World Kidney Forum

Funding Renal Replacement Therapy in Southeast Asia:

Building Public-Private Partnerships in Singapore, Malaysia,
Thailand, and Indonesia

Zaki Morad, MBBS, FRCP (E),1 Hui Lin Choong, MBBS, MMed (IntMed), FAMS,2
Kriang Tungsanga, MD,3 and Suhardjono, MD, PhD4

The provision of renal replacement therapy (RRT) in developing economies is limited

WKF Advisory Board by lack of financial and other resources. There are no national reimbursement policies
for RRT in many countries in Asia. The Southeast Asia countries of Singapore,
John T. Harrington, MD Malaysia, Thailand, and Indonesia have adopted a strategy of encouraging public-
Boston, Massachusetts private partnerships to increase the RRT rates in their respective countries. The pri-
Rashad S. Barsoum, MD vate organizations include both for-profit and philanthropic bodies. The latter raise funds
Cairo, Egypt from ordinary citizens, corporations, and faith-based groups, as well as receive sub-
sidies from the government to support RRT for patients in need. The kidney foundations
Christopher R. Blagg, MD of these countries play a leadership role in this public-private partnership. Many of the
Mercer Island, Washington private organizations that support RRT are providers of treatment in addition to offering
John Boletis, MD financial assistance to patients, with hemodialysis being the most frequently supported
Athens, Greece modality. Public-private partnership in funding RRT is sustainable over the long term
with proper organization and facilitated by support from the government.
Garabed Eknoyan, MD Am J Kidney Dis. 65(5):799-805. ª 2015 by the National Kidney Foundation, Inc.
Houston, Texas
INDEX WORDS: End-stage renal disease (ESRD); renal replacement therapy (RRT);
Tazeen H. Jafar, MD, MPH health care funding; health care disparities; economic incentives; public-private
Singapore partnership; public health; nongovernmental organizations; medical charities;
Nestor Schor, MD, PhD Southeast Asia; Singapore; Malaysia; Thailand; Indonesia.
São Paulo, Brazil

such reimbursement, a number of This review looks at the expe-

countries in South and Southeast rience of selected countries in

T he provision of renal replace-

ment therapy (RRT) in
developing economies is limited by
the lack of financial and other re-
sources,1,2 with the rate of treat-
ment for end-stage renal disease
(ESRD) being directly proportional
to the wealth of the country. For
many patients with ESRD, devel-
oping countries are not able to offer
any or adequate treatment; in many
instances, patients drop out from
the treatment program primarily
due to financial reasons.3
Many countries in Asia do not
have a nationally reimbursed RRT
program,4 and in the absence of
Asia have developed a major
initiative: collaboration between
public and private sectors. In
Pakistan, a low-resource country
with no national health insurance,
individual donors, foundations,
business corporations, and com-
munity and faith-based organiza-
tions have contributed to support
health care.5 For example, for more
than 25 years, the Sindh Institute of
Urology and Transplantation in
Karachi has been an example of a
successful and sustainable program
of dialysis and kidney trans-
plantation through joint community
and government funding for RRT.6
Southeast Asia, where such sup-
port, especially from philanthropic
organizations, has enhanced the
treatment of patients with chronic
kidney disease (CKD).
HEALTH CARE CAPACITY IN
SOUTHEAST ASIA
Southeast Asia generally is
understood to include the coun-
tries of Brunei, Cambodia, East
Timor, Indonesia, Laos, Malaysia,
Myanmar, Philippines, Singapore,
Thailand, and Vietnam. Of th-
ese, the only country with a
comprehensive RRT program
funded entirely by the government

From the 1School of Medicine, International
Medical University, Kuala Lumpur, Malaysia;
2
Department of Renal Medicine, Singapore
General Hospital, Singapore; 3Department of
Medicine, King Chulalongkorn Memorial
Hospital, Bangkok, Thailand; and 4Division of
Nephrology and Hypertension, University of
Indonesia, Jakarta, Indonesia.
Received April 19, 2014. Accepted in
revised form September 8, 2014. Origi-
nally published online February 28,
2015.
Address correspondence to Zaki Morad,
MBBS, FRCP (E), School of Medicine,
International Medical University, No.
126, Jalan Jalil Perkasa 19, Bukit Jalil,
57000, Kuala Lumpur, Malaysia. E-mail:
zakimorad@imu.edu.my

2015 by the National Kidney Foun-
dation, Inc.
0272-6386
http://dx.doi.org/10.1053/j.ajkd.2014.09.031

