End Stage Renal Disease continues to be a result of existing and emerging burden of non-communicable disease. Providing for renal transplant facilities for ESRD patients depends upon availability of infrastructure and robust organ donation system coupled with adequate availability of trained qualified manpower. Within the limited choices, dialysis practically remains the first and in majority of cases, the only choice for ESRD patients.
Every year about 2.2 Lakh new patients of End Stage Renal Disease (ESRD) get added in India resulting in additional demand for 3.4 Crore dialysis every year. With approximately 4950 dialysis centers, largely in the private sector in India, the demand is less than half met with existing infrastructure. Since every Dialysis has an additional expenditure tag of about Rs.2000, it results in a monthly expenditure for patients to the tune of Rs.3-4 Lakhs annually.
Keeping this in mind, strengthening of District Hospitals by providing affordable multispecialty care including dialysis services in district hospitals would be an important step in this direction.
To gain from available capacity of private sector existing in dialysis care segment and their capability to install and operate dialysis care system in quick time, and compliment the emerging strengths of public sector such as availability of drugs and diagnostics, it has been proposed that Dialysis program be undertaken in Public Private Partnership.
Solution Strategy
There are two main types of dialysis, which are Hemodialysis and peritoneal dialysis.
- Hemodialysis (HD, commonly known as blood dialysis): In HD, the blood is filtered through a machine that acts like an artificial kidney and is returned back into the body. HD needs to be performed in a designated dialysis centre. It is usually needed about 3 times per week, with each episode taking about 3-4 hours.
- Peritoneal dialysis (PD, commonly known as water dialysis): In PD, the blood is cleaned without being removed from the body. The abdomen sac (lining) acts as a natural filter. A solution (mainly made up of salts and sugars) is injected into the abdomen that encourages filtration such that the waste is transferred from the blood to the solution. There are 2 types of PD - continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). CAPD needs to be done 3 to 5 times every day, but does not require a machine. APD uses an automated cycler machine to perform 3 to 5 exchanges during the night while the patient is asleep.
Close medical supervision is not required for most PD cases, thus making it a feasible option for patients who may want to undergo dialysis in the home setting. Each treatment option has its advantages and disadvantages, which vary with the condition of the patient and presence of underlying diseases. It is therefore important for every patient with ESRD to discuss various treatment options in detail with his doctor before starting treatment.
Public Private Partnership for Hemodialysis services
Based on consultation with experts and discussion with some of the states implementing the Dialysis program in the PPP mode, the following was considered as the ideal and cost -effective approach.
- It is desirable to roll out dialysis services in the states, beginning with the District Hospitals in a PPP mode. Direct provisioning by the state governments would be time consuming and likely to be costly and risky.
- Service Provider should provide medical human resource, dialysis machine along with RO water plant infrastructure, dialyzer and consumables.
- Payer Government should provide space in District Hospitals, Drugs, Power and water supply and pay for the cost of dialysis for the poor patients.