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Global Dialysis Perspective: Nigeria

2022; Lippincott Williams & Wilkins; Volume: 3; Issue: 9 Linguagem: Inglês

10.34067/kid.0002312022

2641-7650

Ogochukwu Okoye, Manmak Mamven,

Climate Change and Health Impacts

Introduction Despite the high prevalence of ESKD in Nigeria, only 2% of these patients receive hemodialysis, which is the most widely available form of RRT in Nigeria (1–3). The overarching reason behind this devastatingly low hemodialysis uptake is out-of-pocket payment for health services in the country (1–3). Reports from 2018 revealed that only 3000 patients were receiving hemodialysis nationwide (3), and 80% of these patients do not sustain treatment beyond 3 months, resulting in repeated hospitalization of ESKD patients, poor quality of life, high morbidity, and premature deaths (4). Patient advocacy efforts by nephrology health care professionals under the auspices of the Nigeria Association of Nephrology has not yielded a significant government response. The National Health Insurance Scheme (NHIS) does not fund hemodialysis for patients with CKD, and erythropoietin stimulating agents are not included in the NHIS medicines list (5); furthermore, 90% of patients dialyze using central venous catheters, with the majority being temporary femoral catheters, which are the cheapest; 8 11 Pharmacy located within the unit? Yes 28 No 73 Laboratory located within the unit? Yes 38 No 63 aDoctors, technicians, health assistants, student nurses, or biomedical engineers. Barriers to Quality Hemodialysis in Nigeria With a fast-growing population and an increasing disease burden, tremendous progress has been made by collective efforts of stakeholders to improve hemodialysis in Nigeria. Yet, challenges persist. Several factors threaten the availability, affordability, and accessibility of hemodialysis services, including those that are economic, political, manpower related, infrastructure and equipment related, and behavioral. Economic Factors Dialysis is expensive and unaffordable for most patients in Nigeria. Although Nigeria has the largest economy in Africa, 40% of the population live below the poverty line—a situation worsened by the deep recession experienced in 2020 following the pandemic (8). The cost of a session of hemodialysis is presently more than the official minimum wage (N30,000) in Nigeria, and many people earn below this figure. The implication of this meager income is that a large proportion of ESKD patients will either not subscribe to hemodialysis or exhaust their earnings and savings and still not be able to sustain hemodialysis beyond 1–3 months. The resource allocated to health is poor, and there is no meaningful government support for hemodialysis. Consequently, the majority of patients pay out-of-pocket for hemodialysis and most essential medications such as erythropoiesis-stimulating agents. Only a negligible number of patients benefit from corporate bodies and philanthropists. Political Factors The government lacks the political will regarding improved care for ESKD patients, and this is despite advocacy efforts of nephrology associations and other nongovernmental organizations. Unfortunately, accurate data on the burden of ESKD in Nigeria are still lacking, and this crucial information is needed for more effective advocacy. Nevertheless, the devastating outcomes of ESKD are evident to Nigerians and the government, but this has not motivated any appreciable response. Politicians are among the wealthy class who often do not experience the hardships described above and hardly utilize public health institutions, possibly explaining their apathy. Another reason is competing financial demands, where health is hardly considered a priority. A few states have attempted to provide subsidized hemodialysis for their indigenes, but this was not sustainable in some states due to the high associated costs and corrupt practices. Manpower Factors Manpower-related challenges include manpower shortage, poor staff motivation, brain drain, and inadequate training. Other factors are unavailability of staff due to incessant strikes, especially in the public sector to protest against unfavorable remuneration, poor work environment, and embargo on employment, among others. Furthermore, Nigeria, like other Sub-Saharan African countries, is experiencing a disproportionately higher disease burden that overwhelms the available nephrology workforce, resulting in suboptimal patient care and outcomes in underserved areas. Training and education of dialysis staff is inadequate, and training centers are scarce and very competitive. Hemodialysis nurses who are motivated to learn new skills and advance their career cannot afford the opportunities available, and minimal support is provided by their training institutions in terms of financing and protected training time. Several centers are manned by nurses without nephrology certification assisted by other health workers. Staff motivation is low due to poor remuneration when compared with developed countries, and this is a push factor for brain drain, which has further reduced the available staff in many centers and closure of hemodialysis units in extreme situations. Infrastructure and Equipment Compared with hemodialysis units in developed countries, the hemodialysis infrastructure in Nigeria is inadequate, with centers lacking basic utilities and support services such as side laboratories, pharmacy units, or drug dispensaries. Most centers are in-hospital and thus shared by in- and outpatients—a situation that often results in long waiting times. The availability of hemodialysis centers is disparate, with none in rural areas, few in most urban areas, and several in the megacities. This disparity is because hemodialysis centers are mainly for-profit and so the profit drives location. The implication of this is that many patients have to travel long distances to access hemodialysis, thereby increasing the financial burden in addition to travel safety issues. Equipment downtime in many centers is a common challenge; machines are old and often poorly maintained, and spare parts are imported, scarce, and costly. The high costs and resultant scarcity stem from the uncertainties in the Nigerian economy since the coronavirus disease 2019 crisis. In addition, there is a dearth of trained technicians to maintain machines. Other problems are frequent power interruptions, with poor and expensive backups. Behavioral Factors A good number of ESKD patients in Nigeria will resort to alternative practices aimed at treating or curing CKD because the cost of orthodox treatment is prohibitive. These alternatives include buying medicines over the counter for symptom relief, purchasing alternative medicines that are marketed as curative sometimes by health professionals themselves, seeking miracles in prayer houses, and resorting to diabolic means to rid themselves of the perceived curse. The result of this trend is late presentation to the nephrologist with advanced disease and severe clinical features, contributing to increased morbidity, repeated hospitalizations, and mortality. Conclusions Access to hemodialysis services in Nigeria remains poor and concerning. The available dialysis units are insufficient, with a number of areas lacking any functional dialysis unit. Out-of-pocket payment is an enormous barrier to equitable dialysis access, and it will require efforts from all stakeholders. The nephrology community needs to continue steadfastly with public education, preventive programs, and advocacy efforts in partnership with other stakeholders to find sustainable solutions to the devasting outcomes of ESKD treatment in Nigeria. Universal NHIS coverage to include kidney care and improved remuneration, incentives, and training for health care workers is strongly recommended to limit the brain drain. Disclosures O. Okoye reports being the founder of St. Linus Renal Care Initiative, a nonprofit organization focused on preventing CKD and on improving the lives of Nigerians living with CKD. The remaining author has nothing to disclose. Funding None.