Epidemiology and Management of Chronic Kidney Disease in Ethiopia

Background: Chronic kidney disease (CKD) is a growing global health concern; however, comprehensive epidemiological and health system data to understand the burden and care of CKD patients is lacking in Ethiopia. Thus, in the study context of Ethiopia, this thesis aimed to assess the prevalence of CKD; assess service availability and readiness; and explore barriers and enablers to CKD care to inform health system planning and strengthen CKD service delivery. Methods: A multimethod research approach was used that employed both quantitative and qualitative methods. First, a retrospective analysis of the national administrative health data, the District Health Information System 2 (DHIS2; 2019–2022), was conducted to assess its utility for estimating the burden of CKD in Ethiopia. Second, a systematic review and meta-analysis was conducted to synthesise the quality of CKD care against guideline-based indicators in global context. Third, a secondary analysis of the Ethiopian Service Provision Assessment (SPA) survey was conducted to assess the readiness of health facilities to provide services for CKD and related conditions, including diabetes and cardiovascular disease (CVD). Fourth, a descriptive qualitative study underpinned by the Theoretical Domains Framework explored healthcare provider and stakeholder perspectives on the barriers and enablers to CKD care in Ethiopia. Results: Analysis of national DHIS2 administrative data covering all regions of Ethiopia showed that the recorded CKD cases increased steadily from 2019 to 2022, rising from 7,643 cases (7.25 per 100,000 population) in 2019 to 14,992 cases (13.27 per 100,000 population) in 2022. Cases of kidney failure also increased during this period: from 4,076 (3.87 per 100,000) in 2019 to 5,816 (5.14 per 100,000) in 2022. There was substantial regional variation in prevalence estimates, further compounded by inconsistencies in data reporting and data quality across both the study period and the different regions of Ethiopia. The systematic review of 59 studies, encompassing 3,003,641 people with CKD across 24 countries, showed substantial variation in guideline‑concordant CKD care across multiple quality indicators. While rates of blood pressure monitoring (90%) and estimated glomerular filtration rate (eGFR) testing (81%) were reassuring, only 47% of patients had albuminuria testing, which is highly important to CKD risk stratification and management. Angiotensin‑converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and statins were prescribed for 57% of patients. Overall, 56% achieved blood pressure control (≤140/90 mmHg) and 43% achieved glycaemic control (HbA1c <7%). Notably, the systematic review revealed a major evidence gap in the quality of CKD care in low‑resource settings, including Ethiopia, where no eligible studies were identified. Among 901 surveyed health facilities in Ethiopia (338 facilities based on weighted sampling), 57% offered CKD services, while 93% provided diabetes and 93% provided CVD diagnosis and/or management services. However, readiness to deliver these services was low, with mean readiness scores of 42.9% for CKD, 47.8% for diabetes, and 44.0% for CVD. Readiness was lower in rural and private health facilities. Higher readiness levels for CKD, diabetes and CVD care were observed in facilities with better basic amenities, supervisory visits and regular staff meetings. A descriptive qualitative study involving healthcare providers and key stakeholders (n = 15; including those in general practice, nephrology, nursing, and non-communicable disease [NCD] prevention and control programme), identified major barriers to CKD care. These included low patient awareness, healthcare provider knowledge gaps, workforce shortages, limited resources, low prioritisation of CKD, lack of CKD monitoring systems, weak referral pathways, high out‑of‑pocket costs, and conflict‑related service disruptions. Key facilitators included senior clinicians’ adherence to clinical guidelines and the inclusion of CKD within national health strategies. Conclusions: This thesis provides evidence of the growing burden of CKD in Ethiopia. It identifies limitations in current CKD surveillance methods, gaps in health service provision, and multiple barriers to effective CKD care. This thesis offers several potential strategies for addressing these challenges, including prioritising early detection and management of CKD within Ethiopia’s health system; strengthening the country’s routine CKD data and surveillance platforms; and enhancing the readiness of health facilities in Ethiopia to deliver comprehensive CKD care, including expanding and upskilling the health workforce.