« I know what dialysis costs patients« https://www.nhs.uk/tests-and-treatments/dialysis/
other issues that can arise. He may have associated tuberculosis, so it’s important to get it checked. And if he does have tuberculosis (which is free, editor’s note), he needs to see a tuberculosis specialist; that consultation costs money. And now, after all that, there’s the entire assessment process, and then there’s the treatment. And the treatment comes in two types. There’s the treatment given during dialysis and the treatment given outside of dialysis. Even the treatment given during dialysis is paid for by the patient. What do they give during dialysis? Iron. Because most patients with this condition, about 90%, have anemia, meaning their blood levels are low, and this anemia needs to be corrected. They either pay for the transfusion, the blood bags for the transfusion.
They either pay for iron or electro-ethyl, and both are expensive. That’s the patient’s responsibility. There are other expensive medications that we use to offset the cost. However, now there are the medications they use outside of dialysis. They have to take antihypertensives because their blood pressure will contribute to the problem. If the patient is diabetic, sometimes the diabetes persists, and they have to pay for their diabetes. If a patient has HIV, they still have to pay for their antiretroviral medication. It’s true that it’s now funded by the state, it’s free, but they still have to go and get it. The cost remains the patient’s responsibility. If a patient needs medication, they have to pay. So, these are the different expense categories. And now, these expense categories, apart from dialysis, which we know costs patients around 15,000, include transfers (depending on where you live), meals (some patients don’t eat at all), and tests (some patients prefer to stay with coughs for months because they can’t afford all the tests, and some patients can’t afford their consultations). I have listed all the existing expense categories, but unfortunately, we often tend to ignore transportation, meals, and sometimes we neglect biological assessments.
What are the positive aspects that the Cameroonian government has addressed in the monitoring, treatment, and management of kidney disease?
The first good point is that there are dialysis centers in almost every region. A few years ago, there weren’t any. Everyone had to go to Yaoundé or Douala to get dialysis, and those centers were overwhelmed. So, the first good point is that dialysis centers are now being decentralized to all 10 regions. So, Ngaoundéré, Yaoundé, Bafoussam, and I believe one has just opened in Ebolowa. So that’s the first good point: the government has understood the need to decentralize dialysis centers, and that’s a major step forward.
The second good point is the price. The first good point is the decentralization of dialysis centers. You can’t imagine, but at the time, there were people who left Bertoua, there were people who came from very far away to come to Yaoundé. They were taking the train. And others were leaving for elsewhere. So, the first good point is decentralization. That’s the big, first good point. The second big point is the cost. At the time, dialysis was very expensive, averaging 520,000 FCFA per year.
Bring it down to 15,000 francs. Perhaps you don’t realize it because dialysis is very expensive. 15,000 francs a year; if you spread it over 12 months, that’s roughly 1,250 francs per month. You see how enormous the cost of a session is.
The third point is that there are also many more nephrologists. And when there are
many more nephrologists, it’s because the government has allowed many more to train locally. The downside of training abroad, like I did, is that you tend to move on to other countries. But when you train locally, you tend to stay because there are local populations waiting for you. As for my own story, before I continue, I was trained in Senegal. What I do, I did in Senegal. I worked in remote areas of Senegal. Normally, I stayed in Senegal. Why didn’t I stay in Senegal? It’s simply that I was fortunate in my career in France; opportunities arose. Positions were waiting for me, even assistant positions. And I worked in remote areas, which was something I was used to.
It’s just that in my career, when I went away for internships, I would come back, then leave again. I had opportunities that made me stay. But when you’re trained somewhere and you have opportunities, you tend to stay. I had one foot in Senegal, not Cameroon. This means that the more training is done locally, the more people tend to stay because, as they’re sent to different regions for internships, they tend to remain there. And all of this is because the government has allowed more nephrologists to be trained locally.
So, these are the three main points I see. First, the decentralization of centers. Second, the cost of dialysis has decreased significantly.
Thirdly, the training of nephrologists is becoming increasingly comprehensive, because it was a bit more complicated back then, and now we’re training more and more people. A fourth, and significant, point is the decreasing cost of medications. And that, too, must be acknowledged.
