COVER STORY (Spotlight Weekly)

Treatment Accessible To Few

With the rise in the cases of kidney failures, there is an urgent need to expand treatment facilities in the country. As the majority of Nepalese cannot afford even the available facilities like dialysis, a large segment of kidney patients remains out of the health system. Those who can afford go abroad, mainly India, for transplants because they cannot be performed in the country in the absence of regulations. The rest either have to use the basic services available in Kathmandu or suffer in misery.

By SANJAYA DHAKAL

Amala Tuladhar, 39, has been suffering from kidney disease for the last five years. A housewife from Hariharbhawan, Tuladhar has been undergoing dialysis at the National Kidney Center twice a week from March this year. She had gone to New Delhi recently for kidney transplant but she unfortunately came down with pneumonia. As doctors there said she could not undergo the surgery under such a condition, she had to return. "Now I am here again undergoing dialysis," says Tuladhar, complaining about the high cost of treatment.

Patients undergoing dialysis : Costly care

The cost of undergoing dialysis comes to around Rs 20,000 to Rs 30,000 a month. A patient with a failed kidney has to undergo dialysis until he or she lives or undergoes permanent kidney transplant. "The problem of all kidney patients is the high cost. It is simply very, very high," says Tuladhar. She was preparing to undergo a transplant at the Ganga Ram Hospital in New Delhi, India, at a cost of around Rs 200,000.

Each year, there are around 2,500 cases of kidney failures that need dialysis in the country. "But we have the facilities to give dialysis to no more than 100 people," says Dr. Rishi Kumar Kafle, a leading nephrologist and president of Health Care Foundation, Nepal that runs the National Kidney Center. People suffering from chronic high blood pressure and diabetes run a greater risk of kidney failure.

The center is the largest in the country with 10 haemodialysis systems. It provides the service to between 25 and 30 people. Likewise, Bir Hospital and Teaching Hospital give dialysis service to 30-35 and 6-7 people respectively. That apart, 25-30 people get the service at private nursing homes. In total, the country can provide dialysis service to no more than 80-100 people. Compare this with the annual number of 2,500 kidney failures. "Maybe about 50 additional Nepalese may go directly to India for dialysis, but we still don't cover a large portion of the patients," says Dr. Kafle.

The available service is almost exclusively centered in Kathmandu. Apart from the service at the B.P. Health Institute in Dharan, all other dialysis centers are in the capital.

That apart, transplant, which is considered the best available solution to a patient with kidney failure, is not performed inside the country. "This is because there is confusion over the legal implications of such transplants here," says Dr. Kafle.

As a result, every year hundreds of Nepalese flock to hospitals in Indian cities like Delhi, Mumbai, Chennai, Lucknow, among others, for transplants, which cost anything between Rs 100,000 and Rs 500,000 each.

Cost Factor

As most Nepalese live under the poverty line, access to basic health service is limited. So, when it comes the high costs of treating kidney diseases, more than seventy percent of the population are out of the picture.

"The costs involved in dialysis are very high," says Dr. Ram Prasad Shrestha, director of Bir Hospital, the country's oldest hospital which has been providing subsidized treatment. "The cost of the machines, spare parts, technical expertise and other accessories are very high."

Dr. Kafle agrees. According to him, the cost of undergoing dialysis once is between Rs 2,500 and Rs 3000. "And the patient has to undergo such dialysis twice a week for life until he or she undergoes transplant."

With the objective of serving poor people, the government-owned Bir Hospital offers dialysis at the service charge of Rs 250 per patient. "However, the patients will have to buy necessary medicines themselves, which might cost Rs 1,000 to Rs 1500," he says.

"Dialysis and transplants are the most essential treatments for kidney patients. Unfortunately, not many in this country can afford them," says Dr. Pushkar Raj Satyal, president of the Society of Nephrologists, Nepal.

Dr. Shrestha believes the government and the community should help poor people gain access to treatment. "No poor person can afford the cost of private nursing homes. So, definitely the responsibility lies with the government. Bir Hospital has been shouldering this responsibility for a long time. But it cannot do so indefinitely unless it is equipped with more facilities and funds."

At present, Bir Hospital has six dialysis equipment out of which three are very old and could stop at any time. "Yet, we are working those machines in two shift to serve as many people as possible," Dr. Shrestha says.

