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Our purpose was to explore whether private–public partnerships (PPPs) can serve as a model for access to high-cost care in low-resource settings by examining a unique PPP providing haemodialysis services in a remote setting, investigating challenges and enablers. The study setting is a 500-bed teaching hospital serving a catchment population of 8 million in Northern Ethiopia. Based on local data collection, observation and in-depth interviews, we identified the impetus for the PPP, described the partnership agreement, reported outcomes after 6 years of activity and examined challenges that have arisen since the programme’s inception, including funding sustainability. The PPP was established in 2013 based on a decision by local leadership that treatment of patients with acute kidney injury (AKI) is a necessity rather than a luxury. A private partner was sought who could ensure service delivery as well as a reliable supply of consumables. The hospital contributions included infrastructure, personnel and sharing of maintenance costs. The partnership has facilitated uninterrupted haemodialysis service to 101 patients with AKI and 202 with chronic kidney disease. The former (>50% cured) were mainly supported by charitable donations procured by the hospital’s leadership, while the latter were self-funded. The local university and community contributed to the charity. Utilization has increased yearly. Funding and logistical issues remain. In conclusion, this PPP enabled access to previously unavailable lifesaving care in Northern Ethiopia and could serve as a model for potential scale-up for haemodialysis provision in particular, and more broadly, high-cost care in low-resource settings. An ethical commitment to provide the service, combined with ongoing administrative and community involvement has contributed to its sustained success. Lack of affordability for most patients requiring chronic haemodialysis and reliance on charitable donations for treatment of patients with AKI pose challenges to long-term sustainability.

Haemodialysis is extremely limited in low-income countries. Access to haemodialysis is further curtailed in areas of active conflict and political instability. Haemodialysis in the Tigray region of Ethiopia has been dramatically affected by the ongoing civil war. Rapid assessment from the data available at Ayder Hospital’s haemodialysis unit registry, 2015–2021, shows that enrollment of patients in the haemodialysis service has plummeted since the war broke out. Patient flow has decreased by 37.3% from the previous yearly average. This is in contrary to the assumption that enrollment would increase because patients could not travel to haemodialysis services in the rest of the country due to the complete blockade. Compared to the prewar period, the mortality rate has doubled in the first year after the war broke out, i.e., 28 deaths out of 110 haemodialysis recipients in 2020 vs. 43 deaths out of 81 haemodialysis recipients in the year 2021. These untoward outcomes reflect the persistent interruption of haemodialysis supplies, lack of transportation to the hospital, lack of financial resources, and the unavailability of basic medications due to the war and the ongoing economic and humanitarian blockade of Tigray in Northern Ethiopia. In the setting of this medical catastrophe, the international community should mobilize to advocate for resumption of life-saving haemodialysis treatment in Ethiopia’s Tigray region and put pressure on the Ethiopian government to allow the passage of life-saving medicines, essential medical equipment, and consumables for haemodialysis into Tigray.

Background The war on Ethiopia’s Tigray broke out on November 4, 2020. Amid the armed conflict, governmental institutions were destroyed, people were displaced, and thousands of civilians were killed. The region was experiencing an on-and-off type of blockade since the war broke out until June 28, 2021, at which time the federal government of Ethiopia imposed a siege cutting off the region from the rest of the world. Due to the shortage of medicines and medical supplies, witnessing deaths that otherwise were preventable under normal conditions has become the daily predicament of healthcare workers. The burden of healthcare disintegration is particularly carried by patients with chronic medical illnesses including patients on dialysis. Main body Ayder hospital, Tigray’s flagship healthcare institution, hosts the only hemodialysis center in the entire region. This center is currently unable to give appropriate care to kidney failure patients for a lack of access to dialysis supplies and consumables due to the ongoing war and siege. This has resulted in vicarious trauma manifested with compassion fatigue, irritability, a feeling of bystander guilt; sadness about the patient’s victimization, and hopelessness among healthcare workers caring for dialysis patients. Conclusion The suffering of veteran patients and witnessing preventable deaths have continued to haunt and torment healthcare workers in the dialysis unit leading to vicarious trauma. Cognizant of the fact that vicarious trauma has serious health ramifications on healthcare workers; we call up the international community to advocate for a full resumption of access to healthcare and the provision of mental health support and educate and train healthcare workers dealing with end-stage kidney disease patients on hemodialysis.

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