With over 2,00,000 new End Stage Renal Disease (ESRD) patients being added to the disease burden each year, India offers dialysis providers and equipment manufacturers enormous growth potential. As the respective state Governments take note of the situation, public private partnerships (PPPs) will become more prevalent in the coming years. Growth prospects are higher for private dialysis providers as they begin to expand their chain of dialysis centers across major metropolitan and Tier 1 cities. However with a disproportionate growth of dialysis centers between metro and non-metro towns, accessibility and affordability issues may remain. Growing annually at around 16%, the market for Hemodialysis (HD) machines, dialyzers, blood tubing sets, dialysate, PD solutions and APD machine is expected to be valued at $287 Million in 2018.

• What is the percentage split of dialysis centers in semi urban and rural India?
• What is the current infrastructure at dialysis centers in non-metro towns of India?
• What are the need-gaps and challenges as voiced by technicians, nephrologist and patients at dialysis center in non-metro towns of India?
• What is the revenue size for various machines and accessories in the dialysis market?

The stark contrast in socio-economic strata of patients is dominating the types of services offered by dialysis centers across metro and non-metro cities. While a corporate dialysis center may offer premium services such as personalized transportation, wi-fi enabled set-ups (among others), hospital linked (in-hospital) dialysis centers focus strictly on cost-effective dialysis sessions. There has also been an emergence of nephrologist-owned dialysis centers that promote themselves as a one-stop shop for nephrology and urology related diagnosis, therapy and transplantation. By virtue of their influence on purchase decision across multiple dialysis centers, nephrologists look to draw benefits impacting the total cost of ownership of machines for their private set-ups.

• What are various segments of dialysis centers in metro cities and non-metro towns?
• What are the respective strengths, weaknesses and expansion opportunities for each dialysis center segment?
• Who are the key purchase influencers in each segment?
• How are the various purchase parameters different for each customer segment?
• What are the value drivers while purchasing HD machines and accessories for each segment?

Affordability concerns in non-metro towns dominate the daily operational strategies of dialysis centers. “We re-use dialyzers for more than 25 sessions so that patients get some cost benefit. In fact many times patients ask us to reuse blood tubing sets and dialyzers for prolonged periods,” relayed a senior dialysis technician from North India. Cost cutting measures across certain dialysis center segments may also include installing low-cost water treatment systems, and manual washing of dialyzers instead of using re-processors. “In some facilities the water is taken from natural sources like rivers or wells, where the levels of magnesium and calcium are very high. Hard water previous to RO treatment needs to be pre-treated with softener. Many dialysis technicians and owners in small towns do not know about it. Others do not even have RO plants for cost cutting measures.” voiced a nephrologist from tier 3 town in west India.

• In the absence of strict guidelines and protocols what other cost cutting measures are being followed in non-metro towns of India?
• What are the dynamics around ancillary machines such as re-processors, RO plant etc. at the dialysis centers in non-metro towns?
• How equipped are dialysis centers in non-metro towns to cater to Hep-C and HIV positive patients?

Training of technicians and dialysis nurses continues to remain a key challenge for dialysis centers across India. Various machine related challenges have also been voiced by the technicians and nephrologists. “Breakdowns are quite frequent; we tend to resolve them remotely as the travel time for service engineer is high and we can’t wait till then”, described a technician in tier 2 town in South India.  With dialysis centers running on limited number of technicians, the need for technological modifications to the existing HD machines has been observed.

• What are the various training modules that may help dialysis technicians perform activities better?
• What are the after sales services related challenges faced by many technicians and nephrologists?
• What are the various challenges faced by nephrologists and patients in tier 2 and tier 3 towns?
• What are the various technological and design changes sought by end users of HD machines?

Unlike many other developing countries such as Mexico and Thailand, the number of patients on PD is significantly low. With late emergence of CAPD in India, most nephrologists have limited confidence in the modality. However with the formation of Peritoneal Dialysis Society of India (PDSI), a gradual shift in awareness of the modality is expected. “The younger generation of nephrologists seems to have a liking for PD. Once an investment on PD centers is made, hospitals will be forced to take this modality more seriously” says a Senior Nephrologist from Southern India.

• What are the key barriers for nephrologists and patients while accepting PD as modality for RRT?
• In the absence of government aid, what are the key drivers for PD market in India?
• With increasing number of dialysis centers and hospitals setting up PD department, what are the growth prospects for PD in India?

Through this ethnography-backed VOC report, EMeRG attempts to answer the above questions leading to detailed understanding and segmentation of various customer types in India. The report is based on face-to-face interviews with key stakeholders (Dialysis technicians, Dialysis nurses, Nephrologists, Dialysis center owners, Service engineers and Dialysis patients) and ethnographic observations at customer sites (hospitals / stand-alone dialysis centers, etc.). The commercial and quantitative information and market size predictions are based on in-depth interviews with key product managers, sales and marketing managers as well as distributors of various international and regional brands of equipment and devices.