INTRODUCTION:

On account of its increasing prevalence and incidence rates, chronic kidney disease (CKD) is one of the world's biggest mysteries. End-stage renal disease (ESRD) is a life-threatening illness that affects people of all ages.

When a person's kidneys are permanently destroyed and he or she can no longer survive without renal replacement therapy, the condition is known as renal failure. Dialysis or a kidney transplant are the only options to treat renal failure. Hemodialysis is the most often utilized treatment option in India¹. According to World Health Organization estimates, this disease affects almost 8,500,000 people each year. It is the world's 12^th biggest cause of mortality and 17^th leading cause of disability². Kidney diseases are currently the biggest cause of mortality in the World³. In India, the prevalence of CKD is over 800 per million people, while the incidence rate of ESRD is around 150-200 per million people⁴. The prevalence of ESRD has risen in the previous two decades. It has risen to the top of the list of causes of morbidity and mortality. It lowers the overall quality of life of patients⁵. In India, the majority of the CKD patients belong to the younger population when compared with other countries⁶. The responsible factors of CKD include cyst formation in the kidneys, hyperglycemia, arterial hypertension, and diverse difficulties. In 2025, it is estimated that India would have 213.5 million people with hypertension. In 1995, there were 19.3 million diabetes cases in India, which is predicted to rise to 57.2million by 2025. Worsened renal function that occurs over time and is irreversibly described as CKD. Glomerular filtration rate (GFR) is almost less than 15% in patients with end-stage renal failure (ESRF), which forms when most critical symptoms appear and the functions of the kidneys are lost. In this stage, dialysis or renal engraftment is required for survival. Starting with dialysis, a mix of medications, comorbidities, and dietary restrictions, expensive treatment regimens make the life of patients cumbersome⁷. Hemodialysis, peritoneal dialysis, and kidney transplantation are the most frequent renal replacement therapies, with hemodialysis being the most widely used and the only treatment for maintenance⁸.

CKD is a burdensome disease that causes a high rate of morbidity and mortality, as well as a financial burden to the government and the public. Only a few patients in India have access to quality care due to the high cost and complexity of treatment⁹. HD is an effective therapy for ESRD. Cost is always a big issue for dialysis patients. The majority of CKD patients in India cannot afford renal replacement therapy due to health-economic constraints. This is especially true in underdeveloped nations where resources are scarce¹⁰.

The majority of CKD patients in India cannot afford renal replacement therapy due to health-economic constraints. It is estimated that in India, more than 2.25 million people have end-stage renal disease (ESRD) per annum, leading to an annual requirement of around 3.4 million HD consultations. As a result, Some 2/3 individuals with renal failure who begin HD end up leaving it because of lack of funds. CKD has become one of the most expensive diseases to treat and is particularly true in underdeveloped nations where healthcare schemes are limited¹¹. In India, The Indian Government's Department of Health and Family Welfare created the National Dialysis Program (NDP) in 2016 to solve the problems faced by HD patients, such as financial concerns, utility attainability issues, and long-term dependency. As per the NDP, district public hospitals in 444 districts and 765 hubs are said to provide HD services by deploying 4471 equipment¹². ESRD crisis poses a significant socioeconomic issue among the youthful generation of working professionals, which at a global level, chronic renal impairment emerged to be the tenth most common cause of disease in India. The primary obstacles towards getting appropriate care are high fees in corporate hospitals, lack of treatment facilities, and a limited number of nephrologists, in rural areas. A majority, around 4950 hemodialysis centers in India are owned and operated by corporate. Each hemodialysis session costs around INR 2000, which equates to roughly INR 3-4 lakhs per annum¹³. Most ESRD patients get to benefit from HD, while the expense predisposes a grave concern. The majority of patients require the assistance of a family member, which further adds to the expense. A healthcare plan for hemodialysis patients has been deemed essential for both deciding these life-saving procedures as well as reducing poverty on the focus of ongoing expenditures for sufferers. Several private companies in India provide this type of treatment, making it an expensive choice due to the high out-of-pocket expenses. Now, most HD patients in India die without a proper prognosis¹⁴.Central and state governments, non-governmental organizations (NGOs), and even hospitals offer different healthcare initiatives/schemes to HD patients. All of these initiatives must be made known to the public, as well as the benefits offered by the schemes.

