Africa is a vast continent occupying 20% of the global land surface (13, 14). The age structure of Africa's population is young, with the fast growth of the age range 25–64. Moreover, according to data from the World Bank Group, the life expectancy in Sub-Saharan Africa was 60.4 years in 2015 and rose to 64.1 years by 2020 (15, 16).

However, the proportion of poor people in Africa continues to rise. It is worth noting that the health index among countries rises as their Gross Domestic Product (GDP) increases, which explains the inequalities between African countries in terms of the quality of healthcare and life expectancy (17).

The major causes of morbidity and mortality in Africa are communicable diseases such as HIV-AIDS and diarrheal diseases, as well as non-communicable diseases (NCDs) such as kidney and cardiovascular diseases, cancer and diabetes (17, 18).

The healthcare activity in Africa includes different entities, including faith-based and charitable institutions, public hospitals, private sector often located in high-income urban areas, and informal health sector including traditional healers and non-approved medicinal practices more famous among the low-income rural populations (19).

The overall score of essential services availability in Africa is extremely low, 0.36 on average, focused especially on communicable diseases’ control (0.76) (17). In addition, there are significant inequalities in access to these interventions not only between countries but also within each country.

Nephrology has historically received limited attention within the African healthcare system due to competing health priorities. However, significant advancements have been made in the field over the past three decades, largely driven by the efforts of the African Association of Nephrology (AFRAN) and the International Society of Nephrology (ISN). These organisations have played a pivotal role in enhancing nephrology training and research across the continent (20).

Many reports have shown that the number of chronic kidney disease (CKD) patients and patients on dialysis is steadily increasing in Africa, however the incidence of acute kidney failure (AKF) is very variable. A study from Nigeria has found that AKF accounted for 35% of all admissions in Lagos over a 10-year period, other researchers found that it represented 4.5% of all admissions in Dakar and 23.2% of all Intensive Care Units (ICU) (21, 22). Records have shown that severe infection is the major cause of AKF in contrast to developed countries. HIV comes in first line. Other less reported but common causes in Africa include nephrotoxic plants, obstetric complications and various forms of envenomation (23, 24). Mortality due to AKF is very high in Africa, ranging from 13.3% to 79.8%. This is especially due to the lack of access to dialysis, which is self-funded without government assistance in many parts of the continent (22, 25).

The lowest prevalence of CKD is 4% (3%–13%) reported in North Africa, while the highest prevalence, 16.5%, (2%–41%) is observed in West and Central Africa, with the major cause being hypertensive vascular disease, followed by diabetic nephropathy (22, 26).

Regarding the treatment options for end-stage kidney disease (ESKD) in Africa, haemodialysis represents the most commonly utilised renal replacement therapy for ESKD, predominantly accessible in urban centres. However, the development and expansion of this modality are significantly hindered by widespread poverty and resource mismanagement in many countries across the region. Additional challenges include the limited availability of vascular surgeons to establish permanent vascular access, as well as inadequate infrastructure, such as restricted access to reliable water, electricity, and transportation services (27).

Peritoneal dialysis (PD) is theoretically the ideal option for patients in large rural areas. Unfortunately, the importation and transport of PD fluids increase the cost of this technique. In addition, overpopulation, lack of adequate water and sanitation and low levels of education, as well as the shortage of well-trained PD staff, make this therapy impractical. Even in the wealthiest countries of North Africa, only 3% of all dialysis patients benefit from this method (28).

Besides, Egypt, Sudan and South Africa are the leading African countries in terms of kidney transplantation. The major obstacles to the expanding of this treatment are the high cost, the lack of infrastructure and ethnic and religious beliefs regarding transplantation from deceased donors.

Therefore, kidney disease is an important public health problem, particularly in sub-Saharan Africa, many patients die without adequate care due to the shortage of nephrologists and health staff across the continent and a lack of resources.

