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MEETING FUTURE MANPOWER
NEEDS IN NEPHROLOGY-
STRATEGIES AND SOLUTIONS
Dr Zaki Morad
International Medical University
Nephrology in Malaysia
When did Nephrology begin?
• Nephrology as recognised presently started in the early 1970s and there were only three physicians trained in nephrology. There was no long term dialysis program, no renal transplantation until 1975, no renal pathologists or renal trained nurses
• Renal diseases as with all other “medical” diseases were managed by general physicians prior to the 1960s
Nephrology in Malaysia
The present state:
• About 15,000 patients on dialysis
• About 1,700 patients with functioning
transplants
• 70 adult and Pediatric nephrologists
• ~2,000 renal trained nurses
Table 1.01: Stock and Flow of RRT, Malaysia 1997 –
2006
Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
New dialysis pts 1136 1252 1544 1840 2085 2348 2597 2858 3054 3152
New Transplants 126 104 127 143 161 168 160 189 161 126Dialysing at 31st
December 3698 4539 5538 6691 7839 9114 10429 11855 13337 14647Functioning
transplant 1083 1111 1176 1248 1330 1425 1502 1590 1683 1725
No
. o
f p
ati
ents
Year
0
500
1000
1500
2000
2500
3000
3500New Dialysis
1997 1999 2001 2003 2005
Year
0
2000
4000
6000
8000
10000
12000
14000
16000Dialysing at 31st December
1997 1999 2001 2003 2005
Table 1.02: New Dialysis Acceptance Rate and New
Transplant Rate per million population 1997 – 2006
Acceptance rate 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Dialysis 52 56 68 78 87 96 104 112 117 118Transplant 6 5 6 6 7 7 6 7 6 5
Rat
e, p
er m
illi
on p
opula
tion
Year0
20
40
60
80
100
120
Dialysis
1997 1999 2001 2003 2005
Rate
, p
er m
illi
on
po
pu
lati
on
Year
0
2
4
6
8Transplant
1997 1999 2001 2003 2005
Table 1.03: RRT Prevalence Rate per million population 1997 –
2006
Prevalence rate 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Dialysis 171 205 244 285 326 372 416 463 510 550
Transplant 50 50 52 53 55 58 60 62 64 65
Rat
e, p
er m
illi
on p
opula
tion
Year0
100
200
300
400
500
600Dialysis
1997 1999 2001 2003 2005
Rat
e, p
er m
illi
on p
opula
tion
Year0
10
20
30
40
50
60
70Transplant
1997 1999 2001 2003 2005
Primary Renal Disease 1997 – 2006
Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
% Unknown
cause
33 32 29 28 30 30 28 28 26 27
% Diabetes
Mellitus
36 41 41 45 46 50 53 54 55 57
% GN 13 10 10 9 6 6 5 4 5 3
% SLE 1 1 2 2 1 1 1 1 1 1
%
Obstructive
Nephropathy
5 5 4 3 3 3 3 2 2 2
%
Hypertensio
n
9 8 11 12 9 7 7 7 7 6
Nephrology in Malaysia
Meeting future manpower needs
• Estimating manpower needs is a complex process and not quite an exact science
• USA, UK and few other countries have formulated specialists manpower requirements based on certain principles and job description modeled in Full time equivalent units (FTE).
• No such exercise has been done in Malaysia
How do we estimate the future manpower
needs for Nephrology in the country?
Need to determine:
• The scope of work of nephrologists
• The RRT burden
• The role of general physicians/ general
practitioners in nephrology especially in
management of Dialysis patients
• Health care financing system
• Research committments
Scope of work of nephrologists
The nephrologists may have to do more in the future:
• Clinical work – general nephrology, Dialysis and Transplantation
• “Preventive” nephrology – early detection and management of CKD ( in conjunction with Primary care physicians)
• Training – training of nephrologists is increasingly becoming more structured and organised. This requires greater commitment on the part of the supervising consultant.
• Management
The RRT burden
• The prevalence of dialysis patients is increasing
at close to 10%
• There is more elderly and diabetic patients both
of whom require greater care
• Successfully transplanted patients require less
care than dialysis patients after the first few
months. With “stagnating” transplantation rates
more patients will be on dialysis thus increasing
the workload of the nephrologist.
Role of general physicians in Nephrology
• General physicians and GPs have played
important roles in the care of RRT
patients.
• This has enabled the dialysis population to
grow rapidly over the last decade.
• The future manpower needs in nephrology
will be affected to some extent whether
they will continue to play this role
Health care financing
• The government has indicated that it will be
introducing a form of healthcare financing in the
near future
• There is little information on the form of financing
and reimbursement for chronic diseases
requiring long term treatment such as dialysis
• New forms of financing will affect dialysis
provision and hence manpower requirements
Meeting future manpower needs
The present number of Nephrologists is about 3 per million population which meets the target set by the Ministry of Health.
The plan is now to have about 6 per million within the next 10 years which calls for producing about 10 nephrologists per year ( taking into account retirements)
We are now producing 4-6 nephrologists per year
Meeting future manpower needs
Strategies :
• Make nephrology more interesting
- Have more procedures and interventions
within the domain of nephrology practice
- clinical epidemiology
- clinical economics
Meeting future manpower needs
Strategies:
• Improve training programs
- improvements in general specialty training (ensuring physicians start training early and finish training at an earlier age)
- a more structured training program with greater supervision
- training in management issues like cost containment, cost effectiveness, general management
- attitudes and values
Meeting future manpower needs
Clinical research
• More clinical research are being done in
Asia Pacific
• Nephrologists should be involved in
research
• The manpower planning should take into
account involvement in research
Meeting future manpower needs
• Improving conditions in the public sector
service to attract and retain nephrologists
- remuneration
- working enviroment
Meeting future manpower needs
Nurses/Medical Assistants
Dietitians
Medical Social workers
Pharmacists
Technical support staff
Meeting future manpower needs
Nurses/Medical assistants
• There is still a lack of trained renal/dialysis nurses to meet the minimal requirements set by the Private Healthcare Facilities Act
• Dialysing the elderly and the diabetic ESRD patients calls for skilled nurses
• Role for nurses in early CKD detection and management
Meeting future manpower needs
Dietitians
• The RCP/RA of UK recommended in 1991 that a renal unit of 200 dialysis patients would require two dietitians
• There is still a major shortage of dietitians in the country and few of the dialysis patients are attended to by dietitians
• A major need to increase the number of dietitians and train them in renal dietetics
CONCLUSION
• The number or incident and prevailing patients on RRT continues to increase. There will be more patients who are older and have more comorbid conditions posing greater demands on the renal service
• Nephrologists have also to take greater interests in early detection and management of CKD
CONCLUSION
• The future calls for more nephrologists,
nurses and other allied staff
• Training has to include the skills to
manage not just the clinical problems but
management issues of cost containment,
manpower development, epidemiology etc