Global Dialysis Perspective: Jamaica

Background

Jamaica, renowned internationally for reggae music and athleticism, is an upper-middle–income Anglo Caribbean country with a population of 2.9 million¹ located in the center of the Caribbean Sea neighboring Cuba, Dominican Republic, and Haiti. Although characterized as upper-middle income, the island ranks as one of the lowest gross national incomes per capita in the region (US $8950 per capita).¹ The country is subdivided into 14 parishes, which represent the main geographic units of local government (Figure 1). Most of the population, however, is confined to the Kingston and St Andrew parishes (an estimated 1.2 million), and the predominant ethnicity is self-identified Black or African descent.¹

Figure 1.

Distribution of hemodialysis centers throughout the 14 parishes of Jamaica, with bar graph with the numbers of dialysis units per parish.

Cardiovascular disease is the leading cause of death, likely consequent to increasing rates of noncommunicable disease and population aging.^2,3 Over half of the Jamaican population is overweight or obese with 31% and 12% of Jamaican adults having hypertension and diabetes mellitus, respectively.⁴ Despite economic growth in the last decade, the burden of these chronic diseases has resulted in increased health care utilization, overwhelming the available health infrastructure.

CKD has a high burden and is a significant cause of morbidity and mortality and is the fourth leading cause of death in Jamaica, an increase of 18.9% from 2009 to 2019, and the fifth leading cause of combined death and disability.^3,5 An estimated 12,000 Jamaicans have advanced CKD (CKD stage 5),⁶ in which RRT is needed for survival, but a significant proportion lack access to this therapy.¹³ In center, hemodialysis is the predominant form of RRT in Jamaica, and there is no formal national transplant program. In this review, we discuss the epidemiology, funding, and management of dialysis, with recommendations to improve dialysis care in Jamaica.

Epidemiology of CKD in Jamaica

There are no published data on the prevalence of ESKD in Jamaica. On the basis of data from the Jamaican arm of the Caribbean renal registry, an estimated 800 persons from four of 14 parishes are on any form of dialysis.⁷ However, the renal registry utilizes voluntary data entry and not all parishes have data collected, and thus, these are likely underestimates of the national dialysis prevalence.⁸ Furthermore, owing to inequity in access to dialysis care, many persons in need of renal replacement are not on dialysis. In cross-sectional analysis of participants from the Jamaica Lifestyle Survey (2016–2017), a national survey of resident Jamaicans aged 15 and older, 1189 had data for creatinine testing. The national estimated prevalence of CKD, defined as an eGFR <60 ml/min per 1.73 m², was 5%.⁶ Further longitudinal studies to define the risk factors for CKD and ESKD progression are needed in Jamaica.

Dialysis in Jamaica

The first hemodialysis was performed in Jamaica in the 1970s at the Kingston Public Hospital, with the first renal transplant in the Caribbean performed on a patient with GN on dialysis.⁹ Initially, units were hospital based and concentrated in the Kingston and St Andrew region. Over the past three decades, the number of dialysis units has proliferated, with Jamaica having five dialysis units located in major hospitals, and the remaining 20 dialysis units being owned by private entities. For details of the distribution of the dialysis units in the country refer to Figure 1. Legislation governing the regulatory standards of hemodialysis units is under the Nursing Homes Registration Act of 1934. This legislation has not been updated in decades, and quality assurance measures are not required for dialysis units in private institutions by the Ministry of Health and Wellness (MOHW).⁹

Funding and Dialysis Resources in Jamaica

Funding for Dialysis

The health care model of Jamaica is a mixed public-private model. Public institutions are sponsored by the Jamaican government and offer outpatient and inpatient services free of cost to users. Public health systems are under the purview of the MOHW, which allocates resources by geographic regions. As of 2018, the Jamaican health care expenditure was US $320 million, approximately 5.97% of the national gross domestic product. The cost of treating one patient on hemodialysis is estimated at US $16,000.00 per year in the public sector.⁷

Private medical care is outsourced when the capacity of the public system is overwhelmed. In the case of dialysis care, the limited access of public dialysis centers has resulted in the predominant outsourcing of dialysis care to the private sector, as approximately 68% of persons on hemodialysis obtain treatments at private centers. In Jamaica, only a small proportion of Jamaicans (19%) have medical insurance, and thus, to access private medical care, out-of-pocket payment is required.¹⁰ Jamaica has one of the highest proportion of out-of-pocket costs for hemodialysis in the region (ranging from 51% to 75%).¹³ The cost of hemodialysis is approximately $90–$117 US dollars per session, with most persons (70%) dialyzed twice weekly. In Jamaica, with a median household income of US $443.71, the cost of hemodialysis is not sustainable for most (Table 1).¹¹

Table 1.

