With the dialysis patients being spread disproportionately across metropolitan and Tier-II/III towns, the need for new dialysis centers is on the rise.

With over 200,000 new end-stage renal disease (ESRD) patients being added to the disease burden each year, India offers dialysis providers and equipment manufacturers enormous growth potential. As the respective state governments take note of the situation, public private partnerships (PPPs) will become more prevalent in the coming years. Growth prospects are higher for private dialysis providers as they begin to expand their chain of dialysis centers across major metropolitan and Tier-I cities. However, with a disproportionate growth of dialysis centers between metro and non-metro towns, accessibility and affordability issues may remain.

Market Dynamics

The total number of patients undergoing hemodialysis (HD) in India is expected to grow at about 15-20 percent each year till 2018. With the dialysis patients being spread disproportionately across metropolitan and Tier-II/III towns, the need for new dialysis centers is on the rise. While developing countries such as Mexico and Thailand have employed a PD First policy to promote peritoneal dialysis, India does not support PD (peritoneal dialysis) as a first line of RRT. The number of patients undergoing PD in India has increased moderately in the past 3 years. However in India, PD as a first-line modality for RRT is not accepted as yet. This can be attributed to less favorable government policies toward PD and lack of awareness among patients as well as doctors.

Indian dialysis equipment market is expected to reach Rs.1836 crore in 2018. HD machines represent the largest product category, followed by dialyzers. While global companies such as Fresenius, Baxter, and B. Braun are market leaders in India, there is a gradual influx of Chinese and local manufacturers in the Indian market. Driven by the need for cost-effective dialysis sessions, the number of public-private partnerships (PPPs) is on the rise. New corporate dialysis centers are looking to capitalize on this opportunity and expanding through inorganic growth through acquisitions of in-hospital dialysis centers.

Of the total dialysis centers operational in India, 29 percent are concentrated in the metropolitan cities. There exists a stark contrast in the services offered and the mode of operation of dialysis centers in non-metro towns as compared to metropolitan cities. These centers are typically characterized by major cost-cutting measures, and operational streamlining efforts to offer cost-effective dialysis. Corporate chain dialysis centers position themselves as facilities with high-end infrastructure and value-added services for their dialysis patients. Such corporate groups are looking for expansion to non-metro cities by acquiring in-hospital dialysis centers that may be typically running to moderate-to-low profits. In-hospital dialysis centers possess some innate strengths including ability to serve critical renal failure patients due to the availability of ICUs. However, there may be compromised infection-control protocol in such centers due to budget restrictions.

In-hospital dialysis centers are most prevalent types of dialysis centers in non-metro towns catering to middle- and lower-middle socio-economic class. Optimizing operational cost and reducing additional frills in order to pass on cost benefit to the patients continues to take precedence. Owing to shortage of nephrologists in non-metro towns and absence of clinical guidance at most in-hospital dialysis centers, nephrologist-owned in-hospital dialysis centers are being established.

Frequent niggles with the machine and absence of prompt servicing protocols are the most common challenges faced by dialysis technicians. As indicated by the technicians, manual wash of dialyzers and blood tubing sets often increase their workload, hampering them from providing personal assistance to the patient and updating their knowledge and capability. Inadequate training and clinical knowledge of the technician has been a key challenge voiced by many nephrologists and patients in non-metro towns. In addition to the high cost of dialysis, many patients believe that the quality of dialysis provided is sub-standard. Moreover, technical knowledge of the technician, lack of empathy and compassion, delay in appointments, and absence of clinical support during dialysis are indicated to be a few major concerns by many patients.

Government Initiatives

The Union Budget has given a high impetus to the most neglected sector of the country by launching the National Dialysis Program and waiving duty from certain parts of dialysis equipment to boost indigenous manufacturing. The dialysis program aims to have a dialysis center in each district using the PPP model having the potential to become competent to the US Medicare ESRD program. The provision for necessary infrastructure in the hospitals in each district to be able to run a dialysis center, trained staff, dialysis machines, water treatment plants, personnel to maintain dialysis equipment, and nephrologists to be able to prescribe and manage the patients has been planned.

To make the dialysis procedure affordable, Maharashtra state government has recently exempted dialysis machines, consumables, and drugs used commonly by dialysis patients from all taxes. Earlier, the drugs used for dialysis attracted 5 percent VAT in the state while medical equipment were sold with a VAT ranging between 5 and 12.5 percent which made the procedure expensive.

Andhra Pradesh state government has started innovative public-private-partnership for maintenance hemodialysis (MHD) treatments. The project was started on BOOT model (build, own, operate and transfer model) and awarded to B. Braun Medical India through a tendering process.

Bihar state government has also partnered with B. Braun Medical India to start dialysis clinics in the state. These clinics will be set up in medical colleges and district hospitals under public private partnership.

Government efforts to make the dialysis care affordable for the patients will provide an array of opportunities for dialysis equipment manufacturers in India.

Future Outlook

The aim to focus on quality instead of quantity should be met with the help of government initiatives and private companies to enable the masses to get access to quality dialysis services. The need for public and private intervention in order to enhance access to dialysis care and to bridge existing gap in demand and supply and additionally addressing need to manage the dialysis centers need to be understood.

The dialysis centers under public-private partnership will provide world-class dialysis facilities to the patients at much affordable prices than the prevailing rates and will also reduce the travel of the patients significantly. The hemodialyzers developed in India, once commercialized, can equip India with the technology to not only sustain itself in field of dialysis, but also project itself as a major exporter of such hemodialyzers to South-East Asian countries, Africa, and South America.

Efforts are also on to make an end-to-end solution for dialysis by Renalyx and IIT Kharagpur. Another important measure that would go a long way to alleviate the problems faced by dialysis patients would be increasing the exemption on medical expenses from income tax as patients have to pay tax even on the amount spent on dialysis sessions and associated expenses. The government must make a clear distinction between healthcare expenses and expenses on luxuries. The eventual goal should be to provide a system that not merely provides dialysis but also provides better quality of lives for patients with ESRD in India.

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