PROPOSED NATIONAL RENAL CARE POLICY

By
The Nigerian Association of Nephrology

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STATE OF RENAL CARE IN NIGERIA

The incidence and prevalence of renal disease is increasing worldwide with end- stage kidney disease (ESKD) now assuming epidemic proportion in developed countries and some developing countries. The lack of renal registry in Nigeria makes the computation of these data difficult. Available hospital data revealed that advanced kidney failure accounts for about 10% of medical admissions in Nigeria and small scale community studies have reported that prevalence of CKD in adults ranges between 11.4% and 30% in adults and 15 per million in the paediatric population.

Chronic glomerulonephritis and hypertension are the commonest causes of CKD and ESKD; diabetic nephropathy, obstructive uropathy and toxic nephropathy are other major causes. Majority of the patients are young people, aged between 25 and 40 years and in  and in their economically productive years Also worrisome is the fact that a large proportion of these patients (75% - 80%) first consult a Nephrologist when they have reached advanced stage of CKD or ESKD and are requiring renal replacement therapy (RRT).

Renal replacement therapy (RRT) is the use of alternative measures to take over fully or in part the functions of kidneys in patients that are in ESKD. The options of RRT are dialysis and kidney transplantation. RRT is expensive, unaffordable for majority of Nigerians, of low priority for cash-deprived public health institutions; hence in the absence of health insurance plans with wide coverage, less than 10% of all patients requiring RRT actually receive it. In Nigeria, the vast majority of patients starting haemodialysis (HD) die or stop treatment within the first 3 months of commencement because of financial constraints. Only a few centres in Nigeria have PD programmes mainly because of unavailability of consumables and less than 2% of ESKD patients are started on peritoneal dialysis.

Although renal transplantation is the cheapest option of RRT, only about 1% of all patients with ESKD end up having a transplant. Living-related donor transplant is the mainstay in Nigeria for now. Cadaveric transplantation is yet to pick up; the absence of an enabling law on organ donation and brain death constitute major hurdles. Immunosuppressant drugs are expensive with some patients stopping treatment less than one year post- transplant because of financial constraints.

Increasing awareness of renal disease amongst the population and general practitioners could result in early diagnosis of chronic kidney disease/failure and give opportunity for preventive strategies to delay the onset of ESKD.

Renal Health Status of Nigerians
•    Mortality from ESKD (terminal kidney failure) approaches 100% within three month of diagnosis.   

•    Knowledge of indices of kidney health and disease-promoting habits as well as preventive strategies is lacking.

•    Less than 1% of affected patients are able to afford kidney transplantation which is the gold standard in the treatment strategy for ESKD.

Health Policy, Legislation, and Health Sector Reform Agenda
•    There is currently no renal care policy/plan/programme in Nigeria hence the need for its formulation, implementation, monitoring and evaluation at all levels.

•    There are no laws guiding organ donation and transplantation.

•    There is also no health act describing the national system and defining the health functions of each of the 3-tiers of government as it affects renal care delivery.

Renal Health Service Delivery and Quality of Care
•    Renal care has not received any significant attention by the government and is not one of the priority areas covered by the new health care policy.

•    Establishment of renal care centres and standards of care for renal diseases are not monitored.

•    Co-ordination and collaboration between various renal care centres is weak and/or ineffective.

Pharmaceuticals and Medical Supplies
•    Dialysis consumables are very expensive and beyond the reach of most Nigerians.

•    There is no indigenous manufacture of dialysis consumables

•    Supplies of some of the necessary consumables and drugs particularly immunosuppressive are erratic.

Renal Care (Health) Financing
•    Public expenditure on health is less than $8 per capita, compared to the $34 recommended internationally. Expenditures on renal health in most cases come from out -of-pocket expenditures in spite of the high level of poverty.

•    There is no broad-based renal care financing strategy.

•    Renal diseases are not covered in the National Health Insurance Scheme

Public-Private Partnership
Partnerships between the public and private sector are virtually non-existent.

Management of Management Systems
•    Management of the limited health resources available is ineffective and inefficient.

International Community
•    Donor agencies and other development partners are virtually non-existent for renal care.

The current situation summarized above is compounded by increasing poverty in Nigeria.  We are therefore at a point where we need to improve the health of Nigerians not only to break the vicious circle of ill-health, poverty and low level of development but to convert it to the virtuous circle of improved health status, increased well-being and sustainable development.