Am J Kidney Dis. 2015;65(5):799-805 799


is Brunei, a high-income nation
with an end-stage renal disease
incidence and prevalence among
the highest in the region (265 and
1,250 per million population,
respectively, in 2011).7 The other
high-income country in Southeast
Asia, Singapore, conceivably
could finance its RRT program
from the country’s public health
care system, but instead has cho-
sen to adopt a public-private
funding model for the nearly 5.5
million people of this city-state.
It was a pioneer in the region in
this respect. A report in 1999
from the Ministry of Health
Singapore helps explain this
apparent enigma: its health care
philosophy has emphasized the
individuals’ responsibility toward
their health and health care
expenditures.8
In addition to Singapore, we also
focus on 3 middle-income countries
in Southeast Asia that have made use
of public-private funding models:
Malaysia and Thailand (upper-
middle income) and Indonesia
(lower-middle income).9 These
countries, particularly Indonesia, still
face challenges with public health
and tropical diseases, thus limiting
expenditure on clinical services,
including RRT.10 The amount of
health care spending per capita in
each of these middle-income coun-
tries, as compared to Singapore, is
shown in Table 1.
ESRD PREVALENCE AND RRT
PRACTICES
In common with most countries
in the region, Singapore, Malaysia,
Thailand, and Indonesia have ex-
perienced recent marked increases
in the incidence and prevalence of
CKD requiring RRT. Table 2
shows the increase in the inci-
dence and prevalence of treated
ESRD over a 5-year period from
2007 to 2011.11 The overall burden
of ESRD could be substantially
higher given that studies in Ma-
laysia and Thailand showed the
800
Morad et al
Table 1. Health Expenditure in Selected Southeast Asian Countries
Governmental Per Capita
Total Expenditure Component of Government
GNP per on Health as % Total Expenditure Expenditure
Country Capita9 of GDP10 on Health10 on Health10
Singapore $42,784 4.5 31.4% $813
Malaysia $8,754 4.4 55.5% $358
Thailand $4,803 3.9 75% $248
Indonesia $2,947 2.8 36.1% $44
Note: Data for amount spent on renal replacement therapy were not available.
Abbreviations: GDP, gross domestic product; GNP, gross national product.
prevalence of CKD stage 5 in the ago in the region, prevalent rates in
community to be 0.36% and 0.15%, Malaysia, Thailand, and Indonesia
respectively.12,13 The 2 studies still remain less than 100 per million
differed in methodology, but none- population. However, Singapore
theless indicate a gap between cur- has an active kidney transplantation
rent treatment rates and the numbers program and the prevalence rate
that could be treated if resources in 2011 was 369 per million
were available. population.11
Hemodialysis (HD) continues to The development of RRT pro-
be the predominant RRT modality grams in the 3 middle-income
in these 4 countries. Singapore and countries has followed a generally
Malaysia are able to provide stan- similar pattern. In the beginning,
dard thrice-weekly dialysis for when facilities were limited, priority
almost all patients.14,15 In Thailand for treatment of ESRD was given to
and Indonesia, as a consequence of government servants and pen-
the financial burden of HD treat- sioners, as well as their de-
ment, most patients are dialyzed 2 pendents.19-21 These facilities
and 2.3 6 0.5 times a week, usually were available in Ministry
respectively.16,17 The majority of of Health hospitals. As the countries
HD centers in all 4 countries reuse progressed economically, nongov-
dialyzers. Measures of dialysis ad- ernment employees, funded by so-
equacy are available for Malaysia cial security organizations receiving
and Thailand, which have compre- contributions from employers and
hensive dialysis registries. Mean government, were accepted for
prescribed Kt/V values are 1.7 6 treatment. Citizens who were not
0.4 and 1.5 in Malaysia and
Thailand, respectively, while the Table 2. Incidence and Prevalence of
corresponding urea reduction ESRD in Selected Southeast Asia
ratios are 72.5% and 71%. Countries
Peritoneal dialysis (PD) is
Incidence Prevalence
responsible for ,10% of all RRT (pmp) (pmp)
(Table 3), except in Thailand,
where it is the modality used by Country 2007 2011 2007 2011
22% of all dialysis patients. This
can be explained by the Thai Singapore 268 279 1,494 1,661
government’s introduction of a Malaysia 150 209 690 980
“PD first” policy in 2008 under its Thailand 159 227 407 750
universal coverage program, a Note: Data from Indonesia were not
step that has led to a marked in- available because its renal registry only
crease in the number of patients recently was established.
Abbreviations: ESRD, end-stage renal
with CKD treated.18 disease; pmp, per million population.
Although kidney transplantation Data from US Renal Data System
was introduced more than 40 years (2013).11
Am J Kidney Dis. 2015;65(5):799-805
Renal Replacement Therapy in Southeast Asia

