Living on a lifeline: lived experiences of hemodialysis patients in sub-Saharan Africa. A systematic review and qualitative meta-synthesis

Abstract

End-stage kidney disease (ESKD) is a life-threatening condition, and hemodialysis (HD) is the most common form of kidney replacement therapy globally. However, access to dialysis remains highly inequitable, with over 90% of patients receiving treatment residing in high-income countries. In sub-Saharan Africa (SSA), patients face severe financial, infrastructural, and health system constraints, yet their lived experiences are poorly synthesized. This meta-synthesis aims to comprehensively understand the lived experiences of patients undergoing hemodialysis for ESKD in SSA. We carried out a systematic review and meta-synthesis of qualitative research using the Joanna Briggs Institute (JBI) framework and followed the ENTREQ guidelines for reporting. Our search included databases such as PubMed, Scopus, Africa Journals Online (AJOL), and other relevant sources from their start dates up to February 2026. We selected qualitative studies, including phenomenology, grounded theory, and ethnography, that explored the lived experiences, psychological conditions, and needs of adult hemodialysis patients aged 18 to 80 years in sub-Saharan Africa. Two reviewers independently assessed the studies, collected data, and checked the quality using the JBI Critical Appraisal Checklist for Qualitative Research. The findings were combined using the three-stage thematic synthesis method suggested by Thomas and Harden. From 123 initially identified records, nine qualitative studies met the inclusion criteria, representing 110 hemodialysis patients across six SSA countries (Uganda, Rwanda, Ghana, Ethiopia, Botswana, and Malawi). Methodological quality was rated A (high) for five studies and B (moderate) for four studies. Thematic synthesis generated 37 distinct themes, aggregated into 13 subthemes, and further synthesized into five overarching themes (1): Physical and functional burden (dialysis-related symptoms, treatment restrictions, reduced physical functioning) (2); Psychological and emotional challenges (anxiety, fear of death, dependency, adjustment difficulties) (3); Socioeconomic impact (catastrophic out-of-pocket costs, economic strain on families, disruption of social and occupational roles) (4); Health system and access barriers (infrastructure shortages, geographic inaccessibility, workforce limitations); and (5) Coping, support, and meaning of dialysis (family support, spiritual resilience, and perceived life-sustaining value of treatment). Patients in every study reported profound suffering experienced alongside systemic shortcomings in funding, service provision, and social protection rather than just illness. For patients in sub-Saharan Africa, hemodialysis is not only a medical requirement but also a deeply personal experience influenced by systemic unfairness, financial struggles, and limited access to healthcare services. The results of this study clearly show that the existing kidney care system is inadequate to meet the needs of people in this region. Fixing this problem requires more than small changes; it calls for major reforms, ongoing financial support, and a shift in global health goals towards fairness. Without such efforts, the increasing number of people with end-stage kidney disease will continue to expose and deepen existing inequalities, leading to serious effects on individuals, families, and healthcare systems. PROSPERO: CRD420261351338