Skip to main content

Table 1 The minister of health’s dilemma

From: Challenges to the right to health in sub-Saharan Africa: reflections on inequities in access to dialysis for patients with end-stage kidney failure

Dialysis had begun over a decade previously when a senior politician had required it prior to receiving a kidney transplant. Dialysis services continued limping along in the capital city, run by a very committed and knowledgeable nurse. She had since diligently kept a large ledger of patients who started dialysis, with the most common entry next to their names being “rest in peace” a short time after they began. Many patients likely died of infections or being unable to attend regularly given high out of pocket costs of transport to and from dialysis. Some patients managed to survive and became strong advocates for kidney disease. One in particular, who had to commute 250 km for dialysis to the single unit in the capital city from his home town, had been heard by the minister and a plan was developed to open a dialysis unit at the hospital in the town where this man lived.

A small building was built and a dialysis water system paid for and installed. Five dialysis machines which had been donated years prior, somewhat rusty and with instructions written in foreign language that no one understood, were brought out of their boxes. Large volumes of disposable dialysis supplies were procured. The unit was to be run by a physician who had been sponsored to train in nephrology outside of the country, but at the last minute he took an opportunity to emigrate elsewhere, so a foreign nephrologist was asked to help with the start of the service. Because the water system, although installed by a “reputable” company from a neighboring country, was grossly inadequate, the system was highly contaminated and dialysis had to be delayed for over a year until the pipes were all replaced at extra expense. The initial patient advocate died shortly before dialysis began in his home town, from complications related to treatment delays resulting from his long dialysis commute.

Soon it became apparent that the old donated machines were useless as they were breaking down constantly. The machines needed replacement, again at government expense and new supplies had to be purchased to replace the many that had expired unused because of the delays. Once the dialysis unit had safe water and functioning equipment a service developed, free at the point of care for all citizens. The service was to be shepherded by 3 foreign physicians until local nephrology capacity could be built.

The projected cost per patient on long-term dialysis was over 150 times the per capita health expenditure in the country. Demand for the service rapidly escalated and soon choices were needing to be made daily at the bedside of desperate patients and families – which of several patients should get access to the limited capacity, based on which criteria, when they all technically had an equal right to treatment? Physicians and nurses struggled with the moral distress of having to shoulder the burden of these life and death decisions. At this point the minister was approached about development of guidelines governing access to dialysis and he responded by stating that every citizen had a right to dialysis.