From advised to booked: why many advised surgeries never happen

A study in Tamil Nadu followed 4,682 people who had been told they needed cataract surgery. The surgery was free or subsidised. Transport was arranged. Food was provided. Even so, only 67.9 percent of them went on to have the operation. Roughly one in three people who were advised surgery, and offered almost everything they could need, did not get it.

Every eye and orthopaedic hospital has its own version of that gap. A surgeon advises a cataract operation or a knee replacement, the patient nods, takes the papers, and the decision stays open. Nobody refused anything. It simply drifted.

The good news is that this is a problem a hospital can do something about. That is what a counselling desk is for.

What patients say when they do not go ahead

The reasons are rarely about the surgeon. In a 2019 study in rural South Karnataka, researchers spoke to 500 people who had turned down cataract surgery after a screening camp. People could give more than one reason. The most common were:

• "I can still manage my daily work" (66 percent)
• Waiting for a free camp (62 percent)
• "One eye is still good" (57 percent)
• Fear of the operation (12 percent)

A 2025 study in North Karnataka, of patients who came in late with advanced cataract, found something else on top: the single most common reason was having nobody to bring them, at 24 percent. Loss of income was another 13 percent.

Beliefs play a part too. A study in Aligarh found about one in five elderly patients with an unoperated cataract was waiting for it to "ripen", an idea many patients still carry.

These studies are from camps and rural districts, and a private city hospital will hear a different mix. But look at the list again. Almost nothing on it is medical. It is about money, time, fear, family and who will come along. Those are exactly the things a surgeon has no time to talk through in a busy OPD.

Knee and hip replacement are no easier

We could not find a good Indian study of how many people advised a knee or hip replacement go on to have it. When Sparsh Hospital in Bengaluru started a counselling programme for joint replacement in 2022, its chairman put it simply: "not many opt for it due to the fear of pain and discomfort."

Teams that do joint replacements also talk about worry over recovery at home, the cost of the implant and insurance cover, though we found no Indian study that measures these. A knee patient has at least as much to weigh as a cataract patient.

What counselling actually changes

Aravind Eye Care System has built counselling into how it works for decades. It has over 200 patient counsellors, about one for every two ophthalmologists. A counsellor sees the patient, offers a surgery date on the spot, sends reminders, and arranges transport where needed.

Some Indian programmes report big gains after building counselling in, though none can separate counselling from everything else a good hospital does. In West Bengal in the late 1990s, a programme that had counsellors in place from the start saw lens implants go from half of all cataract operations in 1995 to 90 percent in 1997. At Sadguru Netra Chikitsalaya in Chitrakoot, counsellors used a dummy lens to show patients what would go into their eye, shared stories of people from the same villages who had been operated, and let family travel along with the patient. Along with its wider outreach work, the hospital's yearly cataract operations grew from about 23,500 to over 1,17,000.

Sometimes it comes down to who is speaking. A case report from a tea-garden community in West Bengal describes an elderly man who refused surgery through posters, counselling and repeated visits. He agreed only when a local leader he trusted spoke to him in his own dialect.

What a good counselling desk does

None of this needs a large team. It needs one person who has the time, and a small routine.

1. Meet the patient the same day. Right after the doctor advises surgery, while the advice is fresh and the family is still there.
2. Talk to whoever decides. In most Indian families that is not only the patient. A son on a phone call is often the real decision.
3. Put the cost in writing. The package, the lens or implant options and what each one costs, and what insurance is likely to pay. Surprises at the billing counter are where trust breaks.
4. Answer the real worry. Fear of pain, the "ripening" idea, the good other eye, who will bring them, how long they will be off work. Each has a calm, honest answer.
5. Offer a date before they leave. A booked date turns a decision into a plan.
6. Follow up, and write it down. A call a week later, a reminder before the date, a note of what the patient said each time, so the next call starts where the last one ended.
7. Count your advised-to-booked rate. Out of every hundred patients advised surgery this month, how many were booked? It is one of the most useful numbers a surgical hospital can track, and one of the easiest to start.

That last step matters most. Once you know the number, you can see which surgeon's patients drift, which months are slow, and which reasons keep coming back. Then the counselling desk is easy to value, because you can see how many patients it helps through to treatment.

Sources

• Mailu et al., Factors associated with the uptake of cataract surgery, PLoS ONE, 2020 (includes the Tamil Nadu and Sankara outreach cohorts). Article
• Barriers to cataract surgery among those who refused it, rural South Karnataka, African Vision and Eye Health. Article
• Reasons for late presentation with cataract, North Karnataka, International Journal of Community Medicine and Public Health, 2025. Article
• Khan et al., barriers to cataract surgery among the elderly in Aligarh, International Journal of Community Medicine and Public Health, 2017. Article
• Community Eye Health Journal, counselling at Aravind Eye Care System. Article
• Community Eye Health Journal, Sadguru Netra Chikitsalaya, Chitrakoot. Article