In 1998, on the initiative of the Brazilian Council of Ophthalmology (CBO) and the Health Ministry, with the support of medical schools, the National Cataract Campaign was established. Access to treatment was made easy with nationwide campaigns conducted for diagnosis and later for surgery (Cataract Projects). This action had the greatest impact on visual health in Brazil as the number of performed surgeries has almost doubled. By means of epidemiologic studies, the effectiveness and safety of cataract surgeries performed in university hospitals on a large scale were confirmed and Cataract Projects were improved^(1-7). Nevertheless, in 2006, the Health Ministry discontinued the National Campaign due to lack of funds for all surgeries, and public hospitals were granted limited quotas for surgical procedures. This measure negatively impacted progression in the number of surgeries performed annually by reducing the use of the installed cataract surgery capability in public hospitals; thus, an additional barrier was created to limit the access of the needy population to corrective surgery: limitation of surgical offering^(8-9).

Despite the clinical evidence demonstrated by published epidemiologic studies that the methodology used in the National Campaign for blindness eradication by cataract surgery was successful in Brazil^{(1-3,6-8,10,11)}, the National Government and several municipalities have opted for a new strategy to deal with the problem. Currently, many public health projects for cataract surgery are implemented by means of bidding, in which private companies, some with mobile surgical units, negotiate the least value for quotas on thousands of surgeries.

The analysis and interpretation of epidemiological data on total cataract surgeries⁽¹²⁾ performed by the public health system in Brazil from January 2000 to December 2015 demonstrated that the number of surgeries between 2010 and 2015 has increased by approximately 246%, while the amount spent annually on surgeries increased by 371% over the same period (Table 1). The number of cataract surgeries performed at the Hospital das Clínicas of the Medical School of the University of São Paulo (HCFMUSP, a reference public teaching hospital) has decreased by approximately 23%, from 2005 to 2015 (Table 2).

During the legal effect of the National Cataract Campaign, the surgical capacity in teaching hospitals was expanded to accommodate the growing demand. The Ophthalmology Service in the Clinic Hospital of the Medical School of the University of São Paulo (HCFMUSP), for instance, increased the number of resident doctors from 5 to 14 annually, enrolled 20 additional trainee doctors annually, and opened a new surgical center. The number of cataract surgeries performed annually increased from 836 in 1998 to 5,078 in 2005. Recently, due to budget limitations, the number of surgeries performed annually in HCFMUSP in 2015 was 3,902. Similar situations were observed in other teaching hospitals.

Nevertheless, according to the official available data, the number of cataract surgeries performed in Brazil is increasing, probably because of contracts of service rendered to private companies. In the north-northeast, specifically, there are governmental stimuli for performing surgeries in mobile units (trucks with adapted surgical centers), which probably explains the significant increase in the number of procedures performed in that region.

At the time when public universities assumed the responsibility for performing most cataract surgeries and when the Brazilian Council of Ophthalmology coordinated the national actions, the transparency of results and quality of procedures were guaranteed by the university ideology and were made patent via publication of epidemiologic studies. In bidding, in which the winner is the one who offers the lowest price for each procedure, and when the objective of the hired company is to make a profit, there are doubts concerning the quality of the rendered service⁽¹³⁾.

To justify switching from a public health project with confirmed effectiveness, quality, and safety to a new strategy with obscure results, data on postoperative results are necessary and should be made available to the medical community to demonstrate the effectiveness of the new initiative^(14,15). Additionally, if the switch is detrimental to the development of new surgeons and ignores the increased infrastructure of public hospitals, then this should be considered when making a policy decision.

Thus, even if adequate effectiveness of the new public health project for the treatment of cataracts is considered, we believe that there is a need for greater transparency regarding the surgical protocol, the patient pool, and the complication index. In addition, epidemiologic studies on cost-effectiveness are expected to evaluate the quality of services rendered to the society in order to justify the substitution of the university-medical society axis for the private sector as the preferred treatment program for cataracts by the public health system.