Table 3. Government Funding for RRT in Selected South East Asian Countries
Singapore
Population (in millions) 5.4
Total patients on RRTa 6,643
HD 4,609 (69.4%)
PD 628 (9.4%)
Kidney Tx 1,406 (21.2%)
RRT funding by
government
HD Minimal
PD Minimal
Kidney Tx Limited
Note: Information on funding by governments are approximations based on registry
data and unpublished observations of the authors.
Abbreviations: HD, hemodialysis; PD, peritoneal dialysis; RRT, renal replacement
therapy; Tx, transplantation.
a
Data sources: Indonesian Renal Registry (personal communication, Dr Ria
Bandaria, July 23, 2014), Lim et al,15 and Singapore Renal Registry.14
employees of government or private
corporations later were accepted for
RRT. However, access to treatment
still remained limited and the
private sector, both for-profit and
not-for-profit organizations, was
encouraged to provide RRT ser-
vices as described later in this
article. The main beneficiaries of
private support for RRT, especially
from philanthropic organizations,
were the less privileged segments of
society.
ROLE OF THE PRIVATE SECTOR
Provision of RRT
In Singapore, Malaysia, and, to
some extent, Thailand, not-for-profit
organizations, spearheaded by the
respective kidney foundation of
each country, have played major
roles as dialysis providers, setting up
HD centers that complement their
governments’ RRT programs.22-24
However, in Indonesia, much of
the support comes in the form of
financial assistance to patients who
receive treatment in government or
private centers. The National Kid-
ney Foundation of Singapore (NKF
Singapore) is the largest nongov-
ernmental not-for-profit provider of
HD services in the region, followed
by the National Kidney Foundation
of Malaysia (NKF Malaysia). The
kidney foundations are not direct
Malaysia Thailand Indonesia
30.2 67.2 252.8
30,484 — 27,871
26,067 (85.5%) 32,049 24,524 (88%)
2,523 (8.3%) 9,058 1,358 (4.9%)
1,894 (6.2%) — 1,989 (7.1%)
58% 61.1% 41%
100% 95.4% Partial
100% — 100%
providers of PD treatment but offer
financial or other forms of support to
PD patients who have the treatment
in hospital-based PD units. Simi-
larly, charity organizations support
kidney transplantation through
financial assistance to live donors
and transplant recipients.23 Private
for-profit HD centers have devel-
oped over the years, especially in
Singapore and Malaysia; many pro-
vide HD treatment to patients under
contracts funded by the government
and philanthropic organizations.
Awareness and Education
The kidney foundations in these
4 countries play other roles apart
from directly supporting RRT.
They are active in public edu-
cation programs and frequently
are involved in initiatives such
as World Kidney Day activities.
In Singapore, Malaysia, and
Thailand, the respective kidney
foundations also undertake formal
training of allied health staff
(eg, HD nursing programs), com-
plementing the efforts of gov-
ernment agencies.22-24 In recent
years, with increasing awareness
of CKD, particularly regarding
diabetes mellitus as its major
cause, these organizations have
been offering health screening
programs, which are heavily sub-
sidized by public donations.25,26
Fundraising Efforts
Although (aside from Singapore)
government funding primarily is
responsible for funding PD and
kidney transplantation, a consider-
able percentage of HD treatment
costs are funded by the private
sector (Table 3). Because HD is the
most common RRT modality, the
overall amount of such funding
is substantial. Thus, the biggest
challenge for the philanthropic or-
ganizations in supporting renal
replacement services is sustainabil-
ity. Ensuring continuing commu-
nity and corporate donations for
their programs is an all-consuming
objective of these organizations.
They adopt strategies not unlike any
good business enterprise: engage,
retain, and ensure continuing loy-
alty of their “customers” (the do-
nors).27,28 The organizations also
seek donations in kind, such as
dialysis machines, disposable
equipment, and medications.
Another major source of phi-
lanthropy is local and inter-
national faith-based groups. The
Buddhist dogma “giving is a
merit” is an influential impetus
for donations in Thailand (K.T.,
unpublished observations). The
Buddhist Compassion Relief Tzu
Chi Foundation dedicates itself
to helping the poor by carrying
out charitable works, including
providing medical care and edu-
cation.29 In Malaysia, local church
groups have been active in sup-
porting RRT,30 and a number of
churches in Malaysia have set up
HD centers in collaboration with
NKF Malaysia, which provides
the technical and medical exper-
tise to run these centers. In the
predominantly Muslim countries
of Indonesia and Malaysia, a ma-
jor source of funds for medical
philanthropy is the zakat, a tithe,
expected from all Muslims who
have excess income. It amounts to
2.5% of excess income and is paid
to a public treasury empowered by
the state.31 The zakat fund is used

