By Ames Gross, President and Founder of Pacific Bridge Medical
This article was also published on MedTech Intelligence.
China’s ophthalmic market is set to grow rapidly in the coming years, driven by the country’s quickly aging population. Market Scope forecasts this year that China’s $2.7 billion ophthalmic market will grow at a compound annual rate of 8.5% to $4 billion in 2022. China has approximately one-third of the world’s blind people, and about half of these cases of blindness are caused by cataracts. The number of people with glaucoma and retinal disease is also on the rise. In revenue terms, the two largest sub-markets are retinal disease and cataract surgery.
The country now has more than 30,000 practicing ophthalmologists, located in more than 2,700 ophthalmic centers throughout the country. There are more than 1,400 departments of ophthalmology (located in national, university, provincial and prefectural hospitals), with about 1,000 centers in county hospitals and 174 in local clinics. Additionally, there are 121 specialty hospitals and 11 institutes for eye disease prevention.
Despite the market’s growth, there remain wide discrepancies in the level of care provided by local clinics and more sophisticated urban centers. Generally, there is a lack of standardization of clinical practices throughout the country. Chinese ophthalmologists often prefer to rely on their own clinical experience, making them reluctant to buy new lenses and other devices with which they are not familiar.
Hospitals and Clinics
The quality of Chinese eye care varies widely from region to region and between urban and rural settings. Small local clinics provide about 75% of primary care for eye problems. Advanced ophthalmology treatment is heavily skewed towards Class III hospitals, which are located in urban areas. Between 30% to 50% of the inpatients at big urban hospitals are from nearby rural areas, with the majority seeking a second or third opinion. The Chinese government is aiming to promote reforms that will see more advanced diagnosis and treatments performed at lower level hospitals.
The infrastructure and technical skills of Class III hospitals are compatible with international standards, but they are too crowded. Big hospitals are well informed and have the financial resources to purchase advanced technologies, but this does not always happen.
The current Chinese market for ophthalmic devices may be considered an oligopoly dominated by a few foreign firms such as Topcon, Zeiss and Shin-Nippon. Approximately 85% of all sophisticated ophthalmic equipment in hospitals is provided by foreign producers.
Ophthalmologists in China
Chinese ophthalmologists have in general been slow to adapt to the greater availability of high-quality equipment. This is most likely due to a continuing lack of standardized training. Most Chinese ophthalmologists have never received comprehensive standardized training and manage to learn largely on the job. The younger generation of doctors often find their older mentors busy with patients and thus are unable to receive sufficient standardized training. These problems often prevent sophisticated ophthalmic devices from being used to maximize benefits, causing discrepancies in treatment and diagnosis. In a survey of perceived training differences between ophthalmology residents in Hong Kong and China, published by BMC Medical Education in 2015, those in China reported strikingly less surgical experience and supervision. Rather than practicing standardized diagnosis and treatment procedures, Chinese ophthalmologists prefer to rely on clinical experiences.
Generally, the number one requirement of Chinese ophthalmologists for ophthalmic instruments is convenience. They are generally not familiar with nor are they interested in the optical and physical mechanisms of the new, more sophisticated instruments. They prefer instruments that are durable, user friendly, quick to learn, quick to prepare and easy to sterilize. That way, they feel that they do not waste time learning, preparing and cleaning the instruments when facing a crowded waiting room filled with patients.
Thus, oftentimes there is an under-utilization of new ophthalmic lenses and products at top hospitals. The majority of doctors show no intention of purchasing new lenses, and they normally do not pay attention to what brands they are using. Many Chinese doctors do not routinely use a specific lens for the specified examination or procedure, and even disposable lenses are often re-used.
Most Chinese ophthalmologists have their own lenses, which are provided by the hospital or purchased on their own using research grants. Most hospitals have a few slit lamp lenses managed by the nurse team and have 1-2 gonio lens and surgical lens to share within the department. Doctors are generally not trained in the use of new, sophisticated lenses.
Peer advice can be very influential in buying ophthalmology equipment. If a doctor sees something interesting at an overseas trade show and the price is cheaper than in China, they may purchase that product for themself and their colleagues.
Most hospitals have a well-designed procurement process. Public hospitals in China procure most of the medical devices they use through a bidding process centralized at the provincial level. Other methods of procurement are permitted only in special cases.
Most hospitals have specific procurement teams, which are responsible for handling the procurement procedures. For the ophthalmology department, the head doctor would gather information and submit a proposal to the hospital’s procurement department. Then the procurement department would contact suppliers and drive the bidding, selection and negotiation.
To gain an advantage in the bidding, many foreign manufacturers will “lend” their products to the doctors for up to one year ahead of time, which allows them to build brand and user experience. The process of procurement usually takes a year, but can be delayed or suspended due to political or regulatory factors.
Ophthalmic ultrasound and related technology have seen rapid growth in China. As China’s 1.4 billion population ages, it will be a direct stimulus to the increasing patient count for eye diseases. One of the main obstacles that foreign device providers need to overcome is the lack of ophthalmologists capable of operating advanced devices.
In general, Class III hospitals in China have the financial capabilities to invest in cutting-edge devices and are sometimes willing to purchase foreign brands over domestic products. To succeed in China’s ophthalmology market, foreign players should consider establishing educational incentives as a way to overcome Chinese ophthalmologists’ reluctance to adapt to new technologies. Companies should provide technical training to ophthalmologists as a way to introduce their products and build brand and user experience.
It is important to note that ophthalmic practitioners in China place a high value on convenience and durability. Buyers are therefore often more receptive to equipment that is reliable, simple to use and easy to learn.