Dialysis business in growth mode amid rising treatment demand in India

Every week, 220,000 to 250,000 Indians undergo three sessions each of haemodialysis (a treatment to filter wastes and water from the blood). But that amounts to a fraction of Indians who need this treatment. The industry estimates that there are some 20 million patients with chronic kidney disease in India, but only 20 per cent get dialysis treatment. The remaining 80 per cent either can’t access it because they live in rural areas or can’t afford it since dialysis is largely an out-of-pocket expense. The affordability factor is striking because dialysis in India costs $25 a session compared with $300 a session in the US.

India, however, with its high hypertension- and diabetes-prone population, remains a growing market for dialysis service providers. Every year, the country adds 600,000 to 700,000 patients in need of dialysis. Given that some 40 per cent die, the net patient addition is 350,000 to 400,000, which translates into an incremental requirement of 55 million dialysis sessions every year, more than double the current number of 21-22 million. The country has 50,000 dialysis machines, 5,000 centres for dialysis and about 3,000 practising nephrologists.

These grim figures translate into an expanding market opportunity, which is why all major dialysis service providers in the private sector are expanding. NephroPlus plans to launch 35-40 centres per year and says that its patient footfalls are growing at 20 per cent every year; VitusCare plans to add 150 new centres over the next three years; Apex Kidney Care plans to more than double its centres to 350 from 156 in the next three years or so. The cost of opening one centre is Rs 1-1.2 crore.

Vikram Vuppala, founder and CEO, NephroPlus, said the market will continue to grow at 20-25 per cent over the next three or four decades and predicts that the share of organised private sector players in the dialysis market — there are several mom-and-pop centres run by doctors — will increase from 21-22 to 40 per cent in the next five years. The growth will come from expansion into new geographies and further into the hinterland. NephroPlus, for example, has 70 per cent of its centres in the top 10 cities.

But for this expansion to translate into greater access for patients, public spending on dialysis would have to expand, said service providers who run public-private-partnership (PPPs) centres. For example, out of the 156 centres that Apex Kidney Care runs, 84 are in PPP mode. Indranil Roychowdhury, CEO of Apex Kidney Care, said PPP was the way to capture the 80 per cent of patients who were being left out. “In India, out-of-pocket expenditure is high — around 54.8 per cent compared to 11 per cent in the US or 8.7 per cent in Thailand. All our PPP centres are always full, and it shows that this is the way to spread more into the rural areas,” Roychowdhury told Business Standard.

Prabhat Srivastava, co-founder and CEO, VitusCare, added, “PPPs will go a long way in ensuring access to dialysis infrastructure at district hospitals and clinics in the hinterlands of the country. Pradhan Mantri National Dialysis Programme (PMNDP) is a positive step taken towards this journey. There are currently about 1,100 centres under this programme across the country.”

In fact, government spending is already quite high in this sector. Vuppala said out of the Rs 4,500-crore dialysis market in the country, around 15 per cent was reimbursed by the government through various programmes.

Roychowdhury pointed out that the government needed to focus on screening of non-communicable diseases and kidney patients. “With the quality of dialysis improving, the survival rates are also rising and a patient with regular dialysis sessions can live up to more than a decade. Besides, if a patient is diagnosed early, medication can prevent the disease from progressing and delay or avoid the need for dialysis.

A potential solution to access and affordability of dialysis is peritoneal dialysis (PD), but the verdict seems to be divided on this. US giant Baxter, makers of PD solutions, said patients on PD had more control over their lives because they could perform daily activities while on dialysis. It also minimises the frequency of clinic visits, limits the caregiver’s involvement, and requires fewer diet and fluid restrictions.

Compared to the four-hour sessions required for haemodialysis (HD) at designated centres, PD involved two to three 20- to 30-minute exchanges per day that could be performed at home without special infrastructure or medical help, a company spokesperson explained.

But some believe PD is not a great option in lower middle-income households due to risk of infection and hygiene-related issues, especially involving the storage of the PD bags (three per day).

Also, Srivastava pointed out, “In 2019, the Centre had introduced free PD services to beneficiaries who are below the poverty line. But at the moment there is no additional support for other income groups when it comes to PD.”

“So far the penetration of PD in India has not been too successful as nearly 95 per cent of dialysis patients opt for HD. The key reasons for this have been the low awareness and a lack of established supply chain for PD infrastructure and consumables when it comes to OEMs (original equipment makers), distributors, service providers and clinicians,” he explained.

As the dialysis industry grows, local medical device makers are also getting into the game. Dialysis machines in India are mostly imported, and German player Fresenius is the market leader — 35,000 out of the 50,000 machines deployed in the country are from Fresenius, according to industry estimates. These machines cost Rs 7-8 lakh each —exclusive of the cost of dialysers (that part of the HD machine where the blood gets filtered), and other consumables.

Now, however, local players are developing made-in-India dialysis machines and dialysers, which could lower costs significantly. For example, Manish Sardana, president, Poly Medicure Ltd, said his company was ready with its made-in-India dialysis machines, in which 50-60 per cent of the components were locally sourced. Polymed is making these machines at its Faridabad facility under an import substitution programme linked to the government’s signature production-linked incentive scheme. Polymed is also making dialysers, in India which is also an import substitute.

The market

• Currently, 20% of Indian patients get access to dialysis treatment
• The rest can’t access it owing to location (in rural areas) or afford it
• Incremental requirement is 55 million dialysis sessions a year, more than double the current 21-22 million sessions
• The country has 50,000 dialysis machines, 5,000 centres for dialysis and about 3,000 practising nephrologists