Removing Barriers in Kidney Transplantation

What is the issue?

Many studies in high-income countries have been conducted on the barriers to kidney transplantation and the social determinants to access and outcome of kidney transplantation.(2, 3) However, for low- or middle-income countries, it remains poorly understood because most of the studies conducted were focused on medical treatment-related factors, while the complex interplay of personal, cultural, environmental and system-related factors are still not well explored in the health system.

Kidney transplantation may not be a priority in low- and middle-income countries due to the lack of resources (e.g. infrastructure and workforce) and the survival of the kidney transplant recipients can be complicated by the accessibility and affordability of immuno-suppressive drugs, and infectious disease.(4) The role of social determinants (i.e. socioeconomic status) on kidney transplantation is complex because it affects healthcare provision and uptake along the pathway to transplantation. Nevertheless, kidney transplantation should be the modality of choice promoted by the government to treat end-stage kidney disease.

As Malaysia inches closer to achieving high-income nation status, there is a need for more locally relevant research to allow policymakers and clinicians to make an informed and evidence-based decision. The implications of this research could prompt a policy change for a better health service delivery model on par with other high-income countries. By providing information on disparities to access kidney transplantation and in the delivery of post-transplantation care, it is expected that this brief will benefit clinicians, policymakers, civil society, and academia in Malaysia and beyond.

Actions needed to improve end-stage kidney disease patients’ lives

Figure 1 Kidney transplantation rate per 1000 dialysis patients, by country, 2015

Soaring rates of chronic kidney disease should translate to higher accruement of kidney transplantation. However, only a small number of patients undergo transplantation as their initial modality of renal replacement therapy. This figure is mostly unchanged despite the high numbers of end-stage kidney disease patients (refer Figure 1). This policy brief provides an overview of key issues as well as the effect of the social determinant (i.e. socioeconomic status) on kidney transplantation. It focuses primarily on kidney transplantation in Malaysia, which would be relevant to clinicians, policymakers, civil society, and academia of low- and middle-income countries facing a similar predicament.

Social Determinants of Health

“Conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. It is responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”

Source: World Health Organization

About the research

This brief is based on the research project – ReTRAPP, which provides evidence on the issues in kidney transplantation in Malaysia. Although considerable literature exists on kidney transplantation in high-income countries, significant knowledge gaps can be found in relations to kidney transplantation in low- and middle-income countries, especially in Malaysia. ReTRAPP attempts to respond to it with the following questions:

  1. What are the barriers and recommendations to access kidney transplantation in Malaysia?
  2. What is the impact of socioeconomic status of kidney transplant recipients on access to renal transplant?
  3. What is the association of socioeconomic status on the survival of the kidney transplant recipient?
  4. What is the financial burden of kidney transplant recipients according to their socioeconomic status?
  5. What is the influence of kidney transplant recipients’ socioeconomic status on their quality of life?

Barriers and recommendations to access kidney transplantation in Malaysia

Key findings from interviews with subject matter experts. Issues with access to kidney transplantation in Malaysia according to the socio-ecological model

The access and survival of kidney transplant recipients

The research determined the association of socioeconomic status and waiting time as well as post-transplantation survival of kidney transplant recipients. Instead of using community-level indicators of socioeconomic status, the research adopted the individual-level indicators to consider the heterogeneity of the kidney transplant recipients and to avoid misclassification.

Figure 2 demonstrates the socioeconomic characteristics associated with access to renal transplantation in Malaysia. This research found that disparity in household income was significantly associated with access to kidney transplantation. Besides, disparities were noted in the intermediate household income and secondary educational attainment subgroups with poorer access at 33% and 21% respectively compared to the highest household income and tertiary educational attainment.

Figure 2 Association of socioeconomic status on access to kidney transplant

Although the survival rate of kidney transplant patients in Malaysia is comparable to other high-income countries,(5,6,7) disparities between the socioeconomic gradient is evident from the findings of the research (refer Figure 3). Educational attainment is the only characteristic that is significantly associated with post-transplantation survival. Primary educational attainment has 2 times the risk for mortality compared to tertiary educational attainment. While secondary educational attainment is 69% more likely to die compared to tertiary educational attainment.

Household income and employment status showed a decline across the socioeconomic continuum but was not statistically significant. The crucial finding of the current research is that socioeconomic inequality plays an important role in post-transplantation survival.

Figure 3 Association of socioeconomic status on kidney transplant survival

Catastrophic Health Expenditure (CHE)

“When people have to pay fees or co-payments for healthcare, the amount can be so high in relation to income that it results in “financial catastrophe” for the individual or the household. Such high expenditure can mean that people have to cut down on necessities such as food and clothing, or are unable to pay for their children’s education.”

Source: World Health Organization

Financial burden of kidney transplant recipients

Figure 4 Association of household income on financial burden

Kidney transplant recipients experienced financial burden when their out-of-pocket medical-only expenditure is above the 10% household income. Even small out-of-pocket payments may cause financial burden for kidney transplant recipients with household income in the Bottom 40% and Middle 40%.

As anticipated, the research validates what we already know about the disparity in out-of-pocket payment across the household income continuum. The prevalence of catastrophic health expenditure is 5.3 times higher among the Bottom 40% household income and 4.3 times higher among the Middle 40% household income compared to the Top 20% household income (refer Figure 4). The research highlights that socioeconomic disparity plays an important role in the incidence of CHE.

