Fang et al. BMC Public Health 2010, 10:543 http://www.biomedcentral.com/1471-2458/10/543 We compared the mean cost of one cataract surgery episode with disposable annual income of local residents in 2009(Figure 5). In Guangdong province, the Gross Domestic Product (GDP) per capita in 2009 was 5,992US$, with disposable annual income of local urban residents 3,173 US$ and rural residents 1,016 US$, respectively. However in Hubei province, the disposable annual income of local urban residents was 2,113 US$ and rural residents 740 US$, respectively. In all provi- ders except for JCH, the cost exceeded annual disposa- ble income of local rural residents. Proportion of patients with reimbursement and mean reimbursement ratios in ZOC were higher than that in three hospitals in Hubei province, which was related with local eco- nomic level. Discussion This study investigated the costs of cataract surgery from four different graded providers in two provinces of China and analyzed the variation in costs. The results of this study may not be necessarily representative of patients presenting in the other regions of China. The mean total cost for one cataract surgery episode from two hospitals in capital cities, ZOC and UH, was more than 1,000 US$. The lowest cost was from JCH, approximately 536 US$. In all providers except for JCH, the cost was more than annual disposable income of local rural residents. Especially in the UH, the cost was twice as many as annual disposable income of local rural residents. Except the proportion of patients with reimbursement in UH was at only 36%, the proportion in the other three hospitals was more than 60%. There were Figure 5 Comparison among disposable annual income of local urban residents in 2009, disposable annual income of local rural residents in 2009 and the average cost for each cataract surgery episode in November 2009. The abbreviations used are: ZOC, Zhongshan Ophthalmic Center; UH, Union Hospital; FHJ, First Hospital of Jingzhou; JCH, Jingshan County Hospital. Page 5 of 7 significant variations in reimbursement ratio from differ- ent regions. The mean reimbursement ratio was higher in ZOC than in three hospitals in Hubei province. The more economy develops, the higher reimbursement ratio is. Urban patients can be reimbursed at about 40-95% from social medical insurance. Seven years ago, rural patients must pay the cost all by themselves[15], but at present, more than 90% rural residents can be reimbursed due to the attendance of NCMS. However, the ratio of reimbursement for rural patients was approximately 30%, which was significantly lower than urban patients[16]. China’s economic development is characterized by wide geographic disparities between the coastal regions and the central/western regions. Two thirds of China’s population, or around 900 million people, live in rural regions that are largely under-developed and have received few medical services. China had developed a successful health insurance system (Cooperative Medical Scheme, CMS) in the rural areas since the 1950s. Unfor- tunately, CMS collapsed during the shift towards a mar- ket economy at the end of the 1970s[17]. The New Cooperative Medical Scheme (NCMS) is a ‘voluntary’ and heavily subsidized program established in 2003 to reduce the risk of catastrophic health spending for rural residents in China [15,18,19]. The scheme coverage was 95.9% in Shandong province and 88.0% in Ningxia pro- vince in 2006[19], and 85.9% of the total rural population by the end of 2007[16]. However, the reimbursement ratio of the scheme was only around 30% of inpatient expenditure. The relatively poor economic condition in rural areas is a major issue influencing the feasibility of performing cataract surgeries [20]. In 2001, Helen Keller Interna- tional (HKI) initiated free cataract testing and a low- price, high-quality cataract surgery program in rural areas in south China [9]. Surgery was subsidized by HKI and priced at 66US$. A total of 80% of those surveyed stated that they were willing to pay something for sur- gery, but only 56% of these respondents stated a willing- ness to pay amount of 66US$ or more. Blind subjects were significantly more likely to pay anything for surgery, but would pay on average 32US$. The patients suffering from cataract were mostly older patients, and many of them were no longer in control of their family’s income. Compared with the rural annual income per capita, the expensive cost for cataract surgery may be an important contributing factor for the low CSR in rural China. In our survey, the number of patients from rural regions was significantly lower than that from urban regions. Jingshan County located in central China owns 640,000 people, with approximately 440,000 people liv- ing in rural areas. Our data showed that the cataract surgery rate (CSR) per million in Jingshan County was