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Making dialysis affordable and accessible

Making dialysis affordable and accessible

Despite the increase in disposable income, there is a large section of population, that is not able to afford dialysis care, especially in Tier-II and Tier-III cities. There is a need to innovate and come up with business models to tap the potential of the market that is waiting for an intervention.

The growing burden of kidney disease and kidney health disparity among 850 million patients globally has impelled the dialysis equipment fraternity to plunge into the intense research and development of the dialysis equipment. In India alone, a large number of people perish from chronic kidney disease (CKD) and many more remain undocumented, thus pointing toward the lower penetration of dialysis today, which can be attributed to lack of availability of medical practitioners, low presence of healthcare services, and most importantly even lower awareness about CKD. In addition, the high cost of dialysis is also proving to be an impediment, which has further established the need for affordable high-end dialysis care equipment, accurate treatment delivery, and reducing the response time.

The dialysis technology has progressed tremendously. Over the past four decades, continuous renal replacement therapy machines have evolved into devices specifically designed for critically ill patients. Manufacturers of dialysis gear are developing fully automatic, compact, and state-of-the-art dialysis equipment to treat patients of any age experiencing end-stage renal disease (ESRD). A remarkable technological progression incorporates the presentation of high-productivity and high-flux membranes, enabled by advances in membrane innovation and polymer technology. Dissimilar to conventional renal substitution machines, automated dialysis gear facilitates the management of disease parameters carefully, in this manner ensuring more precision and reducing expenses of work. Innovation in dialysis membrane has further improved toxin removal from the blood, thus increasing the chances of enhancing the patient outcome.

The advancement of wearable artificial kidney is a gift for dialysis patients, as it would enable them to break the shackles of restricted mobility to fixed-dialysis hardware and enjoy increased mobility. Due to the headways occurring in the dialysis equipment, wearable dialysis gear may before long develop into a compact size, thus providing ease of use to patients, and adding to the anticipated growth of the dialysis equipment market.

Indian scenario

India has a substantial patient base suffering from various stages of CKD and ESRD. Every year about 220,000 patients of ESRD get added in India, resulting in additional demand for 34 million dialysis every year. With approximately 4950 dialysis centers, largely in the private sector in India, the demand is less than half met with existing infrastructure. Since every dialysis has an additional expenditure tag of about Rs 2000, it results in an expenditure for patients to the tune of Rs 300,000 to 400,000 annually. Besides, most families have to undertake frequent trips, and often over long distances, to access dialysis services, incurring heavy travel costs and loss of wages for the patient and family members accompanying the patient.

Keeping this in mind, strengthening of district hospitals by providing affordable multispecialty care, including dialysis services in district hospitals, would be an important step in this direction.

To gain from available capacity of private sector existing in dialysis care segment and their capability to install and operate dialysis care system in quick time and complement the emerging strengths of public sector like availability of drugs and diagnostics, the government has proposed that dialysis program be undertaken in public-private partnership.

Another critical factor driving Indian dialysis equipment market is the government initiative for greater adoption of peritoneal dialysis. The health ministry has directed all states to establish peritoneal dialysis services under Pradhan Mantri National Dialysis Program (PMNDP). The ministry recently introduced guidelines aimed at serving as a comprehensive manual to states that intend to set up peritoneal dialysis and for providers of peritoneal dialysis as a best-practice document for ensuring delivery of high-quality, cost-effective service, and supplies to develop a clinically safe and effective program for children, young people, adult women, and men. It also aims to achieve equity in patient access to home-based peritoneal dialysis, reduce overall cost of care to the system by focusing on efficient leveraging of resources, and bring consistency of practice, pricing, and a full range of product availability.

Indian dialysis market is severely underpenetrated in terms of the number of ESRD patients on dialysis, with an even smaller number of patients on peritoneal dialysis. Factors as these and the establishment of government initiatives like PD First is expected to drive the Indian dialysis market growth in the coming years.

A focused player can clearly create a double bottom-line impact by serving the society and at the same time rewarding its shareholders.

Challenges

The government recently announced a hike in the import duty, which negates any benefits of duty exemption. This is because 70 percent of parts of complete dialysis are still imported.

Equipment like reverse osmosis facilities, accessory equipment, dialysis beds, continuous supply of water, and availability of trained technicians and nurses are in scarce supply.

The schemes initiated by various government bodies are aimed to facilitate and support the treatment cost of dialysis for this patient group. However, the healthcare institutions empaneled on these schemes often face a challenge due to lower charges per dialysis offered under the scheme, coupled with delays in payment. The average credit period across the board is 45 days.

The healthcare infrastructure is considerably limited to large towns. Due to the lack of availability of professional medical services, the patients get detected with CKD at very late stages.

