Like other students, Chidozie had visions of what to do after graduating as a Medical Laboratory Scientist. Getting a placement for his internship and earning some money was top of his wish list. He would often discuss these plans with close friends. His devotion to his Catholic faith and his calm and collected nature set him apart.
Chidozie performed very well in his academics and was well on his way to achieving his big dreams. However, after one of the holidays in his fourth year of school, he didn’t return to his classes. A few of his close friends received calls from him requesting for financial assistance, but what could they do? They were just students. Then the news came in. Chidozie had died. He died of kidney failure and his calls for assistance to some of his friends were for his dialysis sessions in Enugu where his family lived. His dreams were cut short.
Hidden in plain sight
No clear data exists around the prevalence of kidney disease in Nigeria but in this news article the Nigerian Association of Nephrologists puts the number at 25 million. Data from the association also reveals that only 160 nephrologists are practicing in Nigeria. These are medical doctors who specialise in the management of kidney problems. The association also estimates that 18,000 of these patients will need dialysis every year which would cost around N400,000 every month. A patient whose kidneys fail needs about three dialysis sessions per week, and each session costs an average of N30,000. The dialysis machine helps the patient by performing the function of the kidney, filtering and purifying the patient’s blood, removing waste and excess fluid from their body.
A recent report by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington’s School of Medicine estimated kidney disease to have caused 1.23 million deaths in 2017, globally. Dr. Theo Vos, Professor of Health Metrics at the institute referred to it as “a global killer hidden in plain sight”.
He made the comment following publication of the 2017 Global Burden of Disease report which revealed there were 697.5 million cases of chronic kidney disease in 2017. Nigeria alone accounted for more than 10 million cases.
Making a dent
The size of the problem didn’t discourage two Nigerian nephrologists from making the decision to respond and save as many lives as they could.
The idea started as far back as 2006 after they completed their nephrology training in the United States. They started thinking of ways to give back to friends, family, and the people who supported them. “We considered a lot of things. We thought about the logistics of bringing in the highly specialised equipment we needed, how to find and recruit well-trained staff and how we can leverage technology,” Dr Emmanuel Anekwe, one of the Managing Partners and Medical Directors, said. They didn’t rush to start but kept the vision alive while observing developments in various sectors.
With the massive penetration of internet to 13.8% and adoption of online banking around 2011, they felt it was a good time to try to open a kidney dialysis facility in Nigeria, because they had agreed from day one to adopt electronic medical records for everything including personnel management. In addition, they created meaningful partnerships to help minimise risk and costs, while delivering the best possible care.
Anekwe said it took about three months to adequately train their first staff members. They personally designed their water treatment system before hiring and training the first technician to manage it. All the months of preparations and hard work finally birthed Kidney Solutions Ltd in 2013. While the facility is along the popular Adeniyi Jones Street in Ikeja, Lagos State, it serves patients beyond the city.
They were happy to render care in an area they had expertise in, but they didn’t know Kidney disease had high prevalence in Nigeria. “It’s like a plague,” says Dr Anekwe, “almost everybody is affected. You hardly see anyone who doesn’t directly or indirectly know someone who is affected”.
Creating a standard of care hinged on quality is one thing, but sustaining it is another. This is where Dr Aderemi Oladapo-Sanu comes in. She oversees the day-to-day operations of the facility, working as the Clinical Administrator, bringing her years of medical practice and administration experience to bear.
She said beyond the passion that the managing partners bring to the work, other factors contributed to sustaining the centre since inception. “Even though we charge the least per dialysis session in the city, we never compromise on our standards. Quality is a top priority,” she said. To ensure that, she said all the staff members have basic medical knowledge including the housekeeping staff who are auxiliary nurses. This is necessary because it is important that they understand how maintaining a germ-free facility contributes to the success of a patient’s treatment. Consumables are only used once per patient and discarded thereafter. This, however, generates significant waste and increases costs, having medical waste discarded by the Lagos Waste Management Agency, says Mr Emmanuel Omoarukhe, the Clinical Operations Manager.
Dr Sanu said treating their staff members the same way they treat their patients — with respect — has been integral to their sustenance. Dr Anekwe reaffirmed this. “We take care of our staff because they are our biggest asset. About 75% of them have been with us from the beginning and we are like a family,” he said.
