With end-stage kidney disease (ESKD) continuing to increase worldwide, and the prevalence in South Africa estimated to range from 6% to 17% and predicted to worsen, only a fraction of those with chronic kidney disease – who also have medical aid – have access to lifesaving kidney replacement therapy/dialysis.
The disparities are evident even between provinces, with some, like the Eastern Cape, faring far worse than its Western Cape neighbour, for instance, according to a recent collaborative study from various South African universities and United States health agencies, published in the South African Medical Journal.
Apart from being ranked as the most unequal country in the world, with a Gini index of 63, South Africa also carries the dual burden of non-communicable diseases, including hypertension and diabetes mellitus, and communicable diseases like HIV, all major risk factors chronic kidney disease (CKD).
CKD is often diagnosed at an advanced stage, when kidney replacement therapy (KRT) (dialysis and/or kidney transplantation) is essential to maintain life.
Kidney transplantation is acknowledged as the best KRT for ESKD in terms of both health metrics and cost-effectiveness, but has numerous challenges. Because of the costs, low- and middle-income countries that can institute KRT programmes often have to ration treatment, sometimes resulting in inequitable allocation.
In SA, selection for KRT is based on suitability for kidney transplantation, with guidelines aimed at achieving equitable access to the procedure, yet different regions have adapted local variants of this rationing policy that reflect local resource constraints and disparate access to healthcare.
Only 14.8% of the country’s population have health insurance providing access to the private sector where the provision of KRT is mandated by law. This leaves most (85.2%) of South Africans reliant on the public sector healthcare system, and for those with ESKD, limited access to rationed KRT.
In 2020, according to the SA Renal Registry (SARR), the prevalence rate for the provision of KRT was 729 per million population (pmp) in the private sector compared with 44 pmp in the public sector, which is lower than the 70 pmp reported in 1994.
While an exact comparison may not be accurate, the private sector KRT rate could be used as a surrogate marker for the true required KRT burden in the public sector. Overall, the national kidney transplant rate in SA is low at 4.6 pmp, compared with 38.1 for European Union member states reported in 2016.
Inequalities in KRT provision also exist within and between provinces.
The Eastern Cape is ranked as the most unequal province: it has the highest prevalence of HIV infection (between 28% and 34%), and a critical shortage of medical specialists. A survey in 2018, found only six nephrologists in the province (density of 0.6 pmp), while the neighbouring Western Cape had 37 nephrologists and a corresponding density of 6 pmp.
Three cities in the Eastern Cape have public tertiary healthcare facilities, which service an area of 168 966 km² with a population of 6 676 590 people. Only 7% of the province’s population have private healthcare insurance. Furthermore, only three public sector facilities provide dialysis and pre- and postoperative support for kidney transplant recipients, viz Gqeberha, East London and Mthatha.
For kidney transplantation, waitlisted patients must travel large distances (~1 000km) to quaternary transplant centres in the Western Cape.
This study aimed to investigate the state of the KRT service platform in the Eastern Cape by analysing access to and provision of KRT in the province for people with ESKD, as well as the disparities between the private and public healthcare systems. The results will be used as a foundation to facilitate the investigation of potential barriers to KRT and the initiation of appropriate solutions in the province.
What was found
As of 3 August 2022, 978 patients were receiving KRT in the Eastern Cape, with an overall treatment rate of 146 pmp. The treatment rate for the private sector was 1 435 pmp, compared with 49 pmp in the public sector. The predicted shortfall in public sector KRT provision was 8 606 patients.
Patients in the private sector were older, more likely to be male, HIV positive and to receive haemodialysis as their KRT modality. The number of people with a functioning kidney transplant was 58 pmp in the private sector and 19 pmp in the public sector, with a combined prevalence of 22 pmp constituting 15% of all patients on KRT.
There were 32 private and three public dialysis centres in the province, and a low prevalence of KRT in the public sector in East London and Mthatha. Even though the proportion of public v private KRT provision was similar between East London and Mthatha, the Mthatha region provided KRT for 96 patients compared with 418 in East London. KRT provision in Gqeberha was similar between sectors, reflecting higher transplant rates in the public sector.
There were marginal differences in age between the centres, but patients in the public sector were older in Mthatha than in Gqeberha and East London. East London had a more equal gender distribution between sectors, while the other two centres had more males on KRT, particularly in the private sector.
There were significant differences in terms of dialysis modalities used. In both Gqeberha and East London, peritoneal dialysis (PD) was more commonly employed as the first and subsequent KRT modality, but very little PD was used in Mthatha.
The HIV infection rate among KRT patients was 10%-11% in Gqeberha and 15% in the East London and Mthatha private sector. Only one patient in the public sector in East London was known to be HIV positive, while there were none in Mthatha. However, HIV status was not known in a high proportion of patients in East London and Mthatha (14% and 64%, respectively).
A higher number of patients with a functioning transplant was observed in the public sector in Gqeberha (n=105) compared with East London (n=10) and Mthatha (n=1).
