5 Nov 2019

Pradhan Mantri National Dialysis Programme (PMNDP)

Source: The Hindu

Manifest pedagogy: Health as topic must be studies from two dimensions 

  1. Governance
  2. Science aspects

As an illustration, one can see that the topic below consists of both. The programme is governance part and the disease has science aspects .

Governance is focused on more in Mains and Science in Prelims 

In news: Health Ministry has released guidelines for establishing peritoneal dialysis services under the PMNDP.

Placing it in syllabus: Health sector (explicitly mentioned)

Dimensions:

  • Features of the programme
  • Guidelines for peritoneal dialysis services 
  • Hurdles to PD
  • Importance 

Content:

Features of PMNDP:

  • Was rolled out in 2016 as part of the National Health Mission(NHM) for provision of free dialysis services to the poor
  • It is implemented in Public Private Partnership (PPP) mode.
  • Every year about 2.2 Lakh new patients of End Stage Renal Disease (ESRD) get added in India resulting in additional demand for 3.4 Crore dialysis every year.

There are two types of dialysis: hemodialysis and peritoneal dialysis.

Hemodialysis: In HD, the blood is filtered through a machine that acts like an artificial kidney and is returned back into the body. HD needs to be performed in a designated dialysis centre. 

Peritoneal dialysis (also known as water dialysis): In PD, the blood is cleaned without being removed from the body. The abdomen sac (peritoneum lining) acts as a natural filter. A solution (mainly made up of salts and sugars) is injected into the abdomen that encourages filtration such that the waste is transferred from the blood to the solution then is drawn back out of the body and discarded.

PPP for Hemodialysis services:

  • As per the guidelines, the private partner is to provide medical human resource, dialysis machine along with Reverse Osmosis (RO) water plant infrastructure, dialyzer and consumables.
  • The space, power, and water supply within District Hospitals is to be provided by the State Government.
  • Currently, under NHM 100 % of the service procedure fees for patients from below poverty line (BPL) economic group is covered.
  • Non BPL patients would have the benefit of accessing the services close to the community at the district hospitals at the same rate as paid by the Government for the BPL patients.
  • However, for BPL families registered under Rashtriya Swasthya Bima Yojana (RSBY), the cost of dialysis care shall be catered through RSBY funding up to its maximum coverage.

Guidelines for peritoneal dialysis services:

The Ministry of Health and Family Welfare has come out with a set of guidelines for establishing peritoneal dialysis services under the PMNDP which serve as a comprehensive manual to states that intend to set up peritoneal dialysis services.

  • Reducing procurement costs like local production of PD solution bags, abolition of statutory duties on PD supplies and bulk procurement of PD supplies.
  • Unique survival on PD so that patients are not forced to transition to HD by developing a trained cadre of PD providers at all levels (physicians, nurses, clinical coordinators, etc)
  • Measuring and monitoring quality indices and implementing corrective steps in a timely manner.
  • With rare exceptions, all End stage kidney failure (ESKF) patients are suitable for PD. 

Generally acceptable patients are: 

    • Age <= 60; 
    • With residual renal function; 
    • Adults without significant associated comorbidities; 
    • Patients with a functional peritoneum and no recent history of major abdominal surgery; 
    • Children with adequate home-support; 
    • House with space to store PD supplies, adequate water supply and dedicated space for undergoing PD.
  • The initial decision to start a patient on dialysis can be made by a nephrologist or a physician with appropriate training. 
  • In order to increase the reach of PD, states could consider either providing PD in PHC, CHC and DH, for those who live close to these facilities. Home Based PD could be considered for those who meet the criteria.
  • Providing training to community health workers (ANM, MPW, ASHA) to provide support to persons on peritoneal dialysis at home or in primary healthcare settings.
  • The drugs and diagnostics are to be provided free of cost to the patients under Free drugs programme and Free diagnostic service initiative. 

Hurdles to PD:

  • Place of residence may not permit PD
  • Previous major abdominal surgeries
  • Morbid obesity
  • Large abdominal wall hernias
  • Abdominal walls conduits
  • Large abdominal aortic aneurysms
  • Severe visual impairment or poor manual dexterity
  • Lack of caregivers at home

Importance of new guidelines:

A population-based study has determined the age-standardised incidence of ESKF in India to be around 225,000 people (2006). With approximately 4950 dialysis centres, largely in the private sector in India, the demand is less than half met with existing infrastructure.

Now PMNDP has been expanded to include peritoneal dialysis. This move will instantly benefit 2 lakh Indians who develop ESKF every year in India.

The new guidelines issued aims to 

  • achieve equity in patient access to home-based peritoneal dialysis,
  • reduce the overall cost of care to the system by focusing on efficient leveraging of resources,
  • bring in consistency of practice, pricing and a full range of product availability,
  • reduce the demands placed on the healthcare system and offers patient autonomy.