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NHIF should review its kidney policy

Wednesday March 13 2019

KIDNEY

Kidney transplant. Immunosuppressants pacify the body’s immune system’s reaction to the new organ. PHOTO | FILE | NATION MEDIA GROUP 

ERIC THUO
By ERIC THUO
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MATIKO RIRO
By MATIKO RIRO
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In the past few years, the national health insurer has made significant progress in supporting patients with chronic kidney disease.

Through the National Hospital Insurance Fund (NHIF), kidney patients can now access life-sustaining dialysis and renal transplant care. The insurer covers the initial surgery.

Compared to dialysis, patients with chronic kidney disease who receive a transplant live significantly longer, have fewer complications and a better quality of life. Moreover, transplant reduces the cost of treatment in the long run.

However, these gains stand to be lost if the current NHIF policy fails to cater for crucial medicines required to keep the transplant viable.

ESSENTIAL DRUGS

These medicines, known as immunosuppressants, pacify the body’s immune system’s reaction to the new organ, reducing chances that it will be rejected.

The drugs are required for as long as the patient has the transplant, which is viable for an average of 12 years.

Immunosuppressant drugs are as essential to the life of transplant patients as engine oil is to the car.

Subsequently, transplant recipients who fail to adhere to the medications, for cost or other reasons, face a higher risk of kidney failure.

These drugs are expensive. At an estimated cost of Sh40,000 a month in public hospitals, even the average middle-class household with an average income of Sh100,000 would find it difficult to afford this long-term treatment.

SUSTAINABLE

With the initial cost of surgery trending between Sh700,000 and Sh1.5 million, obtaining a kidney transplant would be a catastrophic expenditure for most Kenyans.

Whereas there is an alternative in dialysis, this can only grant patients an extra five years of healthy life and does not come any cheaper either.

Consider a case of two hypothetical patients, Chebet and Akinyi, both 30, suffering from chronic kidney disease and undergoing treatment over a period of five years. Chebet undergoes dialysis while Akinyi gets a transplant.

At the prevailing market rates, our analyses demonstrate the costs of Akinyi’s renal transplant, including her medicines, are lower than Chebet’s dialysis over the first five years but the latter must also get a transplant at the end of it.

Compared to Akinyi, Chebet will also have to make at least two visits every week to the dialysis centre, taking time away from work and other meaningful life activities.

The case for transplant against dialysis is settled.

COST

But there is a problem: While the NHIF’s decision to help patients in defraying the upfront expenditure on surgery is commendable, its subsequent failure to cover the long-term costs of immunosuppressants reveals an irrational approach in their transplant programme.

Although it is reasonable to argue that coverage for the initial surgery nullifies a significant barrier to accessing transplant care, exclusion of the post-transplant medication means that patients who cannot afford them (a rather common occurrence) face a higher risk of losing their kidney — fast!

Here is the corollary: When the transplanted kidney fails (as inevitably happens in the absence of immunosuppressants), the patient will need to revert to the less desirable and expensive dialysis — paid for by the NHIF.

This means the NHIF’s initial investment in the surgery is wasted and, because the patients remain under the payer’s coverage, the insurer will end up paying more for their return to dialysis and a potential second transplant.

TRANSPLANT

Again, the patient must endure the undesirable quality of life and higher risk of complications that come with dialysis while desperately waiting for a second transplant.

This argument suggests that there is a case for lifelong immunosuppressant coverage for kidney transplant patients. Perhaps a more compelling reason for this is that kidneys for transplant are a scarce resource.

The few we have are made available by family members under very difficult circumstances.

Besides, donors must sacrifice their health to undergo a potentially perilous procedure to make the donation.

It therefore follows that the burden of keeping transplants viable cannot be left to patients alone.

POLICY

The rational approach is to ensure that payment policy at the national health insurer contributes to the preservation of functional kidney transplants through lifelong coverage of immunosuppressants.

The NHIF needs to also extend this strategy to protection of patients at risk of kidney failure.

It can nudge healthcare providers to give better care to patients with critical risk factors such as diabetes, hypertension and obesity, anchored on robust public health prevention efforts.

Kidneys are a scarce resource; preserving their function must be made a national priority.

Dr Thuo is a postdoctoral research fellow at the Department of International Health, Johns Hopkins Bloomberg School of Public Health. [email protected] Dr Riro is a PhD candidate in health economics and policy at the University of Bergen, Norway. [email protected]

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