Abstract
Background:
Public–private partnership (PPP) in hemodialysis delivery in Nigeria is a new concept. We set out to compare the performance of Specialist Hospital Sokoto's (SHS) renal center operating with this model with four other neighboring government-operated dialysis centers.
Materials and Methods:
We reviewed the 6-year records (May 2011 to April 2017) of Dialysis Center of SHS, operated under a PPP and compared some performance indicators with four government-operated dialysis centers over the same period. Comparisons were made using Chi-square and corresponding P values were reported accordingly. P < 0.05 was considered significant.
Results:
A total of 1167 patients’ data were studied. Of these, 252 (21.6%) patients with end-stage renal disease were dialyzed at SHS. The SHS dialysis center experienced 5 months of interruption in dialysis service. Only 38 (15.1%) patients sustained dialysis beyond 90 days and 105 (41.7%) patients had more than three sessions of hemodialysis. Only one patient was referred for kidney transplant from the dialysis center during the review period. SHS performed better than Federal Medical Center and Sir Yahaya Hospitals in terms of service availability, duration on hemodialysis, and greater number of hemodialysis sessions (χ2 = 29.06, df = 3, P < 0.001).
Conclusion:
PPP has improved the availability of dialysis service, mean duration on dialysis, and mean number of dialysis sessions but did not improve the kidney transplant referral rate at SHS. There is a need to encourage the current arrangement in the Hospital as well as other centers offering similar partnerships.
Keywords: End stage renal disease, hemodialysis, Nigeria, public–private partnership, partenariat public-privé, Hémodialyse, Phase terminale de la maladie rénale, Nigeria
Résumé
Contexte:
Le partenariat public-privé (PPP) dans la prestation d’hémodialyse au Nigéria est un nouveau concept. Nous avons entrepris de comparer les performances du centre rénal de l’hôpital spécialisé de Sokoto fonctionnant avec ce modèle avec quatre autres centres de dialyse gérés par le gouvernement voisin.
Méthodes:
Nous avons examiné les dossiers de six ans (mai 2011 à avril 2017) du centre de dialyse de l’hôpital spécialisé de Sokoto, exploité dans le cadre d’un partenariat public-privé et comparé certains indicateurs de performance avec quatre centres de dialyse gérés par le gouvernement au cours de la même période. Des comparaisons ont été faites en utilisant le chi carré et les valeurs p correspondantes ont été rapportées en conséquence. Une valeur p <0.05 était considérée comme significative.
Résultats:
Un total de 1167 données de patients a été étudié. Parmi ceux-ci, 252 (21.6%) patients atteints d’insuffisance rénale terminale ont été dialysés à l’hôpital spécialisé de Sokoto (SHS). Le centre de dialyse SHS a connu cinq mois d’interruption de service de dialyse. Seuls 38 (15.1%) patients ont subi une dialyse au-delà de 90 jours et 105 (41.7%) patients ont eu plus de trois séances d’hémodialyse. Un seul patient a été référé pour une transplantation rénale depuis le centre de dialyse pendant la période d’examen. L’hôpital spécialisé de Sokoto a obtenu de meilleurs résultats que le centre médical fédéral et les hôpitaux Sir Yahaya en termes de disponibilité des services, de durée d’hémodialyse et de plus grand nombre de séances d’hémodialyse (χ2 = 29.06, df = 3, p <0.001).
Conclusion:
PPP a amélioré la disponibilité du service de dialyse, la durée moyenne de la dialyse, le nombre moyen de séances de dialyse mais n’a pas amélioré le taux de référence pour une greffe de rein à l’hôpital spécialisé de Sokoto. Il est nécessaire d’encourager l’arrangement actuel à l’hôpital ainsi que dans d’autres centres offrant des partenariats similaires.
