Editorial: RRT in South Africa – and the relevance of Registries

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In this issue of Nephrology, van Biljon and Karusseit report on the details of Renal Replacement Therapy (RRT) in a paediatric cohort (age < 14 years) based on the South African Renal Registry (SARR).1 There are several aspects that make this publication remarkable, both with respect to South Africa and more broadly.
The previous SARR ceased to exist in 1994 after the introduction of a new government. In 2010, the SARR was revived, and in 2012 the first report became available. The reports highlight the importance of an organized national data collection for provision of RRT on a sustainable and equitable basis. Provision of basic incidence, prevalence and outcome data is a critical first step towards a coordinated approach to the national demand for RRT. Such data not only outline the overall RRT incidence but also serve to provide valuable information on the differences between various communities as well as existing facilities, treatment capabilities and outcomes.
In terms of economics, South Africa is a middle‐income state, with a per‐capita GDP of $US 13 200 in 2015. About 80% of the population are black African; the remaining 20% comprise white, colored and Indian groups. The situation is complicated by the division of health care in South Africa into public and private health systems. The public system is tasked to provide for a population of ~45 million while the private system provides for ~9 million citizens. Approximately 30% of the population represent children <14 years of age. Access to the private health system is complex and (inter alia) determined by affordability, accessibility (geographic proximity) and availability. While accessibility and availability can be problematic particularly in rural areas, affordability poses the main obstacle. The legislation of private health insurances is also complex: The government legislator compels the private health providers to offer RRT to all its members; however, the same standard of care is not applied to the rest of the population that cannot afford to make additional financial contributions for their health care. Furthermore, each of the nine Provinces within South Africa receives a budget and determines relatively independently how to allocate resources for their public health service. At a local level, Assessment Committees within the hospital networks control access to the RRT programmes, within a framework of provincial guidelines.
The overall RRT incidence differs substantially between those eligible for the public versus private systems. For those eligible for treatment in the public system, the point prevalent RRT rate was 73 per million on 31 December 2014; for the private system, the corresponding rate was 716 per million.2 Given that the incidence of ESKD is likely to be similar in these groups, the immediate implication of this is that there is a substantial difference in access to RRT between those in the public versus private systems in South Africa.
The SARR data from 2012 makes for interesting reading as it highlights that rates and therefore access to RRT in children are equally distributed between members of the public and private system, in contrast to the situation among adults. The RRT rate of 3.8 per million age related population is similar in both groups. However, the private system appears to be providing (arguably) better care with a much higher rate of automated peritoneal dialysis and renal transplantation. The reasons for this imbalance appear to be multi‐factorial and anecdotally are not just funding related but also related to administrative issues in the sector including reports of corruption.3
Although children <14 years of age represent almost a third of the population, their access to RRT is severely underrepresented compared with the adult population.
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