STATE OF RENAL CARE WORLDWIDE
The global incidence and prevalence of chronic kidney disease (CKD) and consequently end-stage kidney disease (ESKD) had steadily increased in the last two decades with ESKD now assuming epidemic proportions.

The number of patients being treated for ESKD globally was estimated to be 3,010,000 at the end of 2012 and, with approximately7% growth rate, continues to increase at a significantly higher rate than the world population. 78.3% of these patients are on HD or PD, while 21.7% are living with kidney transplant.

The prevalence of treated ESKD patients in the general population shows a high global variation, ranging from under 100 to over 2,000 patients per million population (p.m.p.). ESKD prevalence is highest in Taiwan with around 2,990 p.m.p., followed by Japan with around 2,590 p.m.p. and then the USA with around 2,020 p.m.p. It averages about 1,070 p.m.p. in the 27 countries that make up the European Union (EU). The much lower global average of 430 p.m.p. suggests that, from the global perspective, access to treatment is still limited in many countries and a number of patients with terminal renal failure do not receive treatment. Increasing global prevalence values over the years indicate a general increase in the numbers of people requiring care for ESKD as well as a gradual improvement in the access to the treatment globally.

Unlike the situation in our country, hypertension-induced CKD contribute significantly to the global ESKD pandemic and accounts for about 40% of patients on renal replacement therapy. Diabetic nephropathy (CKD secondary to diabetes mellitus) and chronic glomerulonephritis are the next most common causes. The median age of ESKD patients in developed countries is generally higher than that in Nigeria.

In most countries, developed and developing, funding of renal care is not solely dependent on patients. Governments and Insurance companies are largely responsible for funding of renal care.  In most countries in North Africa and Middle East renal care is free.  In Sudan, renal transplant recipients receive free drugs from government. Renal care is quite expensive with a session of haemodialysis costing about $120 in most developed countries and in Nigeria while in Asia dialysis cost is significantly lower ($15-25). The cost of RRT for ESKD patients accounts for 6.7% of total medicare expenditure presently in the United States and these patients account for 0.18% of the total US population. It has been estimated that the annual expenditure on ESKD will reach more than 52 billion USD by 2030. In UK, renal services currently consume about 2% of national health service budget even though, ESKD patients account for  0.05% of the total population. In Saudi Arabia, the current annual cost of provision of RRT is 506, 723,847 USD for ESKD patients who account for 0.08% of the total population and this accounts for 3.8% of the ministry of health’s budget.
 
Based on the foregoing 5 and 10 year survival of patients on kidney transplantation many of whom would have received dialysis at one time or the other exceeds 80 and 60 % respectively and the quality of life of ESKD patients on treatment is excellent (almost normal).

NEED FOR NATIONAL RENAL CARE POLICY (NRCP)
The burden and problems of CKD and ESKD is enormous and only a few of the renal care centres are actively engaged in any form of renal replacement therapy (RRT). Majority of the patients are therefore untreated and hence die in less than 3 months.
Unfortunately, the proposed new National Health Care Policy which was developed in 2005 has little or nothing for this rampaging disease.

In order to improve this gloomy outlook, reduce renal disease burden, reduce mortality and improve survival and quality of life, a National Renal Care Policy (NRCP) needs to be put in place.

OBJECTIVES OF NRCP
To develop a national renal health system that will provide effective, efficient quality, accessible and affordable renal health services with the overall aim of improving the health status of Nigerians.

TARGETS OF THE NRCP
The main National Renal Care Policy targets include:
•    To reduce mortality from ESKD by 75% in the next 10 years.
•    To reduce the number of new patients with ESKD by 50% in the next 10 years
•   To develop a patient-centred renal service in which every Nigerian afflicted with kidney disease would have access to timely and appropriate treatment
•   To ensure that there is a national renal transplantation programme with improved outcome to sustain confidence in renal transplantation in Nigeria.
•   To optimize the potentials of heart beating donors, non-heart beating donors and living  donor programme
•    To improve the transplantation rate to cover 10% of ESKD patients in the next 10 years.
•   To improve access to renal replacement therapy, with a minimum of 50% of patients with ESKD benefiting from RRT in the next 10 years.
•    To improve our 5-year and 10-year survival figures in the next 10 years.
•  To encourage indigenous manufacture of dialysis consumables, immunosuppressive and other specialised drugs.
•    To ensure and maintain best practice in organ procurement and transplantation
•    To mount preventive nephrology programmes at primary, secondary and tertiary levels.
•    To ensure continuous and easy evaluation of the effectiveness, strength and weakness of any of the renal treatment modalities including the preventive programme within the policy framework.