He adds that apart from the government, business houses and private citizens should also come forward to help improve facilities at government hospitals. "Rich businessmen and politicians may afford to go overseas for their treatment, but what about the hundreds of thousands of people who work for them here? Don't they have any responsibility towards the general public?"

The government says it is committed to providing service to the needy. "We are aware of our responsibilities. We are committed to improving the facilities and budget at the government hospitals like Bir Hospital," says Padam Prasad Pokhrel, Secretary at the Ministry of Health (MoH).

Many suggest the introduction of a system of social security and health insurance to make the facilities accessible and affordable to poor people. "Maybe the government could collect a health fund for that purpose," they say.

Pokhrel says the government is not mulling such an idea at present. "Though the concept of health insurance is good, there are many difficulties. Our country consists of remote regions like Humla, and it is difficult to assess how we can provide health insurance to people from those regions."

Kidney Transplant

Doctors say transplant is the best solution for patients with kidney failure. It involves the transplantation of a kidney from a healthy person to the patient. Although human beings have two kidneys, they can survive well on one.

"Dialysis, at best, can only serve as a temporary solution to the problem. Though, a patient can survive on dialysis, the ultimate answer is transplant," says Dr. Kafle.

Doctors around the world have been successfully performing kidney transplants for the last couple of decades. So why can't transplants be performed inside Nepal? "The reason lies in the legal environment. There is no regulation. Technically, we are well-equipped and can perform such transplant anytime," say doctors.

The Organ Transplant Act was passed two years ago but the MoH is yet to come up with the regulations. "We are discussing the regulations. The Act encompasses not merely the kidney but other organs too. Since organ transplant is a very sensitive issue, we have to weigh it from every angle before introducing regulations. Anyway, we are seeking opinions from legal and medical experts and though we cannot commit ourselves to a time-frame, the regulations will not be unnecessarily delayed," says MoH Secretary Pokhrel.

In the absence of the regulations, doctors say, there is confusion regarding who can perform such surgery, where it can be performed and what the legal parameters are regarding the responsibility of the doctor. "As such, if we perform transplant surgeries at present and if somehow the donor dies in the operation theater or within three months of the surgery, the doctor will have to face not only a life term in prison but also confiscation of his whole property," says Dr. Kafle. "Say, if the donor dies in a traffic accident within the three months, how can it be justifiable to hold the doctor responsible?"

Doctors also see a problem in the provision of giving doctors the authority to establish the relationship. According to law, only close family relatives can donate a kidney. They say separate government bodies like the district administration office should be entrusted with the authority to establish and confirm the family relationship.

Dr. Shrestha agrees that it is the legal environment, not the lack of physical or technical facilities, that has hindered kidney transplants in Nepal. "The technical team at Bir Hospital has already sent a draft of the regulations where we have specified the minimum prerequisites for starting transplants."

Nepalese doctors have already performed complicated procedures like open heart and neuro surgeries. There is little room to doubt their ability to perform kidney transplants. If transplants could be done in Nepal, every year hundreds of Nepalese would be spared the cost and other hassles of having to go to India.

Prevention

"For a poor country like Nepal, it is better to prevent the disease than to cure it afterwards," says Dr. Satyal.

Among city-dwellers, the primary reason for kdiney failure is high blood pressure and diabetes. So, doctors say, it is prudent to control these diseases to avoid running the risk of kidney trouble.

"Basically, everybody is at risk of suffering from kidney failure, but some simple measures can prevent it," says Dr Kafle. Regular health check-ups, intakes of adequate water and other liquid, controlling diabetes and high blood pressure are some of the measures (See box).

"This is where alternative treatments like naturopathy come in handy," says Dr. Hari Prasad Pokhrel, director of the Institute of Naturopathy. "Through naturopathy we have been curing 70 percent of the people suffering from high blood pressure and diabetes who come to us."

Naturopathy includes treatment through yoga, massage, hydrotherapy, mud-therapy, among others. "We cure people by activating their own body, making them able to fight the disease themselves. So, it is important to note we can help only those people who are able to move by themselves. We cannot cure those who are bed-ridden," Dr. Pokhrel says.