Healthcare Schemes are sorted according to the states of India and compiled based on some commonalities. Central-wide healthcare schemes are given in table 1, government and non-profit schemes in table 2, and hospital-specific schemes in table 3.

Table 1. Cental wide healthcare schemes for hemodialysis patients in India

S. No.	Central schemes for Hemodialysis patients in India	Healthcare scheme name
1		Ayushman Bharat scheme.
2		Rashtriya Arogya Nidhi (RAN)
3		Pradhan Mantri National Dialysis Programme
4		Dr. Ambedkar Medical Aid Scheme
5		Central Government Health Scheme
6		Employees State Insurance (ESI)
7		Ex-servicemen contributory health scheme

Table 2. Government and eleemosynary trust healthcare schemes for hemodialysis patients in India

Sl. No.	States	Govt. Healthcare schemes	NGO Healthcare schemes
1	Andhra Pradesh	Dr YSR Aarogyasri Scheme	-
2	Arunachal Pradesh	Chief Minister Arogya Arunachal Yojana	-
3	Assam	Assam Arogya Nidhi	-
3	Assam	Atal Amrit Abhiyan	-
4	Delhi	Delhi Arogya Kosh	-
		Delhi Government Employees Health Scheme (DGEHS)
		PPP Dialysis project
5	Goa	Deen Dayal Swasthya Seva Yojana	Apex Kidney Care
5	Goa	Mediclaim Scheme	Apex Kidney Care
6	Gujarat	Mukhyamantri Amrutam “MA” Yojana	India Renal Foundation (IRF)
6	Gujarat	-	Gujarat kidney foundation
7	Himachal Pradesh	Himachal Health Care Scheme-HIMCARE	-
8	Jammu & Kashmir	J&K Government Employees Group Mediclaim Insurance Scheme	-
9	Karnataka	Jyothi Sanjeevini Scheme	Bangalore kidney foundation (BKF)
9	Karnataka	Arogya Bhagya Yojane	Bangalore kidney foundation (BKF)
10	Kerala	Samashwasam	Khidma Charitable trust
		Karunya Benevolent	Mathruka Charitable Trust
		Thalolam	Thanal dialysis center cheruvathoor
		-	Shihab Thangal dialysis center
			Navajeevanam free dialysis trust
			Cochin Kidney Foundation (CKF)
11	Maharashtra	Mahatma Jyotiba Phule Jan Arogya Yojana	Kothari Charitable Trust
			Fairfax India Charitable Foundation
			Oswal Mitra Mandal
			Mumbai Kidney Foundation (MKF)
			Narmada Kidney Foundation
			National Kidney Foundation India
12	Manipur	Manipur State Illness Assistance Fund (MSIAF)	-
12	Manipur	Chief Minister-gi Hakshelgi Tengbang (CMHT)	-
13	Meghalaya	Megha Health Insurance Scheme	-
14	Mizoram	Mizoram State Health Care Scheme (MSHCS)	-
15	Odisha	Odisha State Treatment Fund (OSTF)	Utkal kidney foundation
		Odisha Sahaya Scheme
		Biju Swasthya Kalyan Yojana.
16	Rajasthan	Bhamashah Swasthya Bima Yojana	-
17	Tamil Nadu	Chief Minister of Comprehensive Health Insurance Scheme	Tamilnad Kidney Research Foundation
17	Tamil Nadu	Medical aid	Tamilnad Kidney Research Foundation
18	Telangana	Aarogyasri Scheme	Bhagwan Mahavir Jain Relief Foundation Trust
19	Tripura	Tripura Health Assurance Scheme for Poor	-
20	West Bengal	Swasthya Sathi	-
20	West Bengal	West Bengal Health Scheme	-

Table 3. Hospital wise healthcare schemes for hemodialysis patients in Manipal, Udupi, and Mangalore

