A pipe dreamRecent amendment to the law allowing the use of kidneys from a clinically dead patient is a step in the right direction
On May 12, 2016, the Nepal government announced it would provide free lifetime dialysis to all patients with kidney failure. While this was a shot in the arm, especially in light of the high cost of care, the pronouncement was subject to mixed reactions from the public and experts alike. Some experts argue that the proposal is unsustainable over the long term in a country where poverty and corruption are pervasive, and that the decision is merely an attempt to gain political mileage. Realistically, it is imperative upon the government to assist citizens in managing the prohibitive costs at some point. This piece sheds light on the challenges, opportunities and strategies the government can undertake to realise free care for dialysis patients.
Lack of public participation is the first problem. A well thought out programme should go through a pilot phase to assess its feasibility before implementation. However, it appears that the government failed to conduct a thorough assessment before proposing the move to support dialysis patients. For instance, calls by the public for practical data in support of the vision appear to have fallen on deaf ears. Similarly, the failure to report the country’s capacity, operating costs and budget to the public has compounded matters.
The second problem is misuse of resources. The challenges bedevilling the provision of free dialysis include, but are not limited to, the manipulation or falsification of patient records for personal gain by physicians, over-billing, billing for non-existent services or items, duplication of payments for the same service, and intentional misreporting of diagnosis and procedures. In some instances, physicians prescribe expensive treatment plans when cheaper alternatives are available. In order to tackle this problem, the federal monitoring agency needs to set up a robust compliance programme to identify, prevent and eliminate fraud and abuse of resources. A policy of zero-tolerance to such malpractices would help streamline operations and channel funds to the right initiatives.
A study published in the British Medical Journal in 2012 showed that the prevalence of chronic kidney disease (CKD) was 21 percent among Nepali women, compared to a global rate of 10 percent. The incidence is expected to rise by one to three percent annually based on global trends. In such a scenario, the government would have to shoulder a bigger financial burden as the number of patients rises owing to increasing awareness about the availability of CKD screening and an upsurge in the incidence of CKD. Doctors who initiate early dialysis for patients before they are ready for the procedure with the hope of making a quick buck would further hinder the system.
The third challenge is inadequate manpower and poverty. Patients requiring dialysis services far outnumber the workforce—social workers, nutritionists, dialysis nurses, technicians and nephrologists—that is vital to coordinate healthcare delivery. While the onus is on the state to nurture such professionals, it remains a mountainous task. Additionally, up to 25 percent of the Nepali people live below the national poverty line. The logical approach for them is to opt for free dialysis over costly transplantation, although the latter is cost-effective and offers better long-term survival rates.
The efficacy of the free dialysis programmes hinges upon the planning and implementation of the legislation, and in dealing with socioeconomic and political obstacles. Delivering competent and cost-effective care, channelling scarce resources efficiently and implementing preventive care solutions to the marginalised would produce meaningful results.
There is a need to document the current number of dialysis patients and those in imminent need. The government should create a national electronic dialysis database detailing the socioeconomic status of patients, their medical history and demographics. Such a tool would help track new patients and provide comparative data based on epidemiological studies, assess quality of dialysis services and survival rates, rates of complications, and discontinuation of treatment. At policy level, the registry would help design quality dialysis programmes, open avenues for research and innovation, and develop effective kidney transplant programmes. Quality control measures to penalise or incentivise physicians and dialysis centres would help curtail the misuse of resources. Likewise, CKD progress monitoring, screening for depression and monitoring of dialysis adequacy can help address pending concerns. To enhance the quality of care, the state should motivate professionals involved in specialised care through promotions and the provision of training.
In the long run, kidney transplantation appears to be the most viable option as compared to hemodialysis (via fistula) and peritoneal (via abdominal cavity) dialysis. An amendment to Nepali law in 2016 giving the green light to remove kidneys from a clinically dead patient and matching the parts to compatible patients is a step in the right direction. This plan of action offers an effective strategy to scale down the cost of dialysis.
Government incentives to pharmaceutical companies to produce peritoneal dialysate (fluid bags for dialysis) and other dialysis products will significantly lower costs. An innovative model in the Philippines dubbed Sin Tax in 2012 helped raise excise taxes on tobacco and alcohol, leading to a reduction of smoking and a rise in healthcare revenue to fund universal care and train medical practitioners. This shows the value of novel ideas to address pressing concerns.
Public education is a critical first step in the management of medical conditions. Targeted preventive care should focus on fostering CKD awareness in high-risk areas and promoting screening initiatives for early detection of ailments to limit the risk of progression to dialysis. Ultimately, the concerted efforts of I/NGOs, the private sector, the government, communities and patient representatives will translate to the realisation of the free dialysis programme in Nepal, which at the moment appears like a pipe dream.
Bhattarai is a nephrologist and geriatrics fellow at Brown University, US