Challenges in Expanding Access to Dialysis in South Africa—Expensive Modalities, Cost Constraints and Human Rights

Abstract

South Africa is a country with two distinct health sectors, which are both characterised by inequalities. Within this context, patients with end stage renal disease face unique and sometimes impenetrable barriers to accessing dialysis. There are a number of reasons for this situation. These include: the South African government’s endorsement of discordant, unequal policies, which disadvantage the most vulnerable; a lack of robust national guidelines; and divisive rationing practices, which are ad hoc and place the burden of responsibility for rationing dialysis on the clinician. In this paper, we trace the socio-economic mechanisms of how we have come to be in this situation, and overlay this with a detailed examination of South African legislation. Finally, we make comprehensive practical recommendations for rectifying the situation, which include engagement with key stakeholders, public–private partnerships, and more equitable funding mechanisms.

Contemporary outcomes of the pediatric kidney transplant program in Johannesburg, South Africa, between 2004 and 2017: Better or not—And which way forward?

“…At health‐systems level, the improved outcomes from WDGMC (group 2B) could reflect synergistic consequences of (a) a more affluent population with health insurance who can access private health care (16% of South Africans), while the remaining population, many of whom are unemployed or receive social grants, access a weakening public healthcare system, (b) WDGMC, as a service provider, is relatively better resourced than the public service, enabling greater human resources and infrastructural investment to strengthen the transplant program, (c) for health funders, regulated, mandatory coverage of conditions related to ESKD guarantees access to transplantation for all members in the private sector, in contrast to the public service, where access is rationed, based on “available resources” which have contracted over time (d) funded healthcare options for low‐income earners and government employees has facilitated access to chronic dialysis and transplantation for children who might have unmet financial, psychosocial, nutritional, educational, and rehabilitative needs. Cognisant of the impact of social determinants of health, a not‐for‐profit organization provides a comprehensive package of care for children and their families in need of such additional support, and this may have contributed (at least in part), to improved outcomes at WDGMC (group 2B).…”

Increasing access to integrated ESKD care as part of universal health coverage

“…Ethical challenges in ESKD care are encountered at all levels from policy development and administration to clinical practice. Questions at the policy level such as prioritization of CKD prevention versus treatment of advanced disease, equitable access to care for those with ESKD, rationing of resources (e.g., dialysis and transplantation), and decisions to initiate or continue KRT are relevant in all countries, but are especially challenging in LMICs 21,95,96 (see theme 2). For clinicians, decisions regarding starting and/or continuing dialysis may present multiple ethical dilemmas.…”

“…(i) Challenges in resource allocation are particularly acute and ethically complex in resource-limited settings. 21,96,116,117 The provision of ESKD care should aim to promote equity of access, such that criteria used to allocate public funding for ESKD care, or to determine eligibility for KRT, are primarily based on evidence-based medical parameters, not socioeconomic status. [118][119][120] However, in the absence of guidelines to govern resource allocation, the ability to pay for care is often the most influential, or the only, factor determining access to care.…”

Reimagining liver transplantation in South Africa: A model for justice, equity and capacity building – the Wits Donald Gordon Medical Centre experience

“…While donor scarcity here has been widely researched, [1,2] a lesser-known and often misunderstood phenomenon in SA is the challenge of providing effective and integrated transplant services across two socioeconomically disparate healthcare sectors. [3] Ideally, these services should be grounded within a framework that facilitates equal access to transplantation and optimises financial efficiency.…”