Lack of Awareness

The improvement in curative facilities have led to the diagnosis of more cases of kidney failures in the country, exposing its inadequacy to treat all the patients. While the urban population are engaged in a sedentary lifestyle that often lead to diseases like blood pressure and diabetes and, consequently, to kidney failure, the larger portion of poor Nepalese are yet to approach even the available facilities mainly because of lack of awareness as well as the high cost of treatment.

‘Business Houses, Politicians And Private Citizens Should Donate What They Can To Improve Facilities At Government Hospitals’

— DR. RAM PRASAD SHRESTHA

Dr. Ram Prasad Shrestha is the director of Bir Hospital, the largest government hospital in the country. Bir Hospital, which has been providing subsidized treatment to poor people, was the first in the country to offer kidney dialysis back in 1988. Dr. Shrestha spoke to SANJAYA DHAKAL about the facilities provided by the hospital. Excerpts:

What facilities are available in Bir Hospital for treating kidney diseases?

We have six dialysis equipment, which are running to their full capacity. As Bir Hospital caters to the poorer sections of the population, the facilities available are highly inadequate. Every day we give dialysis services to 20-25 people in two shifts.

What is the cost of performing dialysis in the hospital?

This is a hospital the poor and needy look up to. We, therefore, do not charge high prices. We only take Rs 250 per patient as service charge for performing dialysis. This amount is waived in case the patient is very poor. The patient has to buy medicines which might cost around Rs 1,000 to Rs 1,500. However, we are experiencing many difficulties as the cost of dialysis equipment, its spare parts and operating costs are very high. In fact, three of the six dialysis equipment we are operating have become quite old and could stop functioning anytime.

How then do you think a government hospital like yours can sustain itself?

More than 70% of Nepalese people are poor. They cannot afford the high cost of treatment charged by private hospitals. Definitely, the community and the government have the responsibility to provide treatment to these people. In fact, I urge business houses, politicians and private citizens to come forward and donate what they can to improve the facilities in government hospitals. This happens in India all the time. NGOs and INGOs are involved only in prophylactic and awareness-raising programs in the grass-roots level. They should also channel some of their funds and expertise in improving curative treatment in government hospitals. We have political parties preaching socialism and communism in the government and the opposition respectively. Definitely, they are committed to providing services to poor people. What I think can also be done is creating and developing social security like health insurance so that the needy are not deprived of available health facilities.

Do you think kidney transplants can be done in Nepal?

Given the necessary legal environment, we can definitely do that. We have the manpower as well as physical facilities to perform such transplants. Two years have passed since the organ transplant act came into being, but there still are no regulations. This has led to confusion over various aspects of organ transplants. The technical team at Bir Hospital has already sent a draft of regulations to the Health Ministry. The draft also mentions the immediate pre-requisites for performing such transplants in the country.

What Are Kidney Diseases?

There are many types of kidney diseases, such as infection, kidney stones and nephritis. Most are short term and easily curable while others require dialysis/transplant. Basically, the kidney purifies the blood by ejecting toxic materials from the body. In case the kidney fails to do its job, the toxins spread in the body through the blood. This is where dialysis comes in. Dialysis is a method by which the blood is purified artificially. Symptoms of kidney disease are common to many other ailments. "That�s why people can conveniently overlook their kidney problems," says Dr. Rishi Kumar Kafle. The common symptoms of the disease are lethargy, loss of appetite, headache, body itching, nausea and insomnia. Swelling of the legs and acute back-ache are other symptoms. In Nepal, most of the aged people suffering from kidney ailments have high blood pressure and/or diabetes. The younger patients mostly suffer from various types of nephritis.

Who Is At Risk?

"All are at risk," says Dr. Kafle. "Anybody can suffer from kidney diseases." But the people who have to be extra careful are those suffering from high blood pressure and/or diabetes for 10 years or more. Those who take an excessive amount of pain-killers like brufein are also at risk. So are people who have kidney stones or infection. "People should take such pain-killers only with the doctor�s prescription," says Dr. Kafle. That apart, profuse diarrhea, septic abortion and hornet-bite (more than seven) can also result in sudden kidney failure, which if not properly treated immediately, can lead to death.

What Are The Precautions?