INTRODUCTION
Public–private partnership (PPP) is defined as a long-term contractual arrangement between the public and private sector where mutual benefits are sought and where the private sector provides operating services and/or puts private finance at risk.[1] It has been used in many countries to run social services[2] and this helps to attract private financing of public projects.[3] It stems from the assertion that the private sector is sometimes more efficient in service delivery, even though some studies still favor the public sector in terms of efficiency in health-care service delivery.[4]
Hemodialysis for patients with end-stage renal disease (ESRD) was introduced into Nigeria in 1981 at the University College Hospital, Ibadan.[5] To date, over 150 dialysis centers have been established all over Nigeria. Most of these centers are in public health facilities operated by governments (state or federal). A few are run by private organizations, mainly in commercial cities. Even though these dialysis centers are now available in Nigeria, they are mostly in urban cities and are bedeviled with several problems. These problems include frequent breakdown of machines, lack of spare parts, power outage, industrial actions, and lack of well-trained technicians to handle these maintenance challenges.[5]
The cost of maintenance of hemodialysis is enormous for both individuals and governments and is beyond the reach of many individuals and families. Loss to follow-up and mortality arising from complications associated with ESRD are therefore very common in developing countries.[6,7] There have been several calls for governments to support individuals with ESRD so as to relieve the burden of their care from their loved ones.[8,9] Nigeria's health insurance policy currently supports only six sessions of hemodialysis. In response to persistent appeals to corporate organizations and governments, some organizations have started responding to calls to assist in supporting patients with ESRD by subsidizing their cost of treatment or partnering with governments to operate dialysis centers.
Over 100 performance indicators have been proposed to assess the performance of dialysis centers.[10,11] Bodies that proposed these indicators include the National Kidney Foundation's Kidney Disease Improving Global Outcomes guidelines, Dialysis Outcome Practice Patterns Study program Guideline, European Best Practices Guidelines, and the Centers for Medicare and Medicaid Services data set, among others. These indicators have been categorized into four main categories: structure, process, surrogate outcome, and outcome indicators.[10,12] NephroQUEST, for example, included time on hemodialysis, survival on dialysis, and graft survival of kidney transplants as quality outcome variables. Other measures that have been used to assess the performance of renal centers include sustained service delivery, outcome of dialysis, in terms of survival and transplant rate, quality of life of patients while on dialysis, hospitalization rate, and dialysis center audits.[10] It should however be noted that there is no perfect dialysis care quality indicator, as each has its advantages and disadvantages. In fact, Carlos et al.[13] have questioned the validity of some indicators due to a lack of clear definition and established targets.
Some of these indicators have been used to compare the performance of dialysis centers. Szczech et al.,[14] for example, compared the performance of 2685 for-profit versus 1018 not-for-profit dialyses centers. The study showed that more patients in the for-profit dialysis centers met some clinical benchmarks (urea reduction ratio, hematocrit, Albumin, and transferrin saturation) compared to not-for-profit dialysis centers and they also dialyzed a larger volume of patients, but there was no difference in survival among the two groups.
It is on this background that we compared some performance indicators of SHS center with four other dialysis centers in Sokoto, Kebbi, and Zamfara States, all operating as purely public facilities.
MATERIALS AND METHODS
Study site and partnership details
The SHS was established in 1945 and has been a tertiary health center since its inception. It has over 20 relevant departments and is maintained by the state government. It had earlier trained three doctors, eight nurses, and two technicians with the intention of commencing dialysis. Dialysis however started only after the MTN Foundation took over the dialysis center.
MTN is a private mobile telecommunication provider based in South Africa but with subsidiaries in Nigeria. As part of its corporate social responsibility, MTN advertised for the expression of interest from renal centers in Nigeria to partner with the company to support renal patients. SHS applied, competed with other renal centers, and was finally chosen as one of the beneficiaries of the MTN intervention among the over 20 renal centers that were supported.
MTN and ADCEM Health care signed a memorandum of understanding with the management of SHS in May 2011 with the view of providing regular hemodialysis. Under the agreement, the MTN Foundation provided three dialysis machines, a complete water treatment plant and two reverse osmosis machines. The Foundation also renovated the dialysis center, provided an administrative officer, and paid for all the consumables and supplies required to maintain the dialysis center. The funds generated from the dialysis were used to pay for all maintenance cost for the dialysis machines and the water treatment plant. The contract for the supply of the consumables was awarded to ADCEM Healthcare, a private dialysis consumables supplier and maintenance expert. The MTN Foundation also subsidized the cost of each dialysis session for all patients by 50%.