S. No.	Hospitals	Govt. Healthcare schemes	NGOs Healthcare schemes
1	KMC Hospital Manipal	Employee state insurance corporation scheme	Dr. G Shankar trust
		Jyothi Sanjeevini Scheme	Manipal Arogya Card
		Arogya Bhaygya yojane	Sampoorna Suraksha Health Insurance
		Ex-servicemen contributory health scheme	Manipal Arogya Suraksha Card
		Endosulfan Scheme	Manipal University Medicare
		Central government health scheme (CGHS)	Vidal Health
		CM Relief Fund Government of Karnataka	Star Health
			Oriental Health Insurance
			SBI General Insurance
			United India Insurance Company
			New India Assurance Company Limited
			LIC Jeevan Suraksha
			Mangalore electricity supply company (MESCOM)
2	Dr. TMA Pai hospital Udupi		Dr. G Sankar trust
			Manipal Arogya Card
			Manipal Arogya Suraksha Card
			Medi Claim Health Insurance
			National Insurance Mediclaim Plus policy
3	Father Muller Medical College Hospital Mangalore	· Jyothi Sanjeevani Scheme	Dr. G Sankar trust
		Arogya Bhagya Scheme	New Mangalore Port Trust
		ESI	Sampoorna Suraksha health insurance
		Government of Kerala Chief Ministers Distress Relief Fund	Jamiyyatul Falah trust
			Lawrence Memorial fund
			Medi Assist India TPA Pvt. Ltd.
			Medi Claim Health Insurance
			Vidal Health
			Star Health
			United Health Parekh
			Manipal Cigna Health Insurance
			ICICI Lombard Complete Health Insurance
			Oriental Health Insurance
			Aditya Birla Health Insurance
			Cecilia Lobo memorial trust
			Society of Saint Vincent de Paul (SVP)
			Apostolic Carmel Congregation
			Priest Aid fund

