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Public Health Challenge of Chronic Kidney Disease

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By Aseem Garg, Founder, DCDC

Huge dichotomy exists in healthcare in India. On the one hand, our doctors are feted globally and health tourism is on the rise; on the other hand, there is a huge shortage of nurses and doctors, especially in the rural areas—a fact that was brought sharply into light at the start of the Covid-19 pandemic. The other contrast is the “dual disease burden”. Rising numbers, migration to urban areas and increasing prosperity have triggered the dual-disease burden–the prevalence of communicable diseases and a spike in non-communicable diseases (NCDs), or “lifestyle” diseases. About 50 percent of spending on in-patient beds is for lifestyle diseases and this has increased the demand for specialised care, says an India Brand Equity Foundation (IBEF) report of 2019.

As per a WHO report, nearly 5.8 million people die from NCDs (heart and lung diseases, stroke, cancer and diabetes) every year in India, or in other words 1 in 4 Indians has a risk of dying from an NCD before they reach the age of 70. End stage renal disease (ESRD), that keeps patients hooked to hospital care and frequent dialysis, is a result of several NCDs. Every year about 2.2 Lakh new ESRD patients get added in India resulting in additional demand for 3.4 crore dialysis every year. Chronic Kidney Disease (CKD), that leads to ESRD, is the sixth fastest growing cause of death worldwide. High cost of Dialysis leads to financial setbacks for practically all families with such patients. 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 percent–a miniscule figure in comparison to countries like Croatia at 36.5 percent and Spain at 35.3 percent. With substantial gain in quality of life through dialysis, most families prefer to take patients to the nearest dialysis centre.

There are three main types of dialysis: in-centre hemodialysis, home hemodialysis, and peritoneal dialysis. In-centre hemodialysis takes care of logistics of applying tubes correctly and the presence of hospital staff inspires trust. However, lack of dialysis services in remote areas and prohibitive costs of dialysis act as major barriers to access. With approximately 4,950 dialysis centres, largely in the private sector, the demand is less than half met with existing infrastructure. Since each Dialysis entails an additional expenditure of between Rs 2,000-Rs 5,000 per sitting, the monthly costs play havoc with fragile budgets. Besides, most families have to undertake frequent trips, and often over long distances to access dialysis services, incurring heavy travel costs too. This therefore leads to huge financial burdens for most families of such patients.

The first hemodialysis in India was performed at Christian Medical College (Vellore, Tamil Nadu) in 1961 on an erstwhile Maharaja under the supervision of Dr Satoru Nakamoto, who had flown in from Seattle, Washington. More than 60 years later, access and affordability are the major concerns among renal patients. The private sector is a diverse pool that caters to three quarters of the population. The vast majority in India cannot access such expensive healthcare. The challenge for the ruling dispensation is to ensure last mile delivery and to improve health outcomes with better dialysis centres to ward off infection rates that may result in untimely death of patients.

There is now some serious attempt to transform healthcare—in policy, delivery, and in ideas. The government’s National Dialysis Program envisages setting up an eight-station dialysis facility in all 688 districts of the country to provide HD to poor patients. If patients were dialyzed twice a week, only about 50,000 new patients (representing about a third of the current requirement) would be accommodated. According to a study, almost 60 percent of patients on dialysis had to travel >50 km to access HD, and nearly a quarter lived >100 km away from the facility. Further, women are under-represented, and there are few pediatric dialysis services. Huge opportunity exists in reimagining healthcare for dialysis patients, with better penetration of state-of-the-art health centres.

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. As we get down to building back fast post-Covid, healthcare too is poised for growth, riding on the wave for health tech, last-mile connectivity, Fit India movement, and increased focus on preventive care. The disease should be actively addressed to meet the UN’s Sustainable Development Goal to reduce premature mortality from non-communicable diseases by a third by 2030.

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