Are healthcare systems prepared to handle the rising number of patients with end-stage kidney disease requiring dialysis? Over the years, dialysis services have undoubtedly expanded — at least in some parts of the country — but there are critical gaps and shortcomings that need to be addressed to meet the growing demand for dialysis services among patients, say experts.
According to the Pradhan Mantri National Dialysis Program, which was rolled out in 2016 to provide free dialysis to the poor, about 2.2 lakh new patients with end-stage renal disease get added in India every year, resulting in an additional demand for 3.4 crore dialysis sessions. There are however, only 11,148 haemodialysis machines in the country. Among these, three States have over 1,000 machines each: Tamil Nadu (1,258), Kerala (1,259) and Gujarat (1,278).
What is driving the surge in renal failure?
Diabetes, hypertension and Chronic Kidney Disease (CKD) of unknown origin are the main causes for the rise in the number of persons requiring dialysis. While there is better awareness among most, some patients still arrive at healthcare facilities only when they already have serious complications, says M. Edwin Fernando, head, Department of Nephrology, Government Stanley Medical College Hospital (SMCH).
N. Gopalakrishnan, former director, Institute of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, adds: “Metabolic syndromes (diabetes, hypertension and obesity) and environmental factors (pollution, heat stress and probably exposure to chemicals) can cause kidney failure,”. He also notes that a recently-concluded survey (randomised, cluster sampling method) found that 50% of patients (adults) with CKD in Tamil Nadu were neither diabetic or hypertensive. “This shows that there are causes beyond diabetes and hypertension. Unorganised workers such as agricultural and construction labourers are at risk of increased exposure to heat stress and environmental pollution. There is a need to work out strategies to protect them.”
Expansion of services in TN
While pointing out that there has been an exponential rise in the number of patients requiring dialysis for end-stage kidney disease over the years, Dr. Fernando says that Tamil Nadu has adequate number of dialysis machines including at medical college hospital and taluk-level hospitals. “The government has done a lot of work over the years to ensure that people requiring dialysis need not travel long distances. Not to forget that haemodialysis is also covered under the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS), enabling many to access dialysis services easily,” he notes.
At SMCH, the number of dialysis machines has increased from 10 a decade ago to 35 presently. On an average, 100 dialysis sessions are conducted on a day here.
From seeing a paucity of dialysis services during the 1990s as a result of which patients had to travel far and wide, Dr. Gopalakrishnan says, “There has been tremendous progress in the availability of dialysis services in the State over the last decade. It has percolated to tier 2 and tier 3 cities. In the government sector, not only medical college hospitals have dialysis services but district headquarters and many taluk hospitals also offer dialysis services now.”
The magnitude of dialysis services availed of in a State like T.N. can be explained with one piece of information. “Dialysis tops the CMCHIS spending. The State government spends more than ₹150 crore for haemodialysis under the scheme in a year, making dialysis the top procedure,” a senior nephrologist, who did not want to be named, points out.
In fact, Tamil Nadu, through its flagship scheme Makkalai Thedi Maruthuvam for home-based screening and door delivery of drugs, provides Continuous Ambulatory Peritoneal Dialysis bags to patients at their homes. So far, 426 beneficiaries have been reached, according to health officials.
Availability versus accessibility
Sreejith Parameswaran, professor and head, Department of Nephrology, JIPMER, Puducherry, says that availability of dialysis machines differs across the country. “Considering the south – Tamil Nadu, Puducherry, Kerala, Karnataka, Telangana and Andhra Pradesh – I will say that the availability of dialysis services is not an issue. Dialysis services are available every 50 kilometres in many places. In many places in northern and north-east India however, dialysis services are unavailable for 100-200 kilometres and patients need to travel twice a week. States such as Punjab and Haryana are better off, but dialysis services are located far apart in some north Indian States,” he points out.
Noting that there has been a tremendous expansion in terms of infrastructure in some States, he says that a number of NGOs have also stepped in to provide dialysis services in States like Tamil Nadu and Kerala. For instance, in Kerala, NGOs offer highly subsidised dialysis services, while TANKER Foundation offers dialysis services in Tamil Nadu.
Dialysis services are covered under insurance schemes such as CMCHIS (Tamil Nadu) and Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), Dr. Sreejith Parameswaran notes. “So accessibility, not availability, is more of an issue in the south as the majority of the services are largely in the private sector. Dialysis services are more in the private sector than under the government sector in every State in India. That is where accessibility issues come in. Government dialysis services cannot accommodate everyone. Therefore, patients need to depend on the private sector, which is expensive,” he says.
He further explains: “In Tamil Nadu and Puducherry, all government medical college hospitals offer dialysis services. It is the same in Kerala. The problem is that government institutes cannot accommodate all persons in need of dialysis. This is where empanelling of private hospitals comes in. But there are certain issues; under CMCHIS, not enough is paid for dialysis services, while in Puducherry, empanelled hospitals face issues of delayed payments under AB-PMJAY. It is important for governments to ensure that dialysis services are viable for private hospitals with adequate remuneration that match the expenses. So, the package rates under CMCHIS for dialysis should be revised. This is important because dialysis services in the government sector are running full, and private hospitals will serve as the additional capacity.”
Gaps, shortcomings and path forward
In patients with end-stage kidney disease on dialysis, the first 100-day death rate is nearly 40%, another senior nephrologist says, adding, “Dialysis through central venous catheters has a high risk of infections for patients. So, creating an arteriovenous fistula – an artificial connection between an artery and a vein – for dialysis at the level of the elbow/wrist is a crucial step. This requires vascular expertise, and is insufficient to meet the demands.”
Dialysis, in itself, is a stigma for many patients, he observes. “Some try to postpone initiation of dialysis. This is why educating patients is important, but this is lacking now. It should also be understood that socio-economic factors play a big role in CKD and dialysis, as it affects the family’s finances,” he adds.
It is not an easy journey for many patients. “Most patients require dialysis two to three times a week. Many of them find it difficult to meet their expenses towards travel and food and face challenges at their workplace and end up losing the day’s pay. To help patients undergoing haemodialysis, governments can provide ₹200 to ₹300 per session to support them. Telangana, for instance, announced a pension amount of ₹2,000 per month for patients, in addition to providing bus passes to travel to the nearest dialysis facility,” Dr. Sreejith Parameswaran points out.
Nutrition is a key component for patients on dialysis. “Patients belonging to Below Poverty Line face challenges in meeting nutritional needs. Patients on dialysis require a high protein diet but many of them sustain themselves on a rice-based diet and take little protein. It is important to give nutritional support to them. Similar to financial assistance towards nutrition for patients with tuberculosis, governments should come up with a plan to provide nutritional support for patients on dialysis. This will definitely make a difference,” he further stresses.
Doctors also raised the need for a CKD registry at the primary health centre level.
In a step towards improving the services, T.N. is looking at establishing a hub and spoke model of networking dialysis units with the aim of integrating services at the secondary and tertiary level. There are also plans to train general surgeons in performing the AV fistula procedures, officials say.
Dr. Gopalakrishnan emphasises the need to focus on prevention. Screening for diabetes and hypertension is being carried out through MTM, and anti-diabetic and anti-hypertensive drugs are delivered at the homes of patients. This, in fact, addresses the gap between diagnosis and control, and improves adherence to drugs, he adds.
Published – April 18, 2025 04:55 pm IST