Despite the support of many nephrologists, our study only managed to include 310 patients. The three most commonly reported barriers are (30, 31): -

Lack of motivated workforce due to the overwhelming workloads. In fact, sub-Saharan Africa has less than 3% of the world’ health workforce.

Regarding the patients’ satisfaction with the quality and pertinence of care, more than 50% of our patients were satisfied, our results are consistent with western studies (38). Nevertheless, the authors of a large American multicentric study recommended caution in interpreting these results, because only clinically stable patients take part in these surveys and dissatisfied patients often decline invitations to participate, which may represent a non-negligible selection bias (39). Furthermore, Weaver et al. noted that some other patients’ factors (age, educational level expectations and personal preferences) may influence satisfaction (40).

Dissatisfaction is often reported among patients with chronic diseases especially CKD and dialysis patients. A large multicentre study in Europe and South America examining the satisfaction of haemodialysis patients reported that in spite of patients’ satisfaction with the staff attention, they were deceived with the quality of information provided by the medical team regarding treatment modality, prognosis and the likelihood of a kidney transplant (41). Other western studies backed these same constatations, stating that misinformation and inadequate communication were the biggest concern of their patients (39). Indeed, half of adults with chronic diseases in Norway and Sweden complained about the lack of communication with their care givers concerning their care goals and priorities, or their treatment options (42). In contrast, most patients in our survey didn’t particularly raise these questions about communication and information. On the other hand, 45.8% of patients surveyed were neutral about their satisfaction with the environment and general conditions, 10.6% were dissatisfied and 5.8% were very dissatisfied. In fact, a WHO study conducted in Africa noted that poor infrastructure and the inadequate environment of healthcare facilities were among the factors behind patient dissatisfaction with health services (30). The lack of access to healthcare including waiting times, availability of medicines, and healthcare costs, is also one of the main factors of people's dissatisfaction, not to mention long travel distances, unaffordable transport systems, low quality of care, lack of qualified professionals and poor organisation (36, 43, 44). In our study about 45% of patients were neutral about access to health care, less than 20% were satisfied and the rest were dissatisfied. However, it should be noted that access to health is a widespread problem around the world. In fact, about half of Canadian, German and Norwegian adults stated that they could not get an appointment on the same day or on the following day. Moreover, 30% of Canadian adults reported waiting two months or more before seeing a specialist followed by Norwegian 28% (42).

As for professional ethics, neutrality was again noted, as that 49% and 47.9% of patients were neutral about their perceptions of equity in access to healthcare and privacy protection respectively, only a minority was dissatisfied, as well as for their ability to receive treatment regardless of their capacity to pay. These results concord with those of the WHO multicentric study, in which equity in healthcare is closely related to the implementation of universal health coverage permitting a full range of quality health services without the risk of financial hardships (36).

Regarding privacy, only few studies in Africa sought to determine the extent of privacy and personal data protection, but recently, due to the rapidly evolving global digital environment, privacy protection became an important issue, and so many laws have taken place (45).

Our study took a major interest in patients’ perception of hospital SR. This perception was average in 49.35%, good in 26.95%, poor in 12.66%. Our results were far from those of a Chinese study by Liu W et al, published in 2016, reporting that the majority of patients were very satisfied with the SR of the surveyed publics hospitals (46). Besides, Wu and Naidu showed that the quality of care has a positive impact on patient's satisfaction, loyalty and perception of hospital SR (47, 48). Moreover, an Indonesian study noted that patients’ perception was related to three main aspects: quality, pertinence and financial aspects (49). Although, this is quite different from our study's findings. In fact, our study didn't find a significant correlation with the quality of care but with the accessibility of care instead. Contrary to our results, a French survey found that the satisfaction level of dialysis patients was mainly dependent on age. However, there was no correlation to gender, which concords with our study (35). Furthermore, a Saudi study showed that higher levels of education were significantly correlated with better satisfaction rates (50). In addition, a large survey published in 2016, found that financial barriers hindered access to healthcare in developed countries, thus influencing their perceptions of SR. This was mainly due to differences in health insurance design (42). Unexpectedly these two correlations were not found in our study. In fact, the existence of health coverage was significantly correlated to patients’ satisfaction. Same as our study, an earlier African study conducted in Ghana noted that patients treated in larger health facilities were healthier and more satisfied due to the increased availability of medicine supplies (51). Finally, our study found a significant correlation between the country's income and health expenditure which is consistent with many other rigorous studies. In fact, a patient from a high-income country is 3,400 times more likely to be satisfied with their country's healthcare system (52).