Am J Kidney Dis. 2015;65(5):799-805 801


to effect social justice, helping the
sick and poor being one of the
main reasons for using the fund.
Another system of Islamic phi-
lanthropy is the waqf, a form of
endowment. Some HD centers in
Malaysia are built on waqf land.
An important aspect of these
philanthropic organizations’ suc-
cess is to stay relevant and active in
the community. Corporate and
government leaders are appointed
either to the board of directors or
advisory committees and provide
links with the business community
and government agencies. Lu-
minaries are secured as patrons
of these organizations, garnering
prestige.24,27,28 The operations and
accounts of the foundations are
transparent and made public
through annual reports. Members
of professional groups including
nephrologists and nurses often
serve in voluntary capacities in
these centers. Any perception of
misuse of funds can have serious
implications on philanthropic
contributions, as experienced by
NKF Singapore in 2005. As
recounted in its website, the scan-
dal “left an indelible mark in the
charity sector in Singapore, result-
ing in massive changes in the
regulation of charities and raising
awareness of charity accountability
and transparency.”23
PUBLIC-PRIVATE
COLLABORATION
The experiences of the 4 coun-
tries vary. Singapore and Malaysia
have the most organized public-
private collaboration for RRT
and related activities.
Singapore
At the end of 2012, of 5.31
million people then living in
Singapore, 5,237 patients were
receiving dialysis treatment and
1,406 had functioning transplants
(Table 3).14 The main dialysis
modality was HD, with PD pa-
tients forming 12% of the dialysis
population.
802
The majority of HD patients are
funded by not-for-profit organiza-
tions, mainly by NKF Singapore,
which receives donations from the
public and large corporations.
Government subsidies for HD and
PD are minimal and the amount
provided varies according to
household income. NKF Singapore
was established in 1969 and began
sponsoring a dialysis program in
1975. At first, patients and their
helpers were trained at the
Singapore General Hospital to
perform their own dialysis and
subsequently would dialyze them-
selves at a satellite center.32 NKF
Singapore subsequently decided to
operate its own centers and opened
its first HD center at the Kwong
Wai Shiu Hospital, with 10 stations
in 1982. With successful fund
raising and partnerships with many
businesses, as well as philanthropic
organizations and individuals, it
since has steadily added centers,
which now number 25.28
Another organization, the Kid-
ney Dialysis Foundation, shared
in the responsibility to provide
dialysis to the needy from 1996.33
A third voluntary welfare organi-
zation, the Khoo Foundation,
started dialysis services at the
Peoples Dialysis Centre also in
1996. In 1999, the support pro-
vided by all the voluntary welfare
organizations combined cared for
75% of HD patients in Singapore.
More recently in 2009, the pro-
portion was 68.4%. This declining
trend is related to improved rates
of coverage by the national health
and private insurance schemes.34
PD patients have been cared for
largely by hospital physicians. The
Kidney Dialysis Foundation has a
PD program directly involved in
patient care since 2005, whereas
NKF Singapore only provides
subsidies for patients.
Apart from direct patient care,
the voluntary welfare organiza-
tions have many other programs,
which include a patient welfare
fund, children’s dialysis and
Morad et al
transplantation fund, support for
living kidney donors, public edu-
cation, and continuing education
for health care professionals.
The many donors, ranging from
the ordinary citizens to multimil-
lionaire philanthropists and their
charitable foundations or business
organizations, have played a
crucial role in the development of
nephrology services in Singapore.
Malaysia
There were 28,590 patients
receiving dialysis in Malaysia at
the end of 2012, giving a preva-
lence of 975 per million popula-
tion. The corresponding figures
for kidney transplantation were
1,894 recipients, with a preva-
lence of 65 per million population.
Of the patients on dialysis therapy,
only 8.8% were treated by PD.15
In that year, the government fun-
ded 58% of HD patients and all
PD patients. About 40% of those
receiving HD were supported by
private funds, especially from the
philanthropic organizations. Kid-
ney transplant recipients whose
surgery was performed in
Malaysia were supported fully by
the government (Table 3).
Maintenance dialysis treatment
started in Malaysia in 1967 and
became organized in the early
1970s; however, it remained inac-
cessible to most patients with ESRD
until the late 1980s. By 2005, dial-
ysis treatment rates had increased
more than 8-fold compared to 1990,
which coincided with the rapid
economic growth of the country.
More importantly, this period saw a
new initiative in the country; a
partnership between the public and
private sectors, as well as philan-
thropic nongovernmental organiza-
tions, which collaborated to
develop facilities for HD treat-
ment.35 The public sector purchased
HD services from the private for-
profit sector, thereby encouraging
its growth. It encouraged and facil-
itated the growth of HD centers run
by philanthropic nongovernmental
Am J Kidney Dis. 2015;65(5):799-805
