Aseem Garg, Founder & CEO, DCDC Kidney Care stresses on the ways to reimagine kidney care in India
Kidney disease requires life-long management and is the sixth fastest growing cause of mortality globally. In India, about 2.2 lakh new patients of end stage renal disease (ESRD) get added annually, resulting in an overall demand for 3.4 crore dialysis every year. There is a wide gap in demand and supply. India has one of the lowest nephrology workforce densities worldwide, only about 2,600 nephrologists (1.9 per million population), and a chronic shortage of reliable, efficient and accessible dialysis centres, nurses and technicians.
With little or no symptoms, the disease is a silent health crisis. Over 50 per cent of patients with advanced kidney disease are first seen at a hospital when the eGFR is <15 ml/min per 1.73 m2 . When kidneys start deteriorating, and the patient is diagnosed as having Chronic Kidney Disease (CKD), the only solutions so far available are to manage the illness, not in curing it.
Patients of ERSD are faced with challenges such as high costs of treatment, and low penetration of dialysis centres. At 1.38 billion, India has nearly 17 per cent of the earth’s population, and large numbers of people are too poor to afford costly treatments. Many dialysis patients tend to give up the ordeal, due to financial or access reasons, and that can be life-threatening.
Each dialysis may cost upwards of Rs 2,500 and most patients need to dialyse at least two-three times a week. This leads to financial setbacks for many as the disease has to be managed lifelong. Renal replacement therapy is an expensive procedure and requires organ donation that is still not a route most people can take since organ donation rate in India is 0.01 per cent–an abysmal figure compared to countries like Croatia at 36.5 per cent and Spain at 35.3 per cent. With substantial gain in quality of life through dialysis, most families prefer to take patients to the nearest dialysis centre.
Though in-centre Hemodialysis (HD) was introduced in India in 1962, so far, we have only 4,000 dialysis centres and 28,000 dialysis machines. Most of these are privately managed facilities in metro cities. The need for dialysis centres is less than a quarter met in India.
According to a study, almost 60 per cent of patients on dialysis had to travel more than 50 kms to access HD, and nearly a quarter lived over 100 kms away from the facility. Further, women are under-represented, and there are few pediatric dialysis services. A huge opportunity thus exists in reimagining dialysis care, with better penetration of state-of-the-art centres, to reduce out-of-pocket expenses of the patients, particularly from the weaker sections. The burden of kidney failure deaths in India is greater in comparison to other low- and middle-income economies with a similar socio-demographic index, suggesting an improvement in mortality rates in India is possible.
Reimagining kidney care
There have been some serious attempts to transform healthcare—in policy, delivery, and in ideas. Ayushman Bharat puts the lens on India’s growing burden of non-communicable diseases, like stroke, kidney disease and cardio-vascular disease, and was brought in to bring in affordability, accountability, inclusivity, and decentralisation. The government’s National Dialysis Program focuses on PPP initiatives to improve access of high-quality care. By partnering with private sector healthcare institutions, CKD patient care can be brought to district hospitals. Currently, under the Program, medical human resources, dialysis machines, and dialyzers are provided by the private partners, while the responsibility of space, water supply, and power are on the state government at district hospitals.
In the revised Health Benefit Package 2.2, launched on April 6, 2022, 365 new procedures have been added and dialysis treatment relief has gone up from Rs 1,500 to Rs 1,800. The plan is that all 750 districts should have at least one dialysis centre each. Moreover, the portability feature of the scheme allows the beneficiary to avail treatment anywhere in the country—a big relief for kidney patients who have to travel long distances. Out of more than 24,000 hospitals empanelled under the scheme, many are from the private sector, giving beneficiaries multiple avenues to seek treatment.
World-class treatment options can be introduced in tier II, III and IV areas through the PPP route. Access to state-of-the-art infrastructure, virtual consultation with renowned nephrologists, and flexible dialysis options for patients will improve outcomes. Another benefit of such partnerships is that the costs of treatment are minimized.
The dangers of kidney patients catching infections is high as immunity is low. Therefore, the availability of clean and hygienic centres, along with the 24/7 availability of nephrologists and technicians at the centres are important. Failure to maintain quality standards may even lead to fatal infections. Most centres have separate areas for dialyzing patients positive for hepatitis B/hepatitis C.
A thorough study of the epidemiology profile of the country is needed to improve healthcare. The government’s aim, under the National Health Programme, is to increase the targeted public expenditure to 2.5 per cent of the GDP by 2025. An increase in government budgets for better dialysis penetration, awareness drives, routine screening, and digitisation of records will go a long way in the prevention and management of the disease, aligned with the goal of Swasth Nagrik Abhiyan.
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