Global Nephrology: The Growing Inequity of Providing Dialysis in India

I was busy most of the day yesterday attending a conference by the South Asia Initiative at Harvard University. The focus was on health care in South Asia.

One of the speakers was until recently a senior member of the Indian civil service in the ministry of health. She spoke quite lucidly about the Indian experiment with public-private partnerships in health care. At the end of her talk I asked her about how the Government of India was addressing the growing inequity in health care in India. Specifically, I was interested in the growing disparity with access to dialysis care.

An article titled “The Big Market for Dialysis in India” by Adi Narayan in Business Week frames the issue well:

“As growing incomes give India’s millions access to First World staples such as cars and cell phones, the population is also experiencing an unpleasant byproduct of Westernized lifestyles: an epidemic of diabetes and the kidney disease it causes. While the number of Indian diabetics is predicted to hit 101 million by 2030, the cost of dialysis makes it a luxury for most patients. “There’s a huge demand for dialysis centers, but only those who can afford it get it,” says Georgi Abraham, a professor at India’s Pondicherry Institute of Medical Sciences and founder of the nonprofit Tamilnad Kidney Research Foundation that provides subsidized dialysis to the poor. “Often I find that patients just disappear. They get one or two sessions when they have some money and then stop. Within a week or two of stopping dialysis, they may just collapse and die.” …About 52,000 patients in India are on kidney dialysis. It’s only 4 percent to 33 percent of the cost in the U.S., but too rich for most Indians.”

The example of dialysis brings up an important concept, namely the issue of health equity. In a fabulous paper in J Epidemiol Community Health, which I recommend you read, Braverman defines equity in health as “the absence of systematic disparities in health (or in major social determinants of health) between groups with different levels of underlying social advantage – that is, wealth, power, or prestige…. Equity is an ethical principle, it also is consonant with and closely related to human rights principles”.

What I find most troublesome with the expansion of dialysis in India is that it is occurring in the private but not in the public sector. Increasingly, the rich who can afford dialysis get it, whereas the poor don't. Indeed, the poor end up dying from kidney failure. The total number of patient's in India undergoing chronic dialysis is increasing, but the expansion is in the private sector. The Government of India is not increasing funds to provide chronic maintenance dialysis in the public sector hospitals where most of the economically disadvantaged receive their care.

In other words, the Government of India's policies are widening the inequity gap. Braverman writes: “Equity means social justice or fairness”. Simply put, the Indian Government's policy around dialysis care is unfair and unjust.