Improving global access to integrated ESKD care. David Harris 01/10/17

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1 University of Sydney Westmead Hospital Improving global access to integrated ESKD care David Harris 01/10/17

2 the problem resources numbers

3 GLOBAL 125/202 countries 6.73/7.24b (93%) ASIA 25/42 countries 3.89/3.97b (98%) N&E ASIA 6/7 countries 1.56/1.58b (99%) Bello AK et al. JAMA 2017 April

4 Global Renal Scorecard 2-yearly cycles Each country/region scored on 6 domains for AKI, CKD & ESKD Nephrology workforce Health funding Essential medications & technology access Service delivery & safety Health information systems & statistics Strategies & policy frameworks Capacity for nephrology research & development

5 Overall country funding for chronic RRT Publicly funded by government (free at point of delivery) 42% Publicly funded by government (some fees at point of delivery) 12% A mix of publicly funded (free at point of delivery) & private systems 35% Solely private and out-of-pocket Multiple systems* 2% 9% HD Publicly funded by government (free at point of delivery) 51% Publicly funded by government (some fees at point of delivery) 12% A mix of publicly funded (free at point of delivery) & private systems 29% Solely private and out-of-pocket Multiple systems* 1% 7% PD Publicly funded by government (free at point of delivery) 30% Publicly funded by government (some fees at point of delivery) 19% A mix of publicly funded (free at point of delivery) & private systems 30% Solely private and out-of-pocket Multiple systems* 6% 15% KTx Healthcare Financing 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% *programs provided by government, Non-government organizations, and communities

6 In your opinion, is there a shortage of any of the following providers in your country? Overall Vascular access coordinators Transplant coordinators Social workers Renal pathologists Pharmacists Nurse practitioners Nephrologists Laboratory technicians GP/primary care physicians Dietitians Dialysis technicians Dialysis nurses Counselors/psychologists Health workforce 0% 20% 40% 60% 80% 100% Yes

7 In your opinion, is there a shortage of any of the following providers in your country? Overall Vascular access coordinators Transplant coordinators Social workers Renal pathologists Pharmacists Nurse practitioners Nephrologists Laboratory technicians GP/primary care physicians Dietitians Dialysis technicians Dialysis nurses Counselors/psychologists Health workforce 0% 20% 40% 60% 80% 100% Yes

8 Health workers (pmp) Global distribution of Kidney Doctors < > 15 N/A (not available)

9 Health workforce (pmp) Kidney Doctor Density by ISN Region North America 24.2 Western Europe Eastern & Central Europe NIS & Russia Latin America & the Caribbean North & East Asia Middle East 6.17 Oceania & South East Asia 3.98 Africa 3.64 South Asia 1.17

10 Chronic hemodialysis Chronic peritoneal dialysis Kidney transplantation 100% 68% 76% Availability of RRT services 100% 100% 100% Acute hemodialysis 97% 100% Acute peritoneal dialysis 59% LMIC 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HIC Chronic hemodialysis Chronic peritoneal dialysis Kidney transplantation Acute hemodialysis Acute peritoneal dialysis 100% 29% 12% 94% 18% LIC but. in LIC, LMIC & UMIC: very uneven availability vs access

11 Conclusions of GKHA Substantial inter- and intra-regional variability in kidney care across the world Important gaps in services, facilities and workforce in many countries Frequent kidney health workforce shortages Poor availability of healthcare services for identifying and treating kidney disease Underutilisation of peritoneal dialysis Low rate of public funding for kidney care Lack of national strategies for kidney disease Lack of kidney disease registries Suboptimal advocacy for kidney disease Less than half countries have research capacity

12 Conclusions of GKHA Substantial inter- and intra-regional variability in kidney care across the world Important gaps in services, facilities and workforce in many countries Frequent kidney health workforce shortages Poor availability of healthcare services for identifying and treating kidney disease Underutilisation of peritoneal dialysis Low rate of public funding for kidney care Lack of national strategies for kidney disease Lack of kidney disease registries Suboptimal advocacy for kidney disease Less than half countries have research capacity

13 Relationship between RRT prevalence and GDP per capita White et al. Bull World Health Organ. 2008;86:

14 Catastrophic out-of-pocket expenditure for health Percent of household expenditure for dialysis in Thailand before UHC coverage for dialysis Share of non-food consumption > 40% Making fair Choices on the path to universal health coverage: who.org; Prakongsai et al., J Int Dev 2009

15 Health expenditure per person per year by African country Dialysis $20,000/person per year insufficient funds dialysis too expensive Abu-Aisha and Elamin, PDI 2010

16 the problem resources numbers

17 High Burden of ESKD 2.6 million people received RRT in million by 2030 only 80,000 transplants globally in 2014 (3%) million died in 2010 for want of RRT for ESKD, esp in LIC & LMIC RRT too expensive prevention & early detection and treatment essential

