Global Nephrology - Innovative models for dialysis care in low income settings

In the developing world 90% of patients die from kidney failure. However, the statistic is misleading because the number embodies a tragic inequity: 99.99% of poor people die from either unaffordability and/or lack of access to dialysis treatment, whereas those in the middle class are frequently able to afford dialysis - even if it is only twice a week. So the question is: are there models that are being developed to help poor people receive dialysis.

One recently publicized model has been introduced in the western Indian state of Maharashtra. Here, the state government has begun a scheme called Rajiv Gandhi Jeevandayee Arogya Yojana (RGJY) that provides medical care for poor patients.

Some important elements of RGJY:

1.  Families with annual income less than Rs 1 lakh ($2000) are eligible
2. A total 972 procedures ranging from angioplasty to bypass surgery to removal of uterus are covered;  the upper limit for the cost of these procedures is Rs. 1.5 lakh ($3000) for the family as whole per year.
3. In the current year's budget, the state government has earmarked $1.6 million - an amount that constitutes the biggest rise on any item in the state health budget, and the biggest PPP ( Public Private Partnership) in the history of the health sector of Maharashtra.

A recent article in the Indian newspaper The Hindustan Times highlights how this benefits people needing dialysis.

"The insurance scheme, launched on June 2, provides cashless insurance for families whose income is less than Rs1 lakh per annum. The state has enrolled 18 dialysis centres with 483 patients registered till date in Mumbai alone.

“Around 4,000 people who fit into our scheme need dialysis. We are still in the process of enrolling new centres. Anyone with a ration card can avail of dialysis at these centres,” said K Venkatesham, chief executive officer, RGJY."

The The RGJAY is a variant of the Southern Indian state Andhra Pradesh government's Rajiv Aarogyasri Scheme (RAS). 

However, not everyone agrees that models like the ones developed in Mahrashtra or Andhra Pradesh are best. Senior health activist Anant Phadke of JAA (Jan Arogya Abhiyaan (JAA), a network of non governmental organisations working in the field of health) was interviewed in a recent article:

"The scheme RGJAY is procedure driven, that too focused on the high-tech, costlier ones. Thus a hospital would get reimbursement for treating a case of ischaemic heart disease with angioplasty or bypass surgery, but not if it is treated with medicines alone. Hence private hospitals have a tendency to over-perform surgeries and procedures. Besides, the care is not totally free as patients have to pay for medicines and other expenses," Phadke said.

The most marginalised people like migrants, homeless and street children are not covered. "RGJAY provides large scale public funds to a section of large private hospitals, and increases the flow of patients to these private hospitals, while investments for improving public hospitals remain neglected."

While no model to pay for expensive chronic care is ever without some issues, it is nevertheless heartwarming that politicians and public health officials are thinking about the plight of people with kidney failure.