Health Policy Declaration and Commitments
In the new National Health Policy, the declaration and commitments are as follows:

•    The federal, state, local governments and private health sector of Nigeria hereby commit themselves and all the people to intensive action to attain the goal of health for all citizens, that is, a level of health that will permit them to lead socially and economically productive lives at the highest possible level.

•    All Governments of the Federation are convinced that the health of the people not only contributes to better quality of lives but is also essential for the sustained economic and social development of the country as a whole.

•    The people of this nation have the right to participate individually and collectively in the planning and implementation of their health care.  However, this is not only their right, but also their solemn duty.

The Federal Government undertakes:-
•    To provide policy guidance and strategic support to states, local governments and the private sector in their efforts at establishing health systems that are primary health care oriented and are accessible to all their people;

•    To coordinate efforts in order to ensure a coherent, nationwide health system;

•    To provide incentives in selected health fields to the best of its economic ability to promote this endeavour; and

•    In collaboration with the state and local Governments and the organized private sector as well as non-governmental organizations (NGOs), to undertake; the overall responsibility for monitoring and evaluation of the implementation of the health strategy.

All Governments accept to exercise political will to mobilize and use all available health resources rationally.

INTEGRATION OF NRCP INTO THE NATIONAL HEALTH POLICY
Based on the health policy declaration of the different tiers of government and the neglect of renal disease in the new National Health Policy it has become imperative to put a the NRCP together which should be integrated into the National Health Policy

STRUCTURES OF THE NRCP
The National Renal Care Policy is aimed at improving renal health of Nigerians thereby improving overall health status. Major areas covered in this document include:

1.    Definition and establishment of Renal Care Centres
2.    Preventive Nephrology Program                
3.    Funding of Renal Care                            
4.    Monitoring and Evaluation                                
5.    National Kidney Institute
6.    Relationship between States LGAs and Federal under the NRCP
7.    National Renal Registry                            
8.    Organ Procurement/Transplant Program/Legislation    
RENAL CARE CENTRES

Definition of Renal Care Centre
A renal care centre is any institution providing health care to patients with kidney diseases. Health care includes screening/early detection, diagnosis and management of kidney diseases including renal replacement therapy.

Centres that offer renal replacement therapy will be classified as dialysis or kidney transplant centres

Establishment of Renal Care Centres

•    The Renal Standards Committee of The National Kidney Institute  in collaboration with other committees shall define appropriate guidelines for:
•    Establishment of renal care centres.
•    Minimum facilities and personnel required for registration.
•    Minimum standards of care acceptable etc.

Manpower requirements for dialysis and kidney transplant centres
The following personnel will be required for dialysis and kidney transplant centres:

Dialysis centre personnel
•    Consultant Nephrologist (registered member of NAN)
•    Vascular surgeons
•    Medical officers
•    Renal nurses
•    Renal Technicians
•    Dieticians
•    Medical social workers
•    Dialysis attendants/cleaners
•    Support staff from other relevant departments

Kidney transplant centre personnel    
•    Transplant surgeons
•    Clinical psychologist
•    Renal Pathologist
•    Immunologist
•    Others as in dialysis centre

Facilities/equipment for dialysis and kidney transplant centres
•    Haemodialysis machines
•    Haemofiltration machines
•    Continuous Ambulatory Peritoneal Dialysis (CAPD) softwares
•    Peritoneal dialysis cycler
•    Kidney biopsy sets
•    Specialised Renal Care Ward/procedure room
•    Support laboratories
•    Weighing scale
•    Side laboratory
•    Generator
•    Renal Library
•    Information technology equipment

Inspection and accreditation of renal care centres
The National Kidney Institute in collaboration with NAN will be responsible for inspection and accreditation of renal care centres.


NEPHROLOGY PREVENTIVE PROGRAM

Introduction:
The main objective of preventive nephrology is to reduce the burden of chronic kidney disease on the available resources for managing kidney disease.

Preventive strategies:
•    Primordial prevention
•    Primary Prevention
•    Secondary Prevention
•    Tertiary Prevention

Primordial prevention:
•    Aims to minimize hazards to health that could predispose to kidney disease such as environmental, socio-economic and cultural factors that predispose to kidney disease.

•    Will include, among others, optimal antenatal care and prevention of delivery of low birth weight babies. Small for gestational age and low birth weight babies have been associated with low nephron numbers, hypertension, and kidney diseases

•    Improvement in sanitation, promotion of healthy lifestyle in childhood

Primary prevention:
•    Aims at preventing renal disease from occurring at all
•    Calls for knowledge of
    -     risk factors that predispose to renal disease
    -     risk factors that initiate renal damage.
    -     modification, removal,  and avoidance of factors.

