How South Africa rations dialysis

ProPublica’s Sheri Fink, M.D., went to South Africa, where panels in hospitals still decide which patients deserve the scarce dialysis treatments and which must be left with failing, untreated kidneys. Fink was in the room as the assembled physicians gave the final approval or denial, and when they expressed their bitterness that hospital executives required folks on the medical side to make what were, essentially, cost-control decisions. The costs, after all, are not negligible.

In South Africa, only the roughly one out of five patients who have a form of health insurance or the small proportion of patients who can afford pay are able to get dialysis at private clinics or hospitals based on medical need alone. The cost of paying out of pocket—about $20,000 per year— is nearly double the gross domestic product per capita.

Probably in the middle of the last decade we were turning away 50 percent of the patients,” said Dr. Rafique Moosa, a kidney specialist at Tygerberg Hospital and head of the Department of Medicine at the University of Stellenbosch. According to him, as of August they were turning away 80 percent, and in November, only two out of 20 patients were accepted. “We just don’t have the resources to deal with the patients,” Moosa said..

Until relatively recently, there weren’t any formal guidelines for rationing dialysis care, an omission which opened the door for broad racial disparities.

The new general guidelines were drawn up by medical ethicists and emphasize medical criteria, which Fink reports on. It’s a carefully chosen set of criteria, but the enormity of the medical shortage gets in the way of neat formulae like those, Fink writes.

The problem is, few actually are able to get transplants. There are far more good medical candidates than there are dialysis slots. Therefore, the committee falls back on subjective criteria—does the patient seem motivated? Does he or she have a good social support network?

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