden on government resources and on eye care. Of 60 million cataract patients, 5 to 6 million have severe, blinding symptoms and are waiting for surgery. Between 300,000 and 400,000 cataract procedures are performed annually in China. Between 30,000 and 40,000, or about 10%, are performed with phacoemulsification, and the remainder are extracapsular cataract extractions (ECCEs). Ten to 20% of Chinese ophthalmologists use phacoemulsification to treat cataracts regularly, and Prof. Chen Wei, MD, the director of the Cataract Surgery Center of Shandong Medical University and the Jinan Municipal Central Hospital in Shandong, estimates there are more than 1,000 phaco machines in China. Lixin Xie, MD, director and president of the Institute of Ophthalmology and Eye Hospital in Quingdao, notes that in some areas, as many as 50% of all cataract operations are performed with phaco.

When the government made eye care part of the insurance scheme of urban workers in 1987, it initiated a program designed to prevent blindness. County-level hospitals were empowered to oversee activities normally administered by the central government. Allowing for more grassroots control of blindness prevention programs made them more adaptable and better able to keep up with demand. Prevention of blindness programs generally call for better patient education, and has set treatment goals for cataract patients at 70%, meaning that the health centers intend to treat at least 70% of the patients blinded by cataract. The central government also is empowered to relocate some urban ophthalmologists to higher-need rural regions.

For phaco surgery in northern China, reimbursement could be around RMB3,500 (US$421), with PMMA lenses to RMB5,000 (US$602), and this price includes a foldable lens. Costs do not include the patient’s hospital fee, which typically must be absorbed out of pocket. ECCE is less expensive — about US$250 per procedure.

It is estimated that 30% to 40% of urban citizens are knowledgeable about refractive surgery, but in the rural areas, it is unheard of. Every year about 200,000 patients undergo refractive surgery. Ten to 20% of Chinese ophthalmologists are capable of performing laser in situ keratomileusis (LASIK), but there are only about 1,000 surgeons devoted exclusively to refractive procedures, according to Prof. Zhao. There are about 200 excimer lasers in China. Photorefractive keratectomy (PRK) and LASIK are both practiced, but PRK is probably more common. Refractive surgery costs range from US$250 to US$1,000 per eye, according to Prof. Yuan Jia-Qin, MD, professor of ophthalmology at the International Tianjin Intraocular Implant Training Center at Tianjin Medical University.

Nearly 50% of China’s younger population have refractive errors amenable to excimer laser eye surgery. Currently, this demand for cataract and laser eye surgery cannot be met given the level of surgical training, efficiency and technology in China.

Editor’s note: Staff member Joy Foder contributed to this article. Additionally, the author acknowledges the invaluable assistance of Prof. Arthur L.M. Lim, MD, director of the Singapore National Eye Center.

For Your Information:

Craig F. Beyer, DO, can be reached at +(001) 303-678-7600; fax: +(001) 303-527-3664; e-mail: cbeyer@boulder.net. Dr. Beyer is president of Mednet International.

Prof. Yuan Jia-Qin, MD, can be reached at the International Intraocular Implant Training Center, Tianjin; fax: +(86) 22-23-34-64-34. Prof. Jia-Qin has no direct financial interest in any of the products mentioned in this article, nor is she a paid consultant for any companies mentioned.

Prof. Hong Rong Zhao, MD, can be reached at the Xiamen Eye Center, Fujian, China; fax: +(86) 59-22-02-43-25. Prof. Zhao has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Prof. Chen Wei, MD, can be reached at the Cataract Surgery Center of Shandong Medical University; fax: +(86) 531-697-2700. Prof. Wei has no direct financial interest in any of the products mentioned in this article, nor is she a paid consultant for any companies mentioned.

Lixin Xie, MD, can be reached at the Institute of Ophthalmology & Eye Hospital, 5 Yanerdao Road, Quingdao 266071, China; +(86) 532-588-5195; fax: +(86) 532-588-1212; e-mail: lixinxie@public.qd.sd.cn. Dr. Xie did not disclose whether or not he has a direct financial interest in any of the products mentioned in this article or if he is a paid consultant for any companies mentioned.

Yan-Nian Hui, MD, can be reached at the Department of Ophthalmology, Xijing Hospital, 4th Military Medical University; fax: +(86) 29-323-4516; e-mail: Aofujie@ pub.xaonline.com. Dr. Hui did not disclose whether or not he has a direct financial interest in any of the products mentioned in this article or if he is a paid consultant for any companies mentioned.