The Sokoto State Government was tasked with the responsibility of supplying the workforce and utilities for the center. The state government additionally offered to pay the balance of fifteen thousand Naira (N15000, equivalent to $34) for each patient who could not afford to pay the 50% cost of dialysis. All funds generated were deposited in a joint account managed by the hospital and the supplier. All other expenses associated with laboratory support, hospitalization, and medications were borne by the patients. The agreement was for an initial period of 4 years that could be renewed based on satisfactory performance. This was renewed after the first 4 years of operation.
The other centers compared with the MTN center are the renal centers of Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto; Federal Medical Center (FMC), Birnin Kebbi; Sir Yahaya Memorial Hospital, Birnin Kebbi; and Ahmad Sani Yariman Bakura Hospital, Gusau. They are all tertiary hospitals, but UDUTH has the added advantage of being a teaching hospital and has over 650-bed capacity. The centers are accessible to each other within a 300 Km radius. Patients assessing dialysis service in all these centers pay for service as out-of-pocket expense.
Data collection
This is a multicenter prospective study. Renal center data collected included the year of commencement of hemodialysis, number of hemodialysis machines, number of reverse osmosis machines at the time of commencement of the study, cost of the first session of hemodialysis, number of months with service interruption, and the number of doctors, renal nurses, and technicians operating the center. All records of patients seen in the five renal centers were collected over the 6-year period (between May 1, 2011, and April 30, 2017). Data collected included age, sex, the total number of sessions done per patient, duration on dialysis, and outcome. The outcome of interest was kidney transplant, death, or loss to follow-up for the patients. None of the five renal centers had a transplant program during the review period. All patients who were ready for transplant were referred to other centers with transplant facilities, either within or outside the country. The total number of dialysis sessions was categorized into those who had three or fewer number of dialysis sessions versus patients who had more than three sessions of dialysis. Most of the patients in the five centers were routinely discharged after receiving the first three sessions of hemodialysis and with evidence of clinical improvement. Duration on dialysis was categorized into those that spent <90 days and those that spent more than 90 days on dialysis. Ethical clearance was obtained from the ethical committees of the respective hospitals.
Statistical analysis
All statistical analyses were performed using the IBM SPSS statistical software for Windows, version 23 (SPSS Inc., Chicago, IL, USA). All continuous variables were tested for normality using the histogram with normality curve as well as the Kolmogorov–Smirnov test. Normally distributed continuous variables were expressed as means (with standard deviation) and skewed variables were presented as medians (with interquartile ranges [IQRs]). Categorical variables were expressed as frequencies and percentages. The baseline characteristics were compared between the groups using the Chi-square test for binary categorical variables. P < 0.05 was considered statistically significant.
RESULTS
A total of 1167 patients were managed in the five renal centers, of which 252 (21.6%) were dialyzed at the Specialist Hospital's renal center. Table 1 shows the baseline characteristics of the five hospitals. Overall, the mean age of the patients was 42.9 ± 16.8 years, of which 69.2% were male. UDUTH had the highest number of patients, with 584 (50.1%) being managed during the study period. UDUTH commenced dialysis 4 years before the MTN center. The cost of hemodialysis was comparable between the centers, even though the MTN center had subsidized the cost of treatment of its patients by 50%. UDUTH also had a larger (650) bed capacity. The overall median duration on dialysis was 8 (IQR 4–9) days. The overall median number of sessions for all patients was three (IQR 2–6) sessions. UDUTH had the best workforce to run the center, with six doctors and 14 nurses. Sir Yahaya Hospital had the highest number of dialysis machines.
Table 1.