Secondary prevention:
Aims at identifying factors that aid or hasten progression of renal disease and accelerate loss of renal function, and preventing or removing such factors

Tertiary prevention:
•    Usually hospital based and capital intensive.
•    Main goal is the prevention of complications that arise and affect quality of life of patients on haemodialysis, peritoneal dialysis and transplantation.


Integration of Preventive Nephrology into The NRCP:
Involves the development of community based nephrology practice or “community nephrology” utilizing primary care physicians and other health workers at the primary care level

•    Primary health care centres and general practitioners are required to screen for kidney disease at first contact using the following tests – dipstick urinalysis, serum creatinine and estimation of glomerular filtration rate.

•    These tests will be carried out as part of pre-primary, pre-secondary,  and pre-tertiary school admission  medical evaluation.

•    The tests will also be carried out as part of pre-employment medical evaluation.

•    Community based programmes designed to
    o    Screen for risk factors for development of CKD
    o    Detect early evidence of markers of CKD e.g. proteinuria

•    Health Promotion programmes to minimize the risk for the development of chronic kidney disease

Designing a Community based Nephrology Programme:
•    Training and education of general practitioners and first line primary health workers on how patients at risk should be detected and treated or appropriately referred.
•    Providing facilities for training on simple urine testing for protein and sugar for first line primary health workers
•    Providing reliable blood pressure measuring kits
•    Providing appropriate treatment options for identified people at risk of progressive renal function loss:
•    Treatment of the risk factors with appropriate agents
•    Intensified community health education talks to promote improved personnel and environmental hygiene.
•   Emphasizing the need for prompt referral of patients that need more expert attention and/or detailed investigations.
•    Timely and effective treatment of infections


FUNDING OF RENAL CARE

CRF/ESKD is prevalent in Nigeria. The treatment is expensive and as at today the majority of affected Nigerians bear the cost of their renal care. In the face of high poverty rate and the resultant inability to maintain treatment options for more than a few months, countless lives have been lost.  Many Nigerians in their productive years have died of kidney failure.

For adequate planning, funding and coverage of RRT, an efficient national Renal Registry is needed.

There is an urgent need for the FGN to step into funding of renal care to avert the unnecessary loss of lives who otherwise would have contributed to the social and economic growth of Nigeria.  FGN intervention will reduce the frustration currently been faced by renal care providers.

COST OF RENAL CARE IN NIGERIA:

Treatment options for RRT when patients are in ESKD are haemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation (KT). All the treatment options are expensive/ unaffordable e.g HD in a Nigerian government hospital costs N1,404,000 – N2,080,000/year excluding drugs.                                                                                         

SOURCES OF HEALTH CARE FINANCING IN NIGERIA:

  • Government
    • LGA
    • State
    • Federal
  • Federal
  • Private Funding
  • Health Insurance
  • Employers
  • Foreign Aid
  • FUNDING BY THE FEDERAL GOVERNMENT OF NIGERIA

•    Inadequate

  • In 2003, health allocated 3% of national  budget , the World Health Organisation however  stipulates 5% of gross national product

FUNDING OPTIONS:
•    Government
•    Direct payment by patients
•    Health Insurance:
•    Compulsory health insurance or social security
•    Private insurance
•    Managed Care (HMO and Providers)
•    Community, employer and the voluntary local financing:
•    Private voluntary (NGOs)
•    Co-operatives
•    Employer-provided health care
•    Donor Financing
•    Development loans:
•    World Bank
•    Regional development loans

FUNDING OF NRCP WITHIN THE NHIS:
The NHIS, as it is now, cannot cater for patients needing renal care as renal disease treatment is still not covered.
•    Renal disease should be included and appropriate premium attached to it.

•    Only accredited renal care centres should be used

•    Decision on best modality of renal replacement therapy should only be taken by nephrology specialists and not the HMOs.

•    The Government should support at least 50% of renal care funding.

  • There may be the need for a separate body outside the NHIS and HMOs to manage renal care funding.

