The Cost of Bad Water

One center for six million.

Grateful to the leadership at Amoud Foundation for hosting me in Jigjiga, Ethiopia in late 2025. I went to look at the healthcare infrastructure. I didn’t expect to spend most of my time thinking about water.

The dialysis center there serves six million people. It has eleven working machines and four broken ones. There are thirty patients currently in treatment and eighty-five on a waiting list.

Each patient needs treatment three times a week, four hours each session. That’s a 12-hour commitment, every week, for the rest of their life. When a machine breaks there’s often no one to fix it. The technicians who get trained leave for better jobs in other countries.

A partnership with the regional government subsidizes treatment so patients pay $5 per session instead of the full $50 cost.

Jigjiga dialysis center, October 2025 field assessment. Pictured: Amoud Foundation President Mohamoud Egal, Executive Director Issam Abdallah, Ethiopia Country Director Abdul Kadir, and Mazhar Memon of CharitySense, alongside dialysis medical and executive staff.

Dialysis basics

Your kidneys are a filter. When they fail, you need an external one. Three times a week, blood leaves your body, passes through a bundle of hollow fibers while a cleaning solution removes the waste from the other side, and returns. That’s it.

The dialyzer, the actual filter, contains around 15,000 fibers thinner than a human hair. Your kidneys normally process about 180 liters of blood per day. The dialyzer replicates this across four hours, processing your entire blood volume multiple times.

The dialysis unit at Jigjiga, eastern Ethiopia. The only center serving a population of six million.

Per-session consumables (hover to explore)

Cost ranges from Karopadi et al., BMC Health Services Research 2013. Consumables account for 70 to 85% of session cost in low-income settings.

The only hard part: water quality

The cost question starts with water. Of the $50 it costs to run a session, $2 goes to purification, the most fundamental input and the one most directly linked to where patients live.

Drinking water standards sit at 500 ppm. Dialysis water has to be under 10 ppm, fifty times stricter than the drinking water standard. A single reverse osmosis unit brings that down to dialysis grade. One unit serves an entire center. It costs $5,000 to $15,000.

A typical RO system. Tap water enters under pressure; membranes reject dissolved solids; ultrapure water exits. Adapted from Renal Fellow Network.

The RO system at Jigjiga. Source water at 1,380 ppm TDS is brought below 10 ppm for dialysis use.

What a session actually costs

At $50 per session, a patient needs $7,800 per year (3x/week, 52 weeks). In the US, the USRDS estimates annual per-patient costs above $90,000. Medicare spends $36 billion per year on end-stage kidney disease alone.

Where the money goes

Consumables (dialyzer, tubing, needles, saline) account for 70 to 85% of total costs in low-income settings. They are manufactured plastic and basic chemistry. The machines are a one-time cost.

Tying it all together

What’s missing is coordination. Water infrastructure funding is scoped to access, not purification grade. Health funding is scoped to drugs and equipment, not infrastructure. The two systems don’t talk to each other, and dialysis centers fall in the gap between them.