“Financing mix or free care for renal illnesses”. Aasim Ahmad

Story of Mr. AR Mr. AR was seen in 1985 (34 years of age) because of vomiting & generalized swelling (fluid overload). Diagnosed as End Stage Renal Disease (ESRD)secondary to small kidneys and hypertension. He required Renal Replacement Therapy (RRT)

Pakistan statistics-WHO Total population (2012)179,000,000 Gross national income per capita (PPP international $, 2012) 2,880 Life expectancy at birth m/f (years, 2011)66/68 Probability of dying under five (per live births, 2012) 86 Probability of dying between 15 and 60 years m/f (per population, 2011) 186/152 Total expenditure on health per capita (Intl $, 2011) 69 Total expenditure on health as % of GDP (2011) 2.5

In the range of DALYs/1000 capita from 13 (lowest) to 289 (highest), WHO's latest data indicates that India is at 65 while Pakistan is slightly better at 58.

CountryGDP per capita Per capita total expend iture on health Per capita govern ment expend iture on health Total expend iture on health as % of GDP General governm ent expendit ure on health as % of total health expendit ure Out-of- pocket expend iture as % of total health Expend iture General government expenditure on health as % of total government expenditure YBUDGET%BUDGET% Pakistan ‘111.5 Health Expenditure Indicators Demographic, Social and Health Indicators for Countries of the Eastern Mediterranean 2013 WHO-EMR

8 Burden of Disease Source: NHPU, MoH Communicable, 38.4% Non- Communicable, 37.7% Injuries, 11.4% Maternal & Perinatal Conditions 12.5%

© 2006 POPULATION REFERENCE BUREAU Burden of Disease Disease Conditions % total deaths % total DALYs Communicable, maternal, and perinatal conditions Diarrheal diseases Respiratory infections Maternal conditions Perinatal conditions Low birthweight Nutritional deficiencies Non-Communicable Diseases Cancers Diabetes mellitus Neuropsychiatry Cardio-vascular diseases Injuries Source: Mathers, Lopez & Murray, Burden of Disease Volume, 2006.

Pakistan

Non Communicable Disease (NCD) NCDs impose the largest health burden in Pakistan. – In terms of the number of lives lost due to ill-health, disability, and early death (DALYs), NCDs (inclusive of injuries) accounts for 59% of the total disease burden while 41% is from communicable diseases, maternal and child health, and nutrition issues all combined. The major NCDs are Cardiovascular Diseases (CVD), Mental Health (neuropsychiatric conditions), Injuries, – and to a more moderate extent, Chronic Respiratory Diseases, Cancers, and Diabetes. A third of the population was classified as having metabolic syndrome, a risk factor for CVD. Approximately 10% to 16% of the population suffers from mild to moderate psychiatric illness.

The costs of NCD treatments are expensive and continuous one months treatment cost for cardiovascular medication & anti-diabetics treatment is about 4- 8 days wages. Or about one fourth to one third of monthly minimum wage.

Table 4. Prevalence of risk factors for NCD and infectious diseases. Khan FS, Lotia-Farrukh I, Khan AJ, Siddiqui ST, et al. (2013) The Burden of Non-Communicable Disease in Transition Communities in an Asian Megacity: Baseline Findings from a Cohort Study in Karachi, Pakistan. PLoS ONE 8(2): e doi: /journal.pone

Facts about CKD 1 out of 10 adults in the world has some form of kidney damage. The commonest causes of CKD are – diabetes (high blood sugar) – hypertension (high blood pressure) – Glomnerulonephritis – Stone disease – Prolonged use of NASIDs Independent risk factor for – Heart attacks – Strokes

Global Burden of renal diseases “Estimates of the global burden of the diseases report that diseases of the kidney and urinary tract contribute with ∼ deaths annually and disability- adjusted life years (DALY), making them the 12th highest cause of death (1.4% of all deaths) and the 17th cause of disability (1% of all DALY)”. Nephrol Dial Transplant (2012) 0: 1–8 Chronic kidney disease: a research and public health priority

Table 2. Estimated incident ESRD and reported initiation of RRT in patients with diabetes and hypertension. Anand S, Bitton A, Gaziano T (2013) The Gap between Estimated Incidence of End-Stage Renal Disease and Use of Therapy. PLoS ONE 8(8): e doi: /journal.pone

Figure 4. Proportion of diabetes, hypertension and glomerulonephritis among patients undergoing RRT. Anand S, Bitton A, Gaziano T (2013) The Gap between Estimated Incidence of End-Stage Renal Disease and Use of Therapy. PLoS ONE 8(8): e doi: /journal.pone

Chronic Kidney Disease (CKD) in Pakistan Pakistan is suffering a silent epidemic of chronic kidney disease. A dramatic increase in non communicable diseases like Diabetes Mellitus (20% among 40 years or older) and hypertension (33% among 45 years or olde)r which are major causes for Chronic Kidney Disease (CKD) & End Stage Kidney Disease (ESRD). More than 20 percent of all persons 40 years of age or older have a reduced kidney function.

Current status of end-stage renal disease care in India and Pakistan Vivekanand Jha

The total (estimated) incidence of ESRD is 100/million population Each year more than 18,000 individuals are added to the pool that require renal hemodialysis (most, unfortunately, die before initiating dialysis or being transplanted). It is estimated that only less than 3000 annually initiate hemodialysis

Figure 2. Regional income and use of RRT. Anand S, Bitton A, Gaziano T (2013) The Gap between Estimated Incidence of End-Stage Renal Disease and Use of Therapy. PLoS ONE 8(8): e doi: /journal.pone

Table 1. Use and annual initiation of renal replacement therapy. Anand S, Bitton A, Gaziano T (2013) The Gap between Estimated Incidence of End-Stage Renal Disease and Use of Therapy. PLoS ONE 8(8): e doi: /journal.pone

Reported Prevalence and Incidence of ESRD and Rates of Acceptance for Renal-Replacement Therapy (RRT), in Relation to Wealth. Barsoum RS. N Engl J Med 2006;354:

Back to patient AR What choices does he have? Not start renal replacement therapy Start hemodialysis Go for a transplant

AR had no donor for transplant so initiated hemodialysis. – Free but most would only dialyze till transplant & if no donor then some will do only two sessions per week – Pay and do three sessions per week

Hemodialysis rates per month (minimal monthly wage) 1/1/ ,850(1650) 9/1/ ,735 (1950) 10/28/ ,200 (3000) 7/15/ ,800 (4600) 7/1/ ,100 (6000) 7/1/ ,350 (6000) 7/1/ ,950 (7000) 7/15/ ,250 (7000) 8/1/ ,850 (8000) 8/1/ ,450(10000) 7,08,40,800

Patients on hemodialysis >20 yr yr yr yr65

COST OF TREATMENT PROVIDED TO WELFARE PATIENTS Amount spent on treatment of welfare patients 2011 – 2012 = Rs Million Amount spent on treatment of welfare patients 2010 – 2011 = Rs Million Amount spent on treatment of welfare patients 2009 – 2010 = Rs Million Amount spent on treatment of welfare patients 2008 – 2009 = Rs Million Amount spent on treatment of welfare patients 2007 – 2008 = Rs Million Amount spent on treatment of welfare patients 1999 – 2012= Rs Million

Community & self generation –The Kidney Centre model

Government community partnership –SIUT model Rizvi, A H. Kidney International Supplements (2013) 3, 236–240; 2013

Cost of transplant Rs. 800,000/ Treatment cost (exclusive of admissions) Rs /month

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