National Kidney and Transplant Institute
Best Practice Focus Area/s
Citizens / Customers Operations
Fiscal year 2021
This is a GBPR 2021 recipient entry
The NKTI-Baxter Peritoneal Dialysis (PD) Center of Excellence is the penultimate private-public partnership (PPP) between the National Kidney and Transplant Institute (NKTI) and Baxter Healthcare Philippines Inc (BHPI). In this collaboration, the NKTI provided a 1,000 square meter property while BHPI provided infrastructure by constructing a 2-story building and a supplies tie-up for PD solutions and accessories for five years. This resulted in a state-of-the-art PD Center. It is a one-stop multi-purpose complex where patients have the convenience of collecting their monthly supply of PD solutions under the PhilHealth Z Benefit, having a clinic visit with their physicians, or an automated PD treatment outpatient session.
The NKTI is the first healthcare institution to adopt a PD First Policy for patients diagnosed with end-stage kidney failure, recognizing that this treatment modality is the most affordable, accessible, and sustainable form of treatment for a developing country like the Philippines, being not capital intensive, requiring limited personnel, and being performed by patients in the convenience and comfort of their homes.
The NKTI-PD Center of Excellence is the most innovative procurement model of the NKTI, combining infrastructure with the provision of dialysis supplies. This pioneering and ground-breaking facility is part of NKTI’s thrust to provide the highest quality care for Filipino patients with end-stage kidney disease.
Background and Problem
NKTI is the DOH’s national referral center for patients with known and suspected kidney disease, especially those needing therapy for permanent kidney failure. There are three modalities for replacing kidney function. These include kidney transplantation, hemodialysis, and peritoneal dialysis.
PD is performed by infusing a 2-liter special dextrose solution (PD solution or PD bag) into the abdominal cavity through a surgically placed permanent soft catheter. The PD solution dwells in the abdomen for 6 to 8 hours, exchanging toxins and excess fluid from the body to the solution. After the dwell period, the solution is drained, and a fresh PD solution is infused again, called an “exchange.” This is repeated 3 to 4 times a day every day.
NKTI adopted the PD-First policy in 2004, recognizing the benefits and advantages of PD, and the Dialysis Kalinga Program was established, providing financial assistance for patients belonging to the low socio-economic class (called service patients), as long as they chose PD as their permanent therapy. Specially trained PD nurses educate patients and their caregivers on these daily exchanges at home. PD is advantageous in being a home-based therapy, not requiring considerable capital investment in setting up the service. However, the lifelong therapy cost was unaffordable for many, and patient survival was very low.
Solution and Impact
To address the increasing burden of patients in collecting their monthly PD supplies and the insufficient clinic areas, the NKTI initiated the first step towards its solution by offering a Private Public Partnership model for procurement of PD solutions by including the construction of a PD warehouse with clinic space. After undergoing the bidding process, BHPI was awarded the 5-year contract. Thus, a 2-story building was constructed at no additional cost to the Institute aside from the PD tender.
The terms of reference included a forklift and training of the NKTI operators to efficiently move the boxes of solutions from the delivery vans to the patient claiming areas. The private partner also provided training on proper inventory management. To improve patient services, a queuing system was required to discharge various patient services and various payment modalities competently. This includes services for patients using either PHIC only, using guarantee letters from the DOH or other funding agencies. All of these are tracked automatically by the system, with reports available for review by the PD Unit Head.
Construction took about two years due to delays brought on by COVID-19, and the building was finally inaugurated on 23 February 2021. This PD Center of Excellence now provides the much-needed warehouse space that can store 73,000 PD bags, including a 3-month supplies inventory and a queuing system to organize all the steps for patients to pay for and claim their PD solutions. In addition, there are separate areas for clinic visits with a physician, training and education sessions with a PD nurse, and automated out-patient PD sessions. All these services are performed in this self-contained center. The highest standards of quality care and patient services are now provided to PD patients.
As of October 2021, 955 NKTI patients are enrolled under the PD Z-benefit, and 2900 PD bags are dispensed daily for these patients. About 40 patients come to the PD center daily and enjoy the efficient service and spacious building for all their needs. Patient satisfaction is at an all-time high, and the NKTI PD and administrative staff have very high morale in serving the patients.
In 2012, the NKTI worked ardently with the Department of Health and PHIC to develop an enhanced reimbursement program for lifelong dialysis support to encourage patients to go on this home-based therapy. In 2014 PHIC implemented the PD-Z Benefit Package, where Php 270,000.00 is provided for PD therapy per year. A cost-effectiveness evaluation of kidney replacement in the Philippines by Bayani, et al. in 2021 found that PD was the preferred treatment modality after kidney transplantation since it provided better value-for-money with an incremental cost-effectiveness ratio (ICER) of Php 570,029.00 per QALY gained, compared with the ICER of the PD-First combined with pre-emptive transplant option of PHP 577,989.00 per QALY gained. In addition, she found that expanding existing hemodialysis (HD) coverage to 156 sessions per year was the least cost-effective policy (PHP 1,522 437.00 per QALY gained). The NKTI Team took almost four years to implement the project. It began with a market sounding on 30 August 2017.
Since its implementation, NKTI has observed a continuing increase in PD patients. In October 2017, 750 patients were enrolled under this package, and about 5,000 PD bags were being dispensed daily, including solutions for in-patient use. During this time, the NKTI staff encountered major difficulties in managing supplies due to the lack of a tracking system and more importantly, the lack of sufficient warehouse space to accommodate the voluminous PD solutions. This led to stockouts of various PD solutions. Patients likewise had their battle when claiming PD solutions due to the small area provided for dispensing in the cramped warehouse. The PD Clinic area likewise became too small to accommodate the number of patient consults. This resulted in overcrowding and patient dissatisfaction. There was an urgent need for a bigger space allocation to provide the increased requirement for PD services.
After that, the procurement process was conducted in 2018, followed by the groundbreaking on 4 September 2019. Even during lockdowns due to the COVID-19 Pandemic, the project proceeded (construction phase). The infrastructure component was completed on 30 October 2021. Other items and requirements complied from November 2020 to February 2021. The NKT-Baxter PD Center of Excellence was inaugurated on 23 February 2021 and became operational and available to patients in May 2021.