Baseline characteristics of the renal centers
| Variables | All patients | Specialist | UDUTH | FMC | Yarima | Sir Yahaya |
|---|---|---|---|---|---|---|
| Total number of patients treated, n (%) | 1167 (100) | 252 (21.6) | 584 (50.0) | 144 (12.3) | 119 (10.2) | 68 (5.8) |
| Age, mean (SD), years | 42.9 (16.8) | 42.1 (16.5) | 43.8 (17.3) | 44.1 (15.9) | 39.3 (17.1) | 42.3 (14.5) |
| Sex, n (%) | ||||||
| Male | 807 (69.2) | 177 (70.2) | 407 (69.7) | 96 (66.7) | 74 (62.2) | 53 (77.9) |
| Female | 360 (30.8) | 75 (29.8) | 177 (30.3) | 48 (33.3) | 45 (37.8) | 15 (22.1) |
| Duration on dialysis, median (IQR) (days) | 8 (2-33) | 8.5 (1-50.25) | 9 (3-31) | 6.5 (1-15.5) | 9 (4-50) | 5.5 (1-28) |
| Number of dialysis sessions, median (IQR) | 3 (2-6) | 3 (1-7.5) | 3 (2-6) | 2 (1-4) | 3 (3-9) | 2 (1-3) |
| Year commenced hemodialysis | 2011 | 2007 | 2010 | 2014 | 2014 | |
| Cost of the first dialysis session, n (‘000) | 30a | 23 | 20 | 18 | 18 | |
| Hospital bed capacity | 380 | 650 | 300 | 150 | 200 | |
| Number of doctors | 3 | 6 | 3 | 3 | 3 | |
| Number of nurses | 8 | 14 | 5 | 4 | 5 | |
| Number of technicians | 1 | 2 | 1 | 2 | 1 | |
| Number of hemodialysis machines | 3 | 5 | 3 | 4 | 6 | |
| Number of reverse osmosis machines | 2 | 3 | 1 | 2 | 1 |
aMTN subsidized the cost by 50% per session, translating to N15,000 direct cost to patients. IQR=Interquartile range, UDUTH=Usmanu Danfodiyo University Teaching Hospital, FMC=Federal Medical Center, SD=Standard deviation
Overall, 1014 (86.9%) patients had <90 days of dialysis therapy before they either died or were lost to follow-up [Table 2]. Only 38 (15.1%) Specialist Hospital's patients remained on dialysis beyond 90 days. When the data for Specialist Hospital was compared with a pool of all the patients in the four public hospitals, there was no statistically significant difference in the patients who lived beyond 90 days on dialysis (χ2 = 1.09, df 1, P = 0.30). Comparison of the duration with individual hospitals [Table 3], however, showed that Sir Yahaya and FMC hospitals had significantly poor performance when compared to Specialist Hospital with only 6 (8.8%) and 16 (11.1%) patients remaining on dialysis beyond 90 days (χ2 = 29.06, df = 4, P < 0.001).
Table 2.
Distribution of patient characteristics by hospital type
| Variables | Total patients, n (%) | Service type | Test of significance (χ2, P) | |
|---|---|---|---|---|
|
| ||||
| PPP center, n (%) | Public Hospitals, n (%) | |||
| Duration on dialysis (days) | ||||
| ≤90 | 1014 (86.9) | 214 (84.9) | 800 (87.4) | 1.09, 0.30 |
| >90 | 153 (13.1) | 38 (15.1) | 115 (12.6) | |
| Number of dialysis sessions | ||||
| ≤3 | 679 (58.2) | 147 (58.3) | 532 (58.1) | 0.003, 0.96 |
| >3 | 488 (41.8) | 105 (41.7) | 383 (41.9) | |
| Number of transplants | ||||
| Transplanted | 16 (1.4) | 1 (0.4) | 15 (1.6) | 2.26, 0.13 |
| Not transplanted | 1151 (98.6) | 251 (99.6) | 900 (98.4) | |
Table 3.