Table 4. Central and statewide schemes for Haemodialysis patients in India

Sl. No.	Name of the Scheme and Launch Date/Year	Objectives	Advantages/ Benefits	Eligibility Criteria	Finance Assistance limit
Central Scheme
1	Pradhan Mantri National Dialysis Program (PMNDP). Launched in 2016-17 as part of the National Health Mission (NHM), that provides free dialysis services to the underprivileged	To improve access to hemodialysis and transplantation, to provide monetary support to patients, and to minimize the impact on the government's comprehensive medical care financial capabilities.	Hemodialysis facilities, pre-and post-diagnostic testing, medicines, surgical procedures, and emergency medical help.	Everyone who is below the poverty line.	-
Andhra Pradesh
2	Dr.YSR Aarogyasri Scheme Launched on June 4, 2019, under the Dr. YSR Aarogyasri Health Care Trust.	To provide financial security in the event of escalating medical expenditures. To provide comprehensive camouflaged medical care in Andhra Pradesh's cities and underprivileged villages.	Overall, 1059 surgical interventions and 30 medication procedures have been covered.	People who have a BPL card, Annapurna card, or ration cards from the Anthyodaya Anna Yojana program, as well as those who suffer from certain diseases.	Every household can get a maximum of 5 lakhs in a year.
Karnataka
3	Arogya Bhagya Yojane Launched on August 1, 2002, and was administered by the Karnataka Police Health Welfare Trust	To improve the availability of medical services for police officers, including hospitalization and surgical operations; To increase the number of healthcare organizations that can provide police officers high-quality medical care.	Everything is covered, except a few exclusions.	Members of Karnataka's police force and their family members.	As per their ward eligibility, in-patients are eligible for cashless benefits. Up to INR 2,00,000 can be spent on kidney transplantation.
4	Jyothi Sanjeevani Scheme (JSS) released this policy on September 18, 2014. under the Suvarna Arogya Suraksha Trust (SAST).	Assist in the treatment of serious illnesses requiring hospitalization, surgery, and other drugs under the direction of super-specialty treatment centers that have established partnerships with existing medical providers.	Covers 449 processes in seven different categories which include renal dysfunctions.	All Karnataka State Government employees and their dependents are covered under this policy.	Only INR 1.5 lakh per annum is allowed.
Kerala
5	Karunya Benevolent Fund Scheme Introduced during 2011-12 by the UDF Government.	To provide financial assistance to poor persons suffering from severe illnesses through the Kerala lottery.	Covers serious illnesses such as malignant neoplastic disease, blood disorders, kidney difficulties, cardiology diseases, and hospice services.	Residents of Kerala and individuals below the poverty level.	Up to INR 200000 is covered. Can be increased to INR 300000 in some situations of severe conditions.
6	Samashwasam Introduced on 28 January 2013 by Kerala Social Security Mission (KSSM).	The basic goal of the strategy is to give solely hemodialysis care and protection to the most vulnerable individuals in Kerala.	Only hemodialysis services	Must be a BPL Household. The applicant must be a nationalized bank account holder and resident of Kerala.	Coverage of the maximum limit was not specified.
7	Thalolam Launched on 1 January 2010 by the Kerala Social Security Mission and the Social Justice Department introduced this program.	Children under the age of 18 are to be treated for free under Thalolam's plan.	Covers conditions such as renal disorders, cardiovascular ailments, infantile cerebral paralysis, avian bone syndrome, a bleeding problem, drepanocytosis, and orthotics deformities.	The candidate must be under the age of eighteen.	Maximum of INR 50,000. Continued financial assistance will be provided under the medical professional's orders.
Tamil Nadu
8	Chief Minister of Comprehensive Health Insurance Scheme (CMHIS) Launched on 11 January 2012.	The provision of non-financial medical care services, including public and empaneled corporate hospitals.	This plan covers a total of 1016 techniques, including 23 diagnostic technologies and 113 follow-up packages.	Only residents of Tamil Nadu. In addition, the plaintiff must have a government-issued household card and have a yearly income of less than INR 72,000 per annum.	On a floater basis, a household might get up to INR 5,00,000 per year.
9	Medical Aid Implemented from 1 January 2019.	To broaden intervention opportunities for current policy. Government hospitals need to expand their services to include more maladies and better clinics, including paying wards.	All pre-existing conditions are covered according to medical insurance regulations.	Superannuation for government employees and household retirees. Retired schoolmasters.	Superannuation benefits are limited to a maximum of INR 200000 per retired individual (as well as a spouse) and household.
Telangana
10	Aarogyasri Launched on 1 April 2007 by the Telangana government.	Stimulate the access of low-income families to high-quality medical services for the treatment of certain morbidities including hospital admissions, surgeries, and other remedial measures in conjunction with affiliated hospitals.	All the pre-existing cases of the 13 systems are covered under this policy.	Persons having a BPL card. Individuals with specific illnesses and Annapurna and Anthyoday Anna Yojana (ration cards).	Each family is covered for up to INR 200000 per year.
Delhi
11	PPP Dialysis Project Established in the year 2013 by the Delhi Government's Department of Health and Family Welfare	To provide high-quality hemodialysis services at an affordable cost to the whole population of Delhi and a free cost to the underprivileged.	Only hemodialysis services are provided.	Individuals with annual income up to INR 300000. The plaintiff must have been a resident of Delhi for the past three years.	There was no mention of the maximum coverage limits.
Odisha
12	Odisha Sahaya Scheme Came into operation in January 2018.	To obtain free hemodialysis at government hospitals around the state. The public-private partnership (PPP) method was used in March 2018 to install 127 dialysis machines at various government hospitals and community health clinics to meet this need.	Covers hemodialysis services.	Residents of Odisha are from economically marginalized people and those who are impoverished and in need of assistance.	Coverage of the maximum limit was not specified.

Source for the above mentioned Schemes: Respective Government Websites

DISCUSSION:

Different medical care compensation systems have been implemented across the world to help enhance hemodialysis care while also reducing the rising costs of treatment. In a resource-constrained setting, our study is the most essential tool for evaluating the budgetary difficulties of maintaining hemodialysis. Hemodialysis patients in India are growing at a rapid rate, similar to China, South Africa, the United States, and the Philippines. According to the latest data, hemodialysis usage has increased by four times in just five years in India. As an alternative to relying on financial crisis protection, roughly 25% of the family resorts to loan or selling property to pay for their medical expenses¹⁵. According to our records, hemodialysis packages provided by current medical care plans for each dialysis in the hospitals surveyed are quite useful. INR 350 per dialysis concession from the Dr G Shankar Trust, INR 1030 from Sampoornasuraksha, INR 350 from the Jamiyatul Falah Society, and INR 350 from the Lawrence Fund. Medicines and lab tests are discounted by 10% with health cards. Due to the high cost of dialysis in three hospitals, the amount provided to HD patients is found to be still burdensome.

