Nigeria is a member of the United Nations that adopted the primary healthcare (PHC) system, which focused on people-centred health promotion, disease prevention and treatment at the 1978 Alma-Ata declaration. This was later modified to include integration of chronic diseases and their funding into primary health centres as well as promoting community engagement at the declaration of Astana in 2018.^1,2 Primary healthcare has improved our understanding of taking healthcare beyond the limits of healthcare workers within four walls of hospitals as in-hospital medical interventions alone have proven inadequate for achieving equitable universal health coverage for communities, especially the underserved.

Chronic kidney disease (CKD) has become a pandemic with an estimated 700–840 million people affected globally.³ In Nigeria, the prevalence of CKD lies between 10% and 13.9%, being driven mostly by diseases such as hypertension, diabetes and chronic glomerulonephritis.⁴ In Africa, the burden of CKD varies from nation to nation, but the risk factors and settings are similar.⁵ To date, efforts to reduce the prevalence of CKD have largely proven ineffective, especially in developing countries. Key reasons behind this include late presentation to the hospital, high costs of care, poor knowledge of CKD amongst non-nephrologists, late recognition and treatment of hypertension and diabetes mellitus, poor lifestyle, exposure to nephrotoxins as well as poor knowledge and attitude to CKD amongst patients. Of utmost importance is the limited availability of nephrologists in many African countries, with less than 300 serving a population of over 200 million in Nigeria, for instance.^6,7,8

A major challenge facing CKD control is that it is yet to be fully incorporated into the PHC system as a standardised stand-alone component in Nigeria; hence, it does not attract government funding, unlike tuberculosis, cancer, etc. Due to limited resources, available testing materials like urinalysis strips are usually reserved for other clients like pregnant women, diabetics and children.

Indeed, recent efforts by a renal consortium on inclusion of kidney disease in the current World Health Organization (WHO) statement on major noncommunicable diseases drivers of premature mortality are beginning to yield results.^9,10 Therefore, successful integration of CKD care into the PHC system in Nigeria can offer the opportunity to navigate mounting challenges and improve access to kidney care in the community, especially in the more populated, underserved rural areas.¹¹

In this article, we propose an adaptation of a community nephrology practice model that may form a framework for the sustainable integration of CKD prevention into the PHC system in underserved communities. In this adaptation, we aim to weave primary and secondary or tertiary healthcare services into one seamless practice with effective utilisation of the nephrology team as key players in delivering kidney healthcare outside the four walls of the hospital. By this, the following can be achieved with minimal costs: early detection of CKD and referral, attitudinal change to kidney health in the community and capacity building amongst the health centre staff.

Importantly, it will serve as a solution to the ineffectiveness of previous CKD-focused community outreaches to significantly reduce the prevalence of CKD and its attendant rise in morbidity and mortality.^9,12 This is more likely because these outreaches were largely periodic, irregular, isolated, infrequent and short-term with long periods of dormant intervals, hence the little impact. More poignantly, these activities remain largely outside the PHC system and so were unable to receive the needed support for broad-based and sustainable impact.¹³ For instance, amongst approximately 1 million patients across 33 US health systems, only about 6.7% of those with abnormal dipstick results were recommended for confirmatory evaluation, thus leaving many with possible early CKD undiagnosed and failing to change clinical outcomes significantly, if any at all.¹⁴ An adaptation of the model in Nigeria will engender sustained presence of kidney healthcare personnel in communities, which can provide opportunities for lasting and significant reduction in the prevalence of CKD.

In the nephrology clinic extension-mentorship model, existing secondary and/or tertiary hospitals with the presence of at least one Nephrologist will be enlisted as a sectional renal mentoring headquarters. To each enlisted hospital will be assigned a group of health centres which fall within a specified distance from the hospital (Figure 1). This measured distance is to ensure easy accessibility of the team to only the designated centres for clinic consultation and mentoring of health centre staff and the community, reduce travel time and avoid fatigue of the personnel. These health centres will be assigned the tag, ‘Alpha units’ (labelled health centre A–D in Figure 1). The renal team will be required to visit these ‘Alpha units’ on a scheduled itinerary, ensuring that their time and presence are evenly spread amongst the centres within a specified time period.