Quality of Life (QOL) of kidney transplant recipients

The association of socioeconomic status with the quality of life was conducted using the WHOQOL survey that captured 4 domains; physical, psychological, social and environmental aspect of the kidney transplant recipients. Comparison between the domains is made by transforming into a scale from 0 to 100 for each domain.(9)

The research showed that the quality of life kidney transplant recipient varies between the socioeconomic gradient. Those who were more socioeconomic disadvantaged in educational attainment, household income and employment status were associated with lower quality of life in all the WHOQOL domains (refer Figure 5). The overall QOL illustrated that socioeconomic disparity was found to have an impact on the QOL of kidney transplant patients.

Figure 5 Association of socioeconomic status on quality of life

What should be done?

The research raised awareness of the effect of social determinants on the kidney transplantation system. In order to ensure better-valued health outcomes and daily function for the prevention and inequitable access to care, a comprehensive approach focused on the immediate needs as well as the systemic issues is required.

The barriers and recommendations elicited from subject matter experts explore the multilevel challenges faced in the Malaysian healthcare system. As such, the provisional findings underscore the disparities in the access to kidney transplantation and have significant implications for the development of a culturally acceptable and appropriate policy for kidney transplantation in Malaysia.

Policymakers must recognize the importance of social determinants in the delivery of care. Healthcare providers should understand the workings of the social determinants and approaches to manage kidney transplant recipients whose health are influenced by their socioeconomic status. It highlights the importance of socioeconomic status and the underlying individual, community, and systemic issues related to health inequities by integrating it into health education at all levels.

Public-private partnership is essential in the delivery of post-transplantation care and the prevention of chronic kidney disease in the population. It will help create awareness about the risks of kidney disease and promote the early detection, treatment and management of it.(10) At the same time, private entities participating in the provision of care will contribute to the financing of kidney transplantation services. This partnership will allow the sharing of information and resources to improve patients’ outcome better. Public-private partnership will ensure effective delivery, better efficiency and affordable costs that will ease the burden on the public healthcare system.(11)


  1. Saran R, Robinson B, Abbott KC, Agodoa LY, Bragg-Gresham J, Balkrishnan R, et al. US Renal Data System 2017 Annual Data Report: epidemiology of kidney disease in the United States: Elsevier; 2018.
  2. Axelrod DA, Dzebisashvili N, Schnitzler MA, Salvalaggio PR, Segev DL, Gentry SE, et al. The interplay of socioeconomic status, distance to center, and interdonor service area travel on kidney transplant access and outcomes. Clinical Journal of the American Society of Nephrology. 2010:CJN. 04940610.
  3. Hod T, Goldfarb-Rumyantzev AS. The role of disparities and socioeconomic factors in access to kidney transplantation and its outcome. Renal failure. 2014;36(8):1193-9.
  4. Verma B, Bhandari M, Kumar A, editors. Transplantation in developing countries: economics, reality, and solutions. Transplantation proceedings; 2000: Elsevier.
  5. Gan Kim Soon P, Lim SK, Rampal S, Su TT. A qualitative examination of barriers and solutions to renal transplantation in Malaysia: Key-informants’ perspective. PLOS ONE. 2019;14(8):e0220411.
  6. Wong HS, Goh BL. 24th Report of the Malaysian Dialysis and Transplant Registry 2016 2018.
  7. ANZDATA Registry. 39th Report, Chapter 8: Transplantation. Australia and New Zealand Dialysis and Transplant Registry Adelaide2017.
  8. NHS Blood and Transplant. Annual Report on Kidney Transplantation for 2016/2017: NHS Blood and Transplant; 2017.
  9. World Health Organization. Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychological medicine. 1998;28(3):551-8.
  10. Morad Z, Choong HL, Tungsanga K. Funding renal replacement therapy in southeast Asia: building public-private partnerships in Singapore, Malaysia, Thailand, and Indonesia. American Journal of Kidney Diseases. 2015;65(5):799-805.
  11. Ng CW, Hairi NNM, Ng CJ, Kamarulzaman A. Universal health coverage in Malaysia: issues and challenges. Revisiting Malaysia’s Population–Development Nexus. 2014:175.

Dr Peter Gan Kim Soon

This brief was prepared by Dr Peter Gan Kim Soon as part of his doctoral thesis titled “Access to renal transplantation and post-transplantation prognosis (ReTRAPP) study of adults in malaysia” that was sucessfully defended on 25 November 2020. He was supervised by Professor Dr. Sanjay Rampal, Professor Dr. Tin Tin Su, and Assoc. Prof. Dr. Lim Soo Kun.

Dr Peter Gan is also an Atlantic Fellow for Health Equity and an Ex-officio Member of the MERCY Malaysia.

Dr Peter Gan has published the following articles in peer-reviewed journals as part of his Doctor of Public Health journey:

  1. A qualitative examination of barriers and solutions to renal transplantation in Malaysia: Key-informants’ perspective. PLoS One. 2019; 14(8): e0220411.
  2. Impact of socio-economic status on access and outcome of kidney transplantation in Malaysia. Malaysian Journal of Medicine and Health Sciences, 2019;15(106):33-33.
  3. What are the barriers and solutions to renal transplantation in Malaysia? a qualitative key-informant study. Malaysian Journal of Medicine and Health Sciences, 2019;15(106):8-8.