Publicly funded dialysis programs represent a good beginning but need to address poor survival and high drop-out rates, reveals a new study

Making provision for free treatment under a publicly funded dialysis program allows more people with advanced kidney failure to access this expensive treatment but is not able to address all barriers to ensure long-term success, reveals a new study by The George Institute for Global Health, India.

The study, entitled “Utilisation, costs and outcomes for patients receiving publicly funded haemodialysis in India” was based on an analysis of 13,118 beneficiaries who received haemodialysis over a four year period (2008-12) for end-stage kidney disease under the Rajiv Gandhi Aarogyashri Community Health Insurance Scheme (RACHIS) introduced by the Andhra Pradesh Government in 2007.

The study shows that there was a steady year-on-increase in uptake in the number of beneficiaries who accessed treatment – from 29.5  per million in 2008 to 122.2 in 2012, which confirms a high unmet need for dialysis. 


However, the study also found that survival rates were sub-optimal and a significant proportion of patients simply dropped out without any medical reason.

This first of its kind evaluation of a publicly funded program assumes significance in view of the growing recognition of chronic kidney disease as a public health burden. Global Burden of Disease Study has estimated that about 2.35 lakh people died of kidney failure in India in 2016, making chronic kidney disease as the ninth leading cause of death in India, having risen from 15th rank in 2005. Treatment of advanced kidney disease that requires dialysis is expensive. Previous studies have shown that most people with kidney failure in India die without receiving an appropriate treatment, mostly because of financial reasons. RACHIS was the first program that removed this financial barrier, allowing the poor to access treatment. The National dialysis program announced in 2014 envisages setting up dialysis centres in all districts of India.    

The study found that of all people who started haemodialysis during the period of evaluation RACHIS, about 10 percent had died and another 36 percent had stopped coming to dialysis centres after six months and 10 per cent of them were reported dead. The total cost of HD-related care was 63.2 million International dollars accounting for 3.1 per cent of all claim expenses under RACHIS during the study period. The annual spend per patient was low in comparison with that reported from other countries.    

This is the first large-scale study to present population-based data on utilisation of haemodialysis service and outcomes in India.

"It is apparent that there is a large unmet need, the patient survival is much lower than the global standards, especially given the relatively lower age of the population,”

says Professor Vivekanand Jha, Executive Director of the George Institute for Global Health, India and President-Elect, International Society of Nephrology. 

"A notable feature was the high drop-out rate, also noted in small studies earlier, suggesting the existence of additional barriers that force people to stop dialysis. These could include out-of-pocket expenses for travel to dialysis units; management of associated medical conditions the costs of which were not covered by the scheme; loss of income; and caregiver burden. Exploration of these factors requires additional studies” said Professor Jha, adding “Community-focussed models of dialysis delivery such as peritoneal dialysis and satellite dialysis units need to be developed, and the financing model, especially the ancillary costs, and oversight in terms of quality of care need evaluation to ensure that dialysis programs can deliver acceptable outcomes.”

Professor Jha also pointed out that large-scale universal dialysis programs are financially unsustainable and must be coupled with a program of care that includes early detection and prevention of kidney disease, better care of those with pre-dialysis chronic kidney disease, and expansion of the transplant program.