End Stage Renal Disease (ESRD) is a seriuos disease that has adverse health and economic burden (1-4). The treatment of ESRD is expensive, and the high cost of treatment has a substantial effect on patients, their families as well as the healthcare system (5-7). Patients with ESRD require Renal Replacement Therapy (RRT) to stay alive(8). The RRT involves two modalities, Dialysis; whether peritoneal dialysis (PD) or hemodialysis (HD) and Renal Transplantation(9). With RRT, HD is the preferred modality as compared to PD, particularly in African countries(10, 11).
Globally the number of patients with ESRD who receive HD is increasing. In 2004 a study revealed that the number of patients on dialysis is growing annually by 7% (7). In the same study, the global prevalence of patients treated by dialysis was estimated to be 190 patients per million population (PMP).In Africa, the prevalence was 65 PMP. Based on these statistics, the dialysis population was expected to exceed three million patients by the end of the year 2016. Glomerular diseases, hypertension, and diabetes mellitus are driving factors of ESRD cases (2, 12). In Sudan, hypertension is the leading cause of ESRD, followed by glomerular diseases and diabetes mellitus(13, 14). Variation exists between countries in the number of patients who treated with HD; for instance, in 2007 the numbers of HD patients in Sudan, Egypt, and South Africa were 2,750, 33,000, and 2,450 respectively(10). With rising numbers of HD patients, more patients and families need to spend out of their pockets. With a population of approximately 39 million distributed across Sudan’s 18 states (15)ESRD is a common health problem(10, 11, 13, 14, 16); however the true prevalence of ESRD is unknown. In total, there are 51 HD centers in Sudan, 21 being located in Khartoum state, including Ibn Sina Hospital Dialysis center that was established in 1985(11). ESRD patients on an average undergo two sessions of HD per week (16). Data from Sudan indicated that prevalence of ESRD patients increased from 90 PMP in 2009 (16)to 205 PMP in 2013 (Sudan National Center for Kidney Diseases and Surgery database).
In Sudan, HD related expenditures shared between the government, the patients, and patients’ families (16). The government through the National Center for Kidney Diseases and Surgery is responsible for funding the HD centers’ development and operational aspects such as staff salaries, and consumables (i.e., dialyzers, solution, and dialysis' lines). Out-of-pocket (OOP) expenditure has direct consequences for patients, their families, and the government, as they need to mobilize more resources; however, it has been shown to improve accessibility and availability of treatment (5, 6). In comparison to PD, the cost of HD is relatively less (10, 17). The OOP HD spending incurred by the patients and their families includes direct medical and direct none-medical expenditure, and they include payment made on consultations, lab tests, hospitalization, medication, transport, food, and accommodation change (18, 19). The indirect cost includes loss of working days, and in tangible cost such as pain, among others.
Furthermore, in Sudan, OOP HD spending may be difficult for patients and families to meet for numerous reasons. First, there is a high rate of unemployment among HD patients (13, 20). Secondly, HD treatment is usually long-term due to low renal transplantation rates (16). Thirdly the ESRD is generally associated with comorbid conditions (21) and that patients with comorbidities have higher expenses rates compared to their counterparts(22).In India, where governmental funds for dialysis are limited, patients incur high burdened with the cost of treatment and studies have shown that some patients discontinued treatment because they could not afford it(18, 23, 24).
A large proportion of the population of Sudan (46%) lives below the poverty line(25). Hence OOP HD expenditure accentuates the economic burden and financial hardships of patients and households. In 2013, the Gross Domestic Product (GDP) per capita was found to be US$3,265 (25) in Sudan, and the OOP HD expenditure on health was estimated to be 78.9%(15) which is significantly high compared to other countries. In such a context, HD spending has many consequences ranging from the discontinuation of and non-compliance with HD treatment to the impoverishment of patients and households(23, 26). The majority of ESRD patients who undergo HD are enrolled in the Social health insurance scheme. However, patients need to pay or to share payments for some services. A study from China showed that insurance might not prevent patients from being impoverished (27). Available studies in Sudan have not explored OOP HD spending from patients’ perspective, apart from a study that investigated the overall cost of HD(14). Therefore, this study aims to explore the OOP spending of HD patients on direct medical and non-medical expenditure and to predict OOP expenditure from their socio-demographic characteristics, comorbidity, insurance status, and accommodation change. The results of this study may reflect the suffering of the Patients and their families to be put into consideration and policy maker to set economics and non-economic mitigation polices.