Renal Replacement Therapy in Southeast Asia
organizations, which, with funds
raised from donors, were able to
provide HD treatment at reduced or
no charge to patients in need. This
led to a rapid increase in the number
of patients receiving long-term
RRT.
Two important developments
led to a further increase in private
involvement in the treatment of
ESRD in the country. The first
was the liberal implementation of
a health care law in Malaysia that
enabled organizations to start an
HD facility irrespective of
whether they have links to a hos-
pital.36 Both for-profit and charity
groups were able to develop free-
standing HD centers in varied
and sometimes unlikely locations
such as storefronts, renovated
bungalow houses, mosques,
churches, and offices. The second
development was the announce-
ment by the government in its
2001 budget that it would provide
regular financial support to any
nongovernmental organization of-
fering subsidized HD treatment.
This support came in the form of a
matching grant for the start-up
cost and a subsidy of RM $50
(US $15.60) per HD treatment.37
The government grant later was
increased to include the cost of
erythropoiesis-stimulating agents.
The government subsidy, which
continues today, amounts to about
a third of the cost of treatment.
NKF Malaysia, which was
founded in 1969, was the first
nongovernmental organization to
start charity HD centers in 1993,
and later, many others followed.22
It currently provides heavily sub-
sidized HD treatment to 1,550
patients in 26 centers, spending
about US $9 million annually.27
Other philanthropic organizations
in Malaysia that provide HD
treatment include faith-based or-
ganizations from the Islamic,
Buddhist, and Christian groups;
service organizations like the Ro-
tary and Lions clubs, and cultural
bodies.
Am J Kidney Dis. 2015;65(5):799-805
A number of the nongovern-
mental organizations support pa-
tients by paying for their treatment
at private for-profit HD centers
rather than providing the treatment
themselves. Zakat organizations
play a major role in funding renal
replacement services in Malaysia.
Because Muslims form about 60%
of the population, zakat contribu-
tions are sizeable. In one region of
the country, 16.4% of the zakat
allocation for social services was
reported to go toward funding
dialysis treatment.38
At the end of 2012, there were
145 HD centers (22%) belonging
to nongovernmental organization
groups and 367 (55%) belonging
to private for-profit groups of a
total 670 centers, most of which
were freestanding.15
Thailand
The total number of dialysis
patients in Thailand in 2013 was
41,107 (Table 3), with 22% of
these receiving PD. All Thai citi-
zens receive full or partial gov-
ernment support for RRT. About
61.1% of HD and 95.4% of PD
patients receive full government
funding.
There are 5 not-for-profit non–
hospital-based foundations in
Thailand that deal with renal ser-
vices. The oldest is the Kidney
Foundation of Thailand (KFT),
established in 1978, which has
contributed tremendously to
nephrology in the country. KFT
now operates 6 HD centers; 4 in
Bangkok and 2 in other provinces.
It was a great encouragement to
philanthropy when His Majesty
the King of Thailand graciously
allowed 2 HD centers under KFT
supervision to be stationed at
Chitralada Palace (the King’s
residence) and at the Grand
Palace. Together, the 6 centers can
accommodate up to 750 patients.
The cost of HD per session varies
according to a patient’s source of
funding. In the past, when patients
usually paid out of pocket for HD
treatment, the charge was only
30% of the actual HD cost. At
present, patients who are under the
Civil Servants Medical Benefi-
ciary Reimbursement System
(government officers) are charged
US $66 per HD session. Corporate
workers who are under the Social
Security System and other less
privileged Thai citizens who are
under the National Health Security
Office payment scheme are
charged no higher than US $50
per session. For those who have to
pay out of pocket, the dialysis
charge varies from US $7 to $33
per session. Only a few patients
are dialyzed for free at KFT cen-
ters. Beyond dialysis care, other
renal activities that KFT has been
actively and continuously engaged
with for more than 3 decades
include supporting kidney trans-
plantation, training, education,
and research. Altogether, the
KFT’s contribution to the Thai
renal community is about US $35
million (K.T., unpublished data).
Two other foundations, the
General Chamlong Srimuang
Foundation and Srirattanakosin
Foundation, follow HD treatment
models similar to KTF’s subsi-
dization of the poor by charging
full fees for those whose care
is covered by third parties.
The Bhumirajanagarindra Kidney
Institute is the latest foundation
dedicated to kidney disease. The
mission of the US $70 million
institute, established to commem-
orate the 60th anniversary of the
King’s rule, includes high-
standard HD and PD treatment,
public education and awareness,
and research and personnel
training. The Jitra-Nukroa Foun-
dation is the only foundation that
is located outside Bangkok.
The most important philanthro-
pists for kidney diseases in
Thailand are their Majesties King
Bhumipol and the Queen Sirikit of
Thailand, who besides providing
sites for HD centers in their pal-
aces, have supported more than
803