The mean age of nephrologists included in our study was 38.84 ± 7.65 years, with a mean professional seniority of 9.30 ± 5.83. This was observed in multiple publications. An Iranian study evaluating the perception of SR in hospitals found the mean age of participants who accepted to respond to the survey was 34.5 years. On the other hand, an Indian study examining the perception of doctors about hospital SR found that the third of respondents had a working experience less than 5 years (53, 54). The male-to-female sex ratio was 1.15 with 46.51% of female nephrologists. According to American Society of Nephrology, women constitute a reasonable proportion of the total workforce in nephrology (55).

A study sponsored by the American Medical Association reported that being able to provide high-quality healthcare is the primary motivation of doctor's professional satisfaction (56). The evaluation of the quality of care depends not only on therapeutic management, but also on the environment and general conditions of the hospital setting, and care process. In our study, most of the doctors were dissatisfied with their working environment. In fact, in many parts of the world, health professionals are exposed to a number of challenges such as inadequate infrastructure, overcrowded health services and administrative problems, especially in Africa where the lack of skilled healthcare workers and modern equipment constitute one of the main flaws in healthcare systems and a major cause of doctors’ dissatisfaction (57, 58). A satisfactory care process is the act of providing care in conformity with current scientific knowledge without any delays. Only 37.8% of the participating doctors were satisfied with the care process, the rest were either dissatisfied or neutral. This is due to the lack of medicines, imaging and biological tests required for diagnosis, treatment and follow up. Access to health is a major problem in developing countries especially for low-income patients (59). Starting with referral times, only one-third of the included doctors were satisfied. Other studies conducted in many developed countries (Canada, USA, UK, Australia) also reported longer waiting times especially in emergency departments, which leads to delays in the management of serious conditions and potentially adverse consequences (60). Late referral time is also problematic, in Douala, Cameroon. For instance, 3–4 CKD patients present late for nephrology care. As a consequence, 96% of late-referred patients required emergency dialysis on a temporary catheter which exposes them to multiple complications related to the use of this vascular access (61). As for the cost of care, only 24.4% of doctors in our study were satisfied. The low satisfaction rates of nephrologists with the cost of care in Africa are understandable because such care is not affordable and impedes the quality of care. Despite investments in public health, many developing countries are still in struggle. In Ecuador for example, out-of-pocket expenditure on health accounts on average 7.2% of total family income. Better-off families spend more on private consultations and insurance which counts for 71% of health expenditure, while the poorer ones pay more in out-of-pocket expenses for medicines which explains the widespread self-medication in these communities (57). Not to mention the non-availability of essential treatments in hospitals. In our study, 59.5% of nephrologists were dissatisfied with this matter. In fact, 50% of the population in the African region lacks access to essential medicines, according to a study by Kirigia JM et al., this is due to weak and under-resourced healthcare systems, because of the low investment, lack of strategic health financing policies, social security and weak coordination mechanisms (62).

