Where NHIF is wrong on kidney transplant

In the last few years, the National Hospital Insurance Fund (NHIF) has made significant progress in support of care of patients with chronic kidney disease. Through the fund, patients can now access life sustaining dialysis and transplant care.

Further, perhaps informed by overwhelming evidence that transplant is superior to dialysis, NHIF is increasingly supporting renal transplant care through coverage of 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, kidney transplant reduces the cost of treatment in the long run. However, these gains stand to be competed away if the current NHIF policy fails to cater for crucial medicines required to keep the transplant viable after the surgery.

Transplant portends better patient outcomes and long run cost advantage.

These medicines, known as immunosuppressants, pacify the body’s immune system 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 remains viable for an average time of 12 years. Put another way, immunosuppressant drugs are as essential to the life of the transplant as engine oil is to the car.

Subsequently, transplant recipients who fail to adhere to the medications for cost or other reason 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.

Catastrophic expenditure

With the initial cost of surgery trending between Sh700,000 and Sh1,500,000, 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 doesn’t come cheaper. For instance, consider a case of two hypothetical patients: Chebet and Akinyi who are both 30 years old and are suffering from chronic kidney disease and are undergoing treatment over a period of five years. Chebet undergoes dialysis while Akinyi gets a transplant.

Considering the prevailing market rates, our analyses demonstrate that the costs of Akinyi’s renal transplant including her medicines are lower than Chebet’s dialysis over the first five years who must also get a transplant at the end of this period. 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. Failing to cover immunosuppressants is short sighted, irrational and wasteful

However, there is a problem. While the NHIF’s decision to support patients in defraying the upfront costs of surgery is commendable, the subsequent failure to cater for the long-term costs of immunosuppressant drugs 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 (a rather common occurrence) then 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 immunosuppressant drugs), the patient will need to revert to the less desirable and expensive dialysis paid for by the NHIF. This means that the NHIF’s initial investment on 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 for a potential second transplant procedure.

Risk of complications

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.

Kidneys are a scarce resource, preserving their function is a national priority

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 available for transplant are a scarce resource.

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

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 immunosuppressant drugs.

The NHIF needs to also extend this strategy into the protection of patients at risk of kidney failure by nudging providers to provide 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 a national priority.

Riro is a PhD candidate in Health Economics and Policy at the University of Bergen, Norway. Thuo is a Postdoctoral Research Fellow at the Department of International Health, Johns Hopkins Bloomberg School of Public Health.