Effect of socioeconomic status and healthcare provider on post-transplantation care in Malaysia: A multi-centre survey of kidney transplant recipients.

INTRODUCTION: As the rate of end-stage kidney disease rises, there is an urgent need to consider the catastrophic health expenditure of post-transplantation care. Even a small amount of out-of-pocket payment for healthcare can negatively affect households' financial security. This study aims to determine the association between socioeconomic status and the prevalence of catastrophic health expenditure in post-transplantation care. METHOD: A multi-centre cross-sectional survey was conducted in person among 409 kidney transplant recipients in six public hospitals in the Klang Valley, Malaysia. Catastrophic health expenditure is considered at 10% out-of-pocket payment from household income used for healthcare expenditure. The association of socioeconomic status with catastrophic health expenditure is determined via multiple logistic regression analysis. RESULTS: 93 kidney transplant recipients (23.6%) incurred catastrophic health expenditures. Kidney transplant recipients in the Middle 40% (RM 4360 to RM 9619 or USD 1085.39 -USD 2394.57) and Bottom 40% (RM 9619 or > USD 2394.57) income group. Kidney transplant recipients in the Bottom 40% and Middle 40% income groups were more susceptible to catastrophic health expenditure at 2.8 times and 3.1 times compared to higher-income groups, even under the care of the Ministry of Health. CONCLUSION: Universal health coverage in Malaysia cannot address the burden of out-of-pocket healthcare expenditure on low-income Kidney transplant recipients for long-term post-transplantation care. Policymakers must reexamine the healthcare system to protect vulnerable households from catastrophic health expenditures.

A qualitative examination of barriers and solutions to renal transplantation in Malaysia: Key-informants' perspective.

INTRODUCTION: End-stage renal disease (ESRD) is increasing globally, and renal transplantation (RT) is the preferred renal replacement therapy to treat ESRD. Internationally, there are only a few countries with RT rates above 50 per million population (pmp), while most of the countries have RT rates between 30-40 pmp. The low- and middle-income countries (LMIC) makes up the majority for the RT rates below 20 pmp in which Malaysia belongs to despite its increasing ESRD rates. There is a need to explore the barriers to access RT with targeted solutions to improve the RT rates and service in LMIC. Thus, a qualitative study was undertaken in Malaysia to address this issue. METHOD: A qualitative methodological approach was performed between March-May 2018. Semi-structured interviews were used to explore current RT policy and service availability. Key-informants were identified from a detailed stakeholder analysis of RT system in Malaysia. Interviews were digitally audio-recorded, transcribed verbatim, coded with ATLAS.ti software and underwent thematic analysis thoroughly. RESULTS: Eight key-informants participated in the study. Barriers and related solutions were classified using the socio-ecological model (SEM). As reported, the barriers and solutions of RT in Malaysia are the results of a complex interplay of personal, cultural, and environmental factors. Key barriers are linked to public's attitude and perception towards RT and the unaccommodating practices in the healthcare fraternity for RT. Key-informants provided a systematic solution that shed light on how RT could be improved at each SEM level via effective communication, education and inter-agency collaboration. CONCLUSION: The SEM provided a framework to foster a better understanding of current practice, barriers, and solutions to RT in Malaysia. This study is the first to explore the barriers and related solutions to RT comprehensively as a whole. Implications of these findings could prompt a policy change for a better RT service delivery model not just for Malaysia but also for other LMIC. Further stakeholder engagement and evaluation of the systems are required to provide insight into best practices that will help to improve the RT rates and service in Malaysia.