Every week, a group of doctors sit down in Cape Town to decide who lives and who dies.
They are kidney specialists at Groote Schuur and Tygerberg hospitals and, with limited dialysis slots available, they have the painful task of turning away about half the patients who need the life-saving treatment.
Nevertheless, the Western Cape, with five dialysis centres in public hospitals, is the province providing the greatest access to state treatment after Gauteng and the Free State, which each have six centres. Limpopo has just one centre, and Mpumalanga none.
Since 1994, access to treatment for people with end-stage kidney disease has declined in the public health sector relative to the growing population and demand.
Deaths from chronic kidney disease had increased by 67% from 1999 to 2006 because of an increase in new cases and the lack of facilities, said Professor Brian Rayner, head of nephrology and hypertension at Groote Schuur.
He said their most difficult situation was dealing with patients who qualified for dialysis but could not go onto the programme because there were no slots available.Constitutionally, dialysis may be rationed in the public health sector because of its expense, which can even exceed the cost of cancer treatment.
One in eight South Africans has early-stage kidney disease and the figure is rising. The increase in so-called lifestyle diseases - hypertension, diabetes and obesity - is pushing up this risk.
In the private health sector, the number of dialysis units has expanded dramatically in response to demand in the past 20 years. Patients on medical aid have unrestricted access to dialysis and costs are covered under the prescribed minimum benefits.
Inequalities growing
Nearly 10 times more people are getting renal replacement therapy in the private sector than in the public sector: 716.3 people per million of population in private care compared to 72.6 in public care.
Mark Heywood, director of the social justice organisation Section27, said: "Inequalities are growing in every area of health and tragically this plays out in race and class. We need an equal platform for access to health services regardless of wealth."
Private dialysis units have increased from five in 1994 to 196, serving about 8.8 million people.
In public centres, the number has gone up from 27 to 29 since 1994 and some 40 million people rely on them. Socioeconomically disadvantaged patients outside of major cities struggle to access treatment.
Dr Harriet Etheredge, a medical bioethicist at the Wits Donald Gordon Medical Centre, said: "Doctors in the public sector have to turn away so many patients. These are life-and-death decisions."
She said the state should negotiate partnerships to allow state patients access to private dialysis units which were not full, at favourable prices.
Rayner said charities such as the Islamic Medical Association had assisted patients by sponsoring free dialysis in private facilities until space appeared in the public health programme. Private companies have also offered discounted dialysis.Kidney disease ranked third among the most rapidly increasing causes of death internationally, said nephrologist Dr June Fabian, research director at the Wits Donald Gordon Medical Centre.
In the Western Cape, decisions on who to put on dialysis were made rationally, fairly and transparently through an ethically approved process, said Rayner and his colleague, Professor Ikechi Okpechi.
Okpechi said: "We may have to turn away a young mother with kids who does not meet the criteria because she has breast cancer and is not in remission, or a person with diabetes over 50 years old."
Fabian said people were accepted for dialysis in public hospitals only if they were suitable for a transplant and slots were available. Clearer guidelines were needed nationally than the current framework to guide doctors who had to take hard decisions, she said.
Doctors should prioritise screening people with hypertension, diabetes, obesity, HIV and a family history, which would pick up 80% of early kidney disease, the experts said.
"This is not hard medicine: it's easy and cheap," said Fabian...