AIM: Many sub-Saharan African governments expect patients to contribute towards health care. We investigated what happens to patients who reported being too poor too pay for cataract surgery. METHODS: Over 1 year, patients who did not accept cataract surgery after being advised to do so at outreach clinics were enrolled in a prospective cohort study, then followed-up to determine who returned. A subsample was traced for further interviews to learn what they had undertaken to try to obtain funds. RESULTS: A total of 198 patients did not accept surgery and 157 (79%) of these stated the reason was lack of funds. At follow-up, 36 had returned for surgery, 32 with money and 4 with letters from village leaders verifying inability to pay. There was no association between age, sex, or blindness and returning. Interviews with a representative subsample revealed that 44% patients with stated poverty actually had other reasons for not accepting surgery; only 22% took advantage of a free waiver issued at the interview. CONCLUSIONS: Of patients who reported being too poor to pay for cataract surgery, 20% accessed funds after counselling. A significant proportion of those who did not return supplied other reasons for not accepting surgery when interviewed later at home, and did not use a free waiver granted at that time. Access to health care is a complex issue; however, this study does not support the notion that charging small fees for cataract surgery in this setting creates a major barrier to access. That said, it is important to find simple, valid methods to identify those too poor to pay for surgery if we hope to develop sustainable systems to achieve VISION 2020 targets.