Clinical characteristics of patients attending the renal centers
| Variable | Renal centers | ||||||
|---|---|---|---|---|---|---|---|
|
| |||||||
| Total | Specialist | UDUTH | FMC | Yarima | Sir Yahaya | Test of significance (χ2, P) | |
| All patients, n (%) | 1167 (100) | 252 (21.6) | 584 (50.1) | 144 (12.3) | 119 (10.2) | 68 (5.8) | |
| Duration on hemodialysis (days), n (%) | |||||||
| ≤90 | 1014 (86.9) | 214 (84.9) | 511 (87.5) | 128 (88.9) | 99 (83.2) | 62 (91.2) | 29.06, <0.001 |
| >90 | 153 (13.1) | 38 (15.1) | 73 (12.5) | 16 (11.1) | 20 (16.8) | 6 (8.8) | |
| Number of dialysis sessions, n (%) | |||||||
| ≤3 | 679 (58.2) | 147 (58.3) | 310 (53.1) | 105 (72.9) | 65 (54.6) | 52 (76.5) | 29.06, <0.001 |
| >3 | 488 (41.8) | 105 (41.7) | 274 (46.9) | 39 (27.1) | 54 (45.4) | 16 (23.5) | |
| Number of transplants, n (%) | |||||||
| Transplanted | 15 (1.4) | 1 (0.4) | 11 (1.9) | 0 (0) | 4 (3.4) | 0 (0) | 9.34, <0.53 |
| Not transplanted | 1152 (98.6) | 251 (99.6) | 573 (98.1) | 144 (100) | 115 (96.6) | 68 (100) | |
| Regularity of dialysis | |||||||
| F, months, n | 67 | 70 | 57 | 36 | 20 | 35.06, <0.001 | |
| NF, months, n | 5 | 2 | 15 | 3 | 12 | ||
| T, months, n | 72 | 72 | 72 | 39 | 32 | ||
| Success rate (F/T), (%) | 93.05 | 97.22 | 79.16 | 92.31 | 62.50 | ||
| Deviation from benchmark | 0.00* | +4.17# | −13.89 | −0.74 | −30.55 | ||
*Benchmark Hospital, #UDUTH surpassed the benchmark. F=Functioning, NF=Not functioning, T=Total, UDUTH=Usmanu Danfodiyo University Teaching Hospital, FMC=Federal Medical Center
A total of 679 (58.2%) patients had three or fewer number of dialysis sessions [Table 2]. Only 105 (41.7%) Specialist Hospital's patients had more than three dialysis sessions. Comparing these data with all the public hospitals’ pool did not reveal any significant difference in the number patients with more than three sessions of dialysis (χ2 = 0.003, df = 1. P = 0.96). A comparison with the individual hospitals [Table 3] however clearly showed that more patients at Specialist Hospital received more dialysis sessions compared to patients at Sir Yahaya and FMC hospital (χ2 = 29.06, df = 4, P < 0.001).
In terms of kidney transplant, only one (0.4%) patient from Specialist Hospital had a kidney transplant [Tables 2 and 3]. Comparison of these data with the pool of public hospitals [Table 2] did not reveal any significant difference in the transplant rate (χ2 = 2.26, df = 1, P = 0.13). Comparison of Specialist Hospital's data with the individual hospitals [Table 3] showed that UDUTH had the best transplant rate (1.9%), but this was not statistically significant (χ2 = 9.34, df = 4, P < 0.53). Sir Yahaya and FMC Hospitals did not refer any patient for transplant.
In terms of dialysis service availability, UDUTH had the best service delivery during the review period, with only 2 months of interruption in service delivery (equivalent to 97.22% service delivery) [Table 3]. This exceeded Specialist Hospital's service delivery rate of 93.05%. MTN center clearly outperformed FMC and Sir Yahaya Hospitals.
DISCUSSION
Our study showed that under the prevailing conditions, PPP in hemodialysis delivery enhances service availability and gives patients access to have a greater number of hemodialysis sessions and longer duration of hemodialysis service compared to some purely government-operated renal centers. It however does not improve transplant rate.
It is also clear that UDUTH, a public facility, attended to a higher number of patients. This is not too surprising as it is a training center and has more bed capacity and more specialties that can contribute to the pool of dialysis patients. UDUTH also started hemodialysis 4 years earlier than the Specialist Hospital. Both centers are located in the same city and are located within 15 km of each other. PPP therefore does not necessarily attract the highest number of patents. There are several factors that influence patients’ choice of a renal center. These include access, distance, cost, expertise of the personnel, facilities available at the center, referral, availability of other ancillary services, and family influence.
