Ethical principles of renal therapy rationing in Senegal

Background: Since 2012, Senegal has conducted a national program to cover renal therapy (dialysis) expenses in public hospitals and social security-approved centers. Given the increasing demand for dialysis, national guidelines recommend explicit rationing through waiting lists, and hospitals have committees to determine whom to enroll. While national recommendations are known, criteria applied in hospitals to register patients remain unclear. Our study analyzes social justice principles used to ration renal therapy in government-owned centers and highlights inequalities caused by low access to treatment. Methods: We conduct a multivariate logit regression analysis using data collected from patients in public and private centers to identify which socioeconomic or sociodemographic factors determine enrollment. Based on the average marginal effects of these factors on program enrollment, we hypothesize the justice principles applied (or not) in hospitals. Results: We find that the duration of illness, insurance distribution, age, education, and involvement in patient associations influence program access. The duration of illness is the most robust predictor regardless of socioeconomic factors, which suggests the predominant application of egalitarian principles, notably the first-come-first-served rule. However, our findings indicate that the most impoverished patients do not have access to free dialysis. Conclusions: Although the national dialysis program aims to improve access to costly life-sustaining treatment, the first-come-first-served strategy is designed to suit patients who live longer, that is, those who can seek dialysis care in a private center. The program does not address inequalities in access, especially for the most impoverished patients recently diagnosed with end-stage kidney disease.