The centre initially started with four dialysis units in 2013, but now has around 10 functional units with a few others on standby. The same goes for the water treatment room. One extra is always on standby in case there is need for maintenance. Omoarukhe takes particular pride in the water treatment room as he emphasises that the water used for the sessions must be 100% sterile to avoid infections.
He talks about how the dialysis process can sometimes make patients weak, but it isn’t the case with their patients. He shared the story of a patient who came in assisted by his sister, but by the time he started his treatment, he requested to be allowed to come alone. As if on cue, an elderly man walks out of the dialysis room after having a session and walked to his car and drove off, as if he never had any treatment.
The centre has about 18 staff members, including five locum nurses. They also have consultants who come in on specific days to see their patients who may have other complications.
Just as Dr Sanu explained how it works, one of the consultants walks in. She says the opportunity to help patients and to see them get better, to live their best lives drives her. One of her most remarkable stories was a young man diagnosed with chronic kidney disease. After managing him for two years, he had a transplant and went on to fulfil his dreams. “He is now married with children and this gives me great joy. I use his story to encourage my patients,” the consultant said.
Dr Anekwe said beyond the telemedicine consultations, the consultants have developed personal relationships with all their patients. They usually come into the country multiple times a year to personally attend to their patients. Since 2014, they have handled cases of kidney transplants in Nigeria, without the need to refer outside, thereby reducing medical tourism. The transplant cases are handled by a partner facility located in Abuja and all the surgeries, over 30 of them, have been successful with standards comparable to what can be obtained in any part of the world.
Despite the obvious evidence of the impact of their work, there are challenges as much as there are opportunities. Dr Sanu said one of the major limitations to their work is seeing patients cut down their dialysis sessions or post-transplant medications because of a lack of funds. Sadly, they have lost some patients because of this. “I have had to ask some of my friends to pay for patients’ dialysis sessions to mark their birthdays instead of organising lavish ceremonies. I wish more non-governmental organisations can support this,” she said.
Another major limitation is the restrictive operating environment around importing medical equipment. Dr Anekwe said it is sad that importing some of the life-saving equipment needed for their work is treated like luxury goods, with the processes made difficult in both efforts and financial investment. Ideally the import duty shouldn’t be more 5% of the cost of equipment being imported but by the time the clearing process is complete, over 30% of the equipment cost is paid as duty. Unfortunately, some of these expenses are passed on to the patient in order to sustain their work. There have been times when they received recommendations to increase the cost of dialysis sessions, based on the realities of the costs they had incurred, but they insisted on their unique selling point of being the most affordable centre in Lagos. That decision comes at some personal cost and sacrifice.
With a service that is 100 percent dependent on the availability of constant power supply, access to power is also a major challenge as they must spend a lot to generate electricity. Taxes from state authorities which are sometimes difficult to explain also pose limitations.
Despite these issues, Dr Anekwe said they don’t give up even when they consider it because of the people whose lives depend on what they do.
He adds that they are cautiously optimistic and continue to observe improvements in various areas, while hoping the same can happen around private health services. He said research aimed at understanding the major drivers of kidney disease are providing insights around mutations in the human gene that increase the potential of developing the disease.
As for the facility, they have learned to do more with less, he said, and leverage technology in ways they haven’t in the past, so he looks forward to better days ahead.
It is now up to the government. There has been a lot of conversation around public private partnerships (PPPs), but the government must go beyond talking, to ensuring that the public part of the deal works. How? Making the conditions favourable for private health care providers irrespective of their affiliations to run their health facilities efficiently, offering affordable care to a wide range of patients. Instead of having complicated systems that discourage them, incentives should be put in place to improve the ease of doing business for health practitioners in the diaspora who are offering medical services for patients in Nigeria. It is all about getting priorities straight.
We cannot afford to keep losing promising young people like Chidozie whose potential could have contributed to Nigeria’s development. Some of his classmates still remember him and sometimes imagine what he could have been doing now if he were still alive. One of them, Sampson, says he doesn’t think much progress has been made between then and now. “True, there’s better management of patients, but given the state of the economy, I don’t know how many patients with end stage kidney disease that can comfortably afford the dialysis sessions,” he said.
Health facilities like Kidney Solutions are doing their part to provide this care to the communities they serve in Lagos and beyond. This is a step in the right direction, however similar services are needed in other parts of Nigeria, offering affordable and quality care to patients at their time of need.
Are you aware of others doing innovative work in the area of kidney care in Nigeria? Let us know in the comments section below or on our Twitter handle @nighealthwatch or Facebook @nigeriahealthwatch.