The National Health Mission approval, PMNDP is providing free HD services to BPL patients in district-level public hospitals. However, corporate hospitals across the country do not have access to this scheme. A large number of patients were awaiting enrollment in the PMNDP system in public hospitals at the district level. Many people may benefit from the implementation of this system if it were adopted at corporate hospitals. In Karnataka, the Arogya Bhagya scheme is only available to police personnel of government employees. In Karnataka Jyothi Sanjeevani Scheme is only available to government workers. In this review, we discovered that the state of Karnataka was not providing adequate assistance to the general public for HD patients. An example of this is the Ayuasman Bharath is a central scheme, in other states hemodialysis patients were able to make use of this program, but it was not available in the selected three hospitals. According to this survey, long-term hemodialysis patients are unable to manage their finances using these plans. To help long-term hemodialysis patients, the Karnataka government should implement special schemes for HD patients.

Everywhere in India, public-private partnerships (PPPs) are used for hemodialysis government initiatives. Only hemodialysis patients in India are eligible for government initiatives. There are several dialysis projects in India. In Delhi, there is the PPP project, in Odisha, there is the Odisha Sahaya scheme, and in Kerala, there is the Samashwasam, and Thalolam. Though the schemes look plenty, a few are merged to cover other treatments. There will be 13 procedures covered under the CMHT scheme in Manipur that is connected to the Nephrology department and this strategy has a 0.70 percent overall success rate. MGO72A is the package ID for the Himachal Health Care Scheme-HD patient package in Himachal Pradesh, and it costs INR 1500 per session. There is a plan to give eight monthly dialysis treatments in Maharashtra as part of the Mahatmaji Jyotibha Phule Jan Arogya Yojna for INR 10,000 per month.

Most of the NGOs are highly helpful to HD patients since they offer free treatment to needy patients. However, no NGO programs are provided for HD patients in the following 12 states: Andhra Pradesh, Himachal Pradesh, Arunachal Pradesh, Manipur, Mizoram, Rajasthan, Jammu & Kashmir, Assam, Meghalaya, Tripura, West Bengal, and Delhi. Nearly two schemes from the central government and 15 schemes from the state would pay a total amount to HD patients based on severe surgical clinical evaluation of renal disease and lab tests. For HD patients, the package rates were not mentioned in this plan. These programs are quite helpful for HD patients who have to pay out-of-pocket expenses. In India, the majority of NGOs rely on public donations and crowdfunding. Particularly in Kerala, most philanthropists and doctors have set up their dialysis centers. In addition, several of the NGOs offer dialysis technician training to the people in the area. Healthcare plans for HD patients have played a significant role at three hospitals and based on the concessions, persons from coastal areas are more likely to take advantage of these programs. Several obstacles prevent people from using the aforesaid services, including illiteracy, lack of relevant campaigns, and awareness initiatives. However, there is a need for a comprehensive study on available healthcare schemes and their implementation to understand the utilization of the schemes in India.

CONCLUSION:

The great burden of financial problems from our perspective review emphasizes the insufficiency of healthcare schemes for long-standing HD care. The fiscal burden of hemodialysis for families is staggering. Because of the overwhelming costs of treatment, the majority of people could not afford renal replacement therapy. The target treatment should be concentrated on deterrence of ESRD, by encouraging cognizance among the general public regarding problems associated with kidneys as well as the involvement of diabetes, hypertension, and cardiovascular ailments. Various central, state governments and Non-Government organization schemes are implemented in India to provide help to the deprived population. The schemes available in KMC Hospital, Manipal, Dr TMA Pai Hospital, Udupi, and FMMCH, Mangalore were of great help to the hemodialysis patients. However, there is a dire need to bring awareness among the public and the benefits that each scheme provides.

CONFLICT OF INTEREST:

The authors have no conflicts of interest.

ACKNOWLEDGEMENT:

The authors thank the Indian Council of Medical Research, New Delhi for providing financial support to conduct this study.

REFERENCES:

1. Srinivasan K. A descriptive study to assess the knowledge on dietary management among chronic renal failure patients undergoing hemodialysis at a selected Hospital, Kanchipuram. International Journal of Nursing Education and Research.2016;2(3):241-244.