100 kidney patients (including
those receiving RRT) with con-
tributions of more than US
$200,000 a year.
Indonesia
Indonesia is the most populous
country in Southeast Asia. Its
population of more than 252
million is spread over a wide ar-
chipelago, posing challenges for
social services, including health
care. RRT is available in most
parts of the country, but is not
readily accessible to most with
CKD. In 2013, it was estimated
that there were 27,871 patients
receiving RRT, with 24,524
treated by HD, 1,358 receiving
PD, and the rest with functioning
transplants (Table 3). The preva-
lence rates of dialysis and kidney
transplantation were 109 per
million population and 8.4 per
million population respectively
(S., unpublished data).
The number of new patients
accepted for treatment per million
population is still low. There has
been a marked increase in recent
years, but the number that remain
on treatment has not increased as
rapidly.16 About 32% of incident
patients are self-funded, whereas
the rest are supported by insurance
or the state. Of prevalent patients,
w22% are self-funded. There are
many foundations, including those
established by patient groups,
most of which are locally based,
that provide financial support for
patients on RRT; however, they
are not as organized or structured
as those in Singapore or Malaysia.
Although Muslims form more
than 85% of the population, funds
from zakat are not widely used for
RRT, unlike in Malaysia. There
are far greater demands for zakat
funds to be used for low-priced or
free medical services for the
poor.39 The sister of the third
president of the republic of
Indonesia, Mrs Sri Soedarsono,
established the only kidney hos-
pital in the country, named after
804
their late mother, dedicated to help
those with kidney disease and
ESRD (S., unpublished observa-
tions). The hospital also donated
more than 200 HD machines to
dialysis centers in the region.
SUSTAINABILITY OF PUBLIC-
PRIVATE PARTNERSHIPS
The sustainability of public-
private partnerships in supporting
costly treatment such as RRT is
subject to scrutiny. In most ad-
vanced economies, such treatment is
borne by the state. In developing
countries, the competing demands
for limited health care funds con-
strain expenditure on such therapies.
Two countries on the different ends
of the national income spectrum
have shown that such a model can be
sustained for RRT. The Sindh
Institute of Urology and Trans-
plantation in Pakistan not only has
been able to maintain the model for
more than 25 years, but increased
the number of patients treated
annually.6 Singapore, a high-
income country that pioneered the
public-private partnership in RRT,
has continued with the model since
the 1980s. Improvement in the eco-
nomic status of the country may lead
to less reliance on private contribu-
tions and more involvement of the
government in provision of RRT as
seen in Singapore. However,
improved economic status of the
nation also may lead to greater
contributions to medical charities
and thus sustain the partnership, as
seems to have happened in Pakistan.
Similarly, in Malaysia, zakat
collection has increased parri passu
with improvement in the nation’s
economic status, thus enabling the
zakat organizations to increase their
support of RRT.40
The success and sustainability
of public-private partnerships
eventually may rest on the
public’s perception on how well
their contributions have been
used and on good governance of
these programs. The guiding
principles of “equity, transparency,
Morad et al
accountability to its supporting or-
ganizations,” as adopted by the
Sindh Institute of Urology and
Transplantation,6 may be the fac-
tors that sustain the model. A
