Fang et al. BMC Public Health 2010, 10:543 http://www.biomedcentral.com/1471-2458/10/543 552, about one-tenth of that in the United States[21]. Therefore, there is apparent potential for an increase of CSR in China, especially in rural areas. A large variation in costs of intraocular lens was found in four providers. A foldable intraocular lens (IOL) is more expensive than an equivalent rigid IOL. In ZOC, all patients were implanted with foldable intraocular lens. The variation of total costs among patients mainly came from the cost of different IOL types. Costs of multi-focal intraocular lens or adjustable intraocular lens were more than 1,100 US$, which were too expen- sive to be reimbursed; thereby most patients chose sin- gle focus intraocular lens. In three hospitals of Hubei province, neither multifocal nor adjustable intraocular lens was used. All four providers used imported lens. Although there are cheaper domestic lens, none of domestic lens was used in these hospitals because patients thought that the quality of imported lens was better than domestic lenses. Under the current conditions, phacoemulsification and small incision surgery have allowed cataract surgery to be conducted on one-day-case basis, and then it is feasi- ble to use eyedrops to prevent infection. A large part of cost was spent on the usage of antibiotics by vein injec- tion in UH and FHJ. Therefore, using antibiotic eye- drops instead of intravenous antibiotics would decrease 20% cost of cataract intervention. There are no qualified surgeons of cataract surgery in Jingshan County Hospital. In China, there are around 2,200 counties like Jingshan County; and the overwhelm- ing majority of county hospitals have neither qualified sur- geons nor expensive equipments for phacoemulsification. Qualified surgeons from provincial capital carried portable phacoemulsification equipments to county hospitals and then performed cataract surgeries once or twice a month, which was a common health care activity. It is obvious that the phacoemulsification procedure is more expensive than ECCE. Manual small incision cataract surgery (MSICS) is a modified form of ECCE performed through a 6.5 to 7.0 mm sclerocorneal tunnel [22]. As compared with phacoemulsification, MSICS is almost as effective and more economical [10,23,24]. The advantages of MSICS as a low-cost “equally effective” technique make it an alternative, especially in rural regions in China. There are severe shortages of skilled cataract surgeons in the majority of county hospitals in China; thereby it is essen- tial to train qualified surgeons for these hospitals. Most of Chinese elderly population is rural-dwelling and cataract is the leading cause of blindness and low vision in this group. Approximately 66% of the cataract operations were conducted in county hospitals with lim- ited eye care services and 34% in specialized and provin- cial center [20]. Because of the low benefit level and low reimbursement ratio, patients had to face a very high Page 6 of 7 financial burden even after NCMS reimbursement[17]. Moreover, the shortage of cataract care specialists in county hospitals is also a barrier for many patients who need cataract surgery. Consequently, efforts should be made to increase the financing of health care and to train qualified surgeons for county hospitals. Finally, the data from four different graded providers were provided in the results, which were of potential use to blindness prevention programs. However, there was no a statistical point of view in our report, and the selected four places could not fully represent the status of other areas in China. Further work is needed to explore the cost-effectiveness of cataract surgery in different graded provided in China. Conclusions Significant differences in costs of cataract surgery were found among the 4 different graded providers. From the survey, several key messages should be drawn. Firstly, patients from rural areas have many difficulties in pay- ing for surgery cost. Much more financial support should be directed into the rural NCMS to raise the reimbursement ratio. Secondly, more efforts are needed to train qualified surgeons for county hospitals. Lastly, the usage of cheaper IOL and fewer drugs in cataract surgery will lead to lower cost that contributes to increase the CSR in China. Author details 1Department of Ophthalmology, First Hospital of Jingzhou, Yangtze University, Jingzhou 434000, China. 2Department of Ophthalmology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China. 3State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou 510060, China. 4Jingshan County Hospital, Jingshan 431800, Hubei Province, China. Authors’ contributions JHF participated in the design of the survey, undertook the collection of data and drafted the manuscript. XHW undertook the collection of data and assisted in drafting the manuscript. JHY, YY and JBL undertook the collection of data. ZDL participated in the design of the survey. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 22 March 2010 Accepted: 9 September 2010 Published: 9 September 2010 References 1. 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