MONITORING AND EVALUATION OF RENAL CARE CENTRES

Need For Monitoring and Evaluation:
•    High Renal Disease Burden in Nigeria

•    Increasing Number of New Renal Care Facilities

•    Tendency for Relative Poor Funding of Older Health Facilities in Nigeria and the attendant consequences

Responsibility for the Monitoring Exercise:
•    Each State Ministry of Health to Cover all the Renal Care Facilities within its Boundaries

•    The Federal Ministry of Health to provide an oversight function of State Agency Performance

•    The Nigerian Kidney Institute

Scope and Methodology:
•    Quality of Care Assessment in Each Facility – Utilize at least 2 Clinical Performance Measures:
•    Adequacy of dialysis defined as URR >65%,
•    Adequate anaemia control PCV>33%
•    Survey Frequency
•    Survey Specialization
•    Survey Training               
       
Survey Frequency:
•    New facilities to be inspected yearly

•    Older facilities to be inspected at least once in 3 yrs

•    Infrequent  or poorly targeted inspections allow facilities’ quality of care problems to go undetected or remain uncorrected

Survey Specialization:
•    ESKD facilities are technically complex and surveys that focus on ESKD tend to be more proficient in detecting and properly documenting quality of care problems as a result
o    ESKD Specialization – less feasible for states with few ESKD facilities
         

AREAS TO BE COVERED IN THE MONITORING AND EVALUATION EXERCISE
•    Compliance with Federal, State and  Local Government  laws and regulations:
•    Status of the license for the  facility and personnel
•    Compliance with all public safety laws
•    Evaluation of Governing Body and Management

  • Facility must be under the control of identifiable body (The Nigerian Kidney Institute) that adopts and enforces rules and regulations

•    Patient care plans
Written long-term-care plan.-Developed by multidisciplinary health team including patients
Short termPatient care plans personalized for each patient
Regular review and update of patient care plans  to respond to changing needs of patient

Patients’ rights and responsibilities
Patients must be fully informed about services available, their medical condition, reuse dialysis supplies, possibility of home dialysis and kidney transplant

•    Medical records:
o    Must be well documented for each patient

•    Physical Environment:
o    Must be functional, sanitary, safe, comfortable for patients, staff and the public   

•    Reuse of Hemodialyzers and other supplies:
o    Must follow established protocols and standards to ensure patient and staff safety

•    Director of renal facility
o    Responsible for planning, organizing, conducting & directing professional services

•    Staff
o    Must be properly trained and adequate in number

•    Minimal service requirements
o    This should include. – Dialysis, Laboratory, Social and dietetic services

Outcome of Effective Monitoring & Evaluation:
Improved quality of renal care services will be provided, driven by:

−    Fear of imposition of sanctions
−    Need for sustainable credibility

THE NATIONAL KIDNEY INSTITUTE

The National Kidney Institute will serve as a national centre for training and conducting research in kidney disease epidemiology, aetiology and management

It shall have a hospital (The National Kidney Centre) which will serve as a reference hospital for other hospitals in the country. The centre shall also be suitably positioned to co-ordinate cadaveric kidney transplantation and organ allocation when the programme begins.  

The institute shall be a government parastatal under the ministry of health

THE FUNCTIONS OF THE NATIONAL KIDNEY INSTITUTE
The functions of the Institute shall be as follows

•    The institute will be involved in training programs and will convene scientific meetings for all personnel in the field of kidney care.

•    The institute will be involved in the training of technical and nursing personnel as well as in the post graduate training of doctors

•    The institute shall coordinate medical care services offered to patients with end-stage kidney failure by various hospitals and centres in Nigeria and supervise kidney transplantation programs

•    The institute will provide public health education on kidney disease through news media and patient oriented publications.

•    The institute shall follow up of all brain-death cases from designated hospitals in Nigeria as well as harvesting and distribution of kidneys

•    The institute will conduct, promote, facilitate, ground breaking research into kidney diseases to enable the Government to provide better health care to these patients

•    Possible areas of research activity will include basic, clinical, community based and translational research into various aspects of  kidney diseases

•    It will be involved in the development of appropriate technology relevant to care of patients with kidney disease including hemodialysis, peritoneal dialysis and kidney transplantation.

•    The institute shall source and provide grants for research and training in Kidney diseases


•    The institute will lay down criteria for setting up new kidney care centres as well as accreditation/continuous evaluation of the existing centres periodically using the Nigerian Association of Nephrology (NAN) as a fulcrum for this function.

•    The institute will develop guidelines for the diagnosis and management of kidney disease locally in collaboration with NAN.

•    The Institute will run the National Kidney Centre which will be a reference hospital for other hospitals in the country.

