New insights into the prevalence of avoidable blindness and willingness to pay for cataract surgery in the tribal region of Surat district, Gujarat, India

A Surat village undergoes an eye examination. Photograph: Rohan Chariwala

The results of a dual-purpose field survey in a tribal area of India have shown a high level of avoidable blindness and a reluctance to pay for subsequent cataract surgery.

The new paper, published in Ophthalmic Epidemiology, shares the results of a Rapid Assessment of Avoidable Blindness (RAAB) survey conducted in the Tribal Region of Surat District of Gujarat State, India, along with results of a willingness to pay (WTP) survey conducted at the same time.

Tribal communities in India are a minority group making up about 8% of the overall Indian population. They have distinct cultural, socio-economic structure, often inhabiting forested areas with limited relationships with wider society. Eye health for this group has been previously provided through fully subsidised outreach services such as local NGOs. The population of the Surat district are 90% tribal peoples.

Gujarat state itself has a relatively high rate of cataract surgery (at >10,000/ million/ year) but accessibility for tribal groups has been limited. For instance, there are no dedicated eye care facilities available within a 60-mile radius of the district.  This study was undertaken to assess the magnitude of blindness and visual impairment in this specific group, as well as their willingness to pay for services and sustainability.

RAAB is a verified population-based survey methodology (developed at ICEH) which targets people ≥50 years, assessing them for avoidable blindness such as cataract. For this study, the survey tested 44 ‘clusters’ of 50 people within the age bracket. A total of 2137 people were examined using the RAAB protocol (97.1% of people who were asked to be involved participated). Ophthalmic examinations were undertaken by the field team along with a specific questionnaire designed to assess Willingness To Pay (WTP) for surgery amongst those with cataracts.

The results showed that the prevalence of blindness within the population was 2.23%, with cataract as the main cause (67.3% of cases). WTP for surgery was 36.4% amongst those affected and half of whom were willing to pay the full amount of 750INR (approximately £8)  for the surgery. There was a strong association between literacy (13.7 times) and WTP. The main barrier to people fully blind from cataract was a lack of escort to the surgical facility, at just over a third.

The effect of blindness was also particularly pronounced in women, who were shown to experience the condition at three times the rate of men. This may be partly due to women not being the financial decision makers of their households, and more dependent of an escort to take them to a health facility.

Interestingly, despite the relatively high rate of blindness, there is a high rate of coverage for cataract surgery within the area (92% of people with cataract receive surgery for it), suggesting people who are fully blind people are not being prioritised.

Furthermore, the quality of services was also an important factor for WTP. People who had good vision in their one operated eye were 4.2 times more likely to be willing to pay for other eye cataract surgery than those whose had poor vision following previous cataract surgery.

This information can be used to guide programme development, for instance increasing free transport facilities, developing regular outreach activities and increasing affordability of services through a tiered system. The WTP information can help to create a cross-subsidising system for payment, increasing access to care.


Chariwala RA, Shah SP, Patel D, Chaudhari SP, Gajiwala UR. Rapid Assessment of Avoidable Blindness and Willingness to Pay for Cataract Surgery in Tribal Region of Surat District of Gujarat State, India. Ophthalmic Epidemiol. 2020;:1-8.


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