No patients from Mthatha were on the waiting list. Patients in the private sector were older than public sector patients. Gender disparity was most evident in private Gqeberha patients. The mean (SD) waiting time for waitlisted transplant patients was 5 (2-7) years. There were no waitlisted HIV-positive patients in the public sector in East London, compared with 16% of the public sector patients in Gqeberha.
Only 40 (6%) of the 644 private sector patients receiving dialysis were waitlisted for a transplant, compared with 126 (67%) of 188 in the public sector.
East London patients waited a median of three to six years longer for a kidney transplant than Gqeberha patients.
The rate of KRT provision in the public centre remained consistently <60 pmp, while there was a gradual increase in KRT in the private sector between 2013 and 2020.
The study highlights the geographical and health sector disparities in access to KRT in the Eastern Cape, showing private sector patients were 29 times more likely to access KRT than their public sector counterparts, and this inequality increased over time.
Patients in the public sector were on average 18 years younger at initiation of KRT and less likely to have HIV, probably reflecting a marked selection bias in the province’s overburdened public health system.
There is also a geographical difference in access to transplantation, with patients progressively less likely to be waitlisted and transplanted the further east they are located, despite these being the more populous areas in the province. There were fewer patients on dialysis who were waitlisted for a transplant in the private sector compared with the public sector, and very few in either sector were transplanted pre-emptively, prior to initiation of dialysis.
The prevalence of patients with a functioning kidney graft was very low at 22 pmp, and considerably lower than prevalence rates in Brazil (125 pmp) and Spain (748 pmp).
Finally, public sector patients with HIV appeared to be largely excluded from receiving KRT in East London and Mthatha.
There was a very high rate of KRT in the private sector of the Eastern Cape, well above the national average of 729 pmp, and could reflect an increased burden of kidney disease in this province.
Moreover, the distribution of dialysis services in the province is problematic in the public sector, where much of the population lives large distances from the only three centres providing KRT services – in contrast to the wider distribution of dialysis units in the private sector.
These findings are important, given the impending National Health Insurance (NHI) in SA.
Poor communities remain at the highest risk owing to diminished health-seeking behaviour, and therefore need to be more actively screened.
Conclusion
KRT in the Eastern Cape reflects significant disparities in healthcare between the public and private sectors, with a concerning gap in dialysis provision. The prevalence of CKD needs to be estimated to better quantify the burden of kidney disease and forecast KRT provision.
The systemic causes of low transplantation rates in both sectors warrant further investigation. Public health education and awareness programmes are necessary to facilitate and increase screening for CKD. Nephrology human resources remain severely constrained and efforts to boost skilled training and collaboration are needed, especially with the anticipated implementation of NHI.
Study details
The state of kidney replacement therapy in Eastern Cape Province: A call to action
L Mtingi-Nkonzombi, K Manning, T du Toit, E Muller, AD Redd and A Freercks.
Published in the SA Medical Journal on 8 March 2023
Abstract
Background
South Africa (SA) is one of the most financially unequal countries in the world. This situation is highlighted by disparate access to healthcare, particularly provision of kidney replacement therapy (KRT). Unlike the private sector, public sector access to KRT is highly rationed, and patient selection is based on suitability for transplantation and capacity.
Objectives
To investigate the state of the KRT service in Eastern Cape Province, SA, by analysing access to and provision of KRT in the
province for individuals with end-stage kidney disease, as well as disparities between the private and public healthcare systems.
Methods
This was a retrospective descriptive study to examine KRT provision and temporal trends in the Eastern Cape. Data were obtained from the South African Renal Registry and the National Transplant Waiting List. KRT provision was compared between the three main referral centres, in Gqeberha (formerly Port Elizabeth), East London and Mthatha, and between the private and public healthcare systems.
Results
There were 978 patients receiving KRT in the Eastern Cape, with an overall treatment rate of 146 per million population (pmp).
The treatment rate for the private sector was 1 435 pmp, compared with 49 pmp in the public sector. Patients treated in the private sector were older at initiation of KRT (52 v. 34 years), and more likely to be male, to be HIV positive, and to receive haemodialysis as their KRT modality. Peritoneal dialysis was more commonly used in Gqeberha and East London as the first and subsequent KRT modality, compared with Mthatha. There were no patients from Mthatha on the transplant waiting list. There were no waitlisted HIV-positive patients in the public sector in East London, compared with 16% of the public sector patients in Gqeberha. The kidney transplant prevalence rate was 58 pmp in the private sector and 19 pmp in the public sector, with a combined prevalence of 22 pmp, constituting 14.9% of all patients on KRT. We estimated the shortfall of KRT provision in the public sector to be ~8 606 patients.
Conclusion
Patients in the private sector were 29 times more likely to access KRT than their public sector counterparts, who were on average 18 years younger at initiation of KRT, probably reflecting selection bias in an overburdened public health system. Transplantation rates were low in both sectors, and lowest in Mthatha. A large public sector KRT provision gap exists in the Eastern Cape and needs to be addressed urgently.
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