•    The Institute will be responsible for keeping the national registry of patients with specific renal diseases who have been seen in hospitals in the country (Renal Registry)

PROPOSED ORGANISATIONAL STRUCTURE OF THE NATIONAL INSTITUTE OF KIDNEY DISEASE

For effective functioning of the Institute, there will be a Governing board, a Director-General and divisions or committees to handle different aspects of kidney care, education, training and research and supportive functions

The Governing Board:
A body known as the National Kidney Institute Governing Board will be responsible for the management of the affairs of the Institute.

Membership Of The Board:
The Board shall consist of the following members

a)    A Chairman to be appointed by the president on the recommendation of the Minister

b)    The Director-General of the Institute

c)    The President Nigerian Association of Nephrology

d)    A representative of the Federal Ministry of Health

e)    Four people representing the various interests in nephrology including nurses, dialysis technicians, nephrologists, paediatricians, urologist and patients with renal disease)

f)    A representative of the Nigerian Medical Association

g)    Two persons to represent interests not otherwise represented in this section


     

Functions of the board:
1.    The board shall be responsible for the determination of the overall policy of the Institute and in particular for the financial and operational programmes of the Institute and for ensuring the implementation of such policies and programmes

2.    The board will approve research and training programmes of the Institute

3.    It shall approve the conditions of service of the employees of the institute

4.    It shall recommend to the Minister of Health candidates for appointment as director general of the Institute

5.    Engage other persons as employees of the Institute, by direct employment or by way of transfer or secondment from any of the public services including Universities in the Federation or otherwise as it considers necessary

6.    Determine the remuneration and tenure of office of the employees of the Institute (other than the Director-General of the Institute) after consultation with the minister)

7.    Discipline and exercise disciplinary control of staff and officers of the Institute; provided that it may delegate to the Director-General of the Institute the power for the discipline of junior officers, that is, officers currently on CONTISS 06 and below or any other equivalent salary structure for the time being obtainable in the tertiary educational and tertiary institution.

8.    Determine the fees to be paid for research, consulting, training and any other services that may be offered by the Institute and

9.    Promote and undertake any other activity that in the opinion of the board is calculated to help achieve purposes of the Institute.

10.    Perform any other related activity that may be directed from time to time by the Minister

11.    Carry out other activities that are necessary and expedient for the discharge of any of its functions

Tenure of members of the board:
•    The chairman should serve a single term of 5 years and is not renewable.

•    Other board members serve a term of 4 years and may be reappointed for a second term.

•    The board members will be charged with the fiduciary, fund raising and governance responsibilities for the foundation.

•    Appointment of Research Professors

  • The board may appoint Senior Research Scientists, who have made significant contributions in their subject areas to the post of Research Professors subject to approved establishment, provided that candidates for such appointment shall have to their credit distinguished publications in peer reviewed journals and scholarship.  

•    Power to Accept Gifts

  • The board may accept gifts of land, money or other property upon such trusts and conditions as may be specified by the person making the gift
  • The board shall not accept any gift if the conditions attached by the person making the gift are inconsistent with the functions of the Board.

The Director-General
•    The Director-General shall be a renowned nephrologist or urologist of high national and international repute to be appointed by the President on the recommendations of the Minister

•    Subject to the general control of the Board, the Director General shall be the Chief Executive Officer of the Institute and be responsible for the execution of the policy of the Institute and the day to day running of the affairs of the Institute.
•    Appointment of other staff

•    The board may appoint any fit and proper persons on permanent, temporary or contract basis as employees of the Institute as it may consider necessary.

•    Conditions of Service and remuneration of the Director-General and other staff of the Institute

•    The Director-General shall hold office for five years in the first instance, renewable for a further term of five years thereafter, on such terms as the emoluments of his office, and otherwise as may be specified in his letter of appointment.

•    The remuneration, tenure, conditions of service of other employees of the Institute (other than the Director – General) shall be as those applicable to staff in Nigerian Universities or other similar institutions within the Federal Public Service or otherwise as may be determined from time to time by the Federal Government.