Regarding professional ethics, privacy comes first, only 40% of doctors in our study were satisfied with the measures taken to protect patients’ privacy. Many African nephrologists reported the poor quality of record management in their hospitals, low interest in the value of confidentiality and lack of awareness. In the context of medical publications, respecting patients’ confidentiality while communicating the pertinent details of their cases is sometimes delicate (63). Medical journals have taken up this challenge by asking authors to obtain informed consent from patients. This procedure is imperative to help avoid the potential consequences of disclosing patient privacy (64). Equity in health in our context implies providing specialised nephrology care including costly replacement technologies in a resource-limited area. This aligns with the observations of an international group of experts who studied equity of access to healthcare for ESKD in Africa noting that equitable implementation of health programmes such as kidney replacement therapy requires considerations of three elements: availability, affordability and acceptability (65). Yet, low- and middle-income countries often lack financial, logistical and labor force capacity to provide such care, with a low participation of the public sector (66). Furthermore, it has been estimated that 188 million people across low- and middle-income countries experience catastrophic health expenditure annually due to kidney disease (58). Hence, in our study only 17.8% of doctors had a positive perception of equity in healthcare of their hospitals. Moreover, in terms of doctors’ perception of care delivery regardless of patients’ ability to pay, responses were particularly edifying. Despite the efforts made to provide care regardless of patients’ socio-economic level, the inequity gap between health service recipients and their income level continues to widen. Thus, low-income patients remain in waiting lists for dialysis due to their inability to afford access to private facilities. In addition, patients without health coverage cannot be transplanted because of their inability to pay for anti-rejection treatment (67).

Our study concluded that 60% of the included doctors were dissatisfied with their hospitals’ SR, 28.89% described it as average. Dissatisfaction is found in several publications about the perceptions of African doctors (68, 69). Meanwhile, an Iranian study identified a moderate level of satisfaction with a considerable difference in perceptions between managers and staff (53).

While examining the correlation between the dimensions of hospital SR and doctor's perceptions, we noticed that only one item relative to accessibility of care (cost of treatment p = 0.039) was positively correlated. In addition, our study showed no correlation between doctors’ socio-professional attributes and their perceptions of the hospital's SR. In contrast, an Indian study found that younger doctors tend to be more satisfied which decreases with longer time in service beyond five years, probably because the dynamics of the medical work environment usually dampen the initial enthusiasm (54). No correlation between countries’ socio-economic data and doctor's perceptions of hospital's SR was found.

Finally, our study revealed a statistically significant difference (p = 0.05) between doctors’ and patients’ perceptions with better scores among patients. Overall, patients were neutral in responding to several questions about the general conditions of the hospitals and care process while doctors were more commonly dissatisfied. As reported by some authors, usually patients, taking part in this kind of care satisfaction questionnaires, are the clinically stable and satisfied patients which may be a selection bias. Also, many patients worry about the potential negative consequences of their responses, particularly in the context of limited access to healthcare and chronic conditions such as dialysis which require frequent and prolonged contact with the same care facility and caregivers (38, 40).

Compared to Latin-American countries like Brazil—where universal healthcare provides free and widespread access to renal replacement therapies—the African context reveals more pronounced disparities in infrastructure, treatment availability, and legal protections for CKD patients (70). This contrast underscores the need for policy frameworks in Africa that not only address nephrology-specific gaps but also align with global standards in chronic disease management and health equity.

Current research specific to SR within African healthcare contexts reflects an urgent need to address these disparities. Reports by the WHO and regional health studies emphasise that SR is critical for achieving equitable health outcomes, yet African nephrology significantly lags behind global standards in SR-focused policies and investments (71). Factors such as inadequate funding, a shortage of specialised healthcare personnel, and limited policy frameworks contribute to these gaps. These challenges highlight the necessity for targeted policies and context-specific SR frameworks that consider Africa's socio-economic and healthcare infrastructure limitations.

The gaps identified in this study present opportunities for further research into SR-specific interventions tailored to the needs of African nephrology, such as developing sustainable SR policies, increasing nephrology training programmes, and implementing subsidised treatment initiatives. These efforts could bridge disparities in kidney healthcare across the continent, addressing both immediate and systemic barriers to equitable care. Addressing these gaps is essential not only for improving nephrology services in Africa but also for expanding scientific knowledge on effective SR models in low-resource settings.