Health Disparities and Inequity in Access to Kidney Care:

A Review of Literature on Kidney Care in Jamaica and Other Low- and Middle-Income Countries
By Nadia McLean and O’Neal Malcolm

Chronic kidney disease (CKD) is a significant cause of morbidity and mortality worldwide.The global burden of CKD is estimated at 500
million people worldwide, with the majority of people with CKD (80%) living in low- and middle-income countries (LMICs) (1). In 2017, 1.2 million people died from CKD, with the all-age mortality rate increasing 41.5% between 1990 and 2017 and a global prevalence of 9.1%.

The global all-age prevalence of CKD also represented an increase of 29.3% since 1990 (2). Along with the noted increases, there is inequity in the distribution of CKD; people living in LMICs are disproportionately affected more than
people living in high-income countries (HICs) (1). Stanifer et al. (1) noted that although CKD in 2016 represented the
19th-most common cause of death worldwide—an 82% increase since 1990—the annual death rate attributed to CKD is growing more than 5% per year.

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative introduced a framework for the definition of CKD. The aim of the model is to depict risk factors that could be associated with progression to more severe stages of CKD (3). CKD was initially defined based on the presence of kidney damage or a reduction in glomerular filtration rate for more than 3 months (3). In 2004, Kidney Disease: Improving Global Outcomes (KDIGO) endorsed this framework, noting that proteinuria worsened the progression of CKD (4). By standardizing the definition of CKD and offering treatment guidelines, these models have presented an important basis for the diagnosis and management of kidney diseases in LMICs, such as Jamaica, and help us to elucidate the scope of the challenge in delivering expert kidney care to adults and children in this setting by providing a standardized basis for data collection, analysis, and policy recommendations.

The characterization of the scope of kidney diseases in Jamaica is foundational to an understanding of the burden faced by patients and providers, including lack of care and resources, workforce shortages, and chronic disease burden (5). With results from a survey of a specialist diabetes clinic in Jamaica, Ferguson et al. (6) estimated the prevalence of CKD to be 22%. Of note, moderate and severe albuminuria, known to advance CKD, was present in 82.6% of the population (6). The Caribbean Renal Registry, established in 2006, highlighted the difference in patterns of CKD and end stage kidney disease (ESKD) in LMICs. These patterns included high rates of health care demand compounded by a lack of trained nephrologists throughout the Caribbean region. As with other LMICs, such as those in Asia and parts of Africa, there was also inequitable access to kidney replacement therapies (KRTs), including peritoneal dialysis, hemodialysis, and kidney transplantation (5).

Inequity among adults also translates to the pediatric population of LMICs. In 2016, Miller and Williams (7) noted that between 2007 and 2012, 27 children developed CKD, with a cumulative annual incidence per million child population of 7.83 for children under age 12 years and 1.67 for the average population. The study also noted a paucity of pediatric data in LMICs and lack of access to KRTs.

A meta-analysis by Plumb et al. (8) noted an increased risk of late presentation among the pediatric population from LMICs. These children tended to be older and already hospitalized under emergent situations, which increased their risk of poor health outcomes, including mortality. The study pointed to the need for policy focus on reducing modifiable barriers to improve access to care, such as consensus definitions, protocols focused on risk stratification, and early specialist intervention (8).

It has been established that the burden of kidney failure in LMICs approaches that of HICs, but relatively few patients in LMICs receive KRTs (9). Currently, children throughout Jamaica primarily receive KRTs in the capital, Kingston. Major challenges for the pediatric population residing outside of Kingston, including rural areas, are distance, travel duration, and transportation availability. The inequity in access to care extends to the most rural and often resource-limited parts of the country where transportation is unreliable and costly.

White et al. (9) proposed a framework for reducing the global burden of ESKD and improving access to KRTs. This model included a national registry of dialysis and transplant patients, national policy and budgetary planning about KRT delivery and eligibility, retention and training of skilled personnel, and education at the community and regional levels. This framework and call to action were echoed by
Ameh and colleagues in 2019 (10). Their review highlights factors hindering the prevention of CKD progression in LMICs. These components include poor funding of health care, struggling health care systems, lack of local data, and costs of screening systems—all of which prevail among the population in Jamaica (10).

We hope to highlight the inequity as it relates to access to diagnosis, expert care management, and KRTs faced by adults and children living in rural parts of Jamaica, a LMIC. It is our hope that data from this article will represent the basis for recommendations to increase access to care for this vulnerable population and to improve health care outcomes and reduce morbidity and mortality