Divisions
To enable the Director-General to carry out his functions as the Chief Executive Officer of the Institute, the Institute will have divisions and committees and the heads of these units will be responsible to the Director-General. Examples of such divisions will include the following

1.    Education, training and research division
2.    Renal Registry
3.    Kidney care standards division
4.    National Kidney Centre (Hospital)
5.    Library and publications division
6.    The administrative division
7.    The finance and accounts division

The roles of some of the divisions are indicated below:

1.    Education, training and research division
•    Definition of training  curriculum for all nephrology specialists in Nigeria
•    Organisation of educational meetings for the training of health workers
•    Design of educational programmes
•    Organising activities to promote public awareness of kidney disease e,g sports, walk for life, essay writing competition
•    Helping to create kidney disease patient care groups.
•    Running of the Institute’s research laboratory
•    Establishment and maintenance of the renal registry

2.    Renal Registry
•    Collation of data on renal diseases and renal replacement therapy in Nigeria
•    Periodic production of reports on renal disease management and outcomes
•    Provision of  database for collaboration with research studies
•    Provision of data to support health care planning
•    Communication of registry reports to scientific community (annual congresses and conferences, annual reports, publications in scientific journals)

•    Collaboration with other renal registries in other countries and regions around the world

3.    Kidney care standards division
To be headed by the director of kidney care and hospital services division
•    Shall determine standards of care acceptable below which kidney centres may be disaccredited.

•    Shall define the coding system for kidney diseases and operate our kidney disease registry.

•    Shall ensure enactment of a solid organ transplant edict as a matter of urgency.

•    Shall perform effective national oversight of procurement, processing and transplantation of human tissue/organs.

•    Shall establish ethics commissions to ensure the ethics of tissue/organ transplants in the Country to guard against “transplant tourism” and the sale of tissues and organs.

•    Shall  work to extend kidney donation practices to the use of cadaver in addition to live donor kidney transplants

•    Shall determine standards of Haemodialysis care acceptable below which centres may be disaccredited.

•    Shall define targets attainable in the promotion of kidney health from time to time.

•    Shall determine standards of Peritoneal Dialysis care acceptable below which centres may be disaccredited. It will also define targets attainable in the promotion of kidney health from time to time.

•    Shall ensure in collaboration with other agencies, indigenous manufacture of quality and affordable drugs and other consumables used in the management of kidney disease patients

•    Shall ensure, in collaboration with other agencies, development of local facilities for the diagnoses of kidney diseases, and evaluation of kidney donors, and preparation management of kidney transplant recipients.

4.    Hospital (National Kidney Centre)
To be headed by the medical director (who will me a member of the board)
Functions of the division:
•    Training of health personnel
•    Provision of opportunities for clinical research
•    Provision of clinical services at the Institute’s Cinic or National Kidney Centre
•    Running of clinical care laboratory services
•    The centre will be a reference hospital for other hospitals in the country
         
5.    Library and Publications Division
•    Day to day running of the journal.
•    Publication of newsletter
•    Publication of Annual Report
•    Publication of patient education materials
•    Publication of Research articles
•    Responsible for the running of the institute’s library
•    Responsible for the day to day running of the computer and documentation unit.
   
6.    Administrative Division
•    Process applications for staff appointment for all cadres and liaise with the respective management committees as appropriate.

•    Handle all matters relating to staff discipline, advise on subject matters as may be referred and convey decisions as appropriate.

•    Process matters relating to staff promotion, transfer, re-designation, upgrading, conversion in liaison with relevant management committees.

•    Process staff appraisal information as are referred from Departments/Units and the out-stations.

•    Supervision of the staff registry to ensure that staff records are regularly updated.
•    Keep and update the institute's nominal roll

•    Process all applications on Annual Leave, Casual Leave, Examination Leave, sick and compassionate Leave.

•    Prepare Variation advice on salaries sequel to staff appointment and promotions.

•    Monitor staff daily attendance at work through the time keeper.

•    Undertake other duties as may be assigned from time to time.

•    General Administration

•    Legal Matters

•    Tenders matters

7.    Finance and accounts division
The functions of the unit includes the following
•    Coordinating: Salaries, Tax, Capital and other recurrent accounts in the Institute.

•    Coordinating the final accounts and bank Reconciliation

•    Cash Management and Annual Budgeting

•    Management of External projects Accounts

•    Preparing and presenting financial reports to the Governing Board of the Institute,

•    Attending Annual Budget Defence meetings at the Federal Ministry of Health; Federal Ministry of Finance; joint Sections of Senate and House of Representatives in Abuja and any other assignment given by the Chief Executive.

•    Shall ensure in collaboration with other directorates the appropriate utilisation of funds for kidney care, government subsidy and health insurance.

•    Shall also provide ways to seek funding for kidney disease research in the country and enter into partnership with organisations such as the National Kidney Foundation
 


RELATIONSHIP BETWEEN STATES, LGAs AND FEDERAL GOVERNMENT UNDER THE NRCP

1.    The Federal Ministry of Health and where applicable, the National Kidney Institute shall provide technical assistance to the State Ministry of Health:-

a)    Assistance in developing Renal Care Centres in all states of the federation where such is lacking particularly in the Federal Medical Centres.

b)    Training of manpower as well as provision of technical support, including methodologies, policies and standards that are appropriate for excellent renal health.

c)    Other technical assistance as may be necessary in order that such Institutions may properly perform their functions.