A comprehensive annual health check-up is the best precaution. Such check-up is more important for people with high blood pressure and diabetes. Change in life-style is also important. It is better to gradually slow down the intake of alcohol and non-vegetarian dishes as the kidney tends to be less efficient with the advancement of age. Adequate intake of water is important. "You should pass at least two liters of urine each day," says Dr. Kafle.

What Is Dialysis?

There are two types of dialysis - peritoneal and haemodialysis. The former does not need any machine but involves high cost and needs specially trained health personnel. The latter involves the use of machine. Here, the machine cleanses blood with the pure water. In fact, 150 liters of pure water are required to clean the blood each time. The pure water absorbs the toxins from the patient’s body through diffusion and acts as an artificial kidney. On average, a patient will have to undergo dialysis twice a week (four hours each time). Patients whose kidney do not work properly can survive on dialysis. Patients usually depend on dialysis until they undergo kidney transplant.

What Are The Costs Involved?

The average cost of undergoing dialysis is at around Rs 20,000 to Rs 30,000 a month. For transplant, patients have to go to India. It costs between Rs 100,000 to Rs 500,000 depending on the hospital.

‘We Can Perform Kidney Transplants’

—DR. RISHI KUMAR KAFLE

Dr. Rishi Kumar Kafle, a senior nephrologist, is the president of Health Care Foundation, Nepal. The foundation has been running the National Kidney Center, the largest private-sector clinic for kidney disease in the country. Dr Kafle spoke to SANJAYA DHAKAL about the prevalence and treatment of kidney disease in Nepal. Excerpts:

How would you describe the present situation of kidney disease in Nepal?

The ultimate outcome of kidney disease is very vital. If people continue with the progression of the disease, that might lead to kidney failure. The treatment of end-stage renal disease is dialysis or transplant, which is very costly. That’s why kidney disease is a big problem for the average Nepalese. It is indeed very difficult to support a kidney patient, who needs up to 30 thousand rupees every month for treatment. We can easily imagine how many people would be able to afford treatment. The irony of the situation is it is very hard to discover kidney disease because its symptoms — tiredness, insomnia, headache, body itching and so on — are quite common. People who suffer from high blood pressure and diabetes are more susceptible to kidney disease. In fact, people who have been suffering from diabetes for 10 or more years may not know they have kidney disease until they reach the end stage. Therefore, we suggest that people with chronic diabetes or high blood pressure undergo regular health check-up. In fact, kidney disease can occur even to people who are apparently healthy. So, it is best for all to undergo a general health check-up at least once a year. Mild rise in blood pressure or mild leakage of protein in urine may be the first sign of kidney disease and these people may not exhibit any symptoms. It is, therefore, essential to have regular health check-up.

What could be the reasons behind the surge in kidney ailments in the country?

The rise in kidney disease that we are witnessing is not because the actual disease is rising but because people are having better access to treatment. The government has allowed the private sector to become more involved in health care. These facilities have made the people more aware about various diseases. Besides, the people in general are also living longer and, consequently, they are developing new problems. This could be one reason why we are witnessing a rise in the disease.

How are the treatment facilities available in Nepal?

The facilities are inadequate. If we look at the countrywide data, the number of kidney patients (who need dialysis/transplant) is about 2,500. But we can cater to only 100 people for dialysis treatment within the country and we do not have the facilities for transplants. So those people who are on dialysis will either have to quit the treatment because of the high cost involved or go to India for transplant. Many people are dying because they aren’t getting any facilities. Such services are costly all over the world.

So what could be the way out?

My suggestion is that we develop some sort of social security or health insurance scheme with all healthy people contributing part of their income so that those in need can get treatment.

Are Nepalese doctors capable of performing kidney transplants?

We are talking about transplant only after we have been doing dialysis for the last ten, twelve years. People who need transplants can survive on dialysis. We screen patients for dialysis and put them on treatment here until they go outside for transplant. We also do all kinds of tests. Doctors in Nepal have been conducting complicated by-pass or neurological surgery so there is no reason why we can’t perform kidney transplants. We should develop team effort, coordination and the necessary legal environment. An organ transplant act was passed two years ago but because of the lack of regulations, we can do very little. It should be legally clear who can perform the transplant, where it can be performed and under what technical facilities. It should also be clear who can donate organs. If only relatives can donate organs, then it must be defined who will confirm the relationship. The authority to confirm the relation should not be left to the doctor.