government that encourages and
facilitates such partnership and the
presence of organized structures to
handle the partnership can ensure
its viability.
CONCLUSIONS
Many countries in Southeast Asia
have limited expenditure on health
care and thus are unable to provide
treatment for many with ESRD. The
experiences of 4 Southeast Asia
countries—Singapore, Malaysia,
Thailand, and Indonesia—have
shown that public-private collabo-
ration in funding of RRT may
enable more patients to be treated.
Implementation of policies that
acknowledge and support private
contributions, as well as liberal
implementation of health care laws,
encourages voluntary organizations
to participate in the provision of
RRT. Involvement of private orga-
nizations in treating ESRD also may
engage community participation,
promote volunteerism and caring
attitudes among the populace, and
serve as an avenue for creating
awareness of CKD among the
community.
ACKNOWLEDGEMENTS
The authors acknowledge Lee Day Guat
for assistance in the preparation of the
Malaysian section of the article and Dr
Supat Vanichakarn, Dr Teerachai Chan-
tarojanasiri, Dr Dhavee Sirivongs, Dr
Somachai Cheewinsiriwat, Khun Paichit
Rattananon, and Than Puying Ravijitr
Suwanbubpa for assistance in the prepa-
ration of the Thailand section.
Each of the authors has been or is still
involved with the national kidney foun-
dation of his or her country.
Support: None.
Financial Disclosure: The authors
declare that they have no relevant financial
interests.
REFERENCES
1. Barsoum RS. Chronic kidney dis-
ease in the developing world. N Engl J
Med. 2006;354(10):997-999.
Am J Kidney Dis. 2015;65(5):799-805
Renal Replacement Therapy in Southeast Asia
2. Jha V. Current status of chronic
kidney disease in South East Asia. Semin
Nephrol. 2009;29(5):487-496.
3. Abraham G. The challenges of renal
replacement therapy in Asia. Nat Clin
Pract Nephrol. 2008;4:643.
4. Just PM, de Charro FT,
Tschosik EA. Reimbursement and eco-
nomic factors influencing dialysis modal-
ity choice around the world. Nephrol Dial
Transplant. 2008;23(7):2365-2373.
5. Kassim-Lakha S, Bennet J. Philan-
thropic funding for health in Pakistan.
Lancet. 2013;381:2236-2237.
6. Risvi SAH, Naqvi SAA,
Zafar MN. A kidney transplantation
model in a low resource country: an
experience from Pakistan. Kidney Int.
2013;3:236-240.
7. Tan J. End stage renal disease in
Brunei Darussalam—report from the first
Brunei Dialysis Transplant Registry
(BDTR). Ren Fail. 2013;35(8):1101-1104.
8. Ministry of Health Singapore.
Health care expenditure and financing. In:
The Annual Report 97/98. Singapore:
Singapore National Printers Ltd; 1998:
18-25.
9. The World Bank. World develop-
ment indicators. http://data.worldbank.org/
data-catalog/world-development-indicators.
Accessed January 26, 2014.
10. World Health Organization. World
Health Statistics 2013. www.who.int.
Accessed January 26, 2014.
11. Collins AJ, Foley RN, Chavers B,
et al. US Renal Data System 2013 annual
data report. Am J Kidney Dis. 2014;
63(1)(suppl 1):e1-e420.
12. Hooi LS, Ong LM, Ahmad G.
A population-based study measuring the
prevalence of chronic kidney disease
among adults in West Malaysia. Kidney
Int. 2013;84:1034-1040.
13. Ong-ajyooth L, Vareesangthip K,
Khonputsa P. Prevalence of chronic kid-
ney disease in Thai adults: a national
health survey. BMC Nephrol. 2009;10:35.
14. Singapore Renal Registry. Annual
Registry Report 1999-2013. https://
www.nrdo.gov.sg/docs/librariesprovider3/
Publications—Kidney-Failure/singapore-
renal-registry-annual-registry-report-1999-
2013-preliminary.pdf?sfvrsn=0. Accessed
January 26, 2014.
Am J Kidney Dis. 2015;65(5):799-805
15. Lim YN, Goh BL, Ong LM, eds.