The price of iron ten years ago and now are completely different. So, that’s why it’s easier to get certain medications now. I’ll tell you how I started my specialization: the retropotins, the injections you hear about, the squatters who inject themselves with PO to make it last. In Cameroon, it wasn’t easy to prescribe this because it was expensive. Now, thanks to the government, there are now cheaper medications available here, like Neroquaman. Back then, we couldn’t find it. Let me give you a simple example. When I did my first internship in France, I didn’t know how to prescribe oral anticoagulation (OAC) because I hadn’t really done it in Senegal since it was expensive. Now, nephrologists who are trained in it already know that it exists and how it works because it’s becoming increasingly cheaper and more accessible for patients. And the last element, and not the least important, is transplantation. It’s available in Cameroon. Transplantation is available in Cameroon. It’s starting to take hold. And those who have had transplants, from what I know, are doing quite well.
What are the prospects you see and contrary to what you said earlier, I find it to be a very good experience to have been trained outside. Because the experience you’ve gained from working in France, the exchanges of experience you have with your compatriots, will make others better. Unlike if you were in France. We’re all young, we say in 15, 20, 30, 40 years. How do you see the dialysis and nephrology services?
It’s about screening. We need to invest in screening, and that’s what I want to do with blood and urine test strips. It’s about screening because if we don’t do this, we’ll face the same problem we’re seeing in Europe right now: a large number of patients are on dialysis, and that’s costing the state a lot of money.
Dialysis isn’t just expensive for patients; it’s also expensive for the government. The amount the government invests in the care of dialysis patients is enormous. And the point is, the whole world is in an economic crisis, which means that savings have to be made. And that’s the solution to everything. Even in Europe, they are now reversing course; they want to put resources into rewarding doctors who detect better cases, rather than those who spend time solving problems that are already established. And I think that’s where screening comes in, because if it’s detected early, we can delay the need for dialysis. If you start dialysis at 100, the duration of dialysis won’t be long, so it will cost less. But the problem we have in Africa is that we have many young people on dialysis, and that’s not right. So we need to screen very early. And the point is, as you said at the beginning, there are many young people on dialysis. But the problem is that these young people have never been offered the opportunity for screening.
Not directly, since they’ve stopped drinking the beverages that are already being tested for, but if you have a problem, at least they’ll be aware and they’ll start raising awareness too. And it’s about screening because dialysis is expensive. Not just for the patient, but also for the state. If you ask the ministry how much it spends, you’ll get a real shock. In Europe, it’s starting to cost so much that if you follow the debates there, you’ve seen there are a lot of discussions, even strikes by doctors because the government wants to reduce their pay due to the high cost of healthcare. Over there, it’s different; it’s because people live longer. And the older you are, the more it costs. But here, it’s the opposite. It’s expensive because we have a lot of young people who should be working but end up here. Take a look around, you’ll see, the average age is very young here in dialysis. And that’s not normal. And children of 16, 18 years old… In my center, I don’t have anyone who is 18. The
young people I have there are there because they have genetic diseases. There’s nothing we can do about it. They were born with genetic problems that are why they’re there. But I don’t have any young people who came here because they have diseases that could have been stopped. No. All the young people I have here have genetic diseases that have affected them. The very young people I have are around 45, 50 years old. But I don’t have any 18-year-olds like that because they’ve consumed or eaten things that weren’t made. Because they’re lucky enough to have them. And that’s another problem because it affects older people, and we push screening more towards 50- and 60-year-olds because that’s when it starts. But in Africa, we need to screen many more young people. And screening doesn’t cost much.
These urine test strips are always available at the pharmacy. We use them regularly to monitor the results. It’s the same strip we also use for urinary tract infections. The only difference is that creatinine must be added. And for creatinine, there are now test strips with a fairly high sensitivity that can be made available to doctors. They use them when they have high-risk patients. They say, « I have a patient who has a doubt. Right now, I’m confirming with a blood test. If there’s any doubt, he’ll get tested. » This also reduces the cost for the patient. The only risk is that it might change; the doctor might send them for consultations. But that’s the price to pay for the medication.
Interview by Jean Besane Mangam
