Who Controls Health? A Complex Care System Network.

Last Friday, I attended a talk hosted by Dr. Jatin Kothari at the UNC Kidney Center. Dr. Kothari is the Director of Nephrology and Chief Consultant of Renal Transplantation at Nanavati Max Hospital, Founding Trustee at Apex Kidney Foundation, and Director and Founder of Apex Kidney Care. Dr. Kothari’s discussion focused around the need for a concerted dialysis treatment plan throughout India based upon a collaboration between private hospitals and the Indian government.

The data speaks for itself. (1) A 2020 study finds that the prevalence of chronic kidney disease (CKD) is between 15-17% in India (with the global rate being 9%). Furthermore, over 34 million dialysis treatments are required in India every year, but the country only has approximately 15 thousand centers and 2600 nephrologists. Thus, many patients who seek medical care are ultimately turned away contributing to rising disease prevalence and mortality. As demand has surged over the past few decades, the mortality rates from CKD have only worsened.

So what is dialysis and what prevents Indian patients from receiving dialysis? The kidneys are the organs in the body responsible for cleaning the blood and separating waste. Dialysis is a treatment meant for patients suffering from kidney failure that essentially cycles the blood, removing fluid waste. (3) Because the kidneys operate throughout the day and because waste buildup in the blood is toxic, patients suffering from kidney failure must either receive dialysis several times a week or undergo a transplant procedure where their kidneys are replaced with healthy organs.

There are two factors that affect access to care for patients suffering with CKD or ESKD (end-stage renal/kidney disease). (4) These themes appear again and again when we think about limiting disease prevalence in largely rural areas. They are cost and geographic location. On average, a CKD patient requires between 10 and 12 dialysis sessions monthly with each costing about Rs 1600 per session; this means that annually, CKD patients spend Rs 2,40,000 or roughly $2900, not including costs associated with additional doctor consultations and medications. This cost, accumulating every month and accounting for a significant portion of many households’ incomes, is unsustainable for many patients who then must decide to forgo treatment. Additionally, many dialysis centers are in urban areas, far from rural communities. This forces patients to travel hours several times a week to receive life-sustaining treatment.

What does this mean for Indian healthcare and dialysis plans? A 2015 study finds that approximately 136,000 Indian adults died prematurely of renal failure. (5) This statistic represents an upward trend in renal failure mortality. One possible explanation for this trend might be that kidney disease, especially diabetic kidney disease, is appearing earlier in India as compared to other nations. Thus, disease progression beginning earlier in patients’ lifespans will have greater consequences at the community level.

I include a chart below to show the various treatment plans for Indian patients living with ESKD. Patients scheduled for hemodialysis and peritoneal dialysis must travel to a dialysis center several times per week, using dialysis treatment as their permanent lifeline. Patients listed for transplantation are scheduled for kidney replacement, likely a permanent solution for their disease. Patients not receiving dialysis nor replacement therapy (a staggering 61%) must struggle through their illness with little to no medical assistance.

Patient care for CKD is most effective when the patient is at Stage 2 or 3 of the disease. Because dialysis centers are in such high demand and because there is such a large shortage of nephrologists to keep up with the growing patient population, most Indian patients are admitted while they are in Stage 4 or 5 of the disease. At this point, dialysis is not maximally effective and many complications may occur resulting in patient mortality. (6)

This case study, although it may not seem like it, is a struggle for healthcare authority between the private sector and the government. More so, this care system reflects the need for collaboration between private entities and the Indian government to provide the best and most successful care to CKD patients. While the government provides subsidies to private organizations while building public hospitals and setting up collaborations with international organizations, private entities are responsible for the majority of patient care and research while funding the majority of clinics and technology required for treatment.

In the status quo, private and public hospitals operate independently. Most importantly, this means that kidneys for transplantation cannot be swapped between patients in different hospitals. However, depending upon patient consent, data could be shared via a central healthcare system so that CKD patients may be able to travel shorter distances to receive treatment and will have fewer delays in receiving care. This is one of the main goals of Apex Kidney Foundation, as stated by Dr. Jatin Kothari.

To address the ongoing physician shortage, the Indian government should provide incentives for Indian medical schools to produce more nephrologists. While the number of nephrologists was originally in the low hundreds, that number has been climbing steadily over the past few years. Furthermore, private and public hospitals may establish international exchange programs for nephrologists to come to India, helping treat patients and establish dialysis centers.

Finally, international partnerships with universities, research institutes, and various nonprofit organizations will enable the Indian healthcare system to increase patient care capacity while providing physicians with a means of researching ways to improve treatment options. By forming bridges between private entities and the Indian government and by identifying methods to treat CKD and ESKD at an earlier stage, we can reduce renal failure mortality in India.