20th Report of the Malaysian Dialysis and
Transplant Registry 2012. http://www.msn.
org.my/fwbPagePublic.jsp?fwbPageId5
pMdtr2012. Accessed July 1, 2014.
16. 5th Report of the Indonesian Renal
Registry. www.indonesianrenalregistry.
org/. Accessed April 14, 2014.
17. Praditpornsilpa K, ed. Thailand
Renal Replacement Therapy 2011. http://
www.nephrothai.org/nephrothai_boffice/
images_upload/news/391/files/trt2011.pdf.
Accessed July 1, 2014.
18. Dhanakijcharoen P, Sirivongs D,
Aruyapitipan S. The “PD First” policy in
Thailand: three-years experiences (2008-
2011). J Med Assoc Thai. 2011;94(suppl 4):
S153-S161.
19. Morad Z. Medicine in Malaysia:
nephrology. Med J Mal. 1995;50(suppl
A):S29-S32.
20. Chittinandana A; TRT Working
Group. The Nephrology Society of Thailand.
Thailand renal replacement therapy registry
(TRT registry), the first year report. J Jpn
Soc Dial Ther. 1999;32(6):967-968.
21. Prodjosudjadi W. Incidence, prev-
alence, treatment and cost of end stage
renal disease in Indonesia. Ethn Dis. 2006;
16(suppl 2). S2-14-S2-16.
22. Sreenevasan G, Choon TC. Na-
tional Kidney Foundation of Malaysia. In:
Nephrology in Malaysia. Celebrating 50
Years of Progress. Kuala Lumpur,
Malaysia: Malaysian Society of
Nephrology; 2009:238-248.
23. History of NKF Singapore. www.
nkfs.org/our-history.html. Accessed March
15, 2014.
24. The Kidney Foundation of
Thailand. www.kidneythai.org. Accessed
March 15, 2014.
25. Ramirez SPB. Chronic kidney dis-
ease prevention in Singapore. Clin J Am
Soc Nephrol. 2008;3:610-615.
26. Ong LM, Punithavathi N,
Thurairatnam D. Prevalence and risk fac-
tors for proteinuria: the National Kidney
Foundation of Malaysia Lifecheck Health
Screening programme. Nephrology. 2013;
18(8):569-575.
27. National Kidney Foundation
Malaysia. Board of Directors Report,
2013. www.nkf.org.my/. Accessed March
26, 2014.
28. National Kidney Foundation
Singapore. Annual Report 2013, July 1,
2012-June 30, 2013. www.nkfs.org.
Accessed March 25, 2014.
29. Buddhist Compassion Relief Tzu
Chi Foundation. https://www.us.tzuchi.
org/. Accessed March 26, 2014.
30. Full Gospel Tabernacle. Eagle
Dialysis Center. www.fgt2u.org. Accessed
March 26, 2014.
31. Dean MH, Khan Z. Muslim per-
spectives on welfare. J Soc Policy. 1997;
26(2):193-209.
32. Khoo OT, Pwee HS, Lim CH, et al.
Self-dependency dialysis unit in
Singapore. Ann Acad Med Singapore.
1977;6(1):35-39.
33. Kidney Dialysis Foundation. Med-
ical Report 2012. http://www.kdf.org.sg/
pdf/Medical%20Reports/2012_PD_MAB_
report.pdf. Accessed March 25, 2014.
34. Central Provident Fund Board,
Singapore. http://mycpf.cpf.gov.sg/Members/
Gen-Info/mbr-Gen-info.htm. Accessed March
15, 2014.
35. Lim TO, Goh A, Lim YN,
Morad Z, Suleiman AB. How public and
private reforms dramatically improved
access to dialysis therapy in Malaysia.
Health Affairs. 2010;29:12.
36. Laws of Malaysia. Act 586: Private
Healthcare Facilities and Services Act 1998.
www.agc.gov.my/Akta/Vol.%2012/Act%
20586.pdf. Accessed March 26, 2014.
37. Zainuddin D. Minister of Finance’s
Budget 2001 Speech: A New Malaysia—
From Strategic Planning to Strategic
Implementation (pp 35-36). http://www.
treasury.gov.my/pdf/budget/speech/bs01.
pdf. Accessed April 10, 2014.
38. Majlis Agama Islam Selangor.
Lembaga Zakat Selangor: Laporan kutipan
dan agihan Zakat bagi 2012. (Council of
Islamic Religion Selangor. Zakat Board:
Report of the Zakat Collection and Dis-
tribution 2012). www.e-zakat.com.my.
Accessed March 26, 2011.
39. Latief H. Health provision for the
poor: Islamic aid and the rise of charitable
clinics in Indonesia. South East Asia Res.
2010;18(3):503-553.
40. Embong MR, Taha R, Nor MN.
Role of zakat to eradicate poverty in
Malaysia. J Pengurusan. 2013;39:
141-150.
805