18 2012 Romanowski K et al. KI 2016;90:34-40

19 % 100% 17% 9% 47% 40% Romanowski K et al. KI 2016;90:34-40

20 Contributions of changes in population aging & growth in to dialysis prevalence (pmp) Thomas B et al. JASN 2015;26:

21 Thomas B et al. JASN 2015;26: Age-standardized maintenance dialysis incidence

22 Thomas B et al. JASN 2015;26: Age-standardized maintenance dialysis prevalence

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24 the solution advocacy contextual response detection, prevention & treatment transplant conservative care dialysis modality technology capacity-building

25 the solution advocacy contextual response detection, prevention & treatment transplant conservative care dialysis modality technology capacity-building

26 Communication Plan for GKHA Internal External ISN members National nephrology society leadership Policymakers Patients Media WHO IFKF Relevant consumer NGOs Key opportunities to engage key governmental & non-governmental stakeholders to support countries in improving the quality of kidney care holding countries to account in a scorecard process devising policy implications for including AKI,CKD & ESKD in the global health agenda

27 5b ex 7.5b without reliable access to essential care 2.5b with serious illness < 60y WHO SDG #3 good health & well-being Fair choices in achieving UHC Expand priority services based on cost Include more people prioritise the worst-off Ensure financial risk protection...reduce out-of-pocket payments Dialysis for ESKD costs >30x the GDP per capita per heathy life year, low priority 300x more healthy life years saved with TB control than dialysis Voorhoeve et al. Health Economics, Policy & Law 2016: 71-77

28 the solution advocacy contextual response detection, prevention & treatment transplant conservative care dialysis modality technology capacity-building

29 Formulation of a public health policy on CKD Jha V et al. KI 2016;

30 Components of policy development process in Indonesia

31 CONTEXTUAL PROVISION OF ESKD CARE IN LMIC Limited funds, with other priorities sanitation, clean water, malnutrition, infectious disease, reproduction Deficient workforce, with increased dependence on NPHW, general physicians, nurses Lack of integrated ESKD care conservative care, transplantation (choice-restricted) Unique national protocols no dialysis unless transplantation (Sth Africa) PD first (HK, Thailand)

32 the solution advocacy contextual response detection, prevention & treatment transplant conservative care dialysis modality technology capacity-building

33 the solution 10x more cost effective than RRT advocacy contextual response detection, prevention & treatment transplant conservative care dialysis modality technology capacity-building

34 Maximizing RRT to those who need it

35 the solution advocacy contextual response detection, prevention & treatment transplant conservative care dialysis modality technology capacity-building

36 TRANSPLANTATION MORE COST EFFECTIVE THAN DIALYSIS eg Kaminota M Keio J Med 2001;50:100-8 ~2m Y/ DALY vs ~10m Y/ DALY

37 DIALYSIS ONLY IF TRANSPLANT?? (GLOBAL) CKD 500m Dialysis 2.6m (0.5%) ESKD but no dialysis m Transplant 80k/y ( %) Deaths if no dialysis 4.82m-9.62m ( %)

38 Treated and non-treated ESKD in the elderly End-stage kidney disease in Australia, AIHW June 2011

39 the solution advocacy contextual response detection, prevention & treatment transplant conservative care dialysis modality technology capacity-building

40 Robinson BM et al. Lancet 2016;388:

41 Mushi L et al. BMC Health Sciences Res 2015; 15:506

42 Savla D et al. HD Int 2016

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45 Blocks in the dialysis supply chain Local production of PD fluids

46 ISPD Guideline: Peritoneal Dialysis for Acute Kidney Injury Cullis B et al. PD International & Kidney International 2014 ; 34: 494 EXAMPLES OF LOCALLY PREPARED PD FLUIDS 1 L Ringer Lactate + 30mL 50% Dextrose Na 127mmol/L, Lactate 27 mmol/l, Ca 1.36 mmol/l, K 3.8 mmol/l, Glucose 1.45%, Osmo 342 Fluid similar to lactate-based commercial PD solutions

47 the solution advocacy contextual response detection, prevention & treatment transplant conservative care dialysis modality technology capacity-building

48 Capacity Building Programs

49 Regional Breakdown of Members Members

50 ISN Campaigns INTEGRATED ESKD CARE

51 Integrated ESKD Care million died in 2010 for want of RRT for ESKD 1.7m die annually for want of dialysis for AKI Advocacy & education materials for LMIC wanting to start dialysis Regional hub & spoke model for capacity building & support Industry liaison to overcome hurdles to dialysis supply chain Dialysis curriculum on ISN Academy Training in dialysis & interventional nephrology WCN 2019 & Frontiers meeting ESKD Summit in 2018 & Policy Forum in 2019 Disaster preparedness plan

52 0by /2017 Focus: Pilot Feasibility Project BOLIVIA, LATIN AMERICA MALAWI, AFRICA NEPAL, ASIA implementation phase + STH AFRICA + BRAZIL + Saving Young Lives + integrated kidney care

53 How much does Herceptin cost? Barett et al, BMJ, 2006

54 Global access to ESKD care: Investing resources in dialysis is an OPPORTUNITY a CHALLENGE an OBLIGATION

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