Global scenario

The global dialysis equipment market is projected to reach USD 22,405.4 million by 2025, exhibiting a CAGR of 5.1 percent, predicts Fortune Business Insights. The market is likely to gain momentum from the rising prevalence of chronic kidney disease and end-stage renal disease in the coming years. The hemodialysis segment is expected to hold the largest share of the dialysis market as of 2019 mainly with greater accessibility of HD centers, growing number of community dialysis centers, higher physician expertise and awareness to administer HD, reimbursement coverage, and socio-demographic factors.

Over recent years, business players are investing vigorously in R&D activities to develop novel dialysis devices that support specific dialysis treatment. Thus, the availability of advanced quality dialysis equipment and dialyzers will also surge dialysis industry growth in the coming years.

The in-center dialysis end-user segment is expected to hold the largest share of the dialysis market in 2019; mainly with the increasing number of dialysis centers across the globe, new product launches, and the availability of healthcare professionals in dialysis centers.

The Asia Pacific is one of the major revenue-generating regions in both, the hemodialysis and peritoneal dialysis segments.

North America is projected to dominate the global market in terms of revenue share. The foray of leading North American companies into the hemodialysis devices market over the last few years is a factor expected to boost overall sales of these devices in the region. APEJ and Japan are expected to witness significant growth owing to significant investments in healthcare infrastructure and increasing geriatric population in these regions.

Major players operating in the global dialysis market include Asahi Kasei Medical Co. Ltd., Japan; B. Braun Melsungen AG, Germany; Baxter International Inc., USA; DaVita Kidney Care, USA; Diaverum, Sweden; Fresenius Medical Care AG & Co. KGaA, Germany; Fresenius Medical Care North America, USA; JMS Co. Ltd., Japan; Kawasumi Laboratories, Japan; Medical Components, Inc., USA; Medivators Inc., USA; Nikkiso Group, Japan; Rockwell Medical Technologies Inc., USA; Teleflex Medical, USA; Terumo Corporation, Japan; Toray Medical Co. Ltd. , Japan; and Trividia Health, USA.

Outlook

Despite the increase in disposable income, there is a large section of population, that is not able to afford dialysis care, especially in Tier-II and Tier-III cities. There is a need to innovate and come up with business models to tap the potential of the market that is waiting for an intervention. Other than possible collaborations and redevelopment of business models, technology needs to be more cost-effective to combat the mortality rate, or at least make the quality of life better for patients with renal failure, if not elongate it. The cost of cutting-edge dialysis equipment is a major impediment in pushing the dialysis equipment industry toward an upward curve. However, with the Government of India laying emphasis on implementing National Dialysis Program across the country, an attempt is being made to bridge the gap so that each district hospital compulsorily has a few dialysis machines obtained by public-private partnership.

Second Opinion

Dr Sunil Prakash
Director and Head, Nephrology, Renal Transplant Service,
BLK Superspeciality Hospital

Technology trends

COVID-19 outbreak will leave its foot prints on the way dialysis is delivered in India. Dialysis centers in India are mostly housed in hospitals, unlike the in the West where dialysis is given in standalone dialysis centers. In India, standalone centers have yet to find their feet. Post COVID-19, more and more dialysis patients would shun busy hospitals for fear of catching serious infections. They would make a bee line for standalone dialysis centers.

Home dialysis in India is synonymous with peritoneal dialysis (CAPD). Home hemodialysis is a very rare modality. The fear of COVID-19 and many yet unidentified treacherous infections will encourage people to do dialysis in the privacy and safety of their homes. This will translate into need for safe, portable, easy-to-use and price-sensitive HD machines. The need for compact portable RO water will also rise in equal proportions. Technology has to mother these expectations.  Telemedicine will play a big part in delivering safe economical dialysis on a large scale. Multifaceted technical manpower would be in big demand, who could deliver safe event-free dialysis, who are computer savvy, and provide expert advice to remote locations. They will also look after housekeeping. Unfortunately to date, we import all dialysis disposables such as dialyzers, catheters, and needles – not to mention dialysis and CRRT machines. We do not manufacture these articles, which means that not only we spend our hard currency in their imports but also, we could be arm twisted in times of pandemic-induced shortages. India has to become self-sufficient in the supply of all dialysis software and hardware. Make in India mantra should baptize dialysis industry in near future.

Wearable artificial kidneys (WAK). These are portable dialysis machines, which can be worn like a school bag. Advances in WAK include the miniaturization of sensors and pumps; small, long-lasting batteries; ultra-permeable membranes that reduce dialyzer size; and new filtration materials to cleanse and reuse dialysate solutions, without the need for large quantities of purified water. WAK would become a favorable area of intense research and investment. Finally, renal regenerative interventions such as stem cell therapy will face renewed scientific enquiry. Future management of end-stage kidney disease will bank on our abilities to repair, replace, or regenerate failing kidneys. Current dialysis and transplant modalities may then become obsolescent.

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