2. Nandakumar UP, Chacko C, Shenoy P, Ashokan A, Baby B, Pothen C. Drug usage pattern in chronic kidney disease patients undergoing maintenance hemodialysis. Research Journal of Pharmaceutical and Technology. 2019; 12(10):5024-5028. DOI: 10.5958/0974-360X.2019.00872.2

3. Abraham S, Baby A, Jose A, Nixon V, Shenai SN. AV fistula care practices among patients undergoing hemodialysis – A descriptive cross-sectional study. Asian Journal of Nursing Education and Research. 2020; 10(1):103-106. DOI: 10.5958/2349-2996.2020.00023.3

4. Tippegowda SB, Yathi Kumara SB. Coping strategies and quality of life among hemodialysis patients in South India: A co-relational study. International Journal of Nursing Education and Research. 2015; 3(3):243-247. DOI: 10.5958/2454-2660.2015.00001.0

5. Swapna Mary A, Gayathri Priya A. A study to assess the health-related quality of life among clients undergoing hemodialysis in selected hospitals at Bangalore with a view to Develop an Information Booklet. Asian Journal of Nursing Education and Research. 2016; 6(4):425-428. DOI: 10.5958/2349-2996.2016.00080.X

6. Navneet K, Manjeet K, Rasmi. An Exploratory Study to Assess the Knowledge regarding Post Dialysis Home Care among Caregivers of Hemodialysis Patients Attending Selected Hospital of Mohali. International Journal of Nursing Education and Research. 2015; 5(1):45-49. DOI: 10.5958/2349-2996.2015.00011.7

7. Shinjar FJ, Bakey SJ, Khudur KM. Effectiveness of an Education program on hemodialysis patients, knowledge towards dietary regimen at Al-Hussein teaching hospital in AL - Nasiriyaha city. Indian Journal of Public Health Research and Development, 2018; 9:650-655. DOI: 10.5958/0976-5506.2018.01202.0

8. Thenmozhi P, Rajeswari V, Vijayarajan R. Efficacy of intradialytic exercise on blood pressure among patients on hemodialysis. Research Journal of Pharmaceutical and Technology. 2018; 11(6):2209-2212. DOI: 10.5958/0974-360X.2018.00408.0

9. Lakshmi Prabha S. Assess the quality of life of patients undergoing hemodialysis in Vinayaka Mission Hospital, Salem, Tamilnadu. International Journal of Advances in Nursing Management. 2015; 3(3):197-199. DOI: 10.5958/2454-2652.2015.00002.5

10. Duaa Dhia Hameed Al, Rajha A. Quality of life hemodialysis patients with chronic renal failure. Research Journal of Pharmaceutical and Technology. 2018; 11(6):2398-2403. DOI: 10.5958/0974-360X.2018.00443.2

11. Indrawati R. A study to assess the effectiveness of structured teaching program on knowledge regarding lifestyle modifications among hemodialysis patients in shree saedar smarak Hospital, Bardoli. International Journal of Advances in Nursing Management.2015; 3(3):269-274. DOI: 10.5958/2454-2660.2015.0000.X

12. Ministry of Health & Family welfare. Pradhanmantri national dialysis program under NHM. Available from: https://main.mohfw.gov.in/sites/default/files/Pradhan%20Mantri%20National%20Dialysis%20Programme%20under%20NHM_0.pdf [Last accessed on August 15, 2021].

13. Vikaspedia. Pradhan Mantri National Dialysis program. Available from: https://vikaspedia.in/health/nrhm/national-health-programmes-1/pradhan-mantri-national-dialysis-programme. [ Last accessed on August 15, 2021]

14. Kaur G, Prinja S, Ramachandran R, Malhotra P, Gupta KL, Jha V. Cost of hemodialysis in a public sector tertiary hospital of India. Clinical Kidney Journal, 2018; 5:726-733. DOI: 10.1093/ckj/sfx152

15. Bradshaw C, Gracious N, Narayanan R, Narayanan S, et al. Paying for hemodialysis in Kerala, India: A Description of Household financial hardship in the context of Medical Subsidy. Kidney International Reports. 2019:4; 390-398. DOI: 10.1016/j.ekir.2018.12.007

Received on 09.09.2021 Modified on 07.11.2021

Research J. Pharm. and Tech 2022; 15(10):4382-4388.

DOI: 10.52711/0974-360X.2022.00735