2.    The State ministry of health, with the support of the Federal ministry of health and National Kidney Institute will assist the LGAs in setting up programmes in the following areas

a)    Health education on risk factors and prevention of kidney disease

b)    Screening for kidney disease with blood pressure measurement and dipstick urinalysis

c)    Early detection and appropriate referral of patients who need advanced facilities for the management of kidney disease.

NATIONAL RENAL REGISTRY

The aims and objectives of the Nigerian Renal Registry shall be to provide up-to-date information on the incidence and prevalence of renal diseases in Nigeria, renal replacement therapy (RRT), renal service provision and staffing levels. The renal registry shall incorporate paediatric services.

The specific objectives are:

1.    Provision of up-to-date information on renal facilities and renal services and staffing in Nigeria in collaboration with NAN

2.    Collation of data on renal diseases and RRT in Nigeria

3.    Periodic production of reports on renal disease management and outcomes

4.    Provision of database for collaboration with research studies

5.    Provision of data to support health care planning

6.    Communication of Registry reports  to scientific community (annual congresses and conferences, annual reports, publications in scientific journals)

7.    Collaboration with renal registries in other countries and regions around the world

REGISTRY REPORTS:
This will be produced yearly.

Registry Report should address:
1.    Incidence/prevalence of renal diseases in Nigeria
2.    Incidence of RRT for a period by zones, ethnic groups, gender and age
3.    Patient survival by modality of treatment for a period
4.    Expected remaining lifetimes in general population, kidney transplantation and dialysis patients

5.    Expected remaining lifetimes, Nigerian Registry versus other Registries
6.    Patient survival on RRT by zones, crude and adjusted for age, gender etc
7.    Any other relevant data.

STAKE HOLDERS
The Stake holders of the Registry Shall be:

1.    The Nigerian Association of Nephrology
2.    National Kidney Institute
3.    National Kidney Foundation
4.    The renal care industry
5.    State Ministries of Health
6.    Federal Ministry of Health
7.    Support and donor agencies
8.    The National Bureau of Statistics
9.    The participating Renal Units
10.    All health institutions must participate in the renal registry
REGISTRY ADDRESS
The Renal Registry shall be domiciled at the National Kidney Institute. The Renal Registry shall have a website and an e-mail address. The Registry Letter Head’s general information includes:
•    Name of Registry
•    Address of Registry
•    Telephone number of Registry
•    Fax number of Registry
•    E-mail address

The Registry website will contain information as on the letter head (above) and the following additional information:
•    President of NAN and his/her e-mail address
•    Director of Registry and his/her e-mail address
•    Date of establishment of the Registry.

STAFFING
The Registry shall be run by:

1.    The Director or Chairman
2.    Data Managers/Scientists
3.    Information Technology Specialists
4.    Clinical epidemiologists
5.    Secretary
6.    Other ancillary staff
7.    The Director or Chairman shall be a nephrologist and shall serve a term of two years that is renewable up to a maximum of two terms.  

FUNDING
The work of the Registry shall be funded by:

1.    Nigerian Association of Nephrology
2.    The Federal Government of Nigeria
3.    The Industry
4.    Philanthropic organizations
5.    Grants from donor agencies

ENFORCEMENT
The collection and submission of data for the renal registry shall be mandatory for all medical institutions involved in renal care.
•    Defaulting centers will be sanctioned
•    Centers that send in data will be rewarded by acknowledging them on the NAN website, in NAN conferences and publications.

ORGAN PROCUREMENT/TRANSPLANT PROGRAM/LEGISLATION

ORGAN TRANSPLANTATION POLICY

Organ transplantation in the Country shall be in accordance with The Human Organ and Tissue Transplantation Resolution (WHA 57.18) reached at the 57th World Health Assembly on 22nd May, 2004.  An organ transplant policy for the country will provide the legal framework for the following:

•    Effective national oversight of procurement, processing and transplantation of human tissue/organs.

•    Formulation of guidelines with input from the various stake holders.

•    The establishment of ethics commissions to ensure the ethics of tissue/organ transplants.

•    Development of cadaveric kidney transplantation as well as promotion of live donor kidney transplantation.

•    To guard against “transplant tourism” and the sale of tissues and organs internationally.