For patients remaining on dialysis beyond 90 days, the performance of Specialist Hospital is clearly better than FMC and Sir Yahaya Hospitals. UDUTH and Yarima Hospitals had similar duration on dialysis compared to Specialist Hospital. Many factors are known to influence the duration on hemodialysis. These include affordability of dialysis, time of presentation, dialysis adequacy, availability of sponsors, presence of comorbidities, efficiency of the center, ability to travel, family support, age, number of available dialysis machines, adequacy of the dialysis, kidney transplant uptake, loss to follow–up, and death.[15,16,17,18,19] The poor 90-day survival of patients in the Specialist Hospital (84.9%) is similar to the findings of other studies in Nigerian public dialysis centers,[9,20,21,22] but it is higher than the findings of Chijioke et al.[23] (66.7%) and Ifeoma and Chinwuba[24] (66.1%) in Ilorin and Enugu, respectively.
The patients dialyzed at Specialist Hospital clearly outperformed Sir Yahaya and FMC in terms of number of sessions of hemodialysis. All the factors that affect duration on dialysis could also affect the number of dialysis sessions received by a patient.[25,26] During the review period, FMC Birnin Kebbi had challenges with dialysis supplies, whereas Sir Yahaya Hospital had a faulty reverse osmosis machine that interrupted dialysis service. These are issues that could be sorted out with proper financing and elimination of bureaucratic bottlenecks in the public procurement process. The poor performance of Specialist Hospital also compares with the findings of Ifeoma and Chinwuba[24] with 77.9% 0f their patients receiving only 1–5 sessions of hemodialysis.
UDUTH had the best transplant rate. This is not surprising as the Hospital had experienced professionals with the expertise to counsel as well as win the confidence of patients and convince their donors and family members to accept the option of a kidney transplant. It also has the expertise to properly follow-up these patients after the kidney transplant. Yarima Hospital also performed better than the MTN center in terms of referring patients for transplant. This implies that private sector driven dialysis does not necessarily translate to a better transplantation rate. However, it should be noted that there are other factors that affect transplant uptake by individuals or a center. Such factors include age, cause of renal disease, affordability, availability of donor, access to the transplant center, adequate counseling of donor and recipient as well as the presence of comorbidities in the recipient.[27,28,29] The poor transplant rate of these centers is comparable to many centers in Nigeria.[9,21,24] This is due to a lack of government support for transplant patients.
Overall, dialysis service was more regular at UDUTH, with only 2 months of interruption in its service. This is fairly comparable to the MTN Center and Yarima Hospital. The centers clearly outperformed Sir Yahaya and FMC Hospitals in terms of availability of service. In virtually all the centers, service interruption was either due to machine failure, shortage of consumables, or industrial action by the hospital staff.
Our study has its limitations. The choice of centers to compare with the MTN Center was based on convenience as they are closer to the study center. The results may therefore vary if other centers were included in this study. Its small sample size may also not reflect the very wide center variabilities if more centers were involved in the study. Other clinical confounding factors such as family income and comorbidities that could have influenced the outcome of this study were also not assessed in this study.
CONCLUSION
Despite its shortcomings, these data showed that PPP run renal center is reliable in terms of regular access to service delivery when compared to some government-operated hospitals. This is because it is free of the bureaucracy that characterizes public sector management with issues related to maintenance and supplies. This finding is similar to the findings of Ozgen et al.[30] who also noticed a similar trend when they compared government-operated centers with for-profit renal centers in the USA. However, this should be regulated well so that profit should not be the primary motive for the venture as studies have shown that mortality in private for-profit dialysis centers is higher than in private not-for-profit private dialysis centers.[31]
In the absence of a national maintenance hemodialysis program as proposed by Okpechi et al.,[8] there is a need to encourage more PPPs in the delivery of hemodialysis service as this will hopefully provide succour to our teaming ESRD patients requiring hemodialysis. A detailed assessment of the government-operated renal centers is also needed to determine how their efficiency can be improved.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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