The Alpha units are further subdivided into two: the ‘Active’ and ‘Rest’ units. An ‘Active Alpha unit’ is defined as a health centre that is currently hosting the renal team during a particular visit, whilst the adjacent Alpha units awaiting visits are the ‘Rest Alpha units’. As shown in Figure 1, people from ‘Rest Alpha units’ can visit an ‘Active Alpha unit’, thus maximising every presence of the renal team.

The second group of health centres are tagged ‘Beta units’ (labelled health centre X1–X5 in Figure 1). They are the health centres that fall outside the specified distance of coverage by the renal team from the sectional renal mentoring headquarters. It is expected that this set of health centres is served by another renal team in whose jurisdiction they fall. However, if this is not the case, the itinerary of the renal team will be made available to them via the medical officer of health (or health centre coordinators) at the various ‘Beta units’. This way, they can access renal health care in any of the ‘Alpha unit’ any time the team is available (unidirectional). In effect, provided there is sufficient spread of personnel across institutions in a given region, a ‘Beta unit’ to one renal team can simultaneously be an ‘Alpha unit’ to another renal team from another sectional headquarters and vice versa.

This system thus promotes shortened and compact road trips for the renal team, energy conservation and efficient renal healthcare coverage to communities. At an ‘Active Alpha unit’, the team is required to run clinics, train the health centre staff on early detection of CKD, ensure availability of basic tools for laboratory screening for CKD, coordinate community outreaches and establish an efficient system for early treatment interventions and prompt referral in collaboration with the medical officer of health. By so doing, the basic fundamentals of kidney care would have been passed on to the health centre personnel in a hands-on, practical method over a period of time.

A successful adaptation of the model can be achieved by adding the following key elements:

The shortfall of CHEWs in the healthcare system will be addressed by the model through building a sustained pool of medical and allied healthcare students through rural posting. Adjusted school curricula can ensure that students rotating through nephrology are posted to health centres. Other potential personnel include interns (doctors, nurses, medical laboratory scientists, etc.) and National Youth Service Corp (NYSC) members who are trained in healthcare. In fact, the NYSC are already utilising medical corps members in their Health Initiative for Rural Dwellers.¹⁶ Also, serious steps are being taken by various groups and institutions to explore and encourage the rural medical internship.¹⁷ For example, in Australia, final year medical students have been undertaking 8 weeks of rural internships since 2005, with a significant impact on rural health coverage.^18,19 The students, interns and NYSC personnel will participate in house-to-house awareness campaigns, identification of persons with risk factors for CKD, counselling and mobilisation of identified persons to the secondary or tertiary clinics. To ensure uniformity of practice and care, a manual for CKD detection, first aid and referral will be provided for all health centres.

Specifically, in the renal clinic extension-mentoring model, funds will be pooled into an autonomous, Trust Foundation account with members drawn from the renal team, hospital management and the host community, with reports on income and expenditure rendered regularly. In every local government area, a percentage of tax revenue should be set aside for CKD prevention activities and paid into the Trust Fund. The recent Supreme Court judgement, which granted autonomy to local governments in Nigeria to manage their finances and allocate resources without state government interference, could work in favour of this model.²²

A low-hanging fruit is communal fund mobilisation. Landlord Associations, social clubs and societies, traditional and opinion leaders can assist in mobilising people in host communities to donate to the fund. Communities can directly hire ad hoc staff for health centres and donate accommodation facilities.

To avoid abuse and wastage, funds raised shall be restricted to primary prevention activities and infrastructural maintenance. Provision of medications, dialysis or kidney transplantation shall not be covered by the fund which will be used specifically for the following: advocacy and community mobilisation, provision of educational materials, support for laboratory reagents and kits, transportation of medical personnel and students, accommodation of personnel, provision for communication (telephony and internet services) and training of personnel and supervision.

In addition to the foregoing, the key role of government is to provide for the health and safety of its people. Considerable and sustained pressure must be put on the government to ensure that legislation for CKD financing is pushed through in all states of Nigeria, as the enormous amount of resources with the government is incomparable to any other.

Integrating CKD care into the PHC system has become an urgent need that can be facilitated by establishing sustained, close contact between the renal team and surrounding communities. An adaptation of the nephrology clinic extension-mentorship model for the integration of CKD care can be a low-cost, direct and practical medium to achieve sustainable awareness of CKD and change in community attitude to early screening and detection as well as care of CKD in communities through sustained visits to the underserved rural areas, whilst utilising relatively lesser human and capital resources.