Description of dialysis resources and funding in Jamaica

Dialysis Resources and Funding
No. of patients undergoing dialysis	800 (275.9 per million population)
Percent on home dialysis	≤1% (peritoneal dialysis)
Funding of dialysis	Predominantly out of pocket (68%)
Dialysis units	Approximately 80% dialysis units are freestanding or private/for profit
Cost of dialysis per session	USD $90.00–$117.00
Staff for dialysis administration	Dialysis nurses or dialysis technicians
Patient-to-nurse ratio	1:4
Duration of dialysis session	3.5–4 h
Times per month patients seen by a nephrologist	Variable, not routinely reported
Proportion of persons with a AVF/AVG	Approximately 30%

AVF, arteriovenous fistula; AVG, arteriovenous graft.

Peritoneal dialysis is available through only two public centers and a single subsidized academic center. Barriers to the widespread use of peritoneal dialysis have been the cost of peritoneal fluid and accessibility of disposables.

Funding for Medication

The National Health Fund is a government agency that subsidizes medications for Jamaicans living with any of the illness in a list of 17 chronic medical illnesses. Although CKD risk factors, such as hypertension, sickle cell disease, systemic lupus erythematosus, and diabetes mellitus, are part of this list, CKD/ESKD is not. Newer medications such as sodium glucose co-transporter-2 inhibitors, immunosuppressive agents (specifically calcineurin inhibitors and induction agents) for organ transplant, erythrocyte-stimulating agents, intravenous iron, and calcimimetics are not covered. Furthermore, supporting blood investigations, such as tests for iron stores and serum intact parathyroid hormone, are at an additional cost to the patient in private centers and are not routinely available in most public centers. Many drugs used in the management of bone mineral disease in ESKD are not locally available (such as cinacalcet) or expensive (non–calcium-based phosphate binders or intravenous paricalcitol). Although the latter medications are available in public systems, the apparent growth in CKD prevalence has outpaced the available outpatient public clinical services, resulting in many patients without reliable access to these systems.

Dialysis Human Resources

Despite improvements in both the number of nephrologists and dialysis-trained nurses, there remains a lack of nephrology staff nationally. There are now 16 nephrologists (12 adult and four pediatric) in the island, with a mean of 5.5 nephrologists per million per population, compared with the United States with 28 per million population. The median nephrologists per million population is 18.1 in North America and the Caribbean.^12,13 Strides have been made with the training of nephrologists locally, with the University of the West Indies, Mona, offering a fellowship program in nephrology, with having trained six nephrologists, and the International Society of Nephrology and private sponsoring opportunities enabling nephrologists in the United Kingdom and Canada. In addition, most nephrologists are based in Kingston and St Andrew, resulting in gaps in access to renal care in rural and central Jamaica. Similarly for the pediatric population, dialysis is only available in Kingston and St Andrew.

The frequency with which patients undergoing dialysis are assessed by nephrologists in Jamaica is largely unknown, and there is significant variability within dialysis units and by region. Dialysis quality measures, such as clearance measures (e.g., kT/V), number of persons with arteriovenous fistulae versus catheters, rates of catheter-related blood stream infections, and phosphate and hemoglobin levels, are not required by the MOHW and are not routinely reported. Thus, there are no national data on dialysis quality measures. Anecdotally most persons who are on hemodialysis are initiated with a central venous catheter, with about one third on dialysis have an arteriovenous fistula. Often, central stenosis from prolonged catheter use becomes a barrier to definitive access creation. The creation of “fistula clinics” and international missions has aided in preemptive access creation for predialysis patients. Quality initiatives targeting vascular access creation are needed (Figure 2).

Figure 2.

Summary of recommendations to improve dialysis quality of care in Jamaica. Three areas for scope for improvement include reducing CKD risk factors, early detection of CKD, and improving equity in access to quality RRT. NHF, National Health Fund.

Dialysis Personnel

Both dialysis subspecialty–trained nurses and technicians perform hemodialysis in Jamaica. In hospital-associated institutions, only nurses perform hemodialysis, with a ratio of 1:4 (nurses to patients). The nursing ratio or technician ratio is not routinely reported for private institutions. However, retention of nursing staff locally has declined because of enhanced migration to North America and the United Kingdom consequent to increased financial renumeration and quality of life. This has resulted in reductions in the coverage of the shifts available for dialysis, and efforts in training allied health care workers, such as dialysis technicians, are needed.

Future Scope and Recommendations

The burden of ESKD is high in Jamaica and will continue to increase, paralleling the regional increases in noncommunicable disease. Despite significant strides in nephrology training, research, and quality of renal care, large inequities in dialysis care remain. Accessible systems for RRT inclusive of kidney transplantation coupled with preventive measures aimed to reduce CKD risk factors, and screening of high-risk CKD groups is needed to improve the quality of dialysis care in Jamaica.

Disclosures

L.-A. Fisher reports speaker contract from Dr. Reddy's Laboratories Ltd., January 2023 and Servier Panama Limited, March 2023. R. Lowe-Jones reports recipient of stipends for clinical training as a clinical fellow by the International Society of Nephrology and research funding by Kidney Research UK as a research fellow.

Funding

None.

Author Contributions

Conceptualization: Lori-Ann Fisher, Racquel Lowe-Jones.

Writing – original draft: Lori-Ann Fisher